Purpose: This report describes a minimally invasive short-stay open appendectomy technique which improves the length of stay in comparison to traditional open appendectomy and improves the cost of hospitalization in comparison to laparoscopic appendectomy.Study Design: This retrospective analysis reviewed 100 consecutive children treated with traditional open appendectomy and 100 consecutive children treated with a minimally invasive short-stay open technique with local infiltration of bupivacaine hydrochloride. Data collected for each child included age, sex, diagnosis, operative time, return to activity time, complications, length of stay, and hospital charge.Results: The mean length of stay (LOS) was reduced from 2.7 days for traditional open appendectomy patients to 1.0 day for minimally invasive short-stay open appendectomy. The mean hospital charge (HC) for this short-stay open appendectomy, $6795, was significantly less than the mean HC for traditional open appendectomy ($8162), and for laparoscopic appendectomy ($7668).Conclusion: This short-stay open appendectomy technique offers an efficacious alternative to both traditional open appendectomy and laparoscopic appendectomy.

Purpose: The purpose of this study was to determine, in a pediatric population less than 5 years of age, which size catheter is ideal for central venous access via the subclavian and internal jugular vein based on the children's age, weight, and height.Methods: This was a retrospective chart review of children less than 5 years of age at The Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, height, weight, primary disease, access site, type of central venous catheter, size of central venous catheter, and complications were recorded. Age, weight, and height were stratified and compared with catheter size to determine any correlation between age, weight, height, and complications.Results: There were 430 central venous catheters placed via the subclavian or internal jugular vein in 331 patients less than 5 years old. One hundred ninety-five catheters (45.4%) were less than 6F in size, and 235 (54.6%) catheters were greater than or equal to6F in size. Children, who were between 0.5 and 0.99 years old, 5 to 7.49 kg in weight, 7.5 to 9.99 kg in weight, and 60 to 74.9 cm in height had higher complication rates (P < .05) when catheters greater than or equal to6F were inserted. Children who were greater than 1 year of age, greater than 10 kg in weight, and longer than 75 cm in height did not experience a significant difference (P > .05) in complications versus catheter size.Conclusions: The choice of central venous catheter size should be predicated, not only on the primary disease, but also on the child's age, weight, and height. Insertion of central venous catheters larger than 6F in children less than 1 year of age, less than 10 kg in weight, or less than 75 cm in height, was associated with higher complications compared with other settings. (C) 2004 Elsevier Inc. All rights reserved.

PURPOSE:The aim of this study was to determine in a pediatric population whether a routine chest x-ray after central venous access is necessary when the central venous catheter is placed with intraoperative fluoroscopy. METHODS:This was a retrospective review of the charts of all patients at Children's Hospital in Denver, Colorado who underwent subclavian or internal jugular central venous catheter placement from January 1, 1998 through December 31, 2001. Age, sex, primary reason for access, access site, number of venipuncture attempts, type of catheter, intraoperative fluoroscopy results, chest x-ray results, location of the tip of the catheter, and complications were analyzed. RESULTS:There were 1,039 central venous catheters placed in 824 patients, 92.6% in the subclavian vein and 7.4% in the internal jugular vein. There were 604 (58.1%) children who had both fluoroscopy and a postprocedure chest x-ray, there were 308 (29.6%) who had only fluoroscopy, there were 117 (11.3%) who had only a postprocedure chest x-ray, and there were 10 (1.0%) who had neither fluoroscopy nor chest x-ray. On completion of the procedure, there were 12 (1.1%) children with misplaced central venous catheters, only 1 (0.1%) when intraoperative fluoroscopy was used. There were 17 (1.6%) complications; 9 (0.9%) were pulmonary (pneumothorax, hemothorax, or an effusion). All children with pulmonary complications experienced clinical signs and symptoms suggestive of the complication after their central venous catheter insertion but before their postprocedure chest x-ray. CONCLUSIONS:The number of complications encountered in children who had central venous access of the subclavian vein or internal jugular central vein with intraoperative fluoroscopy was infrequent, the number of misplaced catheters was minimized with intraoperative fluoroscopy, and all children with pulmonary complications showed clinical signs suggestive of pulmonary complications before postoperative chest x-ray. Therefore, children who have had central venous access of the subclavian and internal jugular vein with intraoperative fluoroscopy do not appear to require a routine chest x-ray after catheter placement unless clinical suspicion of a complication exists.

Background/Purpose: Appendicitis continues to present a diagnostic dilemma in children of all ages leading to increased utilization of radiographic studies. Focused computed tomography (CT) scanning has become the diagnostic test of choice in many hospitals. The purpose of this study was to critically evaluate the use of radiographic studies for the evaluation of acute appendicitis in children and to determine if diagnostic accuracy has improved.Methods: Children undergoing appendectomy for acute appendicitis were reviewed from 1997 to 2001. Diagnostic workup (CT scan, ultrasound [US], or no radiographic study) was recorded as were the final pathology results.Results: Six hundred sixteen appendectomies were performed. Mean age was 10.4 +/- 4.1 years, and 60% were boys. Overall, 184 children (30%) underwent CT scanning, 104 (17%) had US performed, and 310 (50%) had no radiographic study (18 patients had both CT and US performed). A pathologically normal appendix was removed in 7% (14 of 202) of CT patients, 11% (14 of 122) of US patients, and 8% (26 of 310) of patients without a study. The frequency of CT scanning increased from 1.3% of all children in 1997 to 58% in 2001, whereas utilization of US decreased from 40% to 7%. Over the same period, the overall negative appendectomy rate did not change significantly from 8% to 7%.Conclusions: With increased utilization of focused CT scanning, the negative appendectomy rate has remained unchanged. History and physical examination by an experienced surgeon is as accurate as CT in correctly diagnosing acute appendicitis in children.

BACKGROUND/PURPOSEThis study demonstrates a minimally invasive technique for upper esophageal coin extraction.METHODSA retrospective review was conducted of 36 children who had upper esophageal coins extracted using a Magill forceps.RESULTSAll coins were removed without complication in approximately 45 seconds (33 on the first attempt, 3 on the second attempt).CONCLUSIONSThis technique minimizes instrumentation of the esophagus and is highly successful at removing coins lodged at or immediately below the level of the cricipharyngeus muscle.

Neonatal hyperparathyroidism (NPHP) is exceedingly rare and often fatal. A neonate is presented with a serum calcium concentration of 33 mg/dL, an intrathyroid parathyroid gland, and a family history of hypocalciuric hypercalcemia (FHH). She underwent successful total parathyroidectomy. Six years later, the child is normocalcemic and developmentally normal, requiring calcium and calcitrol replacement. The results of this case support the concept that NPHP is associated with parathyroid hyperplasia and is part of a continuum that includes FHH. J Pediatr Surg 35:1517-1519. Copyright © 2000 by W.B. Saunders Company.

Failure of the Nissen fundoplication can be secondary to disruption of the wrap or slippage of the stomach upward within the wrap. A modification of the Nissen fundoplication was devised and implemented between 1982 and 1995 to eliminate these complications. This report describes the modification and the results. Commonly, the Nissen fundoplication uses a single anterior row of sutures securing the wrapped stomach to the esophagus. This modification reinforces the wrap with two additional rows of suture, one right lateral and one left lateral, each further anchoring the wrapped stomach to the esophagus. This retrospective analysis compares the Nissen and modified Nissen fundoplications performed at our institution. Fundoplication operations were considered a failure if they required a reoperation secondary to wrap disruption or stomach slippage. Data were analyzed using the χ2 method. A total of 948 fundoplication procedures were performed; 326 Nissen and 622 modified Nissen. Follow-up ranged from 0.5 to 13 years (mean, 6 years). Thirteen wrap disruptions and six stomach slippages occurred in the Nissen group (5.8%); 10 wrap failures and no stomach slippages occurred in the modified Nissen group (1.6%), P < .05. The authors conclude that this modification of the Nissen fundoplication significantly reduces wrap disruptions and stomach slippages.

Data from 505 patients (1976 through 1995) who underwent anterior spinal exposure were retrospectively analyzed. There were 222 boys and 283 girls with a mean age of 14.5 years; 166 had thoracic exposure (T), 300 thoracoabdominal (TA), 44 retroperitoneal (R), and 7 transperitoneal (TP); 17 had repeat exposure (5 had initial exposure elsewhere); 70% had scoliosis, 25% kyphosis, 27% a neuromuscular disorder (NMD) and 6.7% a tumor. Average intensive-care-unit stay was 2.5 days, 6.2 days for NMD (P < .05); average ileus was 3.4 days, 4.1 days for NMD (P < .05); and average length of stay was 15.4 days for all patients, 19.3 days for NMD (P < .05). Mechanical ventilation over 96 hours was required in 31 patients, 66% had an NMD (P < .05). The morbidity rate was 9.8%, 10.1% for NMD; the morbidity rate was zero for tumor and repeat exposures. Mortality was zero. Over half of the vessel injuries (57%) and the urinary tract infections (60%) occurred in NMD patients. Differences between the 1976 through 1985 period and the 1986 through 1995 period were a shorter length of stay and a majority of one-stage combined exposures in the latter period. The authors conclude that anterior exposure of spinal deformities is well tolerated by most pediatric patients, and that this technique is easily adaptable to the resection of retroperitoneal and thoracolumbar tumors.