Pablo Aguayo

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.

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.

Physiologic predictors of postoperative abscess in children with perforated appendicitis: Subset analysis from a prospective randomized trial

BACKGROUND Intra-abdominal abscess after appendectomy is the most common complication in patients with perforated appendicitis. There are currently little data that may forecast which patients are more likely to develop an abscess. Therefore, we performed a retrospective analysis of a prospectively collected dataset to determine whether there are predictors for developing a postoperative abscess. METHODS The dataset was collected prospectively in a randomized trial comparing antibiotic regimens in 98 pediatric patients with perforated appendicitis. All patients underwent laparoscopic appendectomy and received a minimum of 5 days of intravenous antibiotics. The Pearson correlation was used to evaluate the influence of patient, intra-operative, and early postoperative variables on the development of an abscess. Two-tailed P values were determined from the correlation coefficient, and significance was defined as P < or = .05. RESULTS At presentation, a positive correlation for abscess formation was identified with increasing age (P = .003), weight (P = .001), body mass index (P = .008), and diarrhea (P = .005). Operative time had no influence on abscess development. After operation, there was progressively increasing positive correlation between abscess and the maximum temperature each successive postoperative day. This relationship became significant at day 3. An increased white blood cell count on day 5 was highly predictive of abscess (P < .001). CONCLUSION In children presenting with perforated appendicitis, increasing age, weight, and/or body mass index correlated with the development of a postoperative abscess. Diarrhea on presentation also poses an increased risk of abscess. Postoperatively, each successive day with a fever is incrementally more predictive of an abscess formation.

The Role of Laparoscopy in the Management of Malrotation

BACKGROUND Malrotation is currently treated via the Ladds procedure. Many surgeons feel this operation should be performed using the open approach to facilitate adhesion development, thus decreasing the risk for volvulus. However, little comparative data exist on the relative merits of laparoscopy for this operation. Therefore, we have analyzed our experience with the open and laparoscopic Ladds procedure. METHODS A retrospective analysis of our most recent 13-y experience with the Ladds procedure was performed. Demographics, approach, diagnosis, hospital course, and outcomes were measured. Data are expressed as mean +/- standard deviation. Comparative analysis was performed using a t-test. RESULTS A total of 284 Ladds procedures were performed during this time, of which 43 were approached laparoscopically. Conversion rate was 33%, usually due to concern for volvulus/orientation. Volvulus after Ladds procedure occurred in six patients, all of whom underwent an open approach (2.4%). Recovery data excluding patients who underwent bowel resection are displayed in Table 1. CONCLUSIONS A laparoscopic Ladds procedure should be the initial approach in patients with malrotation in the absence of volvulus. We encourage a low threshold for conversion to an open approach if there is any concern about volvulus/orientation. This may decrease morbidity for patients who are found at operation to have a low risk of recurrent volvulus.

Contemporary practice patterns in the surgical management of Hirschsprung's disease.

BACKGROUND Many options exist in the surgical management of Hirschsprungs disease (HD). To gain insight into contemporary management, we queried pediatric surgeons listed in the American Pediatric Surgical Association Directory on their management for the typical baby with HD. METHODS Surveys were sent electronically to the surgeons concerning a typical newborn diagnosed with HD. Questions included the preferred approach, number of stages, anastomotic technique, length of muscular rectal cuff, point of initiation of the anorectal dissection, and length of colonic resection. Surgeons performing laparoscopy were asked about how the colonic biopsy was performed. Other questions included the type of leveling colostomy, level of residents, and criteria for performing a primary transanal pull-through. The maximum margin of error was calculated using a 95% confidence interval based on the response percentages for discrete variables. RESULTS Surveys were sent to 719 surgeons with 270 responses. A minimally invasive approach is currently used by 80%, of which 42.3% favor laparoscopy and 37.7% prefer transanal dissection only. Only 5.4% of respondents prefer the Duhamel technique. A 1-stage approach is used by 85.6%. An average muscular cuff length of 2.4 cm (range, 0.5-6 cm) is reported. A divided muscular cuff is reported by 55%. On average, the anal anastomosis is 0.73 cm (range, 0-4.5 cm) above the top of the anal columns and 3.0 cm (0-12.5 cm) above the biopsy site on the ganglionic colon. Of the respondents using laparoscopy, 80.2% report using an intracorporeal colonic biopsy technique. Participation in a training program, either fellows and/or residents, is reported by 84.8% of respondents. The most common reason given for not performing a primary transanal pull-through is long segment disease (45.6%). Margin of error was no greater than 6% for any of the responses. CONCLUSIONS A minimally invasive approach with a 1-stage operation has become the most common strategy for the surgical management of the typical baby with HD. Opinions vary about the amount of colonic resection, length of the rectal cuff, and site of initiation of the anorectal dissection, and these represent potential points for future studies.

Review of the evidence on the management of blunt renal trauma in pediatric patients

Due to the size and location within the pediatric patient, the kidneys are susceptible to injury from blunt trauma. While it is clear that the goal of management of blunt renal trauma in children is renal preservation, the methods of achieving this goal have not been well established in the current literature. Therefore, we have set out to summarize and clarify the current published information on the management strategies for blunt renal trauma in children. While there is extensive literature available, it consists mostly of retrospective series documenting widely varied management styles. The purpose of this review is to display the current information available and delineate the role for future studies that may allow us to develop consistent management strategies of pediatric patients, who have sustained blunt renal trauma, in a safe and cost-effective manner.

Stomal complications in the newborn with necrotizing enterocolitis.

BACKGROUND Infants who develop necrotizing enterocolitis (NEC) are usually managed with fecal diversion. The integrity of the bowel being diverted is often suboptimal. Our clinical impression is that stomas created in this circumstance are fraught with complications. The purpose of this study is to quantify the rate of these complications and identify risk factors. METHODS A retrospective data collection from May 1999 to May 2008 on infants undergoing laparotomy for NEC was conducted. Data collected included gestational age, birth weight, age, and weight at operation, indications for surgical therapy, procedure performed, time to stoma output, time to takedown of stoma, complication directly related to the ostomy, and mortality. Data comparisons were analyzed statistically using chi(2), Pearsons correlation, Fishers exact test, or a 2-tailed Students t-test with significance reported for P<0.05. RESULTS A total of 73 patients were identified. Mean gestational age was 28 (+/-4) wk, mean birth weight was 1247 (+/-713) g. Mean age at the time of surgery was 23 (+/-27) d, and mean weight at operation was 1513 (+/-1306) g. The most common indication for surgical intervention was pneumoperitoneum (n=43, 58%). The most common level of intestinal diversion was the ileum (n=63, 85%). In-house mortality was 13%. There were 31 patients (42%) who developed 32 stoma-related complications. Demographic or preoperative variables that were a significant predictor of stoma-related complications were gestational age (P=0.003) and preoperative weight (P=0.024). CONCLUSION Premature infants carry a risk for developing stoma-related complications. Within that cohort, there is significantly increased risk of stoma-related complications in patients who are younger in gestational age and who have low preoperative weight. Future prospective studies may allow insight into preventative practices.

15-Year experience in the treatment of rectal prolapse in children

BACKGROUND Rectal prolapse is a common and usually self-limited condition in children. Several surgical techniques have been advocated for refractory prolapse. We reviewed our experience with treatment and the outcome of refractory rectal prolapse. METHODS Retrospective review was conducted on patients undergoing surgery for rectal prolapse from January 1993 to March 2009. Patients with imperforate anus/cloacal abnormalities, Hirschsprung disease, spina bifida, or prior pull-through were excluded. RESULTS Twenty patients underwent 23 procedures for rectal prolapse. There were 10 posterior sagittal rectopexies, 6 transabdominal rectopexies, 5 laparoscopic rectopexies, 1 hypertonic saline injection, and 1 anal cerclage. The mean duration of symptoms was 1.6 years (range, 1-10 years). The mean age at operation was 6.8 years (range, 4 months-19 years), with a 5:1 male predominance. There was no operative or perioperative mortality. Median length of follow-up was 7.2 months; 2 patients were lost to follow-up. The overall recurrence rate was 35%. All recurrences followed posterior sagittal rectopexies, which had a 70% recurrence rate. Four patients required reoperation, all done transabdominally (2 open and 2 laparoscopically). None of the 3 remaining patients with mild recurrences required reoperation. CONCLUSIONS A variety of options for management of refractory rectal prolapse in children exist. Laparoscopic rectopexy seems to be safe and a comparatively successful option in these children.

Laparoscopic management of intussusception in pediatric patients.

INTRODUCTION Minimally invasive approaches are beginning to be employed in the management of pediatric patients with intussusception who fail radiographic reduction. Successful laparoscopic reduction has been demonstrated, but the utility of laparoscopy, for more complex cases, is less well documented. Therefore, we reviewed our experience with laparoscopy in patients with radiographically irreducible intussusception to document the safety and effectiveness of this approach. METHODS We conducted a retrospective review of all of the patients who had a radiographically irreducible intussusception treated via the laparoscopic approach at a single institution from 1998 to 2008. Means are expressed +/- standard deviation. RESULTS A total of 22 patients were identified, with an average age of 2.9 +/- 3.0 years. Average length of stay was 2.67 +/- 1.5 days (median, 2). Sixteen (73%) of the 22 patients were male. There were 19 ileocecal and 3 small bowel intussusceptions. Twenty patients (91%) were able to be managed entirely laparoscopically or via extension of the umbilical incision, while 2 necessitated conversion, using a right-lower quadrant incision. Nine patients had an extension of the umbilical incision; 7 of these underwent a bowel resection. Ten patients (46%) had a bowel resection, of which 5 were an ileocecectomy and 5 were segmental small bowel resection. There were a total of 9 patients with a pathologic lead point, 5 patients with lymphoid hyperplasia, and 4 with Meckels diverticula. CONCLUSION We conclude that laparoscopy is a reasonable approach to pediatric intussusception, even in the event when bowel resection is necessary.

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

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.