Introduction: Pectus Excavatum (PEX) is the most common anterior chest wall deformity. While minimally invasive repair of pectus excavatum (MIRPE) has improved perioperative outcomes, there continue to be opportunities to optimize postoperative pain management and reduce length of stay (LOS). We compared the impact of a multimodal expedited protocol utilizing a combination of systemic and regional analgesia (with single shot paravertebral truncal blocks), along with coping techniques (such as meditation), and physical therapy, with systemic analgesia on LOS and opioid requirements.

Purpose: The identification of urachal remnants is occurring more in infancy. Despite evidence that nonoperative management is effective, operative management remains common and has a high complication rate. We sought to determine if the complication rate after urachal resection is associated with age. Methods: Patients undergoing urachal remnant resection were identified from ACS NSQIP Pediatric from 2013 to 2017. Exclusion criteria included emergent operations, contaminated wounds, and any additional procedures. Patients were compared based on complication rates, need for reoperation or readmission, and length of stay. Results: A complication occurred in 16 of 476 patients (3.3%), 6 (1.3%) had reoperation, and 11 (2.3%) were readmitted. The median age for patients requiring reoperation was lower (0.1 years) than those not (1.3 years; p = 0.004). The median age of those readmitted was lower (0.4 years) than those not (1.4 years, p = 0.03), and a weak trend of longer length of stay in younger patients was identified (. = -0.16, p < 0.001). Conclusions: Operative management of younger patients resulted in greater risk of reoperation, readmission, and longer length of stay. Given that nonoperative management is effective, it may be of benefit to delay resection of urachal remnants to after 1 year of age. Study type: Treatment study. (c) 2020 Elsevier Inc. All rights reserved.

Mentor: Robert Cusick Program: General Surgery Type: Original Research Background: In children with gastroschisis, many consider delivery at a specialized pediatric center optimal perinatal care. Previous studies have suggested delivery at the center of definitive surgical care may expedite primary closure, while decreasing time to full enteral feeds. We sought to understand the influence of perinatal transfer to specialized centers on outcomes in infants with gastroschisis. Methods: Patients from Pediatric NSQIP, 2013 – 2017, who had gastroschisis repair were divided into those born in a specialized center and those transferred after birth. The primary outcomes were days to repair, length of stay, and rate of overall complications. Secondary outcomes included 30-day mortality, occurrence of wound or infectious complications, or need for parenteral nutrition (TPN) at discharge. Results: There were 638 transferred patients and 452 patients born in center identified. There was a difference in the days between admission and surgical repair for those transferred and those not (3.2 days vs. 2.5 day, respectively, p = 0.02). There was no difference seen in length of stay, mortality, or need for TPN at discharge, but a difference was identified in the rate of wound complications. Transferred patients had 60 (9.4 %) wound complications compared to 23 (5.1%) for those born in center ( p = 0.008). Most of the wound complications were superficial infections or superficial dehiscence. Conclusion: Perinatal transfer of patients with gastroschisis is associated with a longer time to repair and a higher incidence of wound-related complications. However, these findings do not appear to increase length of stay, mortality, or need for TPN at discharge.

Introduction: Necrotizing enterocolitis (NEC) is a known complication of gastroschisis with an incidence above the expected rate in the neonatal population. While many physicians today are aware of this association, the last publication to explore this association in detail and identify possible risk factors of NEC in gastroschisis patients was published over twenty years ago. From our large database of patients with gastroschisis, managed by a single group of pediatric surgeons, we reviewed our experience and the recent literature to update what is known about gastroschisis and NEC. Methods: From 2001 to 2017, a gastroschisis registry was maintained. Data from 218 gastroschisis patients were reviewed. Patient demographics and hospital course were reviewed. Patients with confirmed NEC were compared to those without NEC. Results: Two hundred eighteen patients were born with gastroschisis during the time frame of this study. We observed a 5% rate (11 of 218) of NEC. Five patients (45%) developed recurring NEC and 4 patients (36%) were readmitted for NEC development following initial discharge. Variables associated with NEC included low gestational age (P=0.016) and low birth weight (P=0.003). Patients born prior to 37 weeks gestation had a 4.8 times greater risk of developing NEC than those born at term. Rates of intrauterine growth restriction (IUGR) were not statistically different between NEC and non-NEC patients. The method of delivery (cesarean vs vaginal), use of a silo, and form of nutrition were not significantly associated with NEC development. Conclusions: The overall incidence of NEC, based on our data, has decreased compared to earlier reports. NEC does complicate the hospital course for patients, significantly increasing duration of in-hospital treatment. NEC in gastroschisis differs in comparison to traditional NEC, presenting later in life. Risk factors identified include low gestational age and low birth weight. Avoiding elective pre-term deliveries may decrease the rate of NEC in gastroschisis.

Purpose: The purpose of this study was to evaluate trends in management of urachal anomalies at our institution and the safety of nonoperative care. Methods: Based on our experience managing urachal remnants from 2000 to 2010 (reported in 2012), we adopted a more conservative approach, including preoperative antibiotic use, refraining from using voiding cystourethrograms (VCUG), postponing surgery until at least six months of age, and considering nonoperative management. A retrospective analysis of urachal anomaly cases was conducted (2011-2016) to assess trends in practice. Charts indicating anomalies of the urachus were pulled and trends in management (nonoperative versus surgical treatment), VCUG and antibiotic use, and outcomes were reviewed. Results: Data from 2000-2010 and 2013-2016 were compared. Our findings indicate care has shifted towards nonoperative management. A smaller proportion of patients from 2013-2016 was treated surgically compared to 2000-2010. Patients receiving nonoperative treatment exhibited lower rates of complication relative to surgically managed cases. VCUGs were eliminated as a diagnostic tool for evaluating urachal anomalies. Prophylactic preoperative antibiotic use was standardized. No patients with a known urachal remnant presented later with an abscess or sepsis. Conclusions: We find that a shift towards nonoperative treatment of urachal anomalies did not adversely affect overall outcomes. We recommend observing minimally symptomatic patients, especially those under six months old. Study type: Performance improvement. (C) 2019 Elsevier Inc. All rights reserved.

BACKGROUND: Infants with heterotaxy syndrome (HS) have abnormal lateralization of organs along the right-left body axis. Intestinal rotation abnormalities (IRAs) are a potential source of morbidity and mortality. For this study, our objective was to prospectively observe a cohort of infants with HS and determine the incidence and natural history of IRA. METHODS: Infants <= 6 months of age with HS were enrolled in this prospective observational study. Exclusion criteria were other congenital abnormalities that necessitated abdominal surgery. HS was defined as any arrangement of organs that was not situs solitus or situs inversus along with associated congenital heart disease. The investigation for IRA was at the discretion of each participating center. RESULTS: Infants were recruited from January 2012 to December 2016. Thirty-eight infants from 7 institutions were included; 22 infants had right isomerism and 16 infants had left isomerism. Twenty-nine infants (76%) were evaluated for IRAs; 21 of 29 evaluations (72%) were abnormal. Eight infants were investigated because of symptoms, and 21 infants were evaluated routinely. The median age at symptom presentation was 46 days (range: 5-171 days). Seven infants had a Ladd procedure; 4 were prophylactic, with 3 as part of a combined procedure, and 3 were emergent. No child suffered acute midgut volvulus over a median follow-up of 1.6 years (range: 0.06-4.93 years). CONCLUSIONS: IRAs are common in infants with HS. Infants with symptoms presented by 6 months of age. There was no failure of expectant management resulting in midgut volvulus during a median follow-up of 1.6 years.

Purpose: The purpose of this study was to perform a retrospective review of tracheoesophageal fistula (TEF) patients who followed up in a state-sponsored program to assess neurodevelopmental outcomes.Methods: Records were reviewed retrospectively of children who underwent TEF repair between August 2001 and June 2014. Children discharged from the neonatal intensive care unit were referred to the state-sponsored Developmental Tracking Infant Progress Statewide (TIPS) program. We reviewed TIPS assessments performed before age 24 months and noted referral for early school intervention services. Poor outcomes were defined as scores of "failure" on the screening assessment or referral for enrollment in early intervention services by 24 months. Children with TEF were compared with case-matched nonsyndromic children of similar gestational age and birth weight.Results: Seventy-eight children underwent TEF repair. Thirty-eight followed up with TIPS. Survival was 93.6%. Predictors of hospital survival were Waterston classification (p=0.001), birth weight (p=0.027), and ventilator days (p=0.013). LOS was the only significant predictor of referral for early intervention services (p=0.0092) in multivariate analysis. There was a borderline significant difference in referral rate between children with TEF and controls. 52.6% of TEF patients were referred, while 34.2% of controls were referred (p=0.071).Conclusion: More than half of TEF patients experience neurodevelopmental delays requiring referral for early intervention (53%). (C) 2016 Elsevier Inc. All rights reserved.

Purpose: We have noted an increasing frequency of diagnosed urachal anomalies. The purpose of this study is to evaluate this increase, as well as the outcomes of management at our institution over 10 years.Methods: A retrospective analysis of urachal anomalies at our institution was performed. Inclusion criteria were Anomalies of Urachus (ICD 753.7) or Urinary Anomaly NOS (ICD 753.9) between January 2000 and December 2010. Exclusion criteria were having an asymptomatic urachal remnant incidentally excised.Results: Eighty-five patients (49 male, 36 female) presented between 0 and 17 years of age (mean 1.5 years). Diagnoses increased from 0 in 2000 to 21 in 2010. Zero was surgically managed in 2000 while 21 were managed in 2010 (p = 0.0145). Fifteen patients (17.6%) were observed with 13 (13/15, or 15.3%) resolving without complication while 2 were operated on. Average time to resolution (clinical or radiologic) was 4.9 months (Range: 0.4-12.6). A total of seventy-two patients (84.7%) underwent excision. Thirty-nine (54%) surgical cases were outpatient while 33 (46%) were admitted. Thirteen (18%) had post-operative complications. Ten (77%) of the complications were wound infections. Patients under 6 months of age accounted for 60% (6 of 10) of all wound infections and 52% (17 of 33) of hospitalizations.Conclusions: Our experience and review of the literature suggest a high complication rate with surgical management in young patients, mostly from infections and support non-operative management of all non-infected urachal remnants in children. (C) 2015 Elsevier Inc. All rights reserved.

PURPOSE:The optimal age at which to perform orchiopexy for cryptorchidism has long been debated. The aim of this study was to determine if age at orchiopexy affected testicular atrophy. METHODS:A retrospective review of patients undergoing orchiopexy from 2000 to 2010 was conducted. An individual testis, rather than patient, was used as the dependent variable. A total of 349 testicles from 1126 charts (ICD-9=752.51) were identified. Primary study outcome was testicular survival without atrophy. RESULTS:Mean follow up for the study was 25 months. There was postoperative atrophy in 27 testes (7.7%). Intraabdominal testicle was independently associated with increased postsurgical atrophy (p<0.0001). The odds of postsurgical atrophy were 15.66 times higher for an abdominal vs. inguinal location (95% CI: 5.5-44.6). Testicular atrophy was highest for orchiopexy at ages 13-24 months (n=16 of 133, 12%) vs. those less than 13 months (n=3 of 64, 5%), and those greater than 24 months (n=8 of 152, 5%) (p=0.0024). After adjusting for location, age was not statistically significant with postsurgical atrophy (p=0.055). CONCLUSIONS:From this study we conclude that there is no increase in testicular atrophy in patients less than 13 months.

Purpose: We describe the infectious complications of gastroschisis in order to identify modifiable factors to decrease these complications.Methods: Data from155 gastroschisis patients (2001-2013) were reviewed. Complicated gastroschisis (intestinal atresia, necrotic bowel, or perforation) were excluded, leaving 129 patients for review. Patient demographics, surgical details, postoperative infections and complications, and length of stay were reviewed. We used CDC definitions of infectious complications.Results: The average gestational age of patients was 35.97 weeks. Silos were used in 46% of patients (n - 59) for an average of 7.4 days. Thirty-one patients (24%) acquired an infection within the first 60 days of life. Patients who developed an infection were born earlier in gestation (P = 0.02), weighed less (P = 0.01), required silos more often (P = 0.01), and received a sutured repair (P = 0.04). Length of stay of patients with an infection was longer than in patients without infection (P = 0.01).Conclusions: Infectious complications following gastroschisis repair are common. Subsets of gastroschisis patients at increased risk of infection include patients with silos, preterm delivery, low birth weight, and sutured repair. Based on our findings, our recommendation would be to carry gastroschisis patients to term and advocate against the routine use of silos, reserving their use for those cases when primary closure is not possible. (C) 2015 Elsevier Inc. All rights resreved.

Objectives: We reviewed the surgical management of chronic cervical esophageal foreign bodies (CCEFBs) in a pediatric population after failed endoscopic retrieval. Methods: A descriptive analysis via a retrospective chart review of patients with CCEFBs who failed initial endoscopic management was performed between 2008 and 2013. Details were recorded regarding presenting symptoms, time from symptom onset to diagnosis of the CCEFB, surgical approach, and complications. Results: Three patients with CCEFBs unsuccessfully managed with endoscopy were identified. The range of ages at diagnosis was 14 months to 4.5 years. The foreign bodies (FBs) were present for at least 1 month before diagnosis (range, 1 to 10 months). Respiratory symptoms were predominant in all cases. Neck exploration with removal of the FB was performed in each case. Complications included esophageal stricture necessitating serial dilations (patient 1), left true vocal fold paresis that resolved spontaneously (patient 3), and tracheoesophageal fistula with successful endoscopic closure (patient 3). No long-term sequelae were experienced. Conclusions: A high index of suspicion is required to recognize CCEFBs in children with respiratory distress. Although endoscopic management remains the first-line treatment, it may fail or may not be possible because of transmural FB migration. In this setting, neck exploration with FB removal is a safe and effective alternative.

Objective: To analyze outcomes in children with intestinal failure treated by our Intestinal Rehabilitation Program (IRP) in a 4-year period.Patients and Methods: A total of 51 parenteral nutrition (PN)dependent patients (20 male) were enrolled in the IRP. Median age was 1.7 years, with the primary diagnoses being gastroschisis, necrotizing enterocolitis, volvulus, and congenital atresia. Median small bowel intestinal length was 35 cm, with the majority of patients having only jejunum as remaining bowel anatomy. Thirty-six of the 51 patients had liver disease characterized by cirrhosis, advance bridging fibrosis, and portal and periportal fibrosis. Height, weight z score, platelet count, albumin, and bilirubin levels were measured at the beginning and end of the study.Results: Of the 51 patients, 29 had 46 different surgical intestinal repairs. Twenty-nine of the 36 patients with hyperbilirubinemia had normalized serum bilirubin with treatment. Ten patients required transplantation. Five patients died of sepsis, influenza, or complications after intestinal transplantation. Of the remaining 37 patients in the IRP, 31 were weaned from parenteral nutrition (5 with cirrhosis); 6 patients are in the process of weaning. Survival rate of the patients in the IRP was 90%. Growth has continued along the same curve, and some patients have exhibited significant catch-up.Conclusions: With an aggressive medical/surgical approach, even patients with intestinal failure and advanced liver disease can avoid transplantation. Patients in the IRP showed improved liver function and nutritional parameters with the ability to discontinue PN while maintaining growth. Early referral of these patients to specialized centers before the development of advanced liver disease is recommended.

Introduction: Trauma is the commonest cause of death in the pediatric population, which is prone to diffuse primary brain injury aggravated by secondary insults (eg, hypoxia, hypotension). Standard monitoring involves intracranial pressure (ICP) and cerebral perfusion pressure, which do not reflect true cerebral oxygenation (oxygen delivery [Do,]). We explore the merits of a brain tissue oxygen-directed critical care guide.Methods: Sixteen patients with major trauma (Injury Severity Score, > 16/Pediatric Trauma Score [PTS], < 7) had partial pressure of brain tissue oxygen (PbtO(2)) monitor (Licox; Integra Neurosciences, Plainsboro, NJ) placed under local anesthesia using twist-drill craniostomy and definitive management of associated injuries. PbtO(2) levels directed therapy intensity level (ventilator management, inotrops, blood transfusion, and others). Patient demographics, short-term physiological parameters, PbtO(2), ICP, Glasgow Coma Score, trauma scores, and outcomes were analyzed to identify the patients at risk for low DO2.Results: There were 10 males and 6 females (mean age, 14 years) sustaining motor vehicle accident (14), falls (1), and assault (1), with a mean Injury Severity Score of 36 (16-59); PTS, 3 (0-7); and Revised Trauma Score, 5.5 (4-11). Eleven patients (70%) had low DO2 (PbtO(2), < 20 mm Hg) on admission despite undergoing standard resuscitation affected by fraction of inspired oxygen, PaO2, and cerebral perfusion pressure (P=.001). Eubaric hyperoxia improved cerebral oxygenation in the low-DO2 group (P=.044). The Revised Trauma Score (r = 0.65) showed moderate correlation with PbtO(2) and was a significant predictor for low DO2 (P=-001) In patients with PbtO(2) of less than 20 mm Hg, PTS correlated with cerebral oxygenation (r = 0.671, P =.033). The mean 2-hour PbtO(2) and the final PbtO(2) in survivors were significantly higher than deaths (21.6 vs 7.2 mm Hg [P =.009] and 25 vs 11 mm Hg [P =.01]). Although 4 of 6 deaths were from uncontrolled high ICP, PTS and 2-hour low DO2 were significant for roots for mortality.Conclusions: PbtO(2) monitoring allows for early recognition of low-Do, situations, enabling appropriate therapeutic intervention. (c) 2006 Elsevier Inc. All rights reserved.

To analyzed the role of an Intestinal Rehabilitation Program (IRP) at the University of Nebraska in the treatment of advance intestinal failure during the last 4 years. 46 patients with short bowel syndrome, TPN dependent, referred for liver/small bowel transplant, after evaluation, were assigned to be treated instead by our IRP. Indications for treatment in the IRP were: 1.Infants with no liver disease that had >15 cm of bowel. 2. Children with >40 cm of bowel with elevated bilirubin but normal INR. 3. Children with advanced liver disease/portal hypertension but normal INR, who had > than 60 cm of bowel and abnormal but potentially repairable intestinal anatomy. Height, weight Z score, platelet count, albumin, and bilirubin were obtained at the beginning and end of the study Table 1.Table 1Of the 46 patients, 25 had 40 different surgical intestinal repairs (12 Bianchi, 11 Intestinal obstruction repaired, 5 takedown, 3 fistulas repaired, 9 tapering/step enteroplasty). 32 had hyperbilirubinemia (7 had cirrhosis, 13 advanced bridging fibrosis, and 12 portal fibrosis). 27 normalized the serum bilirubin with treatment. 4 patients died (3 for sepsis, one for Influenza). 6 required transplantation. 2 are listed for transplant. Of the remaining 34 IRP patients, 24 were weaned from TPN (3 with cirrhosis) 10 patients are in process of weaning (2 of them with stable cirrhosis). Survival of the IRP patients is 91%. Growth has continued along the same curve. 25% exhibited significant catch up. With an aggressive medical/surgical approach, even patients with intestinal failure and advanced liver disease, can avoid transplantation. IRP patients improved liver function and nutritional parameters with the ability to discontinue TPN while maintaining growth. Early referral of these patients to specialized centers prior to the development of advanced liver disease is recommended.

Intestinal failure is most commonly treated by the administration of total parenteral nutrition (TPN). In some patients, however, surgical therapy may increase the ability to use the intestine for nutrition and thereby decrease the complications of TPN therapy. A multidisciplinary comprehensive intestinal failure program was initiated at the University of Nebraska Medical Center in October 2000. Here we describe the surgical approaches to patients with short bowel syndrome and the subsequent impact on the need for TPN and on survival. Fifty patients (children = 30, adults = 20) underwent surgical procedures to restore intestinal continuity (n = 5), repair enterocutaneous fistulas (n = 5), resect dysmotile or strictured/obstructed bowel segments or mesenteric desmoid tumors (n = 7), stricturoplasty (n = 2), Bianchi tapering and lengthening (n = 20), serial transverse enteroplasty (n = 8), and other operations (n = 8). Of these 50 patients, three patients did not require TPN after surgical intervention and seven had remnant small bowel anatomy that precluded TPN weaning (e.g., end duodenostomy) and were listed for transplantation or continued on full TPN support. Of the 40 remaining patients, most received the majority of calories fromTPNat the time of referral, i.e., mean calories fromTPN _ 90%. Subsequent to the surgical and medical therapy, 26 (65%) have been completely weaned off TPN. In addition, 10 had substantial decreases in their TPN requirements (i.e., from 85% of calories from TPN at onset decreased to a median 35% of required calories at most recent follow-up). Four patients remained on the same amount of TPN support. Four of the seven patients listed for transplantation underwent successful transplantation. Despite the complications of short bowel syndrome, 86% (n = 43) of the patients are alive and well at a mean follow-up of 2 years. Patient deaths occurred primarily in those listed or eligible for transplantation and were related to advanced liver disease (n = 3), gastrointestinal hemorrhage (n = 1), or line sepsis (n = 1). Two other patients died, one from influenza A infection and one from unknown cause at home, months after complete discontinuation of TPN. In this series of patients with short bowel syndrome, surgical intervention led to weaning or discontinuation of TPN support in 85% of patients. An organized multidisciplinary approach to the patient with short bowel syndrome is recommended.

Congenital diaphragmatic hernia (CDH) presents beyond the first hours of life in 10% to 20% of cases. Presenting symptoms may be quite nonspecific, and are often gastrointestinal rather than respiratory in origin. We have recently had experience with five such cases, one in a newborn and four in older children. All presented with symptoms related to gastrointestinal complications of their diaphragmatic defect. In the newborn, gastric perforation had occurred, a complication of this anomaly not previously reported. The chest radiograph showed loops of bowel in the chest in all cases, allowing correct preoperative diagnoses. Urgent operative intervention was undertaken in each case with good results and no long-term morbidity. The risk of intestinal strangulation in the late-presenting CDH patient warrants emergent surgical management, which should be rewarded by uniform survival with few complications. Although preoperative stabilization may decrease the severity of pulmonary vasospasm in the newborn with respiratory failure, delay may increase the risk of bowel infarction in the older child presenting with gastrointestinal symptoms.

RAYNOR, STEPHEN C.; WOOD, R. PATRICK; SPANTA, ALI D.; SHAW, BYERS W. JR. Author Information

Amyloid tumors of the gastrointestinal tract are exceedingly rare. Two cases are presented, one in the stomach of a patient who appeared to have systemic amyloidosis and one in the colon which appears to be isolated. The treatment was surgical excision. Extensive diagnostic work-up is required to evaluate the many various possible causes of amyloidosis.