The learning curve associated with pediatric laparoscopic splenectomy.

BACKGROUND: Laparoscopic splenectomy (LS) is technically difficult compared with open splenectomy. This report examines our experience with LS to define the learning curve. METHODS: The first 49 consecutive laparoscopic splenectomies were reviewed. Indications, complications, operative time, and costs were recorded. RESULTS: Indications included hereditary spherocytosis, immune thrombocytopenia purpura, beta-thalassemia, lymphoma, splenic cysts, and abscesses. Surgical time averaged 196 minutes for the first 10 patients, decreasing to 105 minutes for the last 10. Blood loss for the first 10 patients averaged 50 cc and less than 5 cc for the last 10. There were 3 complications and 1 conversion to open operation. Operative and hospital charges averaged $6,670 and $13,402, respectively, for the first 10 cases compared with $5,278 and $10,863 for the last 10. CONCLUSIONS: LS can be performed safely with few complications. LS has a steep learning curve in the first 20 patients after which operative times decrease along with overall costs.

Routine intraoperative cholangiography during laparoscopic cholecystectomy minimizes unnecessary endoscopic retrograde cholangiopancreatography in children.

PURPOSE: The aim of this study was to determine the necessity for intraoperative cholangiography (IOC) during pediatric laparoscopic cholecystectomy (LC). METHODS: A retrospective review of 100 consecutive patients undergoing LC was conducted. RESULTS: Ninety-eight children underwent successful LC. The average age was 11.3 years. IOC was successful in 55 of 63 studies. Operating time for patients with IOC averaged 91 minutes, and without IOC, 67 minutes. Twenty children had preoperative ultrasound, laboratory, or clinical evidence of common bile duct (CBD) stones. Fifteen of these 20 children actually had CBD stones. Three additional children who lacked any ultrasound, clinical, or laboratory evidence of choledocholithiasis had unsuspected CBD stones. Eight children, therefore, had ultrasound, clinical, or laboratory findings not predictive of the actual state of the CBD. Sixteen children underwent endoscopic retrograde cholangiopancreatography (ERCP), 9 preoperatively and 7 postoperatively. Four preoperative ERCP studies showed no CBD stones. There were no complications from performing IOC. CONCLUSIONS: (1) CBD stones are common in children with gallstones, (18 of 100 patients). (2) Preoperative studies and clinical findings may not predict accurately the presence or absence of CBD stones. (3) IOC should be routinely performed in children before the use of ERCP to avoid unnecessary ERCP unless CBD stones are specifically visualized by ultrasound scan. J Pediatr Surg 36:881-884.

Intussusception: hospital size and risk of surgery.

OBJECTIVE: To determine whether the risk of operative management of children with intussusception varies by hospital pediatric caseload. DESIGN: A cohort of all children with intussusception in Washington State from 1987 through 1996. SETTING: All hospitals in Washington State. METHODS: Five hundred seventy children with a hospital discharge diagnosis of intussusception were identified. Sixty-two were excluded because of missing data. Procedure codes for operative management and radiologic management were also identified. RESULTS: Fifty-three percent of the children had operative reduction and 20% had resection of bowel. Children with operative reduction did not differ from those with nonoperative care by median age or gender; however, children with operative care were significantly more likely to receive care in hospitals with smaller pediatric caseloads and to have a coexisting condition associated with intussusception. Sixty-four percent of children who received care in a large children's hospital had nonoperative reduction, compared with 36% of children who received care in hospitals with 0 to 3000 annual pediatric admissions and 24% of children who had care in hospitals with 3000 to 10 000 annual pediatric admissions. Median length of stay and charges were significantly less in the large children's hospital, compared with other centers. CONCLUSIONS: Children who received care for intussusception in a large children's hospital had decreased risk of operative care, shorter length of stay, and lower hospital charges compared with children who received care in hospitals with smaller pediatric caseloads.

Deep soft tissue infections in the neutropenic pediatric oncology patient.

PURPOSE: Necrotizing fasciitis and myonecrosis can be rapidly fatal without prompt and aggressive medical and surgical therapy. We reviewed our experience with necrotizing fasciitis and myonecrosis in neutropenic pediatric oncology patients to describe associated clinical characteristics and outline therapeutic interventions. PATIENTS AND METHODS: A retrospective chart review was performed for all cases of deep soft tissue infection found in neutropenic pediatric oncology patients during an 11-year period. RESULTS: Seven cases of necrotizing fasciitis and/or myonecrosis associated with chemotherapy-induced neutropenia were diagnosed during the study period. Deep soft tissue infection was diagnosed a median of 14 days after the initiation of chemotherapy. All of the patients presented with fever and pain, generally out of proportion to associated physical findings. Most patients (86%) also had tachycardia and subtle induration at the site of soft tissue infection. The pathogenic organism in four of seven patients originated in the gastrointestinal tract. Patients were treated with antibiotics, surgical debridements, granulocyte colony-stimulating factor, and hyperbaric oxygen. Granulocyte transfusions were administered if there were no signs of neutrophil recovery. Five patients survived their deep soft tissue infection. CONCLUSIONS: The diagnosis of necrotizing fasciitis and/or myonecrosis should be considered in any neutropenic patient with fever, tachycardia, and localized pain out of proportion to the physical findings. Appropriate therapy includes broad-spectrum intravenous antibiotics and urgent surgical intervention. Granulocyte colony-stimulating factor should be administered to all patients to enhance neutrophil recovery. Granulocyte transfusions should be considered if a prolonged period of neutropenia is anticipated.

Transplantation of adult living donor kidneys into infants and small children.

HYPOTHESIS: We hypothesized that improved outcomes following renal transplantation in high-risk infants and small children primarily are due to advances in immunosuppression and accurate diagnosis of rejection. Optimizing renal allograft perfusion is critical to achieving good early graft function and decreasing early graft loss. DESIGN: Twenty-eight consecutive recipients (weighing <20 kg) of adult living donor kidneys transplanted at our center from 1984 to 1999 were reviewed. Two groups were identified based on differing immunosuppression protocols and clinical surveillance. Actuarial graft and patient survival reported at 1, 3, and 5 years were compared for group 1 (1984-1991) and group 2 (1992-1999). Graft losses, categorized as immunologic or nonimmunologic, and the incidences of delayed graft function, vascular thrombosis, and rejection were compared. RESULTS: Graft and patient survival in group 1 (n = 13) at 1, 3, and 5 years was 77% and 92%, 54% and 85%, and 54% and 85%, respectively. In group 2, all 15 patients are alive with functioning grafts to date. Immunologic graft loss occurred in 5 of 13 patients in group 1 who developed chronic rejection. Nonimmunologic causes (vascular thrombosis [2 patients]) and patient death [1]) resulted in early graft failure within 2 weeks in 3 of 13 patients in group 1. The overall incidences of delayed graft function (10.7%) and thrombosis (7.1%) were low and did not differ between groups. Percutaneous renal biopsy was used more frequently in group 2 to evaluate graft dysfunction and guide treatment. CONCLUSIONS: We conclude that improved overall graft and patient survival in group 2 is owing to advances in immunosuppression and better treatment of rejection. Percutaneous renal biopsy allows prompt and accurate histological diagnosis of graft dysfunction. Surgical technique and aggressive fluid management aimed at maximizing renal allograft perfusion is critical in optimizing early graft function and decreasing vascular complications.

Acute appendicitis risks of complications: age and Medicaid insurance.

OBJECTIVES: To describe the epidemiology of acute appendicitis in children from Washington State, and to determine important risk factors for complications. DESIGN: Retrospective cohort study. SETTING: All children (<17 years old) treated in Washington State who were identified by hospital discharge diagnosis codes from 1987 through 1996. METHODS: The hospital discharge data were reviewed for all children with a primary diagnosis code for acute appendicitis. Complicated disease was defined as perforation or abscess formation. RESULTS: Young children (0-4 years old) had the lowest annual incidence of acute appendicitis, but they had a 5-fold increased risk of complicated disease (odds ratio: 4.9; 95% confidence interval: 4.0-5.9), compared with teenagers. Children with Medicaid insurance had a 1.3-fold increased risk of complicated disease, compared with children with commercial insurance (odds ratio: 1.3: 95% confidence interval: 1.2-1.4). Children with Medicaid insurance had significantly longer average length of stay (4.0+/-3.7 days) than all other payers (commercial insurance: 3.3+/-4.0 days; health maintenance organization: 3.5+/-3.1 days; and self-insured: 3.7+/-5.8 days). CONCLUSIONS: Very young children had the greatest risk of complicated disease. Children with Medicaid insurance had increased risk of complicated disease, compared with children with commercial health insurance and longer length of stay. Additional studies are needed to evaluate barriers to care for children with Medicaid insurance.

Pediatric postoperative abdominal wound dehiscence: transverse versus vertical incisions.

BACKGROUND: Fascial dehiscence is uncommon in children but can have serious consequences when it occurs. There are multiple risk factors for fascial dehiscence, including the type of incision used. Pediatric surgeons often use a supraumbilical transverse incision particularly in infants because of the access this incision provides to the entire abdomen. This article details the experience with fascial wound dehiscence at a large tertiary children's hospital and focuses on problems with the types of incision used. STUDY DESIGN: This is a retrospective review of 2,785 intraabdominal operations performed over a 5-year period at Children's Hospital and Regional Medical Center in Seattle. Risk factors for dehiscence were reviewed for each case of fascial dehiscence. Statistical analysis using chi-square was used to examine for differences in complication rates between transverse and vertical incisions. RESULTS: In this series, 2,442 children (88%) had transverse incisions and 343 (12%) had vertical incisions. Twelve children had abdominal fascial dehiscence post-operatively. Six cases involved transverse incisions and six involved vertical incisions. Five of the children suffered evisceration. One child died as a direct result of the dehiscence. There were multiple risk factors for dehiscence in 10 of the 12 children. Vertical incisions were found to be much more likely to dehisce than were transverse incisions, especially in children under 1 year of age (p < 0.001). CONCLUSIONS: Vertical incisions are more apt to dehisce than transverse incisions in children, particularly babies. We recommend the use of transverse incisions whenever possible in babies less than 1 year of age, especially when other risk factors for dehiscence are present.

Minimally invasive surgery and clinical decision-making for pediatric malignancy.

BACKGROUND: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. METHODS: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. RESULTS: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. CONCLUSION: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques.

Cholecystectomy is becoming an increasingly common operation in children.

PURPOSE: To determine the cause of a marked rise in cholecystectomy at a regional children's hospital. METHODS: Retrospective review of 185 patients undergoing cholecystectomy since 1984. The years 1984 to 1990 (group I) and 1991 to 1996 (group II) were compared. RESULTS: Cholecystectomy for gallbladder disease increased from 4.4/year (group I) to 16.3/ year (group II). Abdominal ultrasound examinations increased during this time. The ratio of children diagnosed with gallstones and then undergoing cholecystectomy also increased (P = 0.005). In group 11, 43% of children had no apparent etiology for gallstones, and more children developed complications of gallstones and evidence of choledocholithiasis. CONCLUSIONS: (1) The increased incidence of cholecystectomy is probably multifactorial. (2) Gallstone identification has increased owing to increased patient visits and more liberal use of ultrasonography in patients with abdominal pain. (3) More patients with cholelithiasis now undergo cholecystectomy perhaps because of a change in physician perception of the disease and an apparent increase in complications from gallstones.

Post-traumatic hepatic pseudoaneurysms in children.

BACKGROUND: Post-traumatic hepatic artery pseudoaneurysms are rarely seen in children. MATERIALS AND METHODS: We retrospectively reviewed the radiologic studies and medical records of three patients treated at our institution and reviewed the literature. The patients (ages 5-13 years) presented immediately to 2 months after blunt (two patients) and penetrating (one patient) trauma. The hepatic pseudoaneurysms were discovered during work-up for fever (one patient), gastrointestinal bleeding and hyperbilirubinemia (one patient), or widened mediastinum (one patient) on chest radiograph. In two patients, the diagnosis was initially suspected by computed tomography (CT) examination and confirmed by angiography. In the third patient, the diagnosis was made initially by angiography. All three pseudoaneurysms were treated with transcatheter embolization. RESULTS: All three embolizations were initially technically successful. However, there was recurrence in one case, in which embolization distal to the neck of the pseudoaneurysms was not technically possible. With conservative management, however, the residual lesion demonstrated spontaneous occlusion by ultrasound (US) at 6 months. CONCLUSION: This uncommon complication of liver trauma in children can have a delayed presentation, can be clinically unsuspected, and can follow blunt or penetrating trauma. Endovascular embolotherapy is the treatment of choice.

Needle localization for thoracoscopic resection of small pulmonary nodules in children.

BACKGROUND: Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules. METHODS: Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected. RESULTS: Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications. CONCLUSION: CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

Necrotizing fasciitis after Plastibell circumcision.

Necrotizing fasciitis is a potentially life-threatening infection of subcutaneous tissues and Scarpa's fascia that rarely affects neonates. We report the occurrence of this devastating infection in two neonates after routine Plastibell circumcision. These case reports highlight the presentation and management of this complication after a relatively routine and frequently performed operation. This report also emphasizes the differences between cellulitis and necrotizing fasciitis and suggests strategies for management.

Improved long-term outcome for patients with jejunoileal apple peel atresia.

BACKGROUND/PURPOSE: Although apple peel intestinal atresia is a rare lesion associated with significant morbidity and high mortality, the authors have seen no deaths since 1983. Similar success has rarely been reported, and there are no reports of long-term follow-up. This study examines the short-term and long-term complications and outcome for these children, critiques our evolution in care, and gives current recommendations for therapy. METHODS: A retrospective review of 12 patients over 11 years was conducted. Perinatal history and operative and perioperative management were examined and end results and complications using different management plans compared. Long-term outcome was determined through clinic follow-up. RESULTS: Mean follow-up was 5.1 years. Children had a mean 61.4 cm of total small bowel. Seven patients underwent a primary anastomosis and five had enterostomies. The proximal jejunum was tapered, plicated, resected or left intact. Eleven children required gastrostomy tubes. All children required total parenteral nutrition. Full enteral feeding was achieved in all children, but three required gastrostomy supplementation. Three patients who had enterostomies suffered bowel obstruction, two with dilated, dysmotile proximal jejunum required subsequent tapering. Eight children maintained a growth curve between the 5th and 50th percentile. None have short bowel physiology, and all have achieved acceptable bowel function. CONCLUSIONS: (1) Total parenteral nutrition is essential for initial nutritional management. (2) Use of an enterostomy leads to an increased incidence of complications. (3) The dilated proximal bowel should be resected, tapered, or plicated, and a primary anastomosis should be performed. (4) Gastrostomy tubes are necessary for initial management. (5) Early morbidity is common, though excellent long-term outcome and normal growth and development are expected.

Is pediatric laparoscopic splenectomy safe and cost-effective?

OBJECTIVE: To determine whether laparoscopic splenectomy (LS) is a safe, cost-effective alternative to open splenectomy (OS). DESIGN: Retrospective comparison and economic evaluation. SETTING: Tertiary care children's hospital. PATIENTS: Children with hematologic disease involving the spleen. INTERVENTIONS: Laparoscopic splenectomy (10 patients); OS (10 patients). MAIN OUTCOME MEASURES: Safety of LS and cost differential between LS and OS. RESULTS: Operative time was longer for LS. Discharge occurred 64 hours postoperatively for LS and 79 hours for OS (P < .03). Patients who underwent LS returned to activity 1 to 5 weeks faster than patients who underwent OS. The average (+/-SD) operative charges for LS was $7176 +/- $2064 and for OS, $1977 +/- $344 (P < .001). Total hospital charges averaged $13,033 +/- $2976 for LS and $7106 +/- $1923 for OS (P < .001). CONCLUSIONS: Laparoscopic splenectomy can be performed safely in children. In our hospital, LS is more expensive than OS. The faster return to school and normal activity warrants the continued use of this procedure despite the increased cost.

Controversies related to the medical and surgical management of hyperthyroidism in children.

The symptoms of Graves disease were first described more that 150 years ago; however, therapy remains controversial. Surgery was the only treatment available before the development of various drugs and radioiodine. Medication using thionamides has become the most commonly used therapy for Graves' disease in childhood. Historically, radioiodine has been avoided in children because of the presumed risk for carcinogenesis and genetic mutation. More recently, however, long-term follow-up studies have shown little support for these concerns and radioiodine has become more commonly employed. None of these main forms of therapy is without complication, and the decision to use one or the other is in part related to the patient, family, or clinician's perceived risk. None of the three forms of therapy is directed at the underlying immunologic problem, and until such a treatment is found, no consensus regarding the best way to manage these children is likely to be achieved. This review examines the benefits, complications, and rationale for using the three main forms of therapy for childhood hyperthyroidism owing to Graves' disease.

Surgical implications of necrotizing fasciitis in children with chickenpox.

Varicella (chickenpox) affects approximately 90,000 children each year. Although most cases resolve, some develop necrotizing soft tissue infections secondary to group A streptococcus and staphylococcus. Delay in diagnosis is common. At the time of initial presentation, the need for surgical intervention is not always clear. The authors conducted a retrospective review of 30 patients with varicella (seen from December 1993 to June 1995) for whom there was clinical concern for necrotizing soft tissue infection. Various parameters were examined, including tachycardia, band count, temperature, and clinical symptoms, to differentiate the children who required surgery from those who did not. Of the 30, 22 underwent surgery. Eighteen had necrotizing fasciitis and required debridement, and four had abscesses that were incised and drained. Eight patients had simple cellulitis and did not require operation. Group A streptococcus was the most common organism cultured. All patients were treated with appropriate antibiotics. Twenty of the 22 surgical patients had elevated band count (> or = 5%), 21 had tachycardia, and 18 were febrile at the time of presentation (> 4 days after the onset of chickenpox). Although all patients with necrotizing fasciitis had tachycardia, this sign was a less specific indicator for surgery than was increased band count. Severe pain, erythemia, and induration was the most common signs/symptoms in the surgical patients. The survival rate for these 30 patients was 100%, and there was little long-term morbidity. The authors recommend immediate surgical intervention for children with chickenpox who present more than 2 or 3 days after the onset of the viral illness with symptoms that include fever, tachycardia, and an elevated band count in association with an erythematous, indurated, painful lesion. With this sign/symptom complex, the presumptive diagnosis must be necrotizing fasciitis until proven otherwise. If the patient has suspicious symptoms or if these symptoms are associated with tachycardia or an elevated band count, the patient warrants admission, institution of intravenous fluids, nafcillin, clindamycin, and close observation over several hours. If the symptoms progress over the next few hours or if the tachycardia persists despite rehydration and antibiotics, the patient should be taken to the operating room for exploration. The authors strongly endorse such exploration despite the risk of a negative operation, because the morbidity and mortality associated with delayed surgical treatment are potentially significant. With prompt aggressive surgical and medical treatment, a good outcome can be anticipated for these patients.

Preresection chemotherapy improves survival for children with Askin tumors.

OBJECTIVE: To test whether patients with Askin tumor treated with aggressive neoadjuvant chemotherapy have a better clinical outcome. DESIGN: Retrospective case series. SETTING: Pediatric referral center. PATIENTS: All children diagnosed with malignant small-cell tumors of the chest wall (Askin tumor) and treated from 1975 to September 1987 (phase 1, n = 6) and from September 1987 to the present (phase 2, n = 9). MAIN OUTCOME MEASURES: Survival as a function of extent of disease and response to therapy as measured by tumor volume, survival, and recurrence. RESULTS: All phase 2 patients had significant reduction of tumor volume and improved survival by Kaplan-Meier estimates compared with phase 1 patients. No phase 1 patients are still alive. CONCLUSION: Patients with Askin tumor treated with aggressive preresection chemotherapy have smaller tumors to resect and improved survival.

Laparoscopic Ladd's procedure and assessment of malrotation.

Upper gastrointestinal series are frequently obtained on children with abdominal pain and vomiting. If the ligament of Treitz (LOT) is in an equivocal position and not to the left of the spine at L1 or L2 it is important to determine the position and fixation of the cecum to assess the breadth of the mesenteric pedicle. Radiographic studies may not accurately accomplish this because of the changing position of the cecum. Laparoscopy can he used to determine the position of LOT and whether the cecum is fixed in the right lower quadrant. If the patient is judged to be at risk for volvulus (i.e., a shortened mesenteric pedicle) a Ladd's procedure can be accomplished laparoscopically with good long-term results. The use of the laparoscope is not advocated when acute volvulus is suspected.