Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date.Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015.Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years +/- 3.1, the mean operating time was 52 minutes +/- 17.4, the mean length of stay was 4.2 days +/- 1.1, and the mean time to bar removal was 2.7 years +/- 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction.Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.

Background: Laparoscopy through a single umbilical incision is an emerging technique supported by case series, but prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic cholecystectomy to 4-port laparoscopic cholecystectomy.Methods: After IRB approval, patients were randomized to laparoscopic cholecystectomy via a single umbilical incision or standard 4-port access. The primary outcome variable was operative time. Utilizing a power of 0.8 and an alpha of 0.05, 30 patients were calculated for each arm. Patients with complicated disease or weight over 100 kg were excluded. Post-operative management was controlled. Surgeons subjectively scored degree of technical difficulty from 1=easy to 5=difficult.Results: From 8/2009 through 7/2011, 60 patients were enrolled. There were no differences in patient characteristics. Operative time and degree of difficulty were greater with the single site approach. There were more doses of analgesics used and greater hospital charges in the single site group that trended toward significance.Conclusion: Single site laparoscopic cholecystectomy produces longer operative times with a greater degree of difficulty as assessed by the surgeon. There was a trend toward more doses of post-operative analgesics and greater hospital charges with the single site approach. (C) 2013 Elsevier Inc. All rights reserved.

BACKGROUND: A multicenter study of pectus excavatum was described previously. This report presents our final results.STUDY DESIGN: Patients treated surgically at 11 centers were followed prospectively. Each underwent a preoperative evaluation with CT scan, pulmonary function tests, and body image survey. Data were collected about associated conditions, complications, and perioperative pain. One year after treatment, patients underwent repeat chest CT scan, pulmonary function tests, and body image survey. A subset of 50 underwent exercise pulmonary function testing.RESULTS: Of 327 patients, 284 underwent Nuss procedure and 43 underwent open procedure without mortality. Of 182 patients with complete follow-up (56%), 18% had late complications, similarly distributed, including substernal bar displacement in 7% and wound infection in 2%. Mean initial CT scan index of 4.4 improved to 3.0 post operation (severe >3.2, normal = 2.5). Computed tomography index improved at the deepest point (xiphoid) and also upper and middle sternum. Pulmonary function tests improved (forced vital capacity from 88% to 93%, forced expiratory volume in 1 second from 87% to 90%, and total lung capacity from 94% to 100% of predicted (p < 0.001 for each). VO2 max during peak exercise increased by 10.1% (p = 0.015) and O-2 pulse by 19% (p = 0.007) in 20 subjects who completed both pre- and postoperative exercise tests.CONCLUSIONS: There is significant improvement in lung function at rest and in VO2 max and O-2 pulse after surgical correction of pectus excavatum, with CT index >3.2. Operative correction significantly reduces CT index and markedly improves the shape of the entire chest, and can be performed safely in a variety of centers. ((C) 2013 by the American College of Surgeons)

Purpose: Management of postoperative pain is a challenge after the minimally invasive repair of pectus excavatum. Pain is usually managed by either a thoracic epidural or patient-controlled analgesia with intravenous narcotics. We conducted a prospective, randomized trial to evaluate the relative merits of these 2 pain management strategies.Methods: After obtaining permission/assent (Institutional Review Board no. 06 08 128), patients were randomized to either epidural or patient-controlled analgesia with fixed protocols for each arm. The primary outcome variable was length of stay with a power of .8 and alpha of .05.Results: One hundred ten patients were enrolled. There was no difference in length of stay between the 2 arms. A longer operative time, more calls to anesthesia, and greater hospital charges were found in the epidural group. Pain scores favored epidural for the few days and favored patient-controlled analgesia thereafter. The epidural catheter could not be placed or was removed within 24 hours in 12 patients (22%).Conclusions: There is longer operating room time, increase in calls to anesthesia, and greater hospital charges with epidural analgesia after repair of pectus excavatum. Pain scores favor the epidural approach early in the postoperative course and patient-controlled analgesia later. (C) 2012 Elsevier Inc. All rights reserved.

Background There have been numerous reports of techniques used for pectus bar removal after correction of pectus excavatum. We use 2 operating tables positioned perpendicular to each other in a T-shaped configuration with the patients thorax circumferentially exposed so the bar is removed in 1 motion without bending the bar. In this study, we report the results of this procedure. Methods A retrospective chart review of patients undergoing bar removal after repair of pectus excavatum at our institution from August 2000 to March 2010 was performed. Results There were 230 patients with a mean age of 16.7 years (range, 7.8-25.3 years) at bar removal. Mean operative time for bar removal was 28.6 minutes, and average estimated blood loss (EBL) was 9.5 mL (range, 5-400 mL). One patient demonstrated significant hemorrhage from the bar tract after bar removal, which was controlled with circumferential compression wrap. Calcification was noted in 11 patients, and chondroma, in 8 patients. Wound infection after bar removal occurred in 3% of patients. No patient required the bar to be bent into a straight configuration for removal. Conclusions Removal of pectus bars using this 2-table T-configuration technique is safe, is time efficient, and obviates the need for bending the bar.

Only 2 cases of osteosarcoma as a second primary malignancy after neuroblastoma have been reported in the literature. We present a case of chest wall osteosarcoma that developed in a 14-year-old boy 7 years after completion of chemotherapy, autologous peripheral blood stem cell transplantation, radiation, and resection for stage 3, high-risk neuroblastoma. A biopsy of a painful chest wall mass arising from the right third rib diagnosed osteosarcoma. He went on to have preoperative chemotherapy followed by wide local excision and chest wall reconstruction. He then received additional chemotherapy. This case highlights the importance of close observation for second malignancies in this patient population.

BACKGROUND:The 2 most commonly used topical agents for partial thickness burns are silver sulfadiazine (SSD) and collagenase ointment (CO). Silver sulfadiazine holds antibacterial properties, and eschar separation occurs naturally. Collagenase ointment is an enzyme that cleaves denatured collagen facilitating separation but has no antibacterial properties. Currently, there are no prospective comparative data in children for these 2 agents. Therefore, we conducted a prospective randomized trial.METHODS:After institutional review board approval, patients were randomized to daily debridement with SSD or CO. Primary outcome was the need for skin grafting. Patients were treated for 2 days with SSD with subsequent randomization. Polymyxin was mixed with CO for antibacterial coverage. Debridements were performed daily for 10 days or until the burn healed. Grafting was performed after 10 days if not healed.RESULTS:From January 2008 to January 2011, 100 patients were enrolled, with no differences in patient characteristics. There were no differences in clinical course, outcome, or need for skin grafting. Wound infections occurred in 7 patients treated with CO and 1 patient treated with SSD (P = .06). Collagenase ointment was more expensive than SSD (P < .001). However, total hospital charges did not differ.CONCLUSION:There are no differences in outcomes between topical SSD or CO in the management of childhood burns results.

BACKGROUND:The use of steroids in traumatic spinal cord injury (SCI) in children is controversial. There is a paucity of literature on its usage. To help clarify recommendations on steroid use in children, we reviewed the current literature on the administration of high dose methylprednisolone (MP) use in traumatic spinal cord injuries with an emphasis in pediatric spinal cord trauma.METHODS:A retrospective review of the current literature on traumatic spinal cord injuries was conducted. Outcomes were critically reviewed from the National Acute Spinal Cord Injury Studies (NASCIS) II and III and Cochrane review; as well as, other randomized and retrospective studies. Papers describing objective neurological outcomes were only included.RESULTS:The outcomes of neurological improvement following steroid infusion have not been reproducible outside of the NASCIS and one single Japanese trial. High dose steroids significantly increase the risk of infections leading to prolonged hospital stay and ventilator dependence.CONCLUSION:Data from adult studies remains controversial with insufficient data to support administration of MP for treatment of traumatic spinal cord injuries. Randomized controlled trials are needed in the pediatric population to assess the advantages of steroid use after SCI in children. On the basis of the current evidence, the use of steroids in patients is associated with increased infectious risks and no neurological improvements.

Introduction Applicants in the NRMP for pediatric surgery have little objective data available regarding factors predicting successful matching. We analyzed data from applicants at our institution to attempt to identify parameters correlated with three outcomes: successfully matching, or attaining either a top ten or top three ranking in our final submitted match list. Methods After IRB approval, we reviewed ERAS documents for all applicants ( n = 146) over 3 years (candidates for the 2007, 2008, and 2009 fellowship years). An interview was offered to 75% of the applicants (Table 1 ). We analyzed over 20 factors; including demographics, number of publications and first author publications, number of book chapters, national presentations, prior match attempts, advanced degrees, quality of recommendation letters, and ABSITE scores. Significant variables were evaluated with multiple logistic regression analysis to identify independent predictors. Results Variables correlated with successful outcome for each of the three endpoints are shown in Table 2 . The number of peer-reviewed publications and first author publications, and AOA membership were highly correlated with a favorable outcome for all three endpoints. High ABSITE scores were significantly correlated with top ten rank. Research experience and outstanding letters of recommendation were significantly associated with a top ten ranking and overall match success. Variables associated only with overall match success included number of book chapters, graduation from a US medical school, quality of recommendation letters, and being granted an interview at our institution. Logistic regression analysis demonstrated no independent factors for overall match success; number of publications was significant for both top ten and top three ranking ( P = 0.006 for each); number of first author publications ( P = 0.002) and AOA membership ( P = 0.03) were independent predictors for top three ranking. Conclusions Applicant variables associated with success in the match included quality of letters, number and type of publications, research experience, graduation from a US medical school, and AOA membership. Factors not correlated with outcome included advanced degrees (PhD, Masters), other fellowship training, and community-based versus university-based residency training. Logistic regression analysis demonstrated no independent factors for overall match success.

OBJECTIVE:To determine whether pulmonary function decreases as a function of severity of pectus excavatum, and whether reduced function is restrictive or obstructive in nature in a large multicenter study. STUDY DESIGN:We evaluated preoperative spirometry data in 310 patients and lung volumes in 218 patients aged 6 to 21 years at 11 North American centers. We modeled the impact of the severity of deformity (based on the Haller index) on pulmonary function. RESULTS:The percentages of patients with abnormal forced vital capacity (FVC), forced expiratory volume in 1 second (FEV(1)), forced expiratory flow from 25% exhalation to 75% exhalation, and total lung capacity findings increased with increasing Haller index score. Less than 2% of patients demonstrated an obstructive pattern (FEV(1)/FVC <67%), and 14.5% demonstrated a restrictive pattern (FVC and FEV(1) <80% predicted; FEV(1)/FVC >80%). Patients with a Haller index of 7 are >4 times more likely to have an FVC of ≤80% than those with a Haller index of 4, and are also 4 times more likely to exhibit a restrictive pulmonary pattern. CONCLUSIONS:Among patients presenting for surgical repair of pectus excavatum, those with more severe deformities have a much higher likelihood of decreased pulmonary function with a restrictive pulmonary pattern.

Background:Laparoscopic appendectomy through a single umbilical incision is an emerging approach supported by several case series. However, to date, prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic appendectomy to 3-port laparoscopic appendectomy. Methods:After Internal Review Board approval, patients were randomized to laparoscopic appendectomy via a single umbilical incision or standard 3-port access. The primary outcome variable was postoperative wound infection. Using a power of 0.9 and an alpha of 0.05, 180 patients were calculated for each arm. Patients with perforated appendicitis were excluded. The technique of ligation/division of the appendix and mesoappendix was left to the surgeon's discretion. There were 7 participating surgeons dictated by the call schedule. All patients received the same preoperative antibiotics and postoperative management was controlled. Results:There were 360 patients were enrolled between August 2009 and November 2010. There were no differences in patient characteristics at presentation. There was no difference in wound infection rate, time to regular diet, length of hospitalization, or time to return to full activity. Operative time, doses of narcotics, surgical difficultly and hospital charges were greater with the single site approach. Also, the mean operative time was 5 minutes longer for the single site group. Conclusion:The single site umbilical laparoscopic approach to appendectomy produces longer operative times resulting in greater charges. However, these small differences are likely of marginal clinical relevance. The study was registered with clinicaltrials.gov at the inception of enrollment (NCT00981136).

BACKGROUND/PURPOSE:Some institutions recommend early fundoplication in patients with hypoplastic left heart syndrome (HLHS) with signs of gastroesophageal reflux disease because of the risk of reflux-related cardiac events. However, their cardiac physiology may impose high perioperative morbidity and mortality. Therefore, we reviewed our experience with fundoplication in this population to allow for assessment of the risk-benefit ratio.METHODS:A retrospective review of patients with a diagnosis of HLHS who underwent a fundoplication from January 1990 to July 7, 2009, was performed. All patients underwent open fundoplication between first and second stages of cardiac repair.RESULTS:Thirty-nine patients were identified. There were 3 intraoperative complications: hemodynamic instability (n = 2) and a pulmonary hypertensive crisis requiring extracorporeal membrane oxygenation and termination of the procedure (n = 1). There were 27 postoperative complications in 16 patients. There were 2 deaths (4%) within 30 days, and there were 9 deaths (23%) in patients between their first and second stage of cardiac repair during the study period.CONCLUSIONS:Noncardiac surgical procedures in patients palliated for HLHS have a high morbidity and mortality. We recommend that routine fundoplication in this population should only be performed under prospective protocols until the relative risk of operation vs risk of reflux is delineated.

Objective: The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index.Methods: After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (x100) to give the percentage of chest depth the defect represents.Results: There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI.Conclusions: The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations. (C) 2011 Elsevier Inc. All rights reserved.

Background Some surgeons use nonoperative management with or without interval appendectomy for patients who present with perforated appendicitis. These strategies depend on accurately delineating perforation by computed tomography (CT). Since 2005, our institution has used an evidence-based definition for perforation as a hole in the appendix or fecalith in the abdomen. This has been shown to clearly separate those with a high risk of abscess from those without. To quantify the ability of CT to identify which patients would meet these criteria for perforation, we tested 6 surgeons and 2 radiologists who evaluated blinded CT scans. Methods A junior and senior surgical residents, 2 staff interventional radiologists, and 4 attending pediatric surgeons with 3 to 30 years of experience reviewed 200 CT scans of pediatric patients who had undergone a laparoscopic appendectomy. All CT scans were reviewed electronically, and the reviewers were blinded to the results, outcome, and intraoperative findings. None of the patients had a well-formed abscess on CT. The reviewers were asked to decide only on perforated or nonperforated appendicitis according to our intraoperative definition. Clinical admission data were reviewed and compared between groups. Results In total, the reviewers were correct 72% of the time with an overall sensitivity of 62% and a specificity of 81%. The overall positive predictive value was 67%, and the negative predictive value was 77%. Conclusions This study shows that in the absence of a well-formed abscess, the triage of patient care based on a preoperative diagnosis of perforation from CT may be imprudent and subject a portion of the population to an unnecessarily prolonged course of care.

Introduction: Perforated appendicitis is a common condition in children, which, in a small number of patients, may be complicated by a well-formed abscess. Initial nonoperative management with percutaneous drainage/aspiration of the abscess followed by intravenous antibiotics usually allows for an uneventful interval appendectomy. Although this strategy has become well accepted, there are no published data comparing initial nonoperative management (drainage/interval appendectomy) to appendectomy upon presentation with an abscess. Therefore, we conducted a randomized trial comparing these 2 management strategies.Methods: After internal review board approval (# 06 11-164), children who presented with a well-defined abdominal abscess by computed tomographic imaging were randomized on admission to laparoscopic appendectomy or intravenous antibiotics with percutaneous drainage of the abscess (when possible), followed by interval laparoscopic appendectomy approximately 10 weeks later. This was a pilot study with a sample size of 40, which was based on our recent volume of patients presenting with appendicitis and abscess.Results: On presentation, there were no differences between the 2 groups regarding age, weight, body mass index, sex distribution, temperature, leukocyte count, number of abscesses, or greatest 2-dimensional area of abscess in the axial view. Regarding outcomes, there were no differences in length of total hospitalization, recurrent abscess rates, or overall charges. There was a trend toward a longer operating time in patients undergoing initial appendectomy (61 minutes versus 42 minutes mean, P = .06).Conclusions: Although initial laparoscopic appendectomy trends toward a requiring longer operative time, there seems to be no advantages between these strategies in terms of total hospitalization, recurrent abscess rate, or total charges. (C) 2010 Elsevier Inc. All rights reserved.

Introduction In a previous prospective randomized trial, we found a once-a-day regimen of ceftriaxone and metronidazole to be an efficient, cost-effective treatment for children with perforated appendicitis. In this study, we evaluated the safety of discharging patients to complete an oral course of antibiotics. Methods Children found to have perforated appendicitis at the time of laparoscopic appendectomy were enrolled in the study. Perforation was defined as a hole in the appendix or fecalith in the abdomen. Patients were randomized to antibiotic treatment with either once daily dosing of ceftriaxone and metronidazole for a minimum of 5 days (intravenous [IV] arm) or discharge to home on oral amoxicillin/clavulanate when tolerating a regular diet (IV/PO arm) to complete 7 days. Results One hundred two patients underwent laparoscopic appendectomy for perforated appendicitis. On presentation, there were no differences in age, weight, sex distribution, days of symptoms, maximum temperature, or leukocyte count between the 2 groups. There was no difference in the postoperative abscess rate between the two treatment groups. Discharge was possible before day 5 in 42% of the patients in the IV/PO arm. Conclusions When patients are able to tolerate a regular diet, completing the course of antibiotics orally decreases hospitalization with no effect on the risk of postoperative abscess formation.

Background: Since the first description of the Nuss repair for pectus excavatum, many technical variations have been described. Over the past 10 years, we have used a subxiphoid incision to allow finger guidance to protect the mediastinum which obviates the need for thoracoscopy.Methods: A retrospective review was conducted on all our patients who have undergone pectus excavatum repair from December 1999 to March 2009. Demographic, treatment, and outcome variables were recorded. All operations were performed with 2 lateral incisions, one subxiphoid incision, and 2 stabilizers.Results: During this timeframe, 307 patients underwent pectus bar placement. Mean age was 14.0 +/- 3.3 years, and 78% were male. Mean operating time was 50.0 +/- 15.9 minutes, length of hospitalization was 4.1 perpendicular to 1.1 days, and time to bar removal was 33.0 perpendicular to 7.3 months. There were no intraoperative events. Postoperative complications included a bar infection in 13 patients (4.2%), stabilizer displacement/discomfort requiring removal in 5 patients (1.6%), and bar rotation in 4 patients (1.3%). Rotation required operative correction in 3 cases and early removal in the other owing to a cracked sternum. No reoperations have been done for recurrence.Conclusions: The subxiphoid guided technique is a simple, safe, and reproducible method for the minimally invasive repair of pectus excavatum that obviates the need for thoracoscopy. (C) 2010 Elsevier Inc. All rights reserved.

INTRODUCTION Total colectomy, performed either with proctecomy and ileal pouch anal anastomosis or with ileorectostomy, is standard for pediatric patients with ulcerative colitis or familial adenomatous polyposis syndrome, respectively. The complication rates from adult series have been reported to be as high as 40%-50%. We audited our experience to define the complication rates in children and determine whether the use of laparoscopy has the potential to lessen the number or change the type of complications. METHODS We conducted a retrospective review of all pediatric patients who underwent total colectomy with either proctectomy with ileal pouch anal anastomosis or with ileorectostomy at a single institution from 1998 to 2008. Data are expressed as mean +/- standard deviation. Continuous variables were analyzed using a Student's t-test; and discrete variables were analyzed using a Fisher's exact test, where appropriate. Significance was set as P < or = 0.05. RESULTS Forty-four patients aged 58 days to 18 years (mean 11.7 +/- 5.3 years) underwent total colectomy from 1998 to 2008. The indications for surgery were ulcerative colitis (27), familial adenomatous polyposis syndrome (11), total colonic Hirschprungs (2), and others (3). Follow-up was significantly greater in the open group (2.8 years) than in the laparoscopic group (1.1 years, P = 0.02). Nineteen patients (43%) suffered major complications (other than pouchitis). There was 1 anastomotic leak. There were no statistically significant differences found between the laparoscopic and open approaches with regard to postoperative small bowel obstruction, postoperative abdominal or pelvic abscess, anal stricture requiring dilation, wound infection, other complications, or time to complication. Patients who underwent laparoscopic ileal pouch anal anastomosis had one occurrence of pouchitis (1/10) compared with 19/34 in the open group (P = 0.03). CONCLUSIONS This series demonstrates that laparopscopic colectomy yields similar outcomes as the traditional open method, both in type and severity of complications. Patients who had an ileal pouch created through the laparoscopic approach had fewer occurrences of pouchitis.

There is disparity among pediatric surgeons about the optimal surgical approach for patients with Hirschprung's Disease (HD). Surgeons that favor a rectal preservation with a Duhamel operation, cite the advantage of a rectal reservoir and non-disruption of the anal sphincter complex as benefits to avoid post pull-through enterocolitis and incontinence. The endorectal (ERP) pull-through approaches are reported to be beneficial with regard to avoiding a temporary colostomy and less constipation. We reviewed our experience with patients with HD to evaluate for differences in enterocolitis, constipation and incontinence between a rectal and endorectal anastomosis.