Ravindra K. Vegunta

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

PURPOSE The 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. METHODS A 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. TECHNIQUE Two 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. RESULTS One 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. CONCLUSION The 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 (73 %) contained meticillin-sensitive S. aureus (MSSA), 8 (6 %) contained meticillin-resistant S. aureus (MRSA), and 26 (21 %) 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 (26 %) samples contained two genetically distinct S. aureus strains and 6 (5 %) 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.

Sphincter of Oddi dysfunction in children with recurrent abdominal pain: 5‐year follow‐up after endoscopic sphincterotomy

Background:   Sphincter of Oddi (SO) dysfunction has not been reported as a cause of recurrent abdominal pain (RAP) in children. We present a 5‐year follow‐up of a group of children with RAP and manometry proven SO dysfunction.

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

BACKGROUND The 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. SUBJECTS AND METHODS An 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. RESULTS In 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. CONCLUSIONS Our 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.

The novel use of Nuss bars for reconstruction of a massive flail chest

We present the case of a patient who sustained a massive flail chest from a snowmobile accident. All ribs of the right side of the chest were fractured. Nonoperative management was unsuccessful. Previously reported methods of rib stabilization were precluded given the lack of stable chest wall elements to fixate or anchor the flail segments. We present a novel surgical treatment in which Nuss bars can be used for stabilization of the most severe flail chest injuries, when reconstruction of the chest is necessary and fixation of fractured segments is infeasible owing to adjacent chest wall instability.

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

BACKGROUND Staphylococcus 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. METHODS A 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. RESULTS We 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. CONCLUSION Methicillin-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.

Reinfusion of Succus Entericus Into the Mucous Fistula Decreases Dependence on Parenteral Nutrition in Neonates

Background. Neonates who undergo surgery and have an ostomy with a creation of a mucous fistula are at nutritional risk, especially if the ostomy placement is proximal and the remaining bowel is not being used. Total parenteral nutrition (TPN) is used to maintain the neonatal nutritional status, but long-term use is associated with increased morbidities. The concept of reinfusing succus entericus into the mucous fistula to decrease the neonate’s dependence on TPN has been limited to case reports. Methods. This is a retrospective cohort study documenting the effectiveness of reinfusing succus entericus into the mucous fistula for neonates admitted to the neonatal intensive care unit (NICU). The authors’ primary hypothesis was that neonates who had succus entericus reinfused into the mucous fistula had decreased dependence on TPN. Results. Of the premature infants receiving mucous fistula feedings, 65% had TPN discontinued, whereas 67% of the term infants had TPN discontinued. The type of ostomy affected th...

Methylene blue: a simple marker for intraoperative detection of gastroduodenal perforations during laparoscopic pyloromyotomy.

Introduction. We studied the feasibility of using methylene blue (MB) as a marker to detect mucosal perforations during laparoscopic pyloromyotomy using in vitro and in vivo animal models. Materials and methods. MB was initially tested in pig stomachs in vitro. Information gathered from these experiments was then used to test the marker during experimental live piglet laparoscopic surgery. Results. MB stained the gastric mucosa blue; this tint could be seen through the intact mucosal layer exposed via myotomy. Dye extravasation was seen during laparoscopic surgery with mucosal perforations of 1.2 mm and greater with or without air insufflation of the stomach. Air extravasation was seen with perforations of 2.0 mm and greater. Conclusion. Full strength 1% MB dye instilled into the gastric lumen can potentially be used as a marker for detection of mucosal perforations of 1.2 mm or greater during laparoscopic pyloromyotomy.

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.

Adding Dietary Green Beans to Formula Resolves the Diarrhea Associated With a Bowel Resection in Neonates

Background. Traditionally, dietary fiber has been empirically added to infant formulas to improve feeding intolerance for those infants diagnosed with intestinal failure (IF) or short-bowel syndrom...