Troy L. Spilde

Thoracoscopic decortication vs tube thoracostomy with fibrinolysis for empyema in children: a prospective, randomized trial

PURPOSE Management of empyema has been debated in the literature for decades. Although both primary video-assisted thoracoscopic surgery (VATS) and tube thoracostomy with pleural instillation of fibrinolytics have been shown to result in early resolution when compared to tube thoracostomy alone, there is a lack of comparative data between these modes of management. Therefore, we conducted a prospective, randomized trial comparing VATS to fibrinolytic therapy in children with empyema. METHODS After Institutional Review Board approval, children defined as having empyema by either loculation on imaging or more than 10,000 white blood cells/microL were treated with VATS or fibrinolysis. Based on our retrospective data using length of postoperative hospitalization as the primary end point, a sample size of 36 patients was calculated for an alpha of .5 and a power of 0.8. Fibrinolysis consisted of inserting a 12F chest tube followed by infusion of 4 mg tissue plasminogen activator mixed with 40 mL of normal saline at the time of tube placement followed by 2 subsequent doses 24 hours apart. RESULTS At diagnosis, there were no differences between groups in age, weight, degree of oxygen support, white blood cell count, or days of symptoms. The outcome data showed no difference in days of hospitalization after intervention, days of oxygen requirement, days until afebrile, or analgesic requirements. Video-assisted thoracoscopic surgery was associated with significantly higher charges. Three patients (16.6%) in the fibrinolysis group subsequently required VATS for definitive therapy. Two patients in the VATS group required ventilator support after therapy, one of whom required temporary dialysis. No patient in the fibrinolysis group clinically worsened after initiation of therapy. CONCLUSIONS There are no therapeutic or recovery advantages between VATS and fibrinolysis for the treatment of empyema; however, VATS resulted in significantly greater charges. Fibrinolysis may pose less risk of acute clinical deterioration and should be the first-line therapy for children with empyema.

Necrotizing enterocolitis in full-term infants

OBJECTIVES Although necrotizing enterocolitis (NEC) is primarily a disease of prematurity, full-term infants account for approximately 10% of cases. Previous studies have reported conflicting results regarding NEC in full-term (FT) versus preterm (PT) infants. A review of all infants diagnosed with NEC at our institution over the past 3 decades was performed to identify factors associated with this disease in full-term neonates. METHODS The charts of all infants with definitive NEC from January 1, 1972 through January 1, 2001 were reviewed. Two hundred seventy-seven patients made up the study group: 251 PT and 26 FT infants. Data regarding demographics, clinical presentation, management, outcome, and other variables were collected. FT and PT infants were compared. RESULTS Mean gestational age and birth weight in the FT group were 39.3 weeks and 3,132 g versus 30.2 weeks and 1,396 g for PT infants. Apgar scores were similar. Mean age at diagnosis was 5 days in FT versus 13 days in PT neonates (P <.001). Enteral nutrition was initiated earlier in FT infants (1.6 days v 3.1 days; P <.001), and FT infants were discharged an average of 14 days earlier than PT infants (P value not significant). Factors predisposing to NEC were found in 62% (16 of 26) of patients-heart disease in 6 infants and other conditions in 10 patients. Cardiac disease was found significantly more often (23% v 10%; P =.027) in FT infants. Survival rate was 65% (17 of 26) in the FT group versus 69% (173 of 251) in the PT infants (P value not significant). CONCLUSIONS FT infants with NEC differ from their PT counterparts in several distinct ways. FT neonates had NEC at a significantly earlier age, perhaps owing to earlier initiation of feeding. There was a correlation between age at which feeding was begun and age of onset of NEC. Additionally, an association between cardiac disease and development of NEC in term infants was shown. Predisposing factors were present in a majority of FT infants. In contrast to other reports, the outcome of NEC in full-term infants was no better than for PT infants.

Single daily dosing ceftriaxone and metronidazole vs standard triple antibiotic regimen for perforated appendicitis in children: a prospective randomized trial

INTRODUCTION Appendicitis is the most common emergency condition in children. Historically, a 3-drug regimen consisting of ampicillin, gentamicin, and clindamycin (AGC) has been used postoperatively for perforated appendicitis. A retrospective review at our institution has found single day dosing of ceftriaxone and metronidazole (CM) to be a more simple and cost-effective antibiotic strategy. Therefore, we performed a prospective, randomized trial to compare efficacy and cost-effectiveness of these 2 regimens. METHODS After internal review board approval (IRB no. 04 12-149), children found to have perforated appendicitis at appendectomy were randomized to either once daily dosing of CM (2 total doses per day) or standard dosing of AGC (11 total doses per day). Perforation was defined as an identifiable hole in the appendix. The operative approach (laparoscopic), length of antibiotic use, and criteria for discharge were standardized for the groups. Based on our retrospective analysis using length of postoperative hospitalization as a primary end point, a sample size of 100 patients was calculated for an alpha of .5 and a power of 0.82. RESULTS One hundred patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in sex distribution, days of symptoms, temperature, or leukocyte count. There was no difference in abscess rate or wound infections between groups. The CM group resulted in significantly less antibiotic charges then the AGC group. CONCLUSIONS Once daily dosing with the 2-drug regimen (CM) offers a more efficient, cost-effective antibiotic management in children with perforated appendicitis without compromising infection control when compared to a traditional 3-drug regimen.

Open vs laparoscopic repair of congenital duodenal obstructions : a concurrent series

OBJECTIVE The advantages of using laparoscopy for repair of congenital duodenal obstructions (CDO) are unclear because of scant data about complications and outcomes. Nitinol U-clips (Medtronic Surgical, Minneapolis, Minn) were developed to assist in the creation of vascular anastomoses in small vessels. Because of their ability to approximate tissue tightly with little tissue damage, we have begun to use these U-clips for laparoscopic repair of CDO. In this report, we investigate the impact of laparoscopic U-clip repair of CDO compared to the traditional open repair. METHODS With institutional review board approval, a retrospective analysis of all patients undergoing repair of CDO from January 2003 to July 2007 was performed. During this study period, patients who underwent open repair of CDO (group 1) were compared with patients that underwent laparoscopic repair using the U-clip technique (group 2). RESULTS Twenty-nine patients underwent repair of CDO. Fourteen patients (11 atresia, 3 stenosis) were in group 1 and 15 patients (11 atresia, 4 stenosis) in group 2. A female sex bias existed in group 1 (female-male [9:5]) compared to group 2 (female-male [7:8]). There was no difference in birth weight, age at operation, chromosomal anomalies, or congenital heart disease between the groups. There were no duodenal anastomotic leaks in either group. Operative times were similar between groups (96 vs 126 minutes; P = .06). The length of postoperative hospitalization (20.1 vs 12.9 days; P = .01), time to initial feeding (11.3 vs 5.4 days; P = .002), and time to full oral intake (16.9 vs 9 days; P = .007) were all statistically shorter in group 2. CONCLUSIONS The laparoscopic approach to CDO repair using U-clips is safe and efficacious. In addition, patients undergoing laparoscopic repair of CDO had a shorter length of hospitalization and more rapid advancement to full feeding compared to babies undergoing the open approach. We feel that in the hands of experienced laparoscopic surgeons, the preferred technique for correction of CDO will become the laparoscopic U-clip repair.

Current significance of meconium plug syndrome

BACKGROUND The significance of meconium plug syndrome is dependent on the underlying diagnosis. The incidence of pathologic finding, particularly Hirschsprungs disease, contributing to the presence of these plugs, has been debated. However, there are little recent data in the literature. Therefore, we reviewed our experience with meconium plugs as a cause of abdominal distension to evaluate the associated conditions and incidence of Hirschsprungs disease. METHODS We reviewed the records of newborns with meconium plugs found in the distal colon on contrast enema from 1994 to 2007. Demographics, radiologic findings, histologic findings, operative findings, and clinical courses were reviewed. RESULTS During the study period, 77 patients were identified. Mean gestational age was 37.4 weeks and birth weight, 2977 g. Hirschsprungs disease was found in 10 patients (13%). One had ultrashort segment disease and another had total colonic aganglionosis. Maternal diabetes was identified in 6 patients. No patients were diagnosed with cystic fibrosis, meconium ileus, malrotation, or intestinal atresia. CONCLUSION Meconium plugs found on contrast enema are associated with a 13% incidence of Hirschsprungs disease in our experience. Although all patients with plugs and persistent abnormal stooling patterns should prompt a rectal biopsy and genetic probe, the incidence of Hirschsprungs and cystic fibrosis may not be as high as previously reported.

Lectin as a marker for staining and purification of embryonic pancreatic epithelium

The embryonic pancreatic epithelium, and later the ductal epithelium, is known to give rise to the endocrine and exocrine cells of the developing pancreas, but no specific surface marker for these cells has been identified. Here, we utilized Dolichos Biflorus Agglutinin (DBA) as a specific marker of these epithelial cells in developing mouse pancreas. From the results of an immunofluorescence study using fluorescein-DBA and pancreatic specific cell markers, we found that DBA detects specifically epithelial, but neither differentiating endocrine cells nor acinar cells. We further applied this marker in an immunomagnetic separation system (Dynabead system) to purify these putative multi-potential cells from a mixed developing pancreatic cell population. This procedure could be applied to study differentiation and cell lineage selections in the developing pancreas, and also may be applicable to selecting pancreatic precursor cells for potential cellular engineering.

Justification for an abbreviated protocol in the management of blunt spleen and liver injury in children

OBJECTIVE(S) The current management of blunt spleen/liver injury in children requires a number of days of bed rest equal to the grade of injury plus 1. This protocol is used even when there is no clinical indication of ongoing bleeding. To establish a prospective protocol with an abbreviated period of bed rest, we conducted a retrospective review of our blunt spleen and liver trauma experience to examine the safety of such an attenuated protocol. METHODS A retrospective analysis of our most recent 10-year experience (January 1996 to December 2005) with blunt spleen or liver injury was performed. Patient demographics, vital signs, hemoglobin levels, need for transfusion, operations, and outcomes were measured. An abbreviated protocol using 1 night of bed rest for grades 1 and 2 injuries and 2 nights of bed rest for higher grades was designed. This protocol was then applied to our patient population to assess its safety. Data are expressed as mean +/- SD. RESULTS During the study period, 243 patients were admitted with blunt spleen and/or liver injury. The mean patient age was 9.0 +/- 4.6 years, and the mean weight was 35.3 +/- 19.3 kg. Sixty-three percent were male. The spleen was injured in 148 (61.2%) patients and the liver in 121 (50.0%), and 26 (10.6%) had both. The mean grade was 2.0 +/- 1.1, for which the mean bed rest was 3.5 +/- 1.1 days. This resulted in 5.6 +/- 6.5 days of hospitalization. There were 9 patients who died, 7 with severe brain injury and 2 with massive liver hemorrhage on presentation. No patient required an operation or transfusion after 2 nights of observation who did not have clinically obvious signs of ongoing blood loss. Implementation of the abbreviated protocol would have affected 65.8% of our patients and would have saved a mean of 2.0 +/- 1.5 hospital days per patient. CONCLUSIONS According to our data, an abbreviated trauma protocol with overnight bed rest for grades 1 and 2 injuries and 2 nights for higher grades could be safely used. This protocol would immensely improve current resource use. Based on these retrospectively collected data, we have initiated a prospective consecutive controlled series to assess the safety of such an attenuated protocol.

Laparoscopic duodenal atresia repair using surgical U-clips: a novel technique

Laparoscopic repair of duodenal atresia has been reported. Reports to date have indicated use of standard laparoscopic suturing and knot tying. Unfortunately, there has been a high leak rate associated with the technique. We report our technique of using U-clips for the duodenoduodenostomy, thus limiting trauma to the duodenum during the anastomosis and less risk for postoperative leakage.

Evaluation of pectus bar position and osseous bone formation

PURPOSE Minimally invasive repair has become a popular approach for pectus excavatum (PE). The bar is secured to the thoracic wall and left for approximately 2 years. The authors have noticed an intense bone formation (BF) around some of these bars at removal. A review of children undergoing bar removal was performed to better understand this BF in relation to bar placement. METHODS A retrospective review of children undergoing bar removal after PE repair since January 1998 was performed. Chart review included age at bar insertion and removal, bar insertion position (subcutaneous [SC] v submuscular [SM]), BF on Chest x-ray and at bar removal, operating time, and estimated blood loss (EBL). RESULTS Thirty-six patients underwent bar removal during the study period (16 SC and 20 SM). Chest x-ray evaluation was possible in 27 patients (16 SM, 11 SC). No difference existed for length of time the bar was in place or age at insertion/removal between groups. EBL was higher in the SM (18.3 v 8.8 mL, not significant). BF was seen radiographically in 15 SM and 3 SC patients (P <.001). BF was encountered at removal in 19 SM patients and a single SC patient (P <.001). Operating time was statistically longer (P <.01) for the SM group (30.2 v 15.6 min). CONCLUSIONS Bar position during repair of PE is important. SM positioning virtually always results in BF with increased EBL and statistically longer operating time at removal. Careful placement of the bar in the SC position without violating the fascia should be used to avoid these undesirable effects.

Management of Pediatric Acute Appendicitis in the Computed Tomographic Era

BACKGROUND/PURPOSE The treatment options for complicated appendicitis in children continue to evolve. Optimal management of complicated appendicitis relies on an accurate preoperative diagnosis. We examined the accuracy of our preoperative diagnosis including computed tomography (CT) and the influence on the management of children with perforated and nonperforated appendicitis. METHODS Following IRB approval, a 6-year review of all patients that underwent an appendectomy for suspected appendicitis was performed. Treatments included immediate operations and initial nonoperative management (antibiotic therapy +/- percutaneous drainage of abscess). Appendicitis was confirmed by histological examination. RESULTS One thousand seventy-eight patients underwent appendectomy for suspected appendicitis. Preoperative CT scans were performed in 697 (64.7%) patients: 615 (88.2%) positive for appendicitis; 42 (6.0%) negative; and 40 (5.7%) equivocal. One hundred seventy-three (28.1%) positive CT scans further suggested perforation. Initial nonoperative management was initiated in 39 (22.5%) cases of suspected perforated appendicitis with abscess. The positive-predictive value (PPV) for suspected acute appendicitis based on history and physical examination alone was 90.8%. The PPV for positive CT scan for acute appendicitis was 96.4% with a PPV of 91.9% for positive CT scan for perforated appendicitis. CONCLUSIONS The correct preoperative diagnosis of appendicitis appears statistically more accurate with CT scan compared to history and physical examination alone (PPV 96.4% versus 90.8%, P = 0.045). For those with clinically suspicious complicated appendicitis, CT evaluation may direct therapy toward initial nonoperative management. The efficacy of this regimen warrants further investigation.