Frankie B. Fike

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

Outcome of congenital diaphragmatic hernia repair depending on patch type.

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).

Predictors of failed enema reduction in childhood intussusception.

INTRODUCTION Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials. METHODS A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009. RESULTS Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate. DISCUSSION As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.

The Lack of Efficacy for Oral Contrast in the Diagnosis of Appendicitis by Computed Tomography

BACKGROUND Initial management of intussusception is enema reduction. Data are scarce on predicting which patients are unlikely to have a successful reduction. Therefore, we reviewed our experience to identify factors predictive of enema failure. METHODS A retrospective review of all episodes of intussusception over the past 10 years was conducted. Demographics, presentation variables, colonic extent of intussusceptions, and hospital course were collected. Extent of intussusception was classified as right, transverse, descending, and rectosigmoid. Episodes were grouped as success or failure of enema reduction and compared using the Student t test for continuous variables and χ(2) test for dichotomous variables. Significance was P less than .05. RESULTS We identified 405 episodes of intussusception and 371 attempts at enema reduction. There were 285 successful enema reductions. There was no difference between groups in age; sex; or the presence of emesis, fever, or abdominal mass. The failed enema group was more likely to have had symptoms over 24 hours before presentation (P = .006), bloody diarrhea (P < .001), and lethargy (P < .001). The chance of success diminished with colonic extent (right, 88%; transverse, 73%; left, 43%; colorectal, 29%; P < .001). CONCLUSION Predictors of failed enema reduction of intussusception include presence of symptoms over 24 hours, diarrhea, lethargy, and distal extent of intussusception.

The Impact of Postoperative Abscess Formation in Perforated Appendicitis

BACKGROUND Oral contrast is often used with computed tomography (CT) for the diagnosis of appendicitis. This adjunct adds time to evaluation, not all patients can tolerate enteric bolus, and the diagnostic advantages have not been well defined. Therefore, we reviewed our experience to evaluate the impact of oral contrast on diagnostic efficiency and its impact on the patient. METHODS After obtaining IRB approval, a retrospective review was conducted on patients who underwent CT with oral contrast for the indication of appendicitis over the last 4 years. Data recorded included demographics, CT results, emergency room course, operative findings, and pathology interpretation. All images were reviewed to identify presence/absence of contrast at or beyond the terminal ileum. RESULTS There were 1561 patients, of whom, 652 (41.8%) were diagnosed with appendicitis and 909 (58.2%) were not (non-appendicitis). Contrast was identified at least to the level of the terminal ileum in 72.4% of the entire population. The contrast was present in 76.2% of the non-appendicitis patients and 67.0% of the appendicitis patients (P = 0.01). Mean time from oral contrast administration to CT imaging was 105.5 min, which was longer in patients with appendicitis (112.2 min) compared with non-appendicitis patients (100.9 min) (P = 0.01). Emesis of the contrast occurred in 19.3% of those with appendicitis and 12.9% of those without appendicitis (P = 0.001). Nasogastric tubes were placed in 5.8% of those with appendicitis and 5.1% of those without (P = 0.37). Appendicitis was confirmed at operation in 94.3% of those with contrast in the area and 94.4% of those without (P = 1.0). Pathology confirmed appendicitis in 90.6% of those with contrast in the area and 94.0% of those without (P = 0.17). CONCLUSION Nearly 30% of patients receiving oral contrast for the CT diagnosis of appendicitis do not have contrast in the point of interest at the expense of emesis, nasogastric tube placement, and diagnostic delay. These detriments are amplified in patients who have appendicitis. Further, there appears to be no diagnostic compromise in those without contrast in the terminal ileum.

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 (

The Predictive Value of Haller Index in Patients Undergoing Pectus Bar Repair for Pectus Excavatum

82,000 versus

Review of the evidence on the closure of abdominal wall defects

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.

Experience with pilonidal disease 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.

Occurrence of Crohn’s Disease in Children After Total Colectomy for Ulcerative Colitis

BACKGROUND The Haller index (HI) remains the standard metric to quantify the severity of pectus excavatum deformity. However, little data exist to determine how well this parameter correlates with the difficulty or early outcomes of repair. METHODS The study population was comprised of all patients who underwent pectus bar repair for pectus excavatum on whom adequate preoperative images on computed tomography allowed for Haller index calculation, from December 1999 to February 2010. Patients with two bars placed for repair were excluded. All images were reviewed blinded to outcome and Haller index was calculated. Pearsons correlation was used to evaluate the relationship between age, length of operation, postoperative complications, and length of hospitalization. The correlations were performed on the entire population and then individual age groups analyzed: 5-11 y, 12-16 y, and over 17 y. Two-tailed P values were determined from the correlation coefficient and significance was defined as P ≤ 0.05. RESULTS HI was available for 262 patients. There were 66 patients aged 5-11 y, 165 patients aged 12-16 years, and 30 patients over 17 y. The population was 80% male. In the entire population, there was a small correlation between postoperative pneumothorax and HI (R = 0.131, P = 0.05). There was no correlation between age, operative time, postoperative bar infection, or length of stay. No significant correlations existed in any of the individual age groups. CONCLUSION The Haller index holds no correlation with age, operative time, postoperative bar infection, or length of stay.