Background: Published data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design. Methods: Patients aged 6-17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24-48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms < 48 h, WBC < 18, appendiceal diameter < 11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures. Results: Among 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected "pragmatic" challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL TM scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03). Conclusions: These data corroborate findings from non-randomized studies suggesting 70-90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success. Level of evidence: 1; randomized controlled trial.

We thank Dr. Emil for the thoughtful and critical analysis of some recent studies published in the Journal of Surgical Research regarding the management of pediatric appendicitis. 1 Emil S Letter to the Editor. Standardized care and oral antibiotics on discharge for pediatric perforated appendicitis. J Surg Res. 2021; 267: 717-718 Google Scholar It is with utmost importance that surgeons and clinical researchers carefully evaluate the literature and identify their strengths and weaknesses. Along with Dr. Emil's sentiments, I agree that elimination of variability is imperative in our field.

The rarity and variable presentation of congenital obstruction of the vagina can lead to delayed diagnosis and erroneous management. It is important to be aware of the differential diagnoses and associated anomalies, including the consideration of hydrocolpos (vaginal obstruction) or hydrometrocolpos (indicating uterine involvement), in a female newborn with an abdominal mass and urinary obstruction. A thorough physical genital examination and appropriate imaging can aid in achieving the correct diagnosis. Ultrasonography and magnetic resonance imaging are diagnostic modalities of choice and can reveal associated renal anomalies and the anatomy of complex lesions, although further evaluation may require voiding cystourethrogram. Delayed diagnosis may impair the normal functions of the urogenital system and cause compression of surrounding structures. Interventions range from less complex, such as drainage of imperforate hymen, to more complex reconstructive vaginoplasty through a multidisciplinary team. Early surgical intervention will reduce long-term morbidity.

Supplemental Digital Content is available in the text Objective: The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge. Background: Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children. Study Design: We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation. Results: Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29–3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ± 39 vs 47 ± 27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2. Conclusions: Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

Background: There is little consensus regarding the use of postoperative antibiotics in the management of perforated appendicitis in children. Patients are commonly discharged with oral antibiotics after a course of intravenous antibiotics; however, recent literature suggests that patients can be safely discharged without any oral antibiotics. To further evaluate this protocol, we conducted a multicenter retrospective preimplementation/postimplementation study comparing rates of abscess formation and rehospitalization between patients discharged with and without oral antibiotics. Materials and Methods: We reviewed the records of all pediatric patients who underwent appendectomies for perforated appendicitis at NYU Tisch Hospital, Bellevue Hospital, and Hackensack University Medical Center from January 2014 to June 2019. Data pertaining to patient demographics, hospital course, intraoperative appearance of the appendix, antibiotic treatment, abscess formation, and rehospitalization were collected. Results: A total of 253 patients were included: 162 received oral antibiotics and 91 did not. The median length of antibiotic treatment (oral and intravenous) was 11 (10-14) d for patients on oral antibiotics and 5 (3-6) d for patients without oral antibiotics (P < 0.01). The median leukocyte count at discharge was 9.5 (7.4-10.9) and 8.1 (6.8-10.4) for these groups, respectively (P = 0.02). Postoperative abscesses occurred in 22% of patients receiving oral antibiotics and 15% of patients on no antibiotics (P = 0.25). Rates of rehospitalization for these groups were 10% and 11%, respectively (P = 0.99). Conclusions: Children who have undergone appendectomy for perforated appendicitis can be safely discharged without oral antibiotics on meeting clinical discharge criteria and white blood cell count normalization. (C) 2020 Elsevier Inc. All rights reserved.

Choi, Beatrix H.; Shenoy, Rivfka H. MD; Kuenzler, Keith MD, FACS; Ginsburg, Howard MD, FACS; Fisher, Jason C. MD, FACS, FAAP; Tomita, Sandra MD, FACS Author Information

Pancreatic neuroendocrine tumors (PNETs) occur in the context of tuberous sclerosis complex (TSC). To date, PNETs in association with TSC have been described almost exclusively in adults and in the context of TSC2. We present the evaluation of a PNET in a young child with TSC1. A 3-year, 6-month-old boy with TSC1 was found on surveillance to have a small pancreatic lesion measuring 0.4 cm on magnetic resonance imaging (MRI). The lesion showed interval enlargement to 1 cm on serial MRI studies during the ensuing 16 weeks. Endocrine laboratory tests did not reveal a functional tumor. The patient underwent enucleation of the pancreatic lesion. Microscopic examination defined a well-differentiated PNET, grade II/intermediate grade with a mitotic rate of two mitotic figures per 10 high-powered field and Ki-67 proliferation index of ∼15%. The tumor was positive for the TSC1 gene mutation. The patient was free of tumor recurrence at the 5-year follow-up examination, as determined by endocrine surveillance and annual MRI of the abdomen. In the reported data, PNET in patients with TSC has been primarily reported in association with TSC2. Our case demonstrates that patients with TSC1 can develop PNETs, even at an early age. The international TSC consensus group 2012 recommendation was to obtain MRI of the abdomen every 1 to 3 years for surveillance of renal angiomyolipomas and renal cystic disease. It might be beneficial to add a pancreatic protocol to the surveillance guidelines to evaluate for PNET.

Purpose: The purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job instruction model with a preradiation time-out. Methods: We reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013-2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph. Results: 100 patients with valid DAP measurements were identified for analysis (59 preintervention, 41 postintervention). Following implementation of the radiation safety process, there was a 79% decrease in median DAP (61.4 vs 13.1 rad*cm(2), P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01). Conclusion: A preoperative radiation safety briefing and a radiation safety time-out supported by a job instruction model were effective in significantly lowering, the absorbed doses of radiation in children undergoing CVL insertion. Type of study: Case-control study. (C) 2018 Elsevier Inc. All rights reserved.

A previously healthy 8-month-old female presented with 1 day of bilious emesis and bloody stool. An abdominal radiograph was consistent with a small bowel obstruction (Figure 1; available at www.jpeds.com), and abdominal ultrasound scan revealed a target sign, consistent with an ileocolic intussusception (Figure 2). Attempted air enema reduction was unsuccessful, so the patient underwent an uncomplicated exploratory laparotomy with reduction of the ileocolic intussusception as well as an appendectomy. Intraoperative reports noted extensive intussusception of the small bowel to the level of the sigmoid colon, as well as a cecal serosal tear. On postoperative day 1, the patient had increasing abdominal distension with multiple episodes of bilious emesis and a bloody bowel movement. A nasogastric tube was placed for decompression, and a repeat abdominal ultrasound scan showed a double target sign, indicative of double recurrent intussusception, in the right lower quadrant with extensive bowel wall edema and complex ascites (Figure 3; available at www.jpeds.com). The patient went back to the operating room for a second laparotomy that revealed two additional and separate ileoileal intussusceptions that were reduced. No recurrence of the ileocolic intussusception was found. No pathologic lead points were identified on intraoperative examination. The child's past medical history was significant for a complex febrile seizure that occurred the day after receiving a combination vaccination against tetanus, diphtheria, pertussis, polio, and hepatitis B (2 weeks before this presentation). It is unclear whether vaccination or febrile seizure precipitated the event. The ultrasound appearance of intussusception is typically described as a target lesion with concentric hypoechoic and echogenic layers.1Hryhorczuk A.L. Strouse P.J. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception.Pediatr Radiol. 2009; 39: 1075-1079Crossref PubMed Scopus (117) Google Scholar In addition to being a safe diagnostic tool with no ionized radiation, ultrasonography has been shown to have high sensitivity and specificity for detecting intussusception (sensitivity of 97.9%, specificity of 97.8%, positive predictive value of 86.6%, and negative predictive value of 99.7%).1Hryhorczuk A.L. Strouse P.J. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception.Pediatr Radiol. 2009; 39: 1075-1079Crossref PubMed Scopus (117) Google Scholar Recurrent intussusception after a successful reduction can be seen in 3.0%-15.8% of patients, with up to one-half of these recurrences presenting within 48 hours of the index case.2Gray M.P. Li S.H. Hoffmann R.G. Gorelick M.H. Recurrence rates after intussusception enema reduction: a meta-analysis.Pediatrics. 2014; 134: 110-119Crossref PubMed Scopus (72) Google Scholar, 3Wang Z. He Q.M. Zhang H. Zhong W. Xiao W.Q. Lu L.W. et al.Intussusception patients older than 1 year tend to have early recurrence after pneumatic enema reduction.Pediatr Surg Int. 2015; 31: 855-858Crossref PubMed Scopus (21) Google Scholar, 4Niramis R. Watanatittan S. Kruatrachue A. Anuntkosol M. Buranakitjaroen V. Rattanasuwan T. et al.Management of recurrent intussusception: non-operative or operative reduction?.J Pediatr Surg. 2010; 45: 2175-2180Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar Recurrences are less common in children under 1 year of age3Wang Z. He Q.M. Zhang H. Zhong W. Xiao W.Q. Lu L.W. et al.Intussusception patients older than 1 year tend to have early recurrence after pneumatic enema reduction.Pediatr Surg Int. 2015; 31: 855-858Crossref PubMed Scopus (21) Google Scholar as well as after an operative reduction (3%) compared with enema reduction (11.4%-15.8%).2Gray M.P. Li S.H. Hoffmann R.G. Gorelick M.H. Recurrence rates after intussusception enema reduction: a meta-analysis.Pediatrics. 2014; 134: 110-119Crossref PubMed Scopus (72) Google Scholar, 4Niramis R. Watanatittan S. Kruatrachue A. Anuntkosol M. Buranakitjaroen V. Rattanasuwan T. et al.Management of recurrent intussusception: non-operative or operative reduction?.J Pediatr Surg. 2010; 45: 2175-2180Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar For recurrent intussusception, enema reduction is the standard approach to management and is highly successful, even after an initial operative reduction.4Niramis R. Watanatittan S. Kruatrachue A. Anuntkosol M. Buranakitjaroen V. Rattanasuwan T. et al.Management of recurrent intussusception: non-operative or operative reduction?.J Pediatr Surg. 2010; 45: 2175-2180Abstract Full Text Full Text PDF PubMed Scopus (75) Google Scholar, 5Fisher J.G. Sparks E.A. Turner C.G. Klein J.D. Pennington E. Khan F.A. et al.Operative indications in recurrent ileocolic intussusception.J Pediatr Surg. 2015; 50: 126-130Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 6Bai Y.Z. Chen H. Wang W.L. A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children.J Pediatr Surg. 2009; 44: 755-758Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar In our patient, repeat operative management was chosen over enema reduction because of the concern for necrotic bowel and risk of perforation. Overall, the vast majority of intussusceptions are ileocolic (98%), and only a small percentage are ileoileal (0.7%).7Hsu W.L. Lee H.C. Yeung C.Y. Chan W.T. Jiang C.B. Sheu J.C. et al.Recurrent intussusception: when should surgical intervention be performed?.Pediatr Neonatol. 2012; 53: 300-303Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar One case series identified 6 patients with single ileoileal intussusception 2-4 days after surgical reduction of ileocolic intussusception.6Bai Y.Z. Chen H. Wang W.L. A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children.J Pediatr Surg. 2009; 44: 755-758Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Patients in this study presented with progressive abdominal distension and bilious emesis like our patient. However, unlike our patient, none reported bloody stool. Double (simultaneous) intussusceptions are rare, with only 10 cases identified, none of which occurred after reduction of a primary intussusception.8Shiu J.R. Chao H.C. Chen C.C. Chi C.Y. Rare concurrent ileoileal and ileocolic intussusceptions in a child presenting with painless hematochezia.Pediatr Neonatol. 2010; 51: 359-362Abstract Full Text PDF PubMed Scopus (5) Google Scholar, 9Singh J.K. Bawa M. Kanojia R.P. Ghai B. Menon P. Rao K.L. Idiopathic simultaneous intussusceptions in a neonate.Pediatr Surg Int. 2009; 25: 445-447Crossref PubMed Scopus (8) Google Scholar, 10Pandey A. Rawat J.D. Wakhlu A. Kureel S.N. Gopal S.C. Simultaneous occurrence of jejuno-jejunal and ileo-ileal intussusception in a child: a rare occurrence.BMJ Case Rep. 2011; https://doi.org/10.1136/bcr.08.2010.3294Crossref Scopus (8) Google Scholar The reported cases included double ileoileal, double ileocolic, double colocolic, simultaneous ileocolic and ileoileal, and simultaneous jejunojejunal and ileoileal.8Shiu J.R. Chao H.C. Chen C.C. Chi C.Y. Rare concurrent ileoileal and ileocolic intussusceptions in a child presenting with painless hematochezia.Pediatr Neonatol. 2010; 51: 359-362Abstract Full Text PDF PubMed Scopus (5) Google Scholar, 9Singh J.K. Bawa M. Kanojia R.P. Ghai B. Menon P. Rao K.L. Idiopathic simultaneous intussusceptions in a neonate.Pediatr Surg Int. 2009; 25: 445-447Crossref PubMed Scopus (8) Google Scholar, 10Pandey A. Rawat J.D. Wakhlu A. Kureel S.N. Gopal S.C. Simultaneous occurrence of jejuno-jejunal and ileo-ileal intussusception in a child: a rare occurrence.BMJ Case Rep. 2011; https://doi.org/10.1136/bcr.08.2010.3294Crossref Scopus (8) Google Scholar Supported by the National Center for the Advancement of Translational Science (U1TR000038), National Institutes of Health (NIH) (U1TR000038) (to. G.G.-von S), and the National Institute for Diabetes and Digestive and Kidney Diseases (R25DK092170-05), NIH (R25DK092170-05) (PI G.G.-von S.). Figure 3Postoperative abdominal ultrasound scan showing a double target sign, consistent with double ileoileal intussusceptions. Within the right lower quadrant there is intussusception with markedly thickened and edematous loops of bowel measuring approximately 1.5 cm.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Purpose: Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications.Methods: We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application.Results: 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events).Conclusions: This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI.Type of study: Diagnostic study/Retrospective study. (C) 2017 Elsevier Inc. All rights reserved.

Ramaraj, Akila; Lighter-Fisher, Jennifer MD; Shopsin, Bo MD, PhD; Stachel, Anna MPH; Rosenberg, Rebecca E. MD; Chopra, Arun MD; Kuenzler, Keith A. MD, FACS; Tomita, Sandra S. MD; Ginsburg, Howard B. MD; Fisher, Jason C. MD Author Information

Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively.

Purpose Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. Methods Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. Results Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. Conclusion Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.

BACKGROUND:The effect of perforated appendicitis on the adnexa is an issue of concern and controversy. Long-term fertility studies have been conflicting.CASE:We present the case of a patient with chronic pelvic infections, salpingitis, and hydrosalpinx after perforated appendicitis.SUMMARY AND CONCLUSION:Magnetic resonance imaging was helpful in diagnosing a chronically obstructed fallopian tube, likely secondary to the dense adhesions from her previously treated perforated appendicitis. Salpingectomy relieved her symptoms of chronic pain and recurrent infections.

Background: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. Case Report: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. Why should an emergency physician be aware of this?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations. (C) 2015 Elsevier Inc.

The omphalomesenteric duct (OMD), a temporary structure essential to fetal development, normally involutes completely by week 8 or 9 of gestation. On occasion, the OMD persists, the clinical presentations of which vary widely. We describe a case of a 6-week-old male with a patent OMD remnant that was initially treated as an umbilical granuloma, which then potentially allowed for prolapse of the small bowel through the umbilical ring. The patient required resection of the incarcerated bowel but had an otherwise uneventful and complete recovery.

A 3-year-old boy was seen in the emergency room after his mother noted neck swelling, drooling, and dysphonia. This occurred after a brief coughing episode and one episode of vomiting. Although he was never diagnosed with asthma, the patient had a history of severe paroxysms of coughing. On examination, he had palpable subcutaneous emphysema of the neck, upper chest, and upper back. There were bilateral rhonchi (low pitched, snore-like sounds) on lung examination. He had no neurologic deficits. A chest X-ray showed significant subcutaneous emphysema of the soft tissues of the neck and chest. A neck and chest computed tomography (CT) scan ([Figs. 1] and [2]) showed severe pneumomediastinum with extensive subcutaneous emphysema tracking along the fascial planes of the neck, supraclavicular regions, right upper extremity, anterior chest wall, and epidural space. He underwent an esophagram which was negative for perforation. He was observed in the hospital for a day and discharged to home the next day. During this hospitalization he was diagnosed with asthma and is currently being treated for such.