Does Presenting Facility and Race Impact Outcomes and Management of Pyloric Stenosis?

Hypertrophic Pyloric Stenosis (HPS) is a common surgical disease in infants. Traditionally, patients present with projectile emesis and severe dehydration with metabolic alkalosis. We looked to assess if patients presenting as a transfer vs directly to our facility as well as race affected patients' initial presentation and outcomes. We performed a retrospective analysis of 131 patients who presented to with a diagnosis of HPS from 2015 to 2021 assessing how transfer status and patient race affected presenting electrolyte levels and length of stay (LOS). We found no statistically significant difference in patients' presenting electrolyte levels and hospital LOS based on transfer status or patient race. We believe this reflects availability and widespread utility of ultrasound. We suggest that this could be used as a model for standardizing care to equalize outcomes in other pediatric diseases which currently show large disparities in care based on race and geographical location.

Delayed Presentation of Small Bowel Injury Following Extraperitoneal Ballistic Injury.

Lack of peritoneal violation has been a strong tenet of nonoperative management for extraperitoneal penetrating injuries. There have been reports of intraperitoneal injuries without peritoneal violation in adult trauma literature. Such reports are scarce in pediatric trauma. We report delayed presentation of a small bowel injury in a 4-year-old male following extraperitoneal ballistic injury. No peritoneal violation was noted on wound exploration allowing conservative management. Patient developed abdominal distention on postoperative day 1, and radiologic imaging showed intraperitoneal air warranting an exploratory laparotomy. Intraperitoneal injuries without peritoneal violation have been attributed to the transmission of kinetic energy through the extraperitoneal tissue. Clinical judgment, physical exam, and radiologic adjuncts are of the utmost importance in management. Given our findings, extraperitoneal penetrating injuries certainly warrant extended observation of the patient.

Traumatic Gallbladder Rupture in a Pediatric Patient Misdiagnosed as Acute Appendicitis.

We present an 8-year-old male with a history liver surgery as a neonate who presented to the emergency department with a chief complaint of abdominal pain. A computed tomography scan (CT) showed ascites with dilated loops of small bowel and the appendix was not visualized. The pediatric surgery team was consulted for possible perforated appendicitis. Patient was initially treated with conservative management. The patient became peritoneal and was taken for diagnostic laparoscopy. A laceration of the dome of his gallbladder was visualized and a cholecystectomy was performed. Traumatic gallbladder rupture is a rare entity and occurs in 2% of all blunt abdominal injuries. The diagnosis can be difficult to make due to nonspecific symptoms. While an avulsion to the gallbladder may be diagnosed on CT scan, gallbladder lacerations can be difficult to visualize on imaging. The practitioner must have a suspicion for gallbladder injury to aid in the diagnosis.

Total Obliteration and Subsequent Recanalization of Esophagus via Endoscopic Rendezvous Procedure in a Pediatric Patient.

Esophageal strictures are well-known to the pediatric gastroenterology and surgery communities. Such strictures can arise from congenital malformations, inflammatory disorders, gastro-esophageal reflux disease (GERD), or even caustic substance ingestion. Rarely, in the instances of caustic ingestion, GERD, or inflammatory disorders, total obliteration of the esophageal lumen has been described. In those instances, as well as in those with high-grade stenosis refractory to dilations, esophageal reconstruction is the procedure of choice. However, in a small subset of adults with short-segment total esophageal obliteration after radiotherapy, an endoscopic rendezvous procedure has been described. Here we present a case of a 2-year-old female with total esophageal luminal obliteration with successful recanalization using an endoscopic rendezvous procedure. This case presents a unique approach to esophageal recanalization using a minimally invasive technique, only documented in the adult literature.

Minimally Invasive Pediatric Cholecystectomy: A Comparison of Robotic and Laparoscopic Single and Multiport Techniques.

BACKGROUND: Pediatric laparoscopic cholecystectomy is the current standard of care for gallbladder pathology. Single-incision and multiport procedures, as well as robotic and minimally invasive platforms, have been described; however, there is no head-to-head assessment of these interventions in the existing literature. The purpose of our study was to directly compare the minimally invasive cholecystectomy techniques of laparoscopic multiport (LMP), laparoscopic single incision (LSI), robotic multiport (RMP), and robotic single incision (RSI). MATERIALS AND METHODS: All cholecystectomies performed by a single surgeon at a tertiary-care center from 2010 to 2014 were retrospectively reviewed. Seventy-one subjects were included as follows: 30 LMP, 20 LSI, 11 RMP, and 10 RSI. Data were collected on patient characteristics, operative technique, operative times, medications, and postoperative course and analyzed using a Kruskal-Wallis test with a significance of P < .05. RESULTS: Operative times for LMP and RSI were similar and shortest of all groups, while LSI was the most time consuming (P = .04). Pain medication use, both narcotic and non-narcotic, was not statistically different with any operation type (P = .37 and .98, respectively). Postoperative length of stay was similar across all groups except for the RSI group which was significantly shorter (P = .04). CONCLUSIONS: RSI cholecystectomy has significantly shorter postoperative length of stay compared to other minimally invasive techniques. In addition, operative times for RSI are equivalent to the current standard LMP technique.

Quality improvement and patient care checklists in intrahospital transfers involving pediatric surgery patients.

BACKGROUND: Intrahospital transfers are necessary but hazardous aspects of pediatric surgical care. Plan-Do-Study-Act processes identify risks during hospitalization and improve care systems and patient safety. METHODS: A multidisciplinary team developed a checklist that documented patient data and handoffs for all intrahospital transfers involving pediatric surgical inpatients. The checklist summarized major clinical events and provided concurrent summaries by 3-month quarters (Q) over 1 year. RESULTS: There were 903 intrahospital transfers involving 583 inpatients undergoing surgery. Total handoffs were documented in 436 (75% of 583), with greater than 1 handoff in 202 (46% of 436). Documented problems occurred in 31 transfers (3.4%), the most during Q1 (19/191; 9.9%). Incidence fell to 3.5% (9/260) in Q2, 0.4% (1/243) in Q3, and 1.0% (2/209) in Q4 (P < .001). Patient care issues (14/31; 45%) were most common, followed by documentation (10, 32%) and process problems (7, 23%). The quality improvement team was able to resolve patient instability during transport (5 in Q1, none in Q3, Q4) and poor pain control (3 in Q2, 1 in Q3, Q4). Of the patients, 3.2% had identified problems with patient care during intrahospital transfer. CONCLUSIONS: Plan-Do-Study-Act review emphasizes ongoing process analysis by multidisciplinary teams. Checklists reinforce communication and provide feedback on whether system goals are being achieved.

Outcome of splenectomy in children younger than 4 years with sickle cell disease.

PURPOSE: Removal of the spleen in patients younger than 4 years has been reported to carry an increased risk of postsplenectomy sepsis and has not been universally accepted. We reviewed our experience with splenectomy in children with acute splenic sequestration crisis (ASSC) younger than 4 years. METHODS: The study involved retrospective review of demographic and operative data, number of ASSC, operative complications, infections, and death. RESULTS: From 1993 to 2008, 53 patients (28 males, 25 females) younger than 4 years had open (43.8%) or laparoscopic (56.6%) splenectomy after one or more events of ASSC. Six (11.3%) were younger than 18 months, 28 (52.8%) were 18 to 24 months old, and 21 (39.6%) were 24 to 48 months old. Operative complications were diaphragm laceration (laparoscopy, n = 3; 5.7%) and reoperation for bleeding (open, n = 1; 1.8%). Length of stay was similar for laparoscopic (3.6 days) vs open (3.8 days) splenectomy. Mean postoperative follow-up was 5.6 years. In 353 postsplenectomy admissions, 3 (5.7%) patients had positive blood cultures requiring treatment. Three (5.7%) patients died within the 15-year study period; one (1.8%) had documented pneumococcal sepsis. DISCUSSION: The advantage of early splenectomy may outweigh the risks of long-term transfusion. Splenectomy in young children with sickle cell disease carries a low risk of postsplenectomy sepsis with appropriate vaccination and prophylactic antibiotics. We conclude that splenectomy in young children with ASSC is safe and effective, especially with penicillin prophylaxis and improved vaccination strategies.

Sphincter of Oddi dysfunction after Roux-en-Y gastric bypass.

BACKGROUND: Patients who have undergone Roux-en-Y gastric bypass for morbid obesity may develop postoperative abdominal pain disorders that require surgical evaluation. Chronic pancreatitis and pain associated with sphincter of Oddi dysfunction (SOD) is an uncommon disorder whose clinical diagnosis is problematic without sphincter of Oddi manometry. To evaluate the diagnosis and treatment of SOD in the gastric bypass population, a retrospective review and analysis of gastric bypass patients who had undergone transduodenal sphincteroplasty (TS) for SOD was undertaken. METHODS: The medical records of patients who had undergone TS after gastric bypass at the Medical University of South Carolina Digestive Disease Center from January 2002 to December 2006 were evaluated for outcomes-based data with the approval of the institutional review board for the evaluation of human subjects. Long-term patient outcomes were assessed using the Medical Outcomes Study Short Form 36-item, version 2, quality-of-life survey. RESULTS: A total of 16 women (median age 49 years) were identified who had undergone TS with biliary sphincteroplasty and pancreatic ductal septoplasty for SOD. The indications for surgery included pain (100%), nausea (31%), weight loss (13%), and recurrent pancreatitis (31%). The diagnosis of SOD was supported by magnetic resonance cholangiopancreatography with secretin stimulation. Three postoperative complications (18.8%) developed, but no mortality. The average length of hospital stay was 5 days (range 2-9). Of the 16 patients, 13 (81%) responded to the survey follow-up. The mean length of follow-up was 28 months (range 16-57). Of the 13 patients, 11 (85%) reported pain improvement after surgery. The survey's norm-based scores were similar to those of a representative population. CONCLUSION: SOD should be considered in the differential diagnosis of gastric bypass patients with pancreatobiliary pain after cholecystectomy. When the clinical history is supported by laboratory and magnetic resonance cholangiopancreatography data, TS can be undertaken with low morbidity and good patient outcomes. SOD is a notable disorder in the gastric bypass population. With appropriate patient selection, TS can be beneficial.

l-Galactose replaces l-fucose in the pectic polysaccharide rhamnogalacturonan II synthesized by the l-fucose-deficient mur1 Arabidopsis mutant.

Arabidopsis thaliana mur1 is a dwarf mutant with altered cell-wall properties, in which l-fucose is partially replaced by l-galactose in the xyloglucan and glycoproteins. We found that the mur1 mutation also affects the primary structure of the pectic polysaccharide rhamnogalacturonan II (RG-II). In mur1 RG-II a non-reducing terminal 2- O-methyl l-galactosyl residue and a 3,4-linked l-galactosyl residue replace the non-reducing terminal 2- O-methyl l-fucosyl residue and the 3,4-linked l-fucosyl residue, respectively, that are present in wild-type RG-II. Furthermore, we found that a terminal non-reducing l-galactosyl residue, rather than the previously reported d-galactosyl residue, is present on the 2- O-methyl xylose-containing side chain of RG-II in both wild type and mur1 plants. Approximately 95% of the RG-II from wild type and mur1 plants is solubilized as a high-molecular-weight (>100 kDa) complex, by treating walls with aqueous potassium phosphate. The molecular mass of RG-II in this complex was reduced to 5-10 kDa by treatment with endopolygalacturonase, providing additional evidence that RG-II is covalently linked to homogalacturonan. The results of this study provide additional information on the structure of RG-II and the role of this pectic polysaccharide in the plant cell wall.