David Juang

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).

Irrigation versus suction alone during laparoscopic appendectomy for perforated appendicitis: A prospective randomized trial

Background:The efficacy of irrigating the peritoneal cavity during appendectomy for perforated appendicitis has been debated extensively. To date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing peritoneal irrigation to suction alone during laparoscopic appendectomy in children. Methods:Children younger than 18 years with perforated appendicitis were randomized to peritoneal irrigation with a minimum of 500 mL normal saline, or suction only during laparoscopic appendectomy. Perforation was defined as a hole in the appendix or fecalith in the abdomen. The primary outcome variable was postoperative abscess. Using a power of 0.8 and alpha of 0.05, a sample size of 220 patients was calculated. A battery-powered laparoscopic suction/irrigator was used in all cases. Pre- and postoperative management was controlled. Data were analyzed on an intention-to-treat basis. Results:A total of 220 patients were enrolled between December 2008 and July 2011. There were no differences in patient characteristics at presentation. There was no difference in abscess rate, which was 19.1% with suction only and 18.3% with irrigation (P = 1.0). Duration of hospitalization was 5.5 ± 3.0 with suction only and 5.4 ± 2.7 days with group (P = 0.93). Mean hospital charges was

A novel measure for pectus excavatum: the correction index

48.1K in both groups (P = 0.97). Mean operative time was 38.7 ± 14.9 minutes with suction only and 42.8 ± 16.7 minutes with irrigation (P = 0.056). Irrigation was felt to be necessary in one case (0.9%) randomized to suction only. In the patients who developed an abscess, there was no difference in duration of hospitalization, days of intravenous antibiotics, duration of home health care, or abscess-related charges. Conclusions:There is no advantage to irrigation of the peritoneal cavity over suction alone during laparoscopic appendectomy for perforated appendicitis. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

Current Patterns of Practice and Technique in the Repair of Esophageal Atresia and Tracheoesophageal Fistua: An IPEG Survey

OBJECTIVE The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index. METHODS After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (×100) to give the percentage of chest depth the defect represents. RESULTS There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI. CONCLUSIONS The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations.

Topical silver sulfadiazine vs collagenase ointment for the treatment of partial thickness burns in children: a prospective randomized trial

BACKGROUND Optimal surgical treatment of infants with esophageal atresia (EA) and tracheoesophageal fistula (TEF) remains controversial. In order to better understand variability in management, we surveyed the International Pediatric Endosurgery Group (IPEG) membership. MATERIALS AND METHODS An online-based survey, conducted in 2012, was sent to all IPEG members. RESULTS The survey was completed by 170 surgeons from 31 countries. A majority of respondents practiced in academic/university settings (86%) and performed one to three EA/TEF repairs annually (67%). Those practicing for over 15 years made up 39% of the study group, followed by those practicing 6-10 years (24%), 0-5 years (22%), and 11-15 years (15%). Utilization of a thoracoscopic approach was reported by half of the respondents with a frequency of 1-3 cases (76%), 4-6 cases (17%), and greater than 7 cases (7%) per year. Low birth weight, congenital heart disease, long gap length, and compromised physiologic status were identified as the most common exclusion criteria for thoracoscopic repair. The thoracoscopic repair was almost uniformly performed via an intrapleural approach (96%), in contrast with the open repair that was done extrapleurally in 89%. Preoperative bronchoscopy was routinely performed by 60%. Size 4-0 to 5-0 absorbable suture predominated for EA repair. Postoperative chest tube/drain and transanastomotic tube placement were used by 83%. A normal esophagram was required by 85% to initiate oral feeding. Sixty-six percent initiated transanastomotic feeds prior to obtaining an esophagram. Postoperative antibiotic use was common (76%) and varied from less than 1 to greater than 14 days. Acid suppression medication was used by 76% with duration ranging from 7 days to lifelong. For long gap EA, spiral myotomies were rarely performed (10%), and gastric transposition was the favored method for esophageal replacement (66%). CONCLUSIONS Considerable variability existed among the IPEG membership in treatment of patients with EA/TEF. The identification of variance is the first step in creating future studies to identify best practices.

The Impact of Postoperative Abscess Formation in Perforated Appendicitis

BACKGROUND The 2 most commonly used topical agents for partial thickness burns are silver sulfadiazine (SSD) and collagenase ointment (CO). Silver sulfadiazine holds antibacterial properties, and eschar separation occurs naturally. Collagenase ointment is an enzyme that cleaves denatured collagen facilitating separation but has no antibacterial properties. Currently, there are no prospective comparative data in children for these 2 agents. Therefore, we conducted a prospective randomized trial. METHODS After institutional review board approval, patients were randomized to daily debridement with SSD or CO. Primary outcome was the need for skin grafting. Patients were treated for 2 days with SSD with subsequent randomization. Polymyxin was mixed with CO for antibacterial coverage. Debridements were performed daily for 10 days or until the burn healed. Grafting was performed after 10 days if not healed. RESULTS From January 2008 to January 2011, 100 patients were enrolled, with no differences in patient characteristics. There were no differences in clinical course, outcome, or need for skin grafting. Wound infections occurred in 7 patients treated with CO and 1 patient treated with SSD (P = .06). Collagenase ointment was more expensive than SSD (P < .001). However, total hospital charges did not differ. CONCLUSION There are no differences in outcomes between topical SSD or CO in the management of childhood burns results.

The Use of High-Frequency Oscillating Ventilation to Facilitate Stability During Neonatal Thoracoscopic Operations

BACKGROUND Abscess after appendectomy for perforated appendicitis is the most common complication. We have completed three prospective trials and are conducting a fourth in which the included patients had either a hole in the appendix or a fecalith in the abdomen identified at the time of operation. The abscess rate in each of these trials was 20%. Multiple publications have focused on prevention and management of this postoperative complication but the total impact of an abscess on the hospital course has not been well documented. Therefore, we reviewed our experience with patients who developed a postoperative abscess to evaluate the total care received compared with those who recovered uneventfully. METHODS Data from patients with abscess who have been enrolled in our prospective trials from April 2005 to December 2009 were utilized. Patients who recovered without complications in the most recent trial served as a comparison group, as this protocol offers the minimal length of stay without a predetermined length of stay. Data comparison included patient demographics, admission lab values, hospital length of stay, and hospital charges. RESULTS There were 63 patients with a postoperative abscess and 61 patients without an abscess identified. Patients with an abscess were older (11.0 versus 9.7 y, P = 0.04) and had a higher mean body mass index (22.4 versus 19.5, P = 0.03). Total hospital length of stay was significantly longer in the abscess group (11.6 d versus 5.1 d, P ≤ 0.001). Total hospital charges doubled for patients who developed an abscess (

PAPS PapersFollow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

82,000 versus

Neonatal bowel obstruction.

40,000 P < 0.001). CONCLUSION A postoperative abscess after appendectomy for perforated appendicitis translates into an average of an extra week in hospital care with double the total hospital cost.

A review: the role of high dose methylprednisolone in spinal cord trauma in children

BACKGROUND Thoracoscopy has become a surgical option for the repair of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH). Insufflation of carbon dioxide combined with one lung ventilation creates an anesthetic challenge to control acidosis and maintain oxygenation while allowing optimal operative exposure. We have overcome these issues by utilizing the high-frequency oscillating ventilator (HFOV) and report our early experience. METHODS A retrospective review from 2007 to 2010 on neonates who underwent thoracoscopic operation utilizing HFOV. Patient demographics and intraoperative course were reviewed. RESULTS Seventeen neonates were identified, 12 with EA and 5 with posterolateral CDH. The median age at operation was 4 days (range 1-166 days), with a median weight of 2.9 ± 1.0 kg. Median gestational age was 38 ± 3 weeks. Before surgery, 6 patients (35%) were on conventional mechanical ventilation, and no patient was on high-frequency oscillating ventilation. Median American Society of Anesthesiologists score was 3 (range 3-4). There were no intraoperative complications and median operative time was 208 ± 72 minutes. Review of the operative reports identified no significant difficulties with exposure of the operative field in all patients. Median ventilator manipulations needed were 3 per case. Mean intraoperative pulse oximetry was 97% ± 2%. Sixteen patients had intraoperative arterial blood gases; 1 had venous sampling. Patients with arterial blood gases had a mean pH of 7.36 (range 7.18-7.47), mean pCO2 was 41 mmHg (range 25-63 mmHg), and mean pO2 was 156 mm Hg (range 41-426 mmHg). CONCLUSION Usage of HFOV allows for good intraoperative exposure with excellent oxygenation and elimination of carbon dioxide to prevent acidosis.