Katrina L. Weaver

The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis

BACKGROUND Children with a symptomatic indirect inguinal hernia have a patent processus vaginalis (PPV). However, the reverse is unknown, as the natural history of PPV is unclear. Currently, there are little data regarding the incidence and time frame for developing a symptomatic hernia with a known asymptomatic PPV. METHODS A retrospective chart review was conducted in children who were evaluated for a PPV during nonhernia laparoscopic surgery by a single pediatric surgeon (GWH) from 2000 to 2014. Those patients with intraoperative findings of PPV were followed up by chart review and phone inquiry. RESULTS 1548 children underwent a laparoscopic operation, with 308 having an asymptomatic PPV. Phone contact was successful in 125 (43%) of these patients at a median of 8.1years (range 4.8-12.7) after the initial laparoscopic operation. Nineteen (13%) patients returned with a symptomatic hernia at a median age of 17months (range: 5-74) and a median presentation of 9months (range: 1-66) after the initial laparoscopy. Ten hernia repairs were unilateral and 9 bilateral. None of those who were contacted via phone inquiry reported hernia symptoms or hernia repair. CONCLUSIONS These data suggest that the risk of developing a symptomatic hernia during childhood in the presence of a known PPV is relatively low. LEVEL OF EVIDENCE Level 3; type of study: retrospective study.

Preoperative Imaging Does Not Predict Rupture in Acute Appendicitis

We read with interest the article by Bonadio et al. in the July 2015 issue of the Journal (1). Using their institutional data, the authors investigated the impact of timing to appendectomy on perforation rates in pediatric appendicitis, concluding that a delay of >9 h in previous computed tomography (CT)–confirmed nonperforated appendicitis led to a higher rate of perforation. While we applaud the authors’ attempt to determine the timing to surgery of an otherwise prevalent condition in children and an outcome with significantly worse morbidity, the methodology contains some fundamental flaws. The use of CT scan as a predictor of appendiceal perforation is highly misleading. The 2006 Bixby et al. study quoted by the authors concluded that multidetector CT imaging had very poor sensitivity for perforated appendicitis (2). In 2010, Fraser et al. found that the positive predictive accuracy of detecting appendiceal perforation by CT scan was 67% based on the review of 200 CT scans obtained for appendicitis (3).The study concluded that the triage of patients based on preoperative CT scans was highly imprudent. The authors also concluded that the use of antibiotics did not prevent progression of appendicitis, with rates of perforation as high as 41% within 24 h! This finding contradicts research studies, including well-conducted prospective, randomized trials on the role of antibiotics in the treatment of uncomplicated appendicitis (4,5). This brings into question the validity of the initial CT assessment or the efficacy of the antibiotic regimen at the authors’ institution. The supposition that the appendix perforated within 24 h despite adequate antibiotics is therefore misleading and inaccurate. While important factors can potentially contribute to children presenting with appendiceal perforation (including younger age and duration of symptoms), it is erroneous to conclude that a >9 h duration before operative intervention increases the rate of perforation without the backing of a well-conducted randomized clinical trial.

Feeding Advancement and Simultaneous Transition to Discharge (FASTDischarge) after laparoscopic gastrostomy

BACKGROUND Laparoscopic gastrostomy (LG) is a common surgical procedure. However, there is little consensus on a postoperative feeding regimen. With prior nasogastric feed tolerance, there should be no delay in resumption of feeds and subsequent discharge to home. This is a report on a Feeding Advancement and Simultaneous Transition-Discharge (FAST-Discharge) pathway, which to date has not been reported in the literature. METHODS A retrospective review of patients who underwent LG was performed from May 2010 to May 2015. All were outpatients who were on prior nasogastric feeds. The postoperative order set initiates feeds in 4 h to advance to goal as tolerated. Time to initial feed and goal nutrition, and overall length of stay (LOS) were evaluated. RESULTS 122 patients were identified with 55% percent being male and with a median operative age of 15 months (IQR 8-27). 53% were started on bolus feeds. Initial feeds were started at a median of 2.8 h (IQR: 1.8-4.7). The median duration to goal nutrition was 6 h (IQR: 0-14). 97% reached full feeds within 24 h with no complications related to feed advancement. Median LOS was 26 h (IQR: 24-30). CONCLUSION An expedited pathway with early feeding and discharge is possible after laparoscopic gastrostomy tube placement with a low risk for adverse events. LEVEL OF EVIDENCE Level III.

Transabdominal Versus Subcuticular Sutures to Secure a Laparoscopic Gastrostomy

PURPOSE Traditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques. METHODS A retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications. RESULTS A total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, P < .05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, P < .05) and abscess (0.8% versus 7.6%, P < .05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (P < .05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups. CONCLUSION While both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

Does Intravenous Acetaminophen Improve Postoperative Pain Control after Laparoscopic Appendectomy for Perforated Appendicitis? A Prospective Randomized Trial

Introduction The recent increased awareness of the dangers of opioids in the United States has highlighted the need to minimize narcotics and identify nonopioid options for pain control after surgery. With evidence suggesting that intravenous acetaminophen (IVA) can be an opioid sparing option, we conducted a prospective, randomized trial that evaluated the effect of IVA on the postoperative pain course of children with perforated appendicitis. Materials and Methods After IRB approval, children with perforated appendicitis were randomized to receive postoperative IVA with the standard patient/nurse‐controlled analgesia (PCA) or to receive the PCA alone. All patients were treated according to an evidence‐based treatment protocol. The primary outcome was duration of time on PCA. Results Eighty‐two patients were analyzed from 7/14 to 11/15. There was no statistically significant difference in the time to transition from the PCA to oral pain medications for children given IVA compared with children not receiving IVA (76.4 ± 32.5 versus 86.7 ± 49.3 hours; p = 0.73). Children in the IVA group had no statistically significant difference in intravenous narcotics delivered and pain scores compared with the non‐IVA group. There was no significant difference in the amount of oral narcotics between both groups (2.8 ± 2.4 versus 2.9 ± 2.5; p = 0.88). Patients who received IVA had higher medication charges (

A systematic review and individual patient data meta-analysis of published randomized clinical trials comparing early versus interval appendectomy for children with perforated appendicitis

3752.7 ± 1618.3 vs.

A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair

1198.19 ± 521.51; p < 0.01), but not total hospital charges (

Routine use of chest radiographs in the post-operative management of pectus bar removal: necessity or futility

53842.0 ± 19409.2 vs.

Effect of timing of cannulation on outcome for pediatric extracorporeal life support

50501.03 ± 16223.32; p = 0.76). Conclusion Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.