Lizabeth J. Wallace

Incision and loop drainage: a minimally invasive technique for subcutaneous abscess management in children

PURPOSEnThe aim of the study was to evaluate outcomes after a minimally invasive approach to pediatric subcutaneous abscess management as a replacement for wide exposure, debridement, and repetitive packing.nnnMETHODSnA retrospective study was performed of all children who underwent incision and loop drainage for subcutaneous abscesses between January 2002 and October 2007 at our institution.nnnTECHNIQUEnTwo mini incisions, 4-5 mm each, were made on the abscess, as far apart as possible. Abscess was probed, and pus was drained. Abscess was irrigated with normal saline; a loop drain was passed through one incision, brought out through the other, and tied to itself. An absorbent dressing was applied over the loop and changed regularly.nnnRESULTSnOne hundred fifteen patients underwent drainage procedures as described; 5 patients had multiple abscesses. Mean values (range) are as follows: age, 4.25 years (19 days to 20.5 years); duration of symptoms, 7.8 days (1-42 days); length of hospital stay, 3 days (1-39 days); duration of procedure, 10.8 minutes (4-43 minutes); drain duration, 10.4 days (3-24 days); and number of postoperative visits, 1.8 (1-17). Bacterial culture data were available for 101 patients. Of these, 50% had methicillin-resistant Staphylococcus aureus, 26% had methicillin-sensitive Staphylococcus aureus, and 9% streptococcal species. Of the 115 patients, 5 had pilonidal abscesses, 1 required reoperation for persistent drainage, and 1 had a planned staged excision. Of the remaining 110 patients, 6 (5.5%) required reoperation-4 with loop drains and 2 with incision and packing with complete healing.nnnCONCLUSIONnThe use of loop drains proved safe and effective in the treatment of subcutaneous abscesses in children. Eliminating the need for repetitive and cumbersome wound packing simplifies postoperative wound care. Furthermore, there is an expected cost savings with this technique given the decreased need for wound care materials and professional postoperative home health services. We recommend this minimally invasive technique as the treatment of choice for subcutaneous abscesses in children and consider it the standard of care in our facility.

Simultaneous carriage of multiple genotypes of Staphylococcus aureus in children

The co-existence of multiple genotypes in colonization by Staphylococcus aureus has not been fully investigated. The aim of this study was to evaluate the heterogeneity of S. aureus carriage in children. We evaluated 125 nasal and perianal swab samples that were positive for S. aureus from 76 children scheduled for elective surgery. For each sample, at least four colonies with the same or different morphotypes were selected for analysis. Multiple-locus variable-number tandem-repeat fingerprinting was used to determine the genetic relatedness and to characterize the clonality of the S. aureus strains. Of the 125 swabs, 91 (73u200a%) contained meticillin-sensitive S. aureus (MSSA), 8 (6u200a%) contained meticillin-resistant S. aureus (MRSA), and 26 (21u200a%) contained MSSA and MRSA simultaneously. A total of 738 S. aureus strains were evaluated with a mean of 6 colonies (range 4-15) picked from each culture. Of the 125 swabs, 32 (26u200a%) samples contained two genetically distinct S. aureus strains and 6 (5u200a%) contained three different genotypes. Multiple S. aureus strains simultaneously carried by individual children were genetically unrelated to each other. We concluded that the co-existence of multiple genotypes of S. aureus was common. The significance of multiple carriage is yet to be determined, but this intraspecies interplay could be important to pathogenicity and virulence in S. aureus.

Nuss Procedure: Decrease in Bar Movement Requiring Reoperation with Primary Placement of Two Bars

BACKGROUNDnThe Nuss procedure, first reported in 1998, is currently the treatment of choice for pectus excavatum. The most significant bar-related complication documented is bar movement, requiring reoperation in 3.4%-27% of reports. Our report compares the initial placement of one Nuss bar versus two to prevent bar displacement.nnnSUBJECTS AND METHODSnAn Institutional Review Board-approved, retrospective chart review was performed of all Nuss procedures performed from November 2000 through February 2010. Since November 2006, all initial Nuss procedures were started with the intent of placing two bars. Haller index, patient demographics, duration of surgery, length of stay, postoperative wound infections, and bar movement requiring reoperation were collected and compared for the one-bar versus two-bar patient populations.nnnRESULTSnIn total, 85 Nuss procedures (58 with one-bar and 27 with two-bar primary Nuss procedures) were analyzed. Two attending pediatric surgeons performed all the procedures. Reoperation for bar movement when one bar was initially placed occurred in 9 patients (15.5%). No patients with initial placement of two bars required operative revision for a displaced Nuss bar (15.5% versus 0%, P=.05). Patient age and Haller index were not statistically different between groups.nnnCONCLUSIONSnOur data demonstrate improved bar stability with no reoperative intervention when pectus excavatum is initially repaired with two Nuss bars. Primary placement of two bars has now become standard practice in our institution for correction of pectus excavatum by the Nuss procedure and would be our recommendation for consideration by other centers.

A prospective study of methicillin-resistant Staphylococcus aureus colonization in children scheduled for elective surgery

BACKGROUNDnStaphylococcus aureus is a major cause of surgical wound infections. To obtain contemporary data on S aureus, we performed a prospective study of colonization and infection in children scheduled for elective surgical procedures.nnnMETHODSnA nasal swab and clinical information were obtained at the presurgical outpatient visit. At operation, nasal and perianal swabs were obtained. S aureus were isolated and characterized.nnnRESULTSnWe enrolled 499 patients from June 2005 to April 2007. Wound classes were 1 (73%), 2 (22%), 3 (5%), and 4 (0.2%). Prophylactic antibiotics were administered for 153 (31%). Postoperative length of stay ranged from 0 (77%) to 6 days, with 19 (4%) staying 4 days or more. Screening cultures grew S aureus for 186 procedures (36.6%); of these, 141 were methicillin-resistant S aureus (MRSA) (76% of all staphylococcal cultures or 28% of all procedures). Most MRSA had Staphylococcal Chromosomal Cassette mec type II and resistance to clindamycin-typical for hospital-associated strains. There were 10 (2%) surgical site infections, including 4 methicillin-sensitive S aureus, 1 MRSA, 2 with no growth, and 2 with no cultures.nnnCONCLUSIONnMethicillin-resistant S aureus colonization was common in asymptomatic children. Most strains appeared to be health care-associated and resistant to clindamycin. Wound infection rate remained low despite the high prevalence of staphylococcal colonization.

Laparoscopic Pyloromyotomy: Safe, Cost-effective, and Cosmetically Superior

Hypertrophic pyloric stenosis is a relatively common problem of infancy affecting about 4 of every 1000 live births. Currently, the accepted standard treatment is to perform an extramucosal pyloromyotomy, as described by Ramstedt in 1912. Although the technique with which the pyloric muscle is split has not changed significantly since the original description, the manner in which the pylorus is accessed has undergone several modifications. Recent advances in pediatric laparoscopic surgery have allowed yet another method of approaching this common problem. The following is a report of the first 22 laparoscopic pyloromyotomies performed by one pediatric surgeon in a childrens hospital. No immediate or late complications occurred in this group. The operating time and total cost were comparable with those of a small series of open pyloromyotomies performed by the same surgeon in the same hospital. A much better cosmetic result was achieved in the patients who underwent laparoscopic pyloromyotomy.