Barbara A. Gaines

Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial

BACKGROUND A laparoscopic approach to pyloromyotomy for infantile pyloric stenosis has gained popularity but its effectiveness remains unproven. We aimed to compare outcomes after open or laparoscopic pyloromyotomy for the treatment of pyloric stenosis. METHODS We did a multicentre international, double-blind, randomised, controlled trial between June, 2004, and May, 2007, across six tertiary paediatric surgical centres. 180 infants were randomly assigned to open (n=93) or laparoscopic pyloromyotomy (n=87) with minimisation for age, weight, gestational age at birth, bicarbonate at initial presentation, feeding type, preoperative duration of symptoms, and trial centre. Infants with a diagnosis of pyloric stenosis were eligible. Primary outcomes were time to achieve full enteral feed and duration of postoperative recovery. We aimed to recruit 200 infants (100 per group); however, the data monitoring and ethics committee recommended halting the trial before full recruitment because of significant treatment benefit in one group at interim analysis. Participants, parents, and nursing staff were unaware of treatment. Data were analysed on an intention-to-treat basis with regression analysis. The trial is registered with ClinicalTrials.gov, number NCT00144924. FINDINGS Time to achieve full enteral feeding in the open pyloromyotomy group was (median [IQR]) 23.9 h (16.0-41.0) versus 18.5 h (12.3-24.0; p=0.002) in the laparoscopic group; postoperative length of stay was 43.8 h (25.3-55.6) versus 33.6 h (22.9-48.1; p=0.027). Postoperative vomiting, and intra-operative and postoperative complications were similar between the two groups. INTERPRETATION Both open and laparoscopic pyloromyotomy are safe procedures for the management of pyloric stenosis. However, laparoscopy has advantages over open pyloromyotomy, and we recommend its use in centres with suitable laparoscopic experience.

Abdominal and pelvic trauma in children.

Trauma is the leading cause of death and disability in children. More than 90% of pediatric trauma admissions are the result of a blunt mechanism. Although injury to the abdomen and pelvis account for only 10% of injuries sustained by victims of pediatric trauma, they can be potentially life threatening. Optimal evaluation of the injured child may require the use of multiple diagnostic modalities. The spleen is the most frequently injured intra-abdominal organ, followed by the liver, intestine, and pancreas. Fortunately, the majority of injuries to the spleen and liver can be treated nonoperatively. Conversely, injuries involving the intestine and pancreas often require operative intervention.

Contrast extravasation predicts the need for operative intervention in children with blunt splenic trauma.

BACKGROUND Although the presence of a contrast blush (CB) on computed tomographic (CT) scan is associated with an increased failure rate of nonoperative management in adults with blunt splenic injury, little information is available for the pediatric population, where nonoperative management is the standard of care. Our aim was to determine whether the finding of CB on CT scan could predict failure of nonoperative therapy in children with blunt splenic injury. METHODS A retrospective analysis of 343 patients admitted with blunt splenic injury to our Level I pediatric trauma center over a 7-year period was performed. All CT scans were reviewed by a radiologist who was blinded to the patient outcome. We excluded 127 patients who either underwent immediate laparotomy without a CT scan or whose CT scans were unavailable at the time of this review. We divided the patients into two groups on the basis of the presence or absence of CB on the updated reading of the CT scan. Demographic variables analyzed included age, sex, mechanism of injury, Injury Severity Score, Glasgow Coma Scale score, initial hemoglobin and hematocrit, and emergency department pulse rate and systolic blood pressure. Outcome measures compared include length of stay, length of intensive care unit stay, the need for splenic intervention, and mortality. Continuous variables were compared using Students t test for normally distributed data and the Mann-Whitney test for skewed data. Categorical data were compared using chi2 analysis or Fishers exact test. Statistical significance was assigned to values of p < 0.05. RESULTS Among the study population (N = 216), 27 patients (12.5%) had CB on CT scan. Patients with CB had significantly lower hematocrit (p = 0.0004) and required operative intervention more frequently than those without CB (22% vs. 4%;p = 0.0008). Among patients with CB, mean pulse rate at presentation was higher in those that required splenic intervention (SI) (129 +/- 20.1) compared with those who underwent successful nonoperative therapy (100.4 +/- 23.1; p = 0.01). Only grade V injuries correlated with the need for laparotomy. CONCLUSION Children with blunt splenic injury who have CB on CT scan are more likely to require SI than those without CB. However, because the majority of patients with CB did not require SI, in the absence of hemodynamic instability, this finding may be insufficient to determine the need for SI. CB is a specific marker of active bleeding that may predict the need for early splenic intervention in a specific subset of patients at presentation.

Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the american association for the surgery of trauma

BACKGROUND Cervical spine clearance in the very young child is challenging. Radiographic imaging to diagnose cervical spine injuries (CSI) even in the absence of clinical findings is common, raising concerns about radiation exposure and imaging-related complications. We examined whether simple clinical criteria can be used to safely rule out CSI in patients younger than 3 years. METHODS The trauma registries from 22 level I or II trauma centers were reviewed for the 10-year period (January 1995 to January 2005). Blunt trauma patients younger than 3 years were identified. The measured outcome was CSI. Independent predictors of CSI were identified by univariate and multivariate analysis. A weighted score was calculated by assigning 1, 2, or 3 points to each independent predictor according to its magnitude of effect. The score was established on two thirds of the population and validated using the remaining one third. RESULTS Of 12,537 patients younger than 3 years, CSI was identified in 83 patients (0.66%), eight had spinal cord injury. Four independent predictors of CSI were identified: Glasgow Coma Score <14, GCSEYE = 1, motor vehicle crash, and age 2 years or older. A score of <2 had a negative predictive value of 99.93% in ruling out CSI. A total of 8,707 patients (69.5% of all patients) had a score of <2 and were eligible for cervical spine clearance without imaging. There were no missed CSI in this study. CONCLUSIONS CSI in patients younger than 3 years is uncommon. Four simple clinical predictors can be used in conjunction to the physical examination to substantially reduce the use of radiographic imaging in this patient population.

All-terrain vehicle rules and regulations: impact on pediatric mortality

BACKGROUND/PURPOSE All-terrain vehicles (ATV) use by children leads to severe injury and death. Since the US Consumer Product Safety Commission consent decree expired in 1998, there has been little movement in regulating ATV use for children (<16 yr). The authors hypothesized that states with laws and regulations restricting pediatric ATV use may abrogate excess death compared with states without such restrictions. METHODS Pediatric mortality data reported to the consumer product safety commission from 1982 to 1998 were analyzed as well as state all-terrain vehicle requirements compiled by the Specialty Vehicle Institute of America in August 2001. The authors calculated ATV mortality rate by dividing ATV mortality frequency by 1980-2000 pediatric census results. They compared the top 26 states with the highest ATV mortality rates (TOP) with those of all other states (OTH) in terms of age, ATV type, ATV occupancy, and ATV laws. Chi-square analysis was performed. RESULTS There were 1,342 ATV pediatric deaths during the 16-year period. The TOP states averaged approximately a 2-fold increase in adjusted ATV mortality rate compared with the national ATV pediatric mortality rate. Ninety-two percent of TOP states have no licensing laws compared with 73% of the OTH states (P <.07). There is no difference between groups with regard to minimum age requirements and safety certification. CONCLUSIONS Current legal and regulatory standards have low probability of decreasing ATV-related pediatric mortality. States should adopt laws that restrict the use of ATVs for children less than 16 years of age and potentially prevent excess ATV-related pediatric mortality.

Monotherapy versus Multi-Drug Therapy for the Treatment of Perforated Appendicitis in Children

BACKGROUND Children with perforated appendicitis often have a prolonged hospital course complicated by surgical site or intra-abdominal infections. Treatment with multiple intravenous (IV) antibiotics after appendectomy has been the standard of care for these patients. We have recently adopted a protocol using piperacillin-tazobactam (PT) as a single agent in lieu of the standard multi-drug regimen (MD). We hypothesized that PT would be as effective as MD in reducing postoperative complications and would result in decreased resource utilization. METHODS We reviewed the medical records of all children admitted to our hospital between January 1, 1998 and December 31, 2001 with the diagnosis of perforated appendicitis. Patients who underwent operation within the first 24 h of admission were divided into two groups based on their antibiotic regimen: PT versus MD. Demographic data, duration of presenting symptoms, initial WBC, length of stay, and infectious complications were abstracted. Categorical data were compared using Chi square analysis; continuous variables were compared using Students t-test when the data were normally distributed and the Mann-Whitney U test when the data were skewed. RESULTS There was no difference between the PT (n = 51) and MD (n = 43) groups with respect to age, duration of presenting symptoms, initial WBC, or length of hospital stay. However, patients in the MD group had a significantly higher overall complication rate than those in the PT group (14/43 vs. 4/51, p = 0.002). Antibiotic-related complications including surgical site infections, venous catheter-related infections, intra-abdominal abscesses, and drug reactions were also higher in the MD group (10/43 vs. 4/51, p = 0.04). The outpatient charges for each patient based on an average of seven days of home antibiotics were

Pediatric Peripheral Vascular Injuries: A Review of Our Experience

2,460 for the PT group and

The Influence of Down's Syndrome on the Management and Outcome of Children With Hirschsprung's Disease

4,349 for the MD group. CONCLUSIONS Children with perforated appendicitis can be managed effectively with a single broad-spectrum antibiotic after appendectomy. Monotherapy is not only more efficacious than multi-drug therapy, but may be more cost effective. The use of monotherapy for children with perforated appendicitis after adequate source control should be considered the treatment of choice.

Variation in DVT prophylaxis for adolescent trauma patients: a survey of the Society of Trauma Nurses.

BACKGROUND This study evaluated peripheral vascular injuries in a pediatric trauma population to identify injury patterns, to identify diagnostic and therapeutic modalities used, and to understand the role of pediatric surgical subspecialists. METHODS A retrospective review of children treated for trauma between 2000 and 2006 at a Level I Pediatric Trauma Center was performed. Patients with vascular injury were identified through an institutional trauma registry. RESULTS There were 42 vascular injuries identified during the study period. The average age was 9.8 years, with 64% occurring in males. The mechanism of injury was almost equally distributed between penetrating (55%) and blunt (45%) trauma. Forty-eight percent of patients had an associated fracture. Seventeen diagnostic angiograms were performed. Ninety-eight percent of patients were taken to the operating room for definitive management of one or more of their trauma injuries. Sixty-seven percent underwent operative management specifically for their vascular injury. Twenty-six percent of patients were diagnosed with vasospasm, and all were conservatively managed. Of the 42 patients, 23% were managed by pediatric surgeons, 43% by extremity specialists (orthopedic or plastic surgeons), and 29% by adult vascular surgeons. CONCLUSIONS Pediatric traumatic vascular injuries are associated with a higher rate of penetrating trauma than other pediatric trauma and have a relatively high rate of operative intervention. Diagnosis and treatment of pediatric vascular injuries can be made difficult by a high rate of vasospasm. Additionally, traumatic vascular injuries in the pediatric population present a unique challenge in the overlap of their management by many different surgical subspecialists.

Presence of pneumomediastinum after blunt trauma in children: what does it really mean?

BACKGROUND Children with Downs syndrome (DS) have a reportedly poorer outcome after treatment of Hirschsprungs disease (HD) compared with control children. Because of overall improvements in their management, the authors hypothesized that the diagnosis of DS would not influence outcome after the management of HD. METHODS Consecutive children with HD (1995 through 2002) were collected prospectively then divided retrospectively into those with DS and controls (C). Patients who underwent surgery at another institution and those with total colonic aganglionosis were excluded. RESULTS Of 66 patients, 9 had DS. Mean age at diagnosis, gender, racial distribution, gestational age, and proximity to our center were similar between groups. Presenting symptoms, location of the transition zone, and type of initial operation were similar. Patients with DS had significantly more comorbidities than controls, which generated significantly greater treatment costs and a higher mortality rate. However, with an average of 22 months of follow-up, the overall outcome including postoperative complications, enterocolitis, and constipation was similar. CONCLUSIONS These data suggest that in contrast to earlier reports, DS has minimal influence on surgical outcome of patients with HD. Although the overall cost of treating patients with DS is greater, this mainly reflects the impact of managing comorbidities.