Background and Objectives: Prior research shows an association between increased length of stay (LOS) and weekend surgical admissions, but none have looked at this relationship in children undergoing nonelective cholecystectomy for benign noncongenital biliary disease. We investigated whether weekend admissions lead to a longer LOS in this patient population. Methods: The Statewide Planning and Research Cooperative System database was queried for children ≤ 17 years undergoing cholecystectomy in New York State between January 1, 2009 and December 31, 2012. Parametric and nonparametric statistical testing was used for univariate analysis; multivariable binary logistic regression and linear regression models were used for multivariable analysis. Statistical significance was < 0.05. Results: A total of 1066 pediatric patients underwent nonelective cholecystectomy for gallstone pancreatitis (9.7%) and other benign biliary noncongenital diseases (90.3%), of which 22.1% of all patients were admitted over the weekend. Most cases (97.2%) were treated laparoscopically with an overall 3-day median LOS. Weekend admission was associated with an increased LOS of 4 days as opposed to 3 days during the weekday (p < 0.001). On a multivariable binary logistic regression model controlling for hospital factors, indication for surgery, and comorbidities, weekend admission was associated with 1.92 odds of increased length of stay (adjusted odds ratio of 1.924, 95% confidence interval: 1.386–2.673). Conclusion: Weekend admissions were associated with increased LOS and charges for children requiring nonelective cholecystectomy, despite the wide use of laparoscopic surgery.

Duodenal webs in neonates and infants have been traditionally managed with open or laparoscopic surgery. Surgical management has been associated with high morbidity and mortality and prolonged length of stay. Other treatments include endoscopic resection of the web with cautery or laser energy. This modality carries a high risk of perforation. Endoscopic balloon dilatation has been recently reported with good clinical outcome. Most of the patients reported in the literature required serial balloon dilatations to achieve resolution of the symptoms. We report a 10-month-old infant with duodenal obstruction secondary to a congenital duodenal web. He was successfully managed with a single high-pressure balloon dilatation using an interventional radiology technique. He tolerated liquid diet on day 2 post procedure and was discharged home on day 3. He has remained asymptomatic after 4 years of follow-up.

Purpose: To determine the optimal nonoperative management of periappendiceal abscess in a pediatric population, we compared the therapeutic efficacy and cost-effectiveness of antibiotics alone versus antibiotics plus percutaneous drainage (PD). Methods: We conducted a 10-year retrospective chart review of pediatric patients less than 18 years of age who had acute perforated appendicitis complicated by periappendiceal abscess. Group 1 consisted of patients (N = 35) who received nonoperative management with antibiotics only. Group 2 consisted of patients (N = 11) who underwent PD and also received antibiotics. Group 1 was subdivided into groups IA and 1B. Group lA consisted of patients (N = 25) who responded to antibiotics treatment. Group 1B consisted of patients (N = 10) who were initially treated with antibiotics but subsequently required PD. Patients' demographics, initial clinical presentation, abscess size and location, length of hospital stay, outcome, and complications were compared among these groups. Results: Median hospital stay of group 1A and group 2 was identical at 6 days. Group 1B had a significantly longer median hospital stay of 13 days. There were no deaths and no significant long-term complications in any group. One patient in group lA returned to the emergency room (ER) for abdominal pain and was readmitted for observation. Four patients in group 1B returned to the ER shortly after discharge and required readmission. One of these 4 patients developed acute pancreatitis in addition to enlarging abscess and underwent surgical drainage. There were no documented failures or complications of treatment in group 2 prior to interval appendectomy with the exception of 1 patient lost to follow-up. The presence of small bowel obstruction at the time of admission was an independent predictor of increased length of stay. Conclusions: Antibiotic therapy alone can be effective in a majority of patients and is recommended as initial management. To prevent potential complications and increased cost, PD should not be delayed if clinical symptoms persist or the abscess remains unchanged. Reimaging 6 days after initiation of antibiotic therapy with ultrasound or MRI is recommended to identify patients who would progress on antibiotics alone or who need to receive drainage without delay. (C) 2019 Elsevier Inc. All rights reserved.

Analyze institutional data to identify pediatric patients with Acute Lymphoblastic Leukemia with complicated port removals with a goal to investigate risk factors, formulate approach for difficult port removals, and provide recommendations for placement and removals. A retrospective single-center review of Acute Lymphoblastic Leukemia (ALL) patients between 1-18 years who underwent port removal between Jan 2010-Dec 2016 was conducted. IRB and Quality committee approval were obtained. Patient selection and demographic information for patients was performed utilizing procedure codes for port placement. We excluded patients with non-tunneled central venous lines. Documentation of placement and removal was reviewed, difficult extractions were noted. Sixty three port removals were documented during our study period. Of these 16% (n=10) had retained/embedded ports. Six of the patients required joint removal (Surgery and VIR), and four surgical removal only. Success removal rate via combined approach was 50% (3 of 6) versus 0% success via surgical approach (0 of 4). Of the seven unsuccessful removals, one catheter embolized to the pulmonary vasculature and two were fractured. Thoracotomy or invasive cardiothoracic procedures for removal was not reported. Successfully removed ports had a mean dwell time of 969 days vs. 1474 days for retained/embedded ports (P< 0.05). Age at insertion/removal were not significant risk factors. The most common additional techniques used for difficult extractions were venous cut-down procedures and snare removal. Significant morbidity/mortality related to the retained/embedded ports was not reported. Incidence of retained port catheters was found to be 16%, consistent with similar reports (Wilson et al, J Ped Surg, 2006). Dwell time was a significant risk factor for retained port catheters. Prompt removal of catheters after therapy completion in patient with leukemia, preemptive counselling of patient/families in case of prolonged dwell times, and early involvement of VIR in such cases is recommended. A combined approach is suggestive of higher success rate in removal. Further analysis of implant material type will need to be investigated.Table 1Analysis of Risk factors in Pediatric ALL Patients with Retained Implanted Port at time of RemovalRetained or Embedded Ports (N=10)Simple Removals (N= 62)P ValueMean age at insertion (days)240926920.417 (NS)Mean age at removal (days)364328510.0919 (NS)Mean dwell time (days)1474937.90.0383NS, not significant. Open table in a new tab

Introduction: Vascular malformations remain a rare cause of gastrointestinal (GI) bleeding, and they can present a diagnostic challenge. The diagnostic utility of video capsule endoscopy in identifying these malformations in the pediatric population is not well documented. Case Description: A 7-y-old male with chronic iron deficiency anemia had a clinical history of melena and occasional hematochezia of 1-year duration requiring multiple admissions to the hospital and blood transfusions. Ultrasound, Meckel scan, magnetic resonance imaging, and computed tomography (angiogram) did not demonstrate the source of bleeding. Upper and lower endoscopy studies showed no abnormalities. A video capsule endoscopy showed a lesion in the small intestine suggestive of an arteriovenous malformation. Diagnostic laparoscopy identified the vascular malformation in the mid jejunum. Laparoscopic-assisted intestinal resection including the malformation was successfully performed. After surgical resection, the anemia resolved, and the patient had no further episodes of bleeding. Conclusion: This case illustrates the utility of video capsule endoscopy combined with laparoscopy in the management of a suspected GI arteriovenous malformation in a pediatric patient. Keys Words: Anemia; Arteriovenous Malformation; Gastrointestinal Bleeding; Laparoscopy; Pediatric; Video Capsule Endoscopy.

Traumatic thoracic aortic injuries are rare in the pediatric population. Most patients sustaining this injury do not survive and succumb at the scene. Associated injuries can complicate the management of the aortic injury. Aortic injuries have traditionally been treated by open repair. In the adult population, endovascular stenting has become the management of choice. The pediatric literature has isolated reports of the use of endovascular stenting in the repair of aortic injuries. We report an 11 year old female with multiple injuries and a grade III thoracic rupture with a pseudoaneurysm successfully managed with endovascular stenting.

Lynch syndrome is an autosomal dominant disorder in which one's DNA mismatch repair mechanism is impaired, resulting in an increased risk of developing colon and endometrial cancers, as well as other malignancies. With such an increased risk of colorectal cancer, patients diagnosed with Lynch syndrome should undergo colonoscopy screening every 1–2 years beginning at ages 20 to 25 or two to five years prior to earliest diagnosis of colorectal cancer in their family members. In patients with Lynch syndrome, colorectal cancer usually presents after the fourth decade of life. Few cases have been reported in pediatric patients with early onset colorectal cancer. We report here a 16-year-old patient who presented initially with symptoms characteristic of appendicitis. Following a CT scan suggesting perforated appendicitis, the patient was treated with intravenous antibiotics with a scheduled interval appendectomy three months later. Pathology reports from the interval appendectomy showed that the specimen contained a well-to-moderately differentiated adenocarcinoma. The patient then underwent robot assisted right hemicolectomy as definitive management, which demonstrated that the tumor originated in the cecum with invasion into the submucosa and focally infiltrating the muscularis propria. This case illustrates the need to be cognizant that cancer can present similarly to appendicitis, to be aware of the increasing incidence of colon cancer in younger patients, and to catalyze the acceptability of robotics for minimally invasive surgery.

Methicillin-resistant Staphylococcus aureus (MRSA) is commonly isolated from complex intra-abdominal infections. There have been reports of MRSA isolates from various abdominal infections such as diverticulitis, spontaneous bacterial peritonitis and infected peritoneal dialysis catheters. However, there has been no report of MRSA infection related to appendicitis. We present the first case series of MRSA isolated from the abdominal fluid of two patients presenting with appendicitis and managed with laparoscopic appendectomy. Both patients were found to have MRSA isolates from the peritoneal fluid culture. The two patients underwent successful laparoscopic appendectomy and were discharged on appropriate antibiotic coverage for MRSA to complete the course of treatment. Multiple strategies have been involved to manage MRSA infection. Appropriate targeted therapy with source control remains the mainstay of intra-abdominal infections. We present two cases with MRSA isolates from the peritoneal fluid of patients with acute appendicitis. This finding highlights the importance of obtaining intra-operative cultures during appendectomies to guide post-operative antibiotic therapy. Appropriate antimicrobial therapy is the mainstay of treating these infections and preventing the emergence of multi-drug resistant organisms.

Compare the therapeutic and cost-effectiveness of percutaneous drainage in addition to antibiotics versus antibiotics alone in the treatment of periappendiceal abscess among a pediatric population. We conducted a 12 year retrospective chart review of pediatric patients under 18 years of age with acute perforated appendicitis complicated by periappendiceal abscess. Diagnosis was made by CT, US or MRI examination. Appropriate IRB approval was obtained. Group 1 consists of patients who received non-operative management with antibiotics only (n:26). Group 2 consists of patients who underwent percutaneous drainage by the interventional radiology (IR) service and received antibiotics (n:26). 5/26 patients were initially treated with antibiotics and later required IR drainage. Patients' demographics, initial clinical presentation, abscess size and location, length of hospital stay, outcome and complication were compared between the two groups. The technical aspects of catheter placement (transgluteal versus anterior percutaneous approach) and the associated outcomes were also investigated. 5 patients in group 1 failed management with antibiotics alone and required drainage by IR. There were no failures of treatment in group 2. There was no significant difference in mean hospital stay between the two groups (Group 1: 7 ± 3 days; Group 2: 8 ± 4 days). Prolonged hospital stay is frequently associated with small bowel obstruction or ileus at initial presentation in both groups. There were no deaths and no significant long-term complications in either group. All patients were eventually managed with interval appendectomy. Percutaneous drainage of periappendiceal abscess is safe and effective in the pediatric population. Management with antibiotics alone can be successful in a majority of patients, but is insufficient in a small group of patients (16% failure rate in our group). Both anterior and transgluteal approaches are safe and effective. Transgluteal approach provides accessibility to collections within the deep pelvis not amenable to anterior approach.

Background: Sponge bezoars will absorb luminal contents, enlarge, and subsequently harden.There is significant potential for the development of intestinal obstruction and perforation. Methods:We report the case of an unsuspected polyurethane foam (PUF) sponge bezoar causing intestinal obstruction in an 8-year-old boy undergoing laparoscopy for an ingested lithium battery that was adherent to the cecum or the appendix. Results:The PUF sponge bezoar was removed from the small intestine via laparoscopic-assisted enterotomy.The battery was removed from the colon via colonoscopy after multiple attempts failed to retrieve it during surgery and after surgery with laxatives. Conclusion:This case raises awareness about the presence of unsuspected multiple ingested foreign bodies causing complications and the benefits of laparoscopy in identifying them and facilitating safe retrieval.

Background: Handlebar injuries in the pediatric population have been shown to cause devastating intra-abdominal injuries. We analyzed the impact of handlebar injuries in our pediatric trauma patients over the past 20 years. Methods: We reviewed all of the pediatric bicycle accidents ages 15 years old or younger, who required hospitalization for their injuries. Data was collected from 1995 to 2015. Each case was evaluated for mechanism and severity of injuries, physical and radiographic findings, treatment administered length of hospitalization and patient outcomes. Institutional Review Board approval was obtained. Results: There were 83 pediatric bicycle accidents, which required hospital admission over the past twenty years. 20 out of the 83 patients (24%) sustained direct handlebar injuries. There were 15 males and 5 females ranging from age of 5 to 15 years old (mean 10.3 ± 2.55). Type of injuries included traumatic hernia, bony fractures, and multiple solid organ injuries: spleen (5), liver (3), kidney (2), pancreas (3), and adrenal (1). Most patients were successfully managed nonoperatively with close ICU monitoring. Two patients required surgical intervention for traumatic Spigelian hernia and duodenal perforation. Length of hospitalization for handlebar injuries ranged from 2 to 24 days (mean 6.3 ± 5.81). Outpatient follow-up (between 1 to 8 months) with repeat imaging showed resolving injuries. Conclusion: Over the past 20 years, we have had successful management of severe intraabdominal injuries related to bicycle handlebar with no mortality. Since the implementation of state law to mandate helmets in young riders, the incidence of traumatic brain injuries has decreased. Handlebar injuries in children still continue to pose a problem.

A 22-month-old boy presented to the emergency department approximately 24 hours after suspected ingestion of multiple neodymium sphere magnets. At the time of ingestion, he appeared transiently fussy, vomited several times, but thereafter appeared in his normal asymptomatic state. Chest and abdominal anteroposterior radiographs revealed 8 spherical metallic densities joined in string-like formation within the region of the stomach (Figure A). Emergent esophagogastroduodenoscopy was performed with pediatric surgery on standby because of high risk of gastrointestinal tract perforation. Endoscopic retroflexed view visualized a linear engagement of only 6 of the 8 magnets seen on the radiograph; 3 proximal and 3 distal spherical magnets connected via 2 submucosal spherical magnets through a gastrogastric fistula in the cardia region (Figure B). The fundic end of the magnet chain was grasped using a 4.0-cm Roth net and the entire chain of 8 magnets was extracted en bloc. A postextraction endoscopic reevaluation of the area showed a nonbleeding intragastric channel opening (arrow in Figure C; extracted specimen shown in Figure D). Postprocedural radiographs were negative for free air. The patient was admitted for close observation. Serial abdominal and radiologic examinations including contrast studies showed no signs of perforation. The patient tolerated gradual reintroduction of oral feeds and was discharged on hospital day 4. The estimated number of pediatric magnet ingestion-related emergency department visits in the United States has increased annually in the interval between 2002 and 2011 from 327 to 2770 cases per year. Over this 10-year period, most (59.4%) were boys and more than half (54.7%) occurred in children less than 5 years; however, multiple magnet ingestion accounted for less than 30 actual cases per year with an older mean age of 7.1 years.1Abbas M.I. Oliver-Hemker M. Choi J. et al.Magnet ingestions in children presenting to US emergency departments, 2002-2011.J Pediatr Gastroenterol Nutr. 2013; 57: 18-22Crossref PubMed Scopus (66) Google Scholar Operative complications may occur in up to 50%2Tavarez M.M. Saladino R.A. Gaines B.A. et al.Prevalence, clinical features and management of pediatric magnetic foreign body ingestions.J Emerg Med. 2013; 44: 261-268Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar because the magnets can attract each other across adjacent visceral structures leading to compression, pressure necrosis, enteroenteric fistula, bowel ischemia, obstruction, and/or perforation.3Wright C.C. Closson F.T. Updates in pediatric gastrointestinal foreign bodies.Pediatr Clin North Am. 2013; 60: 1221-1239Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar The United States Consumer Product Safety Commission (CPSC) recalled Buckyball sphere magnet sets in May 2014 thereby legally prohibiting their manufacture, sale, distribution, and importation in the United States. The CPSC issued a federal magnet set safety standard, effective April 2015, which legalized individual magnets fitting within the CPSC’s small parts cylinder having a flux index of 50 kG2mm2 or less.4Consumer Product Safety Commission 16 CFR Part 1240Final rule: safety standard for magnetic sets.Federal Register. 2014; 79: 59962-59989Google Scholar Currently, internal CPSC litigation is reevaluating these regulations after an administrative law judge concluded in March 2016 that these objects are a product hazard only when issued without warnings and/or proper age recommendations.5Consumer Product Safety Commission website. Available at: https://www.cpsc.gov/s3fs-public/pdfs/lawsuit_143ComplaintCounselAppealBrief.pdf. Accessed October 22, 2016.Google Scholar The “clear” consensus of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition endoscopy committee is that in an asymptomatic patient, urgent (ie, less than 24 hours) endoscopic removal of either more than 1 magnet or a single magnet and a metallic object is indicated if the location is accessible.6Kramer R.E. Lerner D.G. Lin T. et al.Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee.J Pediatr Gastroenterol Nutr. 2015; 60: 562-574Crossref PubMed Scopus (270) Google Scholar Our patient developed an intragastric fistula by magnet-to-magnet pressure necrosis despite being within North American Society for Pediatric Gastroenterology, Hepatology and Nutrition urgent timing criteria. This case underscores the rapidity with which complications may emerge after multiple magnet ingestion even in asymptomatic children, and that in some cases an earlier endoscopic retrieval response time should be considered.

Objective: (1) To review the indications, techniques, and treatment outcomes of interventional balloon dilation as a treatment option for congenital duodenal stenosis in infants. (2) To compare and discuss the interventional treatment approach to that of endoscopy to further understand the determinants and scope of practice of each treatment option.

Background and Objectives: Duplications of the alimentary tract are rare anomalies. We report our experience with foregut duplication cysts including their clinical presentation, diagnostic modalities, and surgical management.Methods: We report a 20-year retrospective review of all foregut duplication cysts managed at our institution.Results: Twelve patients with 13 foregut duplication cysts were identified. The ages of the children at the time of surgery ranged from infancy to adolescence, with a mean age of 7.2 years. Half of the patients presented with abdominal pain and vomiting, and the remaining either had respiratory distress or were asymptomatic. All resections were performed electively. Two of the 11 patients had other congenital anomalies, including a congenital pulmonary airway malformation and coarctation of the aorta. One patient had prenatal diagnosis by ultrasonography. Nine patients underwent complete successful excision with no complications. Three patients whose symptoms resolved during hospitalization remained under observation because of parental preference.Conclusions: Foregut malformation in children may present with a variety of symptoms or can be found incidentally. The decision and timing of surgery is based on the clinical presentation. Surgical intervention in asymptomatic patients should be based on a thorough discussion with the parents.

Laparoscopic and thoracoscopic surgery have gradually become accepted diagnostic and therapeutic modalities in the management of neonatal surgical conditions. In the hands of experienced surgeons, minimally invasive surgery (MIS) has reduced the need for open procedures. In children younger than 1 year, the advantages of MIS are evident in avoiding the sequelae of open surgery. MIS has shown outcomes comparable to those with open surgery. The recent literature in the PubMed database was reviewed, using the keywords “minimally invasive surgery,” “neonatology,” “pediatric surgery,” “laparoscopy,” and “thoracoscopy.” The review included retrospective and institutional reports of MIS published since January 2000.The results were used to develop a review of the current state of MIS in the neonatal population. The use of minimally invasive techniques in neonatal surgical conditions was successful in the hands of experienced surgeons. Some procedures currently performed include gastrostomy, pyloromyotomy for hypertrophic pyloric stenosis, gastroesophageal reflux surgery, the Ladd procedure for intestinal malrotation, colonic pull-through procedures for Hirschsprung disease and other anorectal malformations, repair of diaphragmatic eventration and congenital diaphragmatic hernia, duodenal atresia, esophageal atresia/tracheoesophageal fistula, pulmonary lobectomy, surgery for necrotizing enterocolitis, and ligation of patent ductus arteriosus. Further formal training of surgeons in these techniques and the development of new and improved instrumentation can reduce the rates of open surgery and its sequelae in the neonatal population.

Background: Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and non-therapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.Methods: We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.Results: There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.Conclusions: The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.

Gastroesophageal reflux (GER) and gastroesophageal reflux disease (GERD) in newborns and children remain a significant cause of morbidity. Practice patterns and preferences among different institutions and among surgeons vary significantly. Controversial issues include the use of gastrostomy alone versus gastrostomy with Nissen fundoplication, laparoscopic versus open fundoplication, the role of the prophylactic Nissen fundoplication in newborns, Nissen fundoplication in neurologically intact versus neurologically impaired newborns, and the role as well as selection of investigations to evaluate the presence of gastroesophageal reflux in surgical decision making. A review of the recent literature as well as the senior author’s personal experience was used to evaluate the current state of GER surgery in the neonatal population. GER in newborns and young children is treated in various ways at different institutions and by different pediatric surgeons. The paucity of controlled studies of these diagnostic and treatment algorithms continues to be a source of controversy. There is general agreement that fundoplication is the preferred option in cases of severe refractory GER with comorbidities, especially when gastrostomy for feedings is indicated. Neurologically impaired children with GER benefit from antireflux surgery to prevent the complications of GERD. Risks and benefits of each treatment modality must be clearly explained to parents and caregivers early in the surgical decision-making process to ensure improved outcomes for these patients. Additional controlled studies are needed to further assess which practice patterns better serve this patient population.

INTRODUCTION:Abdominal pain during cancer chemotherapy may be caused by medical or surgical conditions. A retrospective review of 5 children with cancer who had appendicitis while receiving chemotherapy was performed.CASE DESCRIPTIONS:Three had acute lymphoblastic leukemia,and 1 each had T-cell lymphoblastic lymphoma and rhabdomyosarcoma. Two of the patients had a Pediatric Appendectomy Score of 6, and 1 each had a score of 7, 5, and 2. All had evidence of appendicitis on computed tomography. Laparoscopic appendectomy was performed without any perioperative complication.DISCUSSION:Appendicitis is an important diagnosis in children with cancer, and laparoscopic appendectomy is safe and the procedure of choice.