Use of the Kono-S anastomosis in pediatric Crohn's disease: a single-institution experience.

OBJECTIVES: About 24% of children with Crohn's Disease (CD) require surgery. In 2003, Kono et al. described a novel anastomosis reported to decrease the rate of anastomotic CD recurrence. Subsequent studies have reproduced these outcomes, but none has demonstrated its effect in pediatric patients. This study evaluates short-term outcomes of pediatric patients following ileocolic resection and Kono-S anastomosis. METHODS: A retrospective review of patients < 18 years old who underwent ileocolic resection followed by Kono-S anastomosis compared with those who underwent a stapled anastomosis. RESULTS: Nine Kono-S patients were matched with nine patients preceding them who received traditional side-to-side and end-to-side anastomoses. All patients underwent minimally invasive surgery. Demographics, pre-operative medication usage, and symptom profiles were not significantly different. Traditional anastomosis (TA) patients had longer lengths of stay (4.6 vs 2.9 days; p = 0.03) but had no statistically significant differences in blood loss, procedure length, and pathologic findings. One Kono-S patient had a superficial surgical site infection, and one TA patient had an anastomotic leak requiring reoperation within 30 days. More TA patients experienced post-operative symptoms at both 30-day and 6-month follow-up (66.7% vs 33.3%; p = 0.16 and 77.8% vs 25%; p = 0.03). CONCLUSION: The Kono-S anastomosis appears to be safe in pediatric CD when compared to traditional stapled anastomoses.

Long-term Outcomes of Straight Ileoanal Anastomoses Converted to Ileal Pouch Anal Anastomoses.

BACKGROUND: While ileal pouch anal anastomosis (IPAA) is the recommended way to restore intestinal continuity after total proctocolectomy, straight ileoanal anastomoses (SIAA) are still selectively performed, especially in the pediatric population. In case of SIAA failure, conversion to IPAA is possible, but reports on its outcomes are scarce. METHODS: We retrospectively analyzed our prospectively collected database on pelvic pouches, and identified patients with a SIAA that was converted to IPAA. Our aim was long-term functional outcomes. RESULTS: Twenty-three patients were included (14 females, median age at SIAA 15 years, median age at conversion to IPAA 19 years). The indication for SIAA was ulcerative colitis in 17 (74%) cases, indeterminate colitis in 2 (9%) cases, and familial adenomatous polyposis in 4 (17%) cases. The indication for IPAA conversion was incontinence/poor quality of life in 12 (52%) cases, sepsis in 8 (35%) cases, anastomotic stricture in 2 (9%) cases, and prolapse in one (4%) case. The majority were diverted at IPAA conversion (22, 96%). Three (13%) patients never had stoma closure, due to patient wishes, failed healing of vaginal fistula, and pelvic sepsis, respectively. After a median follow up of 109 months (28-170), pouch failure occurred in 5 additional patients. Overall pouch survival was 71% at 5 years. Median quality of life was 8/10, of health 8/10, and of energy 7/10. Median satisfaction with surgery was 9.5/10. CONCLUSION: Conversion of SIAA to IPAA leads to acceptable long-term outcomes and good quality of life, and can safely be offered to patients with problems related to SIAA. LEVEL OF EVIDENCE: IV.

Obstructing Sigmoid Volvulus: An Unusual Complication in a Pediatric Patient With Ulcerative Colitis.

Acute colonic dilation in pediatric patients with ulcerative colitis (UC) raises a concern for toxic megacolon, but other rare conditions such as sigmoid volvulus may present in a similar manner. We report a rare case of a teenager with UC without prior surgery who developed an obstructing sigmoid volvulus managed with endoscopic detorsion and decompression. Colonic inflammation in patients with UC may result in a volvulus in the absence of other predisposing factors and should be considered in the differential diagnosis of patients with UC who present with obstructive symptoms with an atypical presentation.

Approach to the Adult Colorectal Patient with a History of Pediatric Abdominal Surgery.

Children with colorectal diseases often undergo operative management in their youth. As these patients become adult, it is important for surgeons to understand their postoperative anatomy as well as the pathophysiology of their diseases. Here, we present a description of common colorectal diseases of childhood that may have significant impact on patients' presentations as adult. We also discuss the diagnosis and management of conditions that are usually seen early in life but may present during adulthood as well.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative.

BACKGROUND: APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce. METHODS: Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email. RESULTS: 144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted. CONCLUSION: In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

Next day discharge after the Nuss procedure using intercostal nerve cryoablation, intercostal nerve blocks, and a perioperative ERAS pain protocol.

BACKGROUND: The Nuss procedure for pectus excavatum has historically been associated with significant postoperative pain, which has been the major factor contributing to hospital length of stay (LOS). METHODS: A single-institution, prospective study of 40 consecutive patients undergoing Nuss bar placement for pectus excavatum between November 2019 and January 2021 was conducted to assess the effectiveness of a multimodality pain management protocol. All patients received T3-T8 intercostal nerve cryoablation (INC), T3-T8 bupivacaine intercostal nerve blocks, Exparel at the skin incisions, and management with a perioperative analgesia regimen that minimized narcotic usage. The primary outcome was LOS. Secondary outcomes included opioid use, pain scores, and time to sensory recovery. RESULTS: 37/40 patients (92.5%) were discharged home on postoperative day (POD) 1, and 3/40 (7.5%) were discharged on POD 2 (mean LOS = 1.1 days). The median average postoperative pain score was 2/10. After eliminating IVPCA from our protocol, total oral morphine equivalent (OME) decreased by 73% (55.5 mg to 15 mg) with no change in pain scores or discharge timing. CONCLUSIONS: INC combined with bupivacaine intercostal nerve blocks and a pre- and post-hospital analgesia protocol facilitated discharge one day after the Nuss procedure, achieved excellent pain control, and eliminated the need for intravenous opioids.

Congenital breast deformities: Anatomical basis and surgical approaches for optimal aesthetic outcomes.

Plastic surgeons routinely encounter patients desiring correction of breast asymmetry, hypoplastic growth, or other aesthetic concerns. An appropriate recognition of congenital breast conditions is critical for plastic surgeons. Without consideration of underlying anatomical abnormalities in these patients, surgical intervention may not result in optimal aesthetic outcomes. Often, patients are unaware of their congenital condition and the limitations and difficulties associated with reconstruction must be discussed with the patient preoperatively to ensure optimal aesthetic outcomes. The goal of this article was to summarize the anatomical basis for common congenital breast conditions and discuss options for surgical correction based on the literature and our experience.

Pediatric Colorectal Surgery: A Collaborative Approach From a Single Institution.

BACKGROUND: Inflammatory bowel disease encompasses relapsing gastrointestinal disorders commonly presenting in pediatric patients, with 25% of diagnoses made before age 20 and 4% before age 5. Considering the need for life-long surgical follow-up, a collaborative system involving both pediatric and colorectal surgeons could improve overall patient experiences. We hypothesized that cases performed in collaboration with both pediatric and adult colorectal surgeons may lead to better outcomes. METHODS: Data were gathered retrospectively for 116 patients 18 y old or younger who underwent colorectal resections for inflammatory bowel disease between 2010 and 2017 at our institution. Data included patient demographics, type of procedure, surgical approach, specimen extraction site, surgeon involvement (pediatric, colorectal, or collaborative), operative time, and estimated blood loss. We analyzed days until passage of flatus and bowel movement, length of stay, type of surgical procedure, and surgical complications. RESULTS: Our data showed that days until flatus (2.27 ± 0.47, P = 0.049), first bowel movement (2.64 ± 0.67, P = 0.006), and length of stay (4.45 ± 1.51, P = 0.006) were the shortest in the collaborative group. We also found that single-incision laparoscopic surgery was significantly more common in the collaborative group (77.8%, P = 0.002). We did not see a difference in surgical complication rates among any of the groups. CONCLUSIONS: Our study showed short-term beneficial outcomes in a single institution associated with the collaboration of pediatric surgeons and colorectal surgeons on pediatric colorectal cases in comparison to those performed by pediatric surgeons or adult colorectal surgeons alone.

Oesophageal pseudodiverticulum after foregut duplication cyst excision: Case report and literature review.

Oesophageal pseudodiverticula rarely occur after excision of benign oesophageal neoplasms. While management and outcomes have been reported in the adult leiomyoma literature, sparse data exist on the occurrence and management of pseudodiverticula after foregut duplication cyst excision. We discuss our experience with a paediatric patient and review relevant literature regarding operative techniques and surgical outcomes.

A prospective, multi-institutional study of pediatric all-terrain vehicle crashes.

BACKGROUND: Pediatric all-terrain vehicle (ATV) injuries have been increasing annually for more than a decade. The purpose of this study was to prospectively evaluate crash circumstances and clinical outcomes resulting from pediatric ATV crashes. METHODS: Three pediatric trauma centers prospectively collected data from patients during their hospitalization for injuries sustained in ATV crashes from July 2007 through June 2012. Patients completed a 35-item questionnaire describing the crash circumstances (ATV engine size, safety equipment use, and training/experience). Clinical data (injuries, surgical procedures, etc.) were collected for each patient. RESULTS: Eighty-four patients were enrolled, with a mean (SD) age of 13.0 (3.1) years, and were predominantly male (n = 55, 65%). Injuries were musculoskeletal (42%), central nervous system (39%), abdominal (20%), thoracic (16%), and genitourinary (4%). Multisystem injuries were prevalent (27%), and two patients died. Thirty-three patients (43%) required operative intervention. Most children were riding for recreation (96%) and ignored ATV manufacturers' recommendation that children younger than 16 years ride ATVs with smaller (≤90 cc) engines (71%). Dangerous riding practices were widespread: no helmet (70%), no adult supervision (56%), double riding (50%), riding on paved roads (23%), and nighttime riding (16%). Lack of helmet use was significantly associated with head injury (53% vs. 25%, p = 0.03). Rollover crashes were most common (44%), followed by collision with a stationary object (25%) or another vehicle (12%). Half (51%) of children said that they would ride an ATV again. CONCLUSION: These data demonstrate a relationship between dangerous ATV riding behaviors and severe injuries in children who crash. Children younger than 16 years should not operate ATVs, and legislation that effectively restricts ATV use in children is urgently needed. LEVEL OF EVIDENCE: Epidemiologic study, level III.

Pyloric exclusion for treatment of complicated duodenal atresia.

Duodenal atresia (DA) is a well-described congenital anomaly that usually responds well to surgical correction. Associated defects are common, and these confounding variables often influence outcome. The authors present a case of a newborn female with an unusual constellation of problems including DA with annular pancreas, trisomy 21, and coarctation of the aorta. She developed protracted complications postoperatively and was treated with an innovative surgical strategy.

A multicenter prospective analysis of pediatric trauma activation criteria routinely used in addition to the six criteria of the American College of Surgeons.

BACKGROUND: The American College of Surgeons has defined six minimum activation criteria (ACS-6) for the highest level of trauma activations at trauma centers. The verification criteria also allow for the inclusion of additional criteria at the institution's discretion. The purpose of this prospective multicenter study was to evaluate the ACS-6 as well as commonly used activation criteria to evaluate overtriage and undertriage rates for pediatric trauma team activation. METHODS: Data were prospectively collected at nine pediatric trauma centers to examine 29 commonly used activation criteria. Patients meeting any of these criteria were evaluated for the use of high-level trauma resuscitation resources according to an expert consensus list. Patients requiring a resource but not meeting any activation criteria were included to evaluate undertriage rates. RESULTS: During the 1-year study, a total of 656 patients were enrolled with a mean age of 8 years, a median Injury Severity Score of 14, and mortality of 11%. Using all criteria, 55% of patients would have been overtriaged and 9% would have been undertriaged. If only the ACS-6 were used, 24% of patients would have been overtriaged and 16% would have been undertriaged. Among activation criteria with more than 10 patients, those most predictive of using a high-level resource were a gunshot wound to the abdomen (92%), blood given before arrival (83%), traumatic arrest (83%), tachycardia/poor perfusion (83%), and age-appropriate hypotension (77%). The addition of tachycardia/poor perfusion and pretrauma center resuscitation with greater than 40 mL/kg results in eight criteria with an overtriage of 39% and an undertriage of 10.5%. CONCLUSION: The ACS-6 provides a reliable overtriage or undertriage rate for pediatric patients. The inclusion of two additional criteria can further improve these rates while maintianing a simplified triage list for children.

Goods for Guns--the use of a gun buyback as an injury prevention/community education tool.

BACKGROUND: US children aged between 5 years and 14 years have a rate of gun-related homicide 17 times higher and a rate of gun-related suicide and unintentional firearm injury 10 times higher than other developed countries. Gun buyback programs have been criticized as ineffective interventions in decreasing violence. The Injury Free Coalition for Kids-Worcester (IFCK-W) Goods for Guns buyback is a multipronged approach to address these concerns and to reduce the number of firearms in the community. METHODS: The IFCK-W buyback program is funded by corporate sponsors, grants, and individual donations. Citizens are instructed to transport guns, ammunition, and weapons safely to police headquarters on two Saturdays in December. Participants are guaranteed anonymity by the District Attorney's office and receive gift certificates for operable guns. Trained volunteers administer an anonymous survey to willing participants. Individuals who disclose having unsafely stored guns remaining at home receive educational counseling and trigger locks. Guns and ammunition are destroyed at a later time in a gun crushing ceremony. RESULTS: Since 2002, 1,861 guns (444 rifle/shotgun, 738 pistol/revolver, and 679 automatic/semiautomatic) have been collected at a cost of $99,250 (average, $53/gun). Seven hundred ten people have surrendered firearms, 534 surveys have been administered, and ≈ 75 trigger locks have been distributed per year. CONCLUSIONS: IFCK-W Goods for Guns is a relatively inexpensive injury prevention model program that removes unwanted firearms from homes, raises community awareness about gun safety, and provides high-risk individuals with trigger locks and educational counseling.

Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children.

BACKGROUND/PURPOSE: Although ultrasound is often the preferred pediatric imaging study, many institutions lack ultrasound access at night; and computerized tomography (CT) becomes the only radiological method available for evaluation of appendicitis in children. The purpose of this study was to characterize patterns of daytime and nighttime use of ultrasound or CT for evaluation of pediatric appendicitis and to measure consequent differences in radiation exposure and cost. METHODS: A retrospective chart review of patients evaluated for appendicitis from October 2004 to October 2009 (N = 535) was performed to evaluate daytime and nighttime use of ultrasound and CT for pediatric patients. RESULTS: Average age was 10.2 years (range, 3-17 years). During the day, 6 times as many ultrasounds were performed as CTs (230 vs 35). At night, half as many ultrasounds were performed (50 vs 110). Average radiation dose per child during the day was significantly lower than at night (day, 0.52 mSv per patient; night, 2.75 mSv per patient). Average radiology costs were lower for daytime patients ($2491.06 day vs $4045.00 night; P < .05). CONCLUSIONS: Dependence on CT at night results in higher average radiation exposure and cost. Twenty-four-hour ultrasound availability would decrease radiation exposure and cost of evaluation of children presenting with appendicitis.

Injury prevention and the national agenda-can we make america injury free?

The development of pediatric surgery as a specialty has its roots in disaster medicine. In recent years, the medical community and population at large have begun to acknowledge injury prevention as a public health priority. Domestic terrorist attacks and natural catastrophes over the last decade have highlighted the need for disaster preparedness. Recognition of the unique problems that the pediatric-age population can encounter in a natural or manmade disaster situation has exposed a new facet of injury prevention. Recounting the history of pediatric trauma care and identifying current efforts for injury prevention are essential toward achieving an injury-free America.

Early evaluation and resuscitation of the pediatric trauma patient.

Trauma is the leading case of death for children in the United States. Effective initial resuscitation of pediatric trauma patients can reduce mortality. Guidelines have been developed to facilitate patient care in a systematic and productive manner. Advances have been made in both diagnostic and therapeutic methods. The evaluation and treatment of trauma patients will continue to engage pediatric surgeons as efforts in trauma prevention become more successful.

Differential expression of bladder neurotrophic factor mRNA in male and female rats after bladder outflow obstruction.

PURPOSE: We validated a male rat model of bladder outflow obstruction and compared the expression of bladder neurotrophic factor mRNA in male and female rats 6 weeks after bladder outlet obstruction. MATERIALS AND METHODS: We examined the proximal urethra in male Wistar rats. Urethral lumen reducing ligatures were placed in 15 females and 19 males, while 10 male and 10 female controls underwent sham surgery. Awake cystometry was performed 6 weeks after surgery. Ribonuclease protection assay was used to measure changes in bladder neurotrophic factor mRNA expression in the 2 sexes. RESULTS: Average bladder capacity in rats with bladder outlet obstruction increased 3-fold in males and 4.4-fold in females compared with controls, while bladder weight increased 2.2 and 4.3-fold, respectively. Filling and threshold pressure increased significantly and nonvoiding bladder contractions were recorded in 100% of female and 80% of male rats with bladder outlet obstruction. An 8-fold increase in bladder brain derived neurotrophic factor mRNA was noted in each sex after obstruction. A 2-fold increase in bladder nerve growth factor mRNA after obstruction was only observed in females. CONCLUSIONS: This male rat model of bladder outlet obstruction was created by placing lumen reducing ligatures at the urethrovesical junction. The dramatic increase in bladder brain derived neurotrophic factor mRNA expression and differential expression of nerve growth factor mRNA in male and female rats with bladder outlet obstruction suggest that additional neurotrophic factors may contribute to the lower urinary tract neuroplasticity associated with bladder outlet obstruction and this contribution may be gender dependent.