Silver-impregnated hydrofiber dressing followed by delayed surgical closure for management of infants born with giant omphaloceles.

OBJECTIVE: We successfully employed silver-impregnated hydrofiber dressing for management of giant omphaloceles (GO) followed by delayed surgical closure. STUDY DESIGN: Between 2005 and 2008, eight consecutive GO infants were cared for at Driscoll Children's Hospital. Four patients had additional congenital anomalies including Beckwith-Wiedemann (n = 1), tetralogy of Fallot (n = 1), pulmonary hypoplasia (n = 1), and ruptured omphalocele (n=1). Infants underwent amnion epithelization using a silver-impregnated hydrofiber dressing over the course of several months followed by delayed surgical closure. Mean ± SD of parameters including maternal age, gestational age, infant weight, size of GO, preoperative intubation, preoperative hospitalization, time to epithelization, days to surgical closure, postoperative hospitalization, postoperative intubation and months of follow-up were studied. RESULTS: Five patients underwent successful closure, 2 were lost to follow-up and 1 was lost because of withdrawal of support. The maternal age, gestation age and weight of infant were 28 ± 5.3 years, 34 ± 4 weeks and 2.5 ± 0.62 kg, respectively. The GO size was 11 cm in length and 11 cm in width, respectively. Preoperative hospitalization days were 78 ± 74 days. Preoperative intubation was 3.5 ± 3.1 days with 2 neonates requiring tracheostomy and home ventilation owing to additional congenital abnormalities. Time to epithelization was 2.9 ± 0.9 months. Days to surgical closure and postoperative hospitalization were 331 ± 119 days and 5 ± 3.4 days, respectively. Average follow-up was 37 ± 27 months. No treatment associated morbidities are noted. CONCLUSIONS: Silver-impregnated hydrofiber mediated epithelization of GO followed by delayed surgical closure is safe for management of infants.

Revision of circumcision in children: Report of 56 cases.

BACKGROUND/PURPOSE: Circumcision is the most commonly performed surgical procedure in the United States today. Despite the large number of specialists who perform this procedure, only occasionally are the results unsatisfactory. The purpose of this study is to review the indications for circumcision revision, attempt to identify the specialists who are performing unsatisfactory circumcisions, describe the authors' surgical technique for circumcision revision, and review current coding and billing issues related to this procedure. METHODS: The authors reviewed the charts of 56 consecutive children who underwent circumcision revision over a 4-year period (1995 to 1999). They also reviewed their current coding and billing practices for this procedure. RESULTS: Children undergoing revision of circumcision ranged in age from 6 weeks to 11 years with a mean of 26.7 months. Redundant foreskin was the most common indication for circumcision revision. In 38 patients (68%) the authors were able to identify the specialist who performed the procedure. Pediatricians were most commonly identified (n = 26), followed by residents in training (n = 10) family physician (1), and nurse midwife (1). The authors were unable to identify the type of neonatal circumcision originally performed. Their surgical procedure was the conventional sleeve technique without variation in 55 cases. A gomco clamp was utilized in one patient under local anesthesia and resulted in significant difficulty in the performance of the revision. All patients had a satisfactory cosmetic outcome. There was one complication in a child who required a return to the operating room for postoperative bleeding and hematoma. In review of the authors coding practices they found that there was an appropriate diagnosis code available for redundant foreskin but a specific procedure code was lacking before 2002. The authors also found that midwives perform circumcisions throughout the United States. CONCLUSIONS: Considering the number of neonatal circumcisions performed in the United States, revision of circumcision uncommonly is required. The most common indication for circumcision revision is redundant foreskin. Although pediatricians were most commonly implicated in this study as the source of unsatisfactory circumcisions, that finding probably is more a reflection of local practices and referral patterns. Our recommended surgical procedure, the conventional sleeve technique, is familiar to pediatric surgeons, produces a satisfactory cosmetic result, and is easy to teach to residents and fellows. The authors do not recommend the use of a gomco clamp for circumcision revision. The authors do not feel that a circumcision revision should be delayed expecting that the child will grow into the redundant foreskin. Appropriate diagnosis codes have been available, but a new and more specific procedure code has just been introduced in 2002.