Charles L. Snyder

Single incision versus standard 3-port laparoscopic appendectomy: a prospective randomized trial.

Background:Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series. However, to date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy. Methods:After Internal Review Board approval, patients were randomized to laparoscopic appendectomy via a single umbilical incision or standard 3-port access. The primary outcome variable was postoperative wound infection. Using a power of 0.9 and an alpha of 0.05, 180 patients were calculated for each arm. Patients with perforated appendicitis were excluded. The technique of ligation/division of the appendix and mesoappendix was left to the surgeons discretion. There were 7 participating surgeons dictated by the call schedule. All patients received the same preoperative antibiotics and postoperative management was controlled. Results:There were 360 patients were enrolled between August 2009 and November 2010. There were no differences in patient characteristics at presentation. There was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity. Operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single site approach. Also, the mean operative time was 5 minutes longer for the single site group. Conclusion:The single site umbilical laparoscopic approach to appendectomy produces longer operative times resulting in greater charges. However, these small differences are likely of marginal clinical relevance. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

Necrotizing enterocolitis in full-term infants

OBJECTIVES Although necrotizing enterocolitis (NEC) is primarily a disease of prematurity, full-term infants account for approximately 10% of cases. Previous studies have reported conflicting results regarding NEC in full-term (FT) versus preterm (PT) infants. A review of all infants diagnosed with NEC at our institution over the past 3 decades was performed to identify factors associated with this disease in full-term neonates. METHODS The charts of all infants with definitive NEC from January 1, 1972 through January 1, 2001 were reviewed. Two hundred seventy-seven patients made up the study group: 251 PT and 26 FT infants. Data regarding demographics, clinical presentation, management, outcome, and other variables were collected. FT and PT infants were compared. RESULTS Mean gestational age and birth weight in the FT group were 39.3 weeks and 3,132 g versus 30.2 weeks and 1,396 g for PT infants. Apgar scores were similar. Mean age at diagnosis was 5 days in FT versus 13 days in PT neonates (P <.001). Enteral nutrition was initiated earlier in FT infants (1.6 days v 3.1 days; P <.001), and FT infants were discharged an average of 14 days earlier than PT infants (P value not significant). Factors predisposing to NEC were found in 62% (16 of 26) of patients-heart disease in 6 infants and other conditions in 10 patients. Cardiac disease was found significantly more often (23% v 10%; P =.027) in FT infants. Survival rate was 65% (17 of 26) in the FT group versus 69% (173 of 251) in the PT infants (P value not significant). CONCLUSIONS FT infants with NEC differ from their PT counterparts in several distinct ways. FT neonates had NEC at a significantly earlier age, perhaps owing to earlier initiation of feeding. There was a correlation between age at which feeding was begun and age of onset of NEC. Additionally, an association between cardiac disease and development of NEC in term infants was shown. Predisposing factors were present in a majority of FT infants. In contrast to other reports, the outcome of NEC in full-term infants was no better than for PT infants.

Open Versus Laparoscopic Pyloromyotomy for Pyloric Stenosis: A Prospective, Randomized Trial

Background:Pyloric stenosis, the most common surgical condition of infants, is treated by longitudinal myotomy of the pylorus. Comparative studies to date between open and laparoscopic pyloromyotomy have been retrospective and report conflicting results. To scientifically compare the 2 techniques, we conducted the first large prospective, randomized trial between the 2 approaches. Methods:After obtaining IRB approval, subjects with ultrasound-proven pyloric stenosis were randomized to either open or laparoscopic pyloromyotomy. Postoperative pain management, feeding schedule, and discharge criteria were identical for both groups. Operating time, postoperative emesis, analgesia requirements, time to full feeding, length of hospitalization after operation, and complications were compared. Results:From April 2003 through March 2006, 200 patients were enrolled in the study. There were no significant differences in operating time, time to full feeding, or length of stay. There were significantly fewer number of emesis episodes and doses of analgesia given in the laparoscopic group. One mucosal perforation and one incisional hernia occurred in the open group. Late in the study, 1 patient in the laparoscopic group was converted to the open operation. A wound infection occurred in 4 of the open patients compared with 2 of the laparoscopic patients (P = 0.68). Conclusions:There is no difference in operating time or length of recovery between open and laparoscopic pyloromyotomy. However, the laparoscopic approach results in less postoperative pain and reduced postoperative emesis. In addition, there was a fewer number of complications in the laparoscopic group. Finally, patients approached laparoscopically will likely display superior cosmetic outcomes with long-term follow-up.

Outcome Analysis for Gastroschisis

BACKGROUND/PURPOSE Several factors are reportedly associated with an adverse outcome in gastroschisis, including mode of delivery, in utero diagnosis, type of closure, concurrent anomalies, intestinal atresia, and necrotizing enterocolitis (NEC). Since 1969, the authors have treated 185 patients who had gastroschisis. The authors analyzed their database to identify variables associated with increased morbidity and mortality. METHODS A retrospective study of all patients with gastroschisis treated at our institution in the last 30 years was performed. The characteristics of survivors and nonsurvivors were compared. A logistic regression analysis was performed, with survival as the dependent variable, and the following parameters as independent variables: in utero diagnosis, mode of delivery, gestational age and birth weight, era of repair, type of closure, presence of other associated anomalies, intestinal atresia, and development of necrotizing enterocolitis. Further logistic regression analysis was performed, with various indicators of morbidity as dependent variables. These included development of sepsis, bowel obstruction, and complications related to the closure or to the silo. No attempt at long-term follow-up was made. RESULTS A total of 185 infants with gastroschisis were treated at our institution from 1969 to 1999. Mean gestational age was 36.6 weeks, and the mean birth weight was 2,501 g. A total of 21 infants had intestinal atresia. NEC developed in 8 infants. Six infants had other serious anomalies. The overall survival rate was 91%. Survival improved in last 2 decades (94%). There were no differences in gestational age, birth weight and mode of delivery, method of closure, or presence of intestinal atresia between survivors and nonsurvivors. Only the era of repair (P = .002), presence of necrotizing enterocolitis (P = .044), and presence of other major anomalies (P < .001) correlated with mortality in the logistic regression analysis. Sepsis, bowel obstruction, and closure complications accounted for most of the morbidity. Analysis of these three morbidity factors identified low gestational age (P = .038) and development of necrotizing enterocolitis (P = .020) as independent predictors of sepsis. Closure complications were only associated with lower birth weight (P = .006). No predictors of bowel obstruction were identified. CONCLUSIONS Mode of delivery, method of closure, birth weight and gestational age, and the presence of intestinal atresia do not appear to correlate with survival in infants with gastroschisis. Only the presence of another major anomaly, the era of repair, and the development of necrotizing enterocolitis were associated with increased mortality. Degree of prematurity and development of enterocolitis were associated with an increased incidence of septic complications. Low birth weight was a marker for closure complications. Type of delivery (vaginal or cesarean section) had no influence on either morbidity or mortality.

Initial laparoscopic appendectomy versus initial nonoperative management and interval appendectomy for perforated appendicitis with abscess: a prospective, randomized trial

INTRODUCTION Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies. METHODS After internal review board approval (#06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess. RESULTS On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06). CONCLUSIONS Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges.

Vascular anomalies and tracheoesophageal compression: a single institution's 25-year experience.

BACKGROUND Vascular rings are uncommon anomalies in which preferred strategies for diagnosis and treatment may vary among institutions. In this report, we offer a description of our approach and a review of our 25-year experience. METHODS A retrospective review was conducted of all pediatric patients with symptomatic tracheoesophageal compression secondary to anomalies of the aortic arch and great vessels diagnosed from 1974 to 2000. RESULTS Thirty-one patients (38%) of eighty-two patients (mean age, 1.7 years), were identified with double aortic arch, 22 patients (27%) with right arch left ligamentum, and 20 patients (24%) with innominate artery compression. Our diagnostic approach emphasized barium esophagram, along with echocardiography. This regimen was found to be reliable for all cases except those with innominate artery compression for which bronchoscopy was preferred, and except those with pulmonary artery sling for which computed tomography or magnetic resonance imaging, in addition to bronchoscopy, were preferred. Left thoracotomy was the most common operative approach (70 of 82; 85%). Ten patients (12%) had associated heart anomalies, and 6 (7%) patients underwent repair. Complications occurred in 9 (11%) patients and led to death in 3 (4%) patients. CONCLUSIONS In our practice, barium swallow and echocardiography are sufficient in diagnosing and planning the operative strategy in the majority of cases, with notable exceptions. Definitive intraoperative delineation of arch anatomy minimizes the risk of misdiagnosis or inadequate treatment.

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

INTRODUCTION Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens. METHODS After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82. RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group. CONCLUSIONS Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Survival of patients with esophageal atresia: influence of birth weight, cardiac anomaly, and late respiratory complications.

PURPOSE The aim of this study was to determine the influence of various prognostic factors on the outcome of esophageal atresia patients. METHODS The authors reviewed 240 charts of patients admitted with esophageal atresia or tracheoesophageal fistula (EA-TEF) in a single institution. A logistic regression model was used with survival as the dependent variable and era of repair, birth weight, and cardiac anomaly as independent variables. RESULTS Era was statistically significant (P = .011); 87% (117 of 134) of patients survived in the era from 1980 through 1997 compared with 78% (83 of 106) from 1960 through 1979. Cardiac anomaly (CHD) was a significant risk factor (P = .001); 88% (176 of 199) survived without cardiac anomaly, whereas only 59% (24 of 41) survived with cardiac disease. Eighty-four percent (185 of 219) of infants with a birth weight (BW) of more than 1,500 g survived, compared with 71% (15 of 21) of infants with a birth weight of less than 1,500 g. This was not statistically significant (P = .59). Early hospital deaths were primarily cardiac and chromosomal (61%). Late deaths were primarily respiratory (59%; two-tailed Fishers Exact test, P = .004). CONCLUSIONS (1) Survival of patients with esophageal atresia has significantly improved in the recent years. (2) Low birth weight (<1,500 g) does not seem to affect survival. (3) Associated cardiac and chromosomal anomalies are significant causes of death, particularly for early demise. (4) Late death from respiratory disease (tracheomalacia, reactive airway disease, reflux, and aspiration) warrants attention, and a close follow-up of postoperative patients is suggested.

A complete course of intravenous antibiotics vs a combination of intravenous and oral antibiotics for perforated appendicitis in children: a prospective, randomized trial

INTRODUCTION In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics. METHODS Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days. RESULTS One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm. CONCLUSIONS When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

Survival after necrotizing enterocolitis in infants weighing less than 1,000 g: 25 Years' experience at a single institution☆

Necrotizing enterocolitis (NEC) primarily affects premature newborns. Regional and national decreases in the mean birthweight and gestational age of neonatal intensive care unit (NICU) admissions prompted a review of NEC in VLBW (very low birth weight, defined as < 1,000 g) infants in our institution over a 25-year period. There were 266 patients treated for NEC during the study interval. We compared 71 VLBW with 195 non-VLBW infants and found that VLBW infants were: fed later (6.4 days v 4.1 days, P = .009), developed NEC later (20.8 days v 13.1 days, P = .002), had significantly lower 1- and 5-minute Apgar scores, were more likely to require surgery (51% v 34%, P = .016), more often had panintestinal (defined as > 75% of intestinal length) involvement (10% v 4%, P = .043), and had poorer survival (56% v 72%, P = .013). Overall survival after NEC has improved over the study interval, both in our series and in other reports. However, the increasing number of VLBW infants who have NEC represent a subgroup who appear to be generally more ill, develop NEC later, require surgery with greater frequency than their non-VLBW counterparts, and are less likely to survive.