PURPOSE:The applicability of minimally invasive surgical techniques to pediatric surgical diseases continues to grow. Surgeons have hesitated to apply these methods to congenital diaphragmatic hernia (CDH) of Bochdalek because of the disease-associated pulmonary hypertension and patient fragility. We began performing thoracoscopic repair (CDH-T) in 2004 and have since completed 29 sequential repairs. To evaluate feasibility and outcomes, we compared this experience to a historical control group who underwent open repair (CDH-O) at the same institution by the same surgeons from 2001 to 2004. METHODS:From January 2001 through November 2007, 72 neonates were evaluated jointly by the Neonatology and Pediatric Surgical services for CDH. Fifteen infants died before any corrective operation and were excluded from analysis. Demographics including gestational age, birth weight, Apgar scores, percent outborn, usage of extracorporeal life support, and associated anomalies were recorded. End points were complications, additional operative procedures, initial patch closure, recurrence, length of stay in non-extracorporeal membrane oxygenation patients, and postoperative mortality. RESULTS:Demographic characteristics were similar between the 2 groups. There were no statistically significant differences in complications (71.5% vs 55%, P = .28), additional related operative procedures (42.9% vs 34.5%, P = .59), use of prosthetic patch (42.8% vs 51.7%, P = .60), recurrence (6.9% vs 20.7%, P = .25), length of stay (24 vs 34 days, P = .11), or postoperative mortality (21.4% vs 6.9%, P = .14) between the CDH-O and CDH-T groups, respectively. There was one conversion in the CDH-T group (3.4%). CONCLUSIONS:To our knowledge, this is the largest reported series of CDH-T of neonatal CDH of Bochdalek. We have demonstrated the feasibility of performing this procedure thoracoscopically in an unselected population including children who have undergone prior extracorporeal life support. These results compare favorably with CDH-O, although further follow-up is required to determine the durability of the approach.

After completing this article, readers should be able to: Cholestatic jaundice presenting in the newborn period is a potentially serious disorder that may result from either a treatable or a nontreatable disorder. The clinician initially must recognize the presence of prolonged or pathologic jaundice. Many healthy infants have jaundice during the first postnatal week that resolves spontaneously, often referred to as physiologic jaundice. Persistence of jaundice or the presentation of jaundice after the tenth postnatal day should raise suspicion for pathologic causes. Conjugated hyperbilirubinemia also is of concern and should prompt early investigation. The differential diagnosis of neonatal cholestasis is lengthy, with extrahepatic biliary atresia being the most common single cause (33%). “Idiopathic neonatal hepatitis,” a diagnosis made commonly in the past, is now an anachronistic term because the number of cases labeled “idiopathic” continues to diminish as more definitive genetic and molecular tests become available. The remainder of patients presenting with neonatal cholestatic jaundice have an anatomic abnormality, an obstructing extrahepatic lesion, an infectious cause, or an inherited or metabolic disorder as the explanation for their persistent jaundice. Toxic or hepatic vascular causes have been described rarely.Jaundice and acholic stools may be the only specific signs of these disorders. Weight loss and appetite changes are common but not universal. Often, the sole finding on physical examination is jaundice. When present, the other findings may be mild hepatomegaly or the stigmata of certain inherited syndromes (eg, Alagille syndrome with the typical facies). If biliary atresia is discovered late, the clinician may detect a firm, enlarged liver and even splenomegaly.The various anatomic or obstructive cholestatic disorders tend to be amenable to surgical correction. Included in this set of disorders are choledochal cyst, stenosis of a bile duct and sclerosing cholangitis of the newborn, and biliary atresia. Cholelithiasis can occur in infancy but is extremely rare. Spontaneous perforation of the common bile duct can present with jaundice alone.Neonatal cholestasis also can result from infection. Viral infections, including adenovirus, enterovirus, hepatitis (A, B, C, D, and E), herpesviruses, human immunodeficiency virus, reovirus, rubella, and parvovirus, can present as neonatal jaundice. Bacterial septicemia can present with jaundice, as can infection with Listeria monocytogenes, syphilis, or tuberculosis. Parasitic infestation with toxoplasmosis also can result in neonatal jaundice.A variety of familial intrahepatic cholestatic syndromes exists. Among these, Alagille syndrome (arteriohepatic dysplasia) is the best known. This disorder consists of jaundice, characteristic facies, pulmonary stenosis, butterfly vertebrae, growth and mental retardation, and hypogonadism. Again, the term “intrahepatic biliary atresia” is no longer used.Among the various metabolic disorders that can present with neonatal jaundice are disorders of amino acid metabolism (hypermethioninemia, tyrosinemia), disorders of bile acid synthesis, and disorders of glucose metabolism (galactosemia, fructose intolerance, glycogen storage disease type IV). Metabolic disorders in the differential diagnosis of neonatal jaundice also include Zellweger syndrome (cerebrohepatorenal syndrome), disorders of oxidative phosphorylation, arginase deficiency, alpha-1-antitrypsin deficiency, and cystic fibrosis (which may cause inspissated bile and partial ductal obstruction). The diagnosis and management of extrahepatic biliary atresia is addressed in this article. More detailed discussions of neonatal cholestasis can be found in the articles listed as Suggested Readings.The diagnosis of biliary atresia carries grave implications for the infant and family and cannot be left to probability; it must be established with certainty. No diagnostic studies other than operative cholangiography provide certainty in the time that permits effective, although not assured, long-term intervention (short of liver transplantation). The goal of diagnostic study, therefore, is limited not to a definitive statement as to the diagnosis, but rather to separating cholestatic jaundice in the infant from metabolic and hepatocellular causes of jaundice and providing a sufficiently sensitive differentiation in time to allow effective surgical intervention. Extrahepatic biliary atresia is diagnosed in only 25% to 30% of neonates who have cholestatic jaundice (Table 1).Separating physiologic from pathologic jaundice is the first step in diagnosis and is aided by knowing the natural history of physiologic jaundice, which usually resolves by 2 weeks of age. Therefore, the infant who is jaundiced and older than 2 weeks should be evaluated for potentially treatable forms of jaundice. Infants who have more than 20% of their bilirubin in the direct form have cholestasis or obstruction of bile flow. Accordingly, the initial step in the evaluation of prolonged jaundice in the infant is to measure total and fractional bilirubin concentrations, a procedure also worth pursuing in the baby younger than 2 weeks of age whose total bilirubin level is elevated beyond expectation.The infant who has elevated conjugated bilirubin and cholestasis should be evaluated expeditiously to allow definitive diagnosis and surgical intervention before effective surgical drainage is precluded. Hospitalization should be considered for any infant who is clinically ill to complete the evaluation for cholestatic jaundice. Most children who have underlying metabolic disorders or infections as a cause of their cholestatic jaundice appear or act ill. Biliary cirrhosis in those who have obstructions progresses rapidly. By 4 weeks of age, the liver is firm and often enlarged; by 6 weeks of age, the spleen may be palpable in the left upper quadrant of the abdomen and the stool is acholic. Urine often is dark. However, the infant most often does not appear ill and is growing normally. Splenomegaly frequently is the first indication of developing portal hypertension, suggesting advanced portal fibrosis. Ascites and other manifestations of portal hypertension are late, appearing after 12 to 16 weeks in untreated infants.Studies should be undertaken to identify hemolytic disease, infectious disease, and the genetic-metabolic disorders (Table 2). These tests may be diagnostic and may differentiate intrahepatic from extrahepatic cholestasis. When results of such evaluations are unrevealing, the biliary tract should be evaluated with ultrasonography and a technetium-99m diisopropyl iminodiacetic acid (DISIDA) or other hepatobiliary nuclear medicine scan. When infants have biliary atresia, the biliary system is not dilated and does not contain stones or sludge. If stones or sludge are present, surgical intervention may be appropriate. However, the prognosis is substantially less ominous if cholelithiasis or choledochal cyst is the preoperative diagnosis. The DISIDA scan confirms the absence of excretion of bile through the liver. Although this finding is not specifically diagnostic of biliary atresia, it mandates that the infant undergo the definitive diagnostic studies—laparotomy and operative cholangiography.Percutaneous preoperative liver biopsy has been used to distinguish biliary atresia from other causes of neonatal cholestasis. Although biopsy can be interpreted correctly in 90% to 95% of cases and in some centers can be performed more expeditiously than a DISIDA scan, it is neither sensitive nor specific enough to provide a definitive diagnosis and carries its own set of risks. Nevertheless, biopsy often is used to direct the diagnostic evaluation of the jaundiced infant.Although it is possible to suspect biliary atresia prior to the operative procedure, exploration often is both a diagnostic and therapeutic intervention. Preoperative percutaneous liver biopsy may demonstrate the classic histology of portal fibrosis with bile duct proliferation; magnetic resonance imaging or endoscopic retrograde cholangiography may display the characteristic ductal appearance. Regardless, the surgeon’s first obligation is to investigate the diagnosis expeditiously with a limited laparotomy. Preoperative preparation includes administration of vitamin K to minimize coagulopathy and intravenous antibiotics appropriate for upper gastrointestinal flora, as well as avoidance of hepatotoxic medications and anesthetics.On entering the right upper quadrant, the liver and extrahepatic biliary tree are examined. Typically, a sclerotic gallbladder is encountered, although less common variants may have a normal-appearing gallbladder with sclerotic distal bile ducts. If a lumen can be found within the gallbladder, needle cholangiography should be performed to evaluate the biliary tree. Classically, the surgeon encounters a nondilated, proximally obliterated ductal system. If the biliary architecture is patent, other diagnoses such as Alagille syndrome, hepatitis, and cholestasis must be entertained. Entities other than extrahepatic biliary atresia do not benefit from additional operative intervention.The liver often is enlarged and has a green hue. Occasionally, frank nodular cirrhosis may be found, although its presence is not an absolute contraindication to proceeding with the definitive operation. Unless a preoperative liver biopsy has been obtained, a wedge liver biopsy is performed. A 1-cm square piece is obtained from the anterior right lobe away from the bed of the gallbladder and is sent for frozen section examination. Classic histologic characteristics such as microscopic bile duct proliferation, periportal inflammation, and giant cell reaction should be documented before proceeding with the definitive procedure because the Kasai portoenterostomy has no value in other causes of neonatal jaundice. Any residual tissue should be saved for future studies such as electron microscopy or metabolic testing.Once the diagnosis of biliary atresia is established, the liver is freed of its ligamentous attachments, and the biliary dissection is initiated. The gallbladder is freed from its bed and used to trace the biliary remnants within the porta hepatis. The tissue anterior to the portal venous and hepatic arterial branches is freed up to its insertion into the liver substance between the bifurcation of the portal vessels. A Roux-en-Y limb of jejunum at least 40 cm in length is brought up to reach the hepatic plate. The fibrous plate of the liver is transected in an effort to expose microscopic biliary radicals, and the limb of jejunum is sewn circumferentially around the exposed substance. Thus, the bile ductules drain passively into the small bowel without direct anastomosis. An orogastric or nasogastric tube is left in place for gastrointestinal decompression. Because the biliary flow is diverted to the jejunum, it is unusual to withdraw bile from the gastric tube. Feedings are initiated once the child is stooling and the gastric tube output has waned.Early operative success is defined by the appearance of colored stools and a declining serum bilirubin concentration. However, the high rate of progression of liver disease and portal hypertension requires close observation by either the surgeon or a pediatric gastroenterologist over several years. Early failure is manifested by inexorable worsening of hepatic synthetic function, failure to thrive, and progressive jaundice. Late failure is characterized by signs of portal hypertension and liver failure. Both circumstances require careful nutritional care, vitamin supplementation, and early referral to a liver transplantation center.Recently, several surgeons have reported series of robotically assisted laparoscopic portoenterostomy. Thus far, in early follow-up, the results seem to be comparable to open surgery, with a 33% long-term success rate. However, the newer techniques may result in fewer adhesions and, therefore, may facilitate liver transplantation. Ultimately, two thirds of children progress to liver failure and require transplantation, although results may be better at more experienced centers.The treatment of biliary atresia does not end with the creation of a portoenterostomy. The success rate of portoenterostomy varies from 30% to 50%. A significant number of infants have primary nonfunction of the portoenterostomy and require evaluation for liver transplantation as a lifesaving procedure. Evidence suggests that the number of operative failures can be decreased by careful postoperative management. The use of postoperative steroids at immunosuppressive doses appears to improve survival. It is hypothesized that this therapy may decrease the inflammatory response in the bile ducts and promote bile flow. Ursodeoxycholic acid also augments bile flow and should be started once oral feedings are initiated. The dose ranges from 15 to 30 mg/kg per day. Administration of prophylactic long-term antibiotics can help prevent the development of cholangitis.Cholangitis is a frequent complication seen after portoenterostomy and often is manifested by fever, increasing bilirubin values, and abnormal liver function test results, as well as abdominal pain and, occasionally, changes in stool color. The prompt recognition of cholangitis is essential to avoid scarring. Treatment is administration of broad-spectrum intravenous antibiotics. Some authors recommend prolonged oral suppressive treatment with penicillin or sulfamethoxazole. Pulse-dose steroids have been used by some clinicians. The use of steroids in cholangitis may not be feasible if significant sepsis is involved, and steroids have not been shown definitively to improve outcome. All patients should receive fat-soluble vitamin (A, D, E, and K) supplementation due to the likelihood of poor absorption. Diets containing a predominance of medium-chain triglycerides may be necessary if fat malabsorption is evidenced.Long-term follow-up is essential. Despite early excellent results, patients often develop progressive liver deterioration. The timing of this decline varies, depending on the initial success of the operation. Even patients who have had an excellent response to the portoenterostomy may develop late-onset liver failure. This failure occurs most often during adolescence, when the need for transplantation may exceed 50% of patients. Female survivors of biliary atresia can become pregnant, but need close follow-up because significant liver deterioration can occur during pregnancy. There have been no reports of second-generation biliary atresia.The development of portal hypertension is common in biliary atresia, due to progressive hepatic fibrosis. Treatments vary from sclerotherapy or banding for bleeding esophageal varices to portosystemic shunts for recalcitrant portal hypertension. The use of percutaneous transhepatic portal systemic shunts is an excellent option and often is a successful bridge until liver transplant can be performed.Reoperation for a failed portoenterostomy remains controversial. At this time, no preoperative test can determine if reoperation will be successful. More operative interventions are associated with more scarring, making subsequent liver transplantation more difficult. Some patients, however, benefit from a re-exploration and removal of either granulation tissue or an anastomotic stricture. Reoperation for a primary failure is unlikely to be successful; liver transplantation may be better.Currently, the best long-term outcome for a patient who has biliary atresia is achieved by the Kasai portoenterostomy followed by orthotopic liver transplantation, when indicated. This situation is likely to remain true until the pathophysiology of the disease is better understood and new treatments can be designed. The primary care practitioner can play a significant role in improving the outcome of portoenterostomy by diagnosing biliary atresia early and referring the patient to an appropriate center. Studies have shown an improved success rate if the procedure is performed prior to 7 weeks of age.Hepatic failure from biliary atresia is the leading indication for liver transplantation in the pediatric age group. Approximately 20% of patients undergoing portoenterostomy survive into adulthood without liver transplant. Fortunately, the results of pediatric liver transplantation have improved consistently over the past 2 decades. Ten-year survival has been reported at 81%, but current techniques likely will improve this result. An older age at transplant also has been shown to improve outcome, reinforcing the value of portoenterostomy as a first-stage therapy. Recent series have reported up to 100% 1-year survival for patients 6 years of age and older. The increased success is attributed to better surgical techniques, improved intensive care, better understanding of infectious diseases, and new immunosuppressive agents such as cyclosporine and FK 506. Patients must be followed very closely, particularly in the first several months after transplant. The balance is delicate between the immunosuppression required to avoid graft rejection and the toxic and infectious complications of the agents used.The shortage of donor organs has led to the development of several creative alternatives to whole organ transplantation in children. Reduced-size cadaveric liver transplantation enables an adult donor to provide a graft to a child, with the left lobe of the donor liver being used. Split-liver transplantation extends this capability by creating two allografts from a single donor to benefit two recipients. These concepts also have been used to develop living-related or even living-nonrelated donor programs, whereby a parent, relative, or friend can serve as the donor. Morbidity to the living donor has been minimal, and the graft function of these other methods has been comparable to whole organ transplants.Although there are not many long-term outcome studies, most children who have had liver transplants attend school and function normally. A few recent studies performed 1 to 2 years after liver transplantation have shown some speech and language delays. This finding warrants additional study, and affected patients may benefit from seeing child development and behavioral specialists for early intervention. The primary cause of extrahepatic biliary atresia remains elusive but is the subject of numerous ongoing collaborative studies.Extrahepatic biliary atresia is a rare and highly morbid condition. When unrecognized, it progresses inexorably to liver failure and death unless liver transplantation is available. However, expeditious evaluation of the jaundiced infant that excludes other disorders and determines the biliary anatomy and function, employing nuclear, ultrasonographic, magnetic resonance, or other modalities, may lead to earlier referral for the appropriate operative intervention, the Kasai procedure. When successful, this procedure may delay or forestall the need for liver transplantation and its attendant morbidity. Improvements in the future may come from venues such as improved diagnostic techniques, determination of causes, better operative technique (including the application of robotics), and refinements in transplantation.

Rizvi, Adnan Z. MD; Kaufman, John A. MD; Smith, Pamela MD; Silen, Mark L. MD, MBA, FACS Author Information

BACKGROUND:Fetal and neonatal ovarian cysts are detected frequently by ultrasonography. The presence of these lesions can result in adnexal torsion in utero with autoamputation. Historically, these have been removed at laparotomy.METHODS:Retrospective chart review was performed at a single children's hospital from October 1996 to September 2001.RESULTS:Six cases of torsion of ovarian cysts were removed laparoscopically. Five of the 6 patients had prenatal ultrasound diagnosis. The sixth had the cyst detected incidentally by magnetic resonance imaging (MRI) at 3 months of age. All cysts were complex by ultrasound criteria. All 6 procedures were performed via a 2-port laparoscopic approach. The average age at surgery was 3.7 months (range, 9 days to 7.5 months). There were no postoperative complications. Five patients were discharged on the day of surgery.CONCLUSION:Laparoscopy offers a safe, effective, and cosmetic means of managing perinatal torsion of ovarian cysts.

OBJECTIVE:Acute appendicitis in children is managed by both general surgeons (GSs) and pediatric surgeons (PSs). Our objective was to investigate the economics of surgical care provided by either GSs or PSs for appendicitis.METHODS:The outcome of children within our state who underwent operative treatment for appendicitis (January 1994 to June 1997) by board-certified GSs were compared with the results of PSs. Data were sorted according to patient age and diagnosis according to the International Classification of Diseases, Ninth Revision. Analysis of variance was performed on continuous data, and chi(2) analysis was performed on nominal data; data are depicted as mean +/- standard error of the mean.RESULTS:GSs (n = 2178) managed older children when compared with PSs (n = 1018; 11.0 +/- 0.1 vs 9.1 +/- 0.1 years) and less frequently treated perforated appendicitis (18.8% vs 31.9%). Independent of diagnosis (simple or perforated appendicitis), younger children (0-4 years, 5-8 years, and 9-12 years) who were treated by PSs had a significantly shorter hospital stay and/or decreased hospital charge when compared with those who were treated by GSs. However, older children (13-15 years) seemed to have comparable outcomes.CONCLUSIONS:Younger children with appendicitis have reduced hospital days and charges when they are treated by PSs.

Background.The major objective of the present study was to determine the severity of nonfatal injuries sustained by children (<16 years old) when a motor vehicle rolls over them. We also sought to determine whether younger children (<24 months old) demonstrated different patterns of injury and/or a worse outcome, compared with older children (>24 months old).Methods.We reviewed the medical records of 3971 consecutive admissions to a single trauma service at an urban children's hospital between March 1990 and October 1994. During this time period, 26 (0.7%) children presented with rollover injuries incurred by motor vehicles in residential driveways. Outcome was measured by length of both intensive care unit admission and hospitalization.Results.Two children died shortly after admission and were excluded from the remainder of the study. Younger children (<24 months old) had significantly higher injury severity scores and lower pediatric trauma scale scores. Both the duration in the intensive care unit and the length of hospitalization were significantly longer in younger children, compared with children >24 months old. One explanation for these observations was that younger children had a significantly higher incidence of both head and neck and extremity injury but a similar incidence and severity of chest and abdominal trauma, compared with older children. Injuries requiring operative intervention were rare.Conclusion.Younger patients sustaining rollover injuries in the residential driveway have a worse outcome, in part, because of the head and neck or extremity injures that they incur. The majority of rollover injuries can be managed conservatively. pediatric trauma, driveway, pedestrian events, rollover injuries, injury severity score, pediatric trauma scale.

BACKGROUND:Traditional therapy for refractory chylothorax in the pediatric population has included pleurodesis and thoracic duct ligation. These procedures are associated with high morbidity and questionable success rates. METHODS:We retrospectively reviewed our experience with 15 patients who underwent treatment for chylous effusions using pleuroperitoneal shunts with exteriorized pump chambers. Mean patient age at time of shunt placement was 2.1 (0.1 to 11.5) years and the most common indication (7 of 15) was refractory chylothorax following surgical correction of congenital heart disease. Mean chylothorax duration before shunt placement was 76 (5 to 810) days and shunts were in place for an average of 104 (12 to 365) days. A total of 19 chylous effusions (pleural or pericardial) were treated with shunts. RESULTS:Nine of 11 right-sided chylothoraces, 5 of 6 left-sided chylothoraces, and 2 of 2 chylopericardia resolved with shunt therapy (84% total). Pleuroperitoneal shunting failed to clear the effusion in 3 children. There were six episodes of shunt malfunction that were repaired and two episodes of infection. Inguinal or umbilical hernia developed in 4 patients. CONCLUSIONS:Externalized pleuroperitoneal shunting is a safe, effective, and minimally invasive treatment for children with refractory chylous effusions.

BACKGROUND:The early experience with thoracoscopy in children has involved the diagnosis and treatment of pleural and pulmonary diseases. Recent advances have allowed surgeons to perform more complex procedures through video-assisted thoracoscopic surgery (VATS), potentially decreasing the pain and pulmonary impairment associated with an open thoracotomy. The authors report their initial experience with thoracoscopic assisted anterior spinal exposure and release as part of the treatment for children with spinal deformities.METHODS:A retrospective chart review of five children who underwent VATS for anterior spinal surgery between June 1995 and January 1997 was performed.RESULTS:The ages of the patients ranged from 11 to 16 years with a mean of 13.4 years. All patients had an anterior spinal release with or without fusion and same-day posterior spinal fusion with instrumentation. VATS was successfully completed in all patients without major morbidity and no mortality. The average operative time for the anterior portion of the procedure was 305 minutes, and a mean of 7 disc levels were released. Mean length of chest tube drainage and hospitalization were 6.8 and 8.6 days, respectively.CONCLUSIONS:The objectives of anterior exposure for spinal surgery in children can safely and effectively be accomplished using minimally invasive surgery.

OBJECTIVE:To compare the survival rates for 3 therapeutic eras, each using different treatment strategies for the management of newborns with congenital diaphragmatic hernia (CDH).DESIGN:Retrospective review of all infants with CDH from 1970 through 1997.SETTING:Tertiary care children's hospital.PARTICIPANTS:A total of 203 newborns with CDH.INTERVENTIONS:Extracorporeal membrane oxygenation (ECMO) was performed with arterial and venous cannulation connected to a membrane oxygenatorroller pump perfusion apparatus, using systemic heparinization. Delayed operative therapy involved operative repair 2 to 5 days after birth using preoperative ventilation support only. Since 1970, 203 newborns with CDH were managed in 3 therapeutic eras: era 1 (1970-1983, 102 patients) was immediate CDH repair with postoperative ventilator and pharmacologic support; era 2 (1984-1988, 45 patients) was immediate repair with postoperative ventilator support (18 patients), immediate ECMO with CDH repair on ECMO (4 patients), or immediate repair with postoperative ECMO (23 patients); and era 3 (1989-1997, 56 patients) was immediate ECMO with repair on ECMO (23 patients), immediate repair with postoperative ECMO (9 patients), or delayed (2-5 days) CDH repair (24 patients).MAIN OUTCOME MEASURES:Survival, defined as discharge from the hospital, and morbidity.RESULTS:Survival was 42% (43/102 patients) in era 1, 58% (26/45 patients) in era 2, and 79% (44/56 patients) in era 3 (P<.02 vs eras 1 and 2). In era 3, the survival for immediate ECMO with repair on ECMO was 57% (13/23 patients), 89% (8/9 patients) for immediate repair with postoperative ECMO, and 96% (23/24 patients) for delayed repair. Eight late deaths were caused by pulmonary hypertension (1 death), sudden infant death syndrome (1 death), and other causes (6 deaths). Morbidity in survivors included mild neurologic deficit (5 patients) and pulmonary disease (3 patients).CONCLUSION:These data demonstrate a significant improvement in survival in CDH with preoperative ECMO and with delayed repair with and without ECMO support and suggest that immediate repair of CDH without the availability of ECMO support should be abandoned.

Background: Most protocols for the operative treatment of perforated appendicitis use a routine culture. Although isolated studies suggest that routine culture may not be necessary, these recommendations generally are not based on objective outcome data.Methods: The authors reviewed the records of 308 children who underwent operative treatment for perforated appendicitis between 1988 and 1998 to determine if information gained from routine culture changes the management or improves outcome. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation.Results: Mean patient age was 7.5 years, 51% were boys, and there was no mortality. The majority of children (96%) underwent culture that was positive for either aerobes (21%), anaerobes (19%), or both (57%). Antibiotics were changed in only 16% of the patients in response to culture results. The use of empiric antibiotics, as compared with modified antibiotics, was associated with a lower incidence of infectious complication, shorter fever duration, and decreased length of hospitalization. We also investigated the relationship between culture isolates and antibiotic regimens with regard to outcome. The utilization of antibiotics suitable for the respective culture isolate or organism sensitivity was associated with an increased incidence of infectious complication and longer duration of both fever and length of hospitalization. Finally, the initial culture correlated poorly with subsequent intraabdominal culture (positive predictive value, 11%).Conclusion: These outcome data strongly suggest that the practice of obtaining routine cultures can be abandoned, and empiric broad spectrum antibiotic coverage directed at likely organisms is completely adequate for treatment of perforated appendicitis in children.

BACKGROUND:Many aspects of the management of perforated appendicitis in children remain controversial. The objective of this study was to define risk factors associated with the development of postoperative complications in children undergoing treatment for perforated appendicitis.METHODS:We reviewed all children (age < 16 years) who were treated for perforated appendicitis at Cardinal Glennon Children's Hospital between 1988 and 1997. Inclusion criteria included either gross or microscopic evidence of appendiceal perforation.RESULTS:Of 285 children with perforated appendicitis, 279 underwent immediate operative treatment. Mean patient age was 7.7 years and there were no deaths. Major postoperative complications included intra-abdominal abscess (n = 17), ileus (n = 7), mechanical intestinal obstruction (n = 6), and wound infection (n = 4). All children who had a postoperative abscess had more than 5 days of symptoms before operation. Within this subgroup, drain placement was associated with not only decreased postoperative abscess formation and but also shorter duration of fever and length of hospitalization. The incidence of mechanical obstruction or ileus was not increased and the rate of wound infection was actually lower after drainage.CONCLUSIONS:Drain placement appears to be helpful in children with late diagnosis but is of little benefit when the duration of symptoms is less than 5 days. Thus it is likely that drains are most useful in patients with well-established and localized abscess cavities.