Publications (142)257.14 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Watercraft-associated trauma (WAT) in children has received little attention so far, despite the potentially severe and debilitating resulting injuries. The aim of this study was to evaluate all cases of major watercraft-associated trauma admitted to the Children's of Alabama during the past 10 years, identify patterns in mechanism and injury, and propose future prevention strategies. We reviewed our (prospective) database for children admitted through our trauma center after major WAT. Charts were abstracted for mechanism, epidemiologic data, injury type and injury severity scale (ISS), as well as outcome. We identified 15 children (6 males, 9 females, age range 7 to 15, mean 12±2 years), involved in 14 accidents. Sharp trauma was inflicted by a propeller (n=4) or a rope (n=1). Towed tubing (riding an inflatable tube while being pulled by a boat) was the most prevalent mechanism (n=6). There was a trend towards higher ISS after towed tubing (24.8±12.4) compared to all other mechanisms (15.1±7.7). Mean length of stay was longer after towed tubing accidents (14.2±7.2 versus 4.9±3.4 days). All patients survived and eventually were discharged home. In one of the incidences, involving 2 victims of this series, the driver of the boat was intoxicated with alcohol. Pediatric watercraft-related accidents are infrequent, but often result in major injuries. More awareness for safety measures to prevent these injuries is warranted. Alcohol is not a major factor in pediatric watercraft-associated trauma. Tubes towed by a boat seem to be particularly dangerous, perhaps because of the rider's limited maneuverability and the fact that centrifugal force lets the tube travel well outside the wake in curves. Limiting boat speed and the use of protective gear on towed tubes when children are involved may decrease the incidence and severity of pediatric WAT.
Article: Crohn's Disease
- [Show abstract] [Hide abstract] ABSTRACT: Background: Currently, the Georgeson procedure (laparascopic-assisted, single-stage transanal endorectal pullthrough) is a widely-accepted procedure for Hirschsprung disease patients. However, few studies have been conducted to rigorously evaluate the long-term results of this operation. Purpose: We evaluated long-term fecal continence and quality of life outcomes of Hirschsprung patients treated with the Georgeson procedure through multiple established scoring systems designed for pediatric patients with fecal continence issues. Methods: We performed a retrospective chart review for all patients and attempted telephone interviews for those 4 years or older who underwent the Georgeson procedure at the Children’s Hospital of Alabama from February 1993 to April 2009. Demographic, operative, and postoperative data were collected and reviewed. Fecal continence was evaluated by the use of two different scoring systems, namely, Templeton Score and Rintala Score. Quality of life was assessed through two established systems, the Templeton Score and Bai Score. Results: A total of 84 patients underwent the Georgeson procedure by 9 surgeons. Mean age at operation was 1.5 (+/- 3.1) years with 14 (16%) patients having concurrent comorbities such as trisomy 21, tetralogy of Fallot, imperforate anus, and malrotation. The mean operation time was 206 (+/- 82) minutes. Transition zones were rectosigmoid (72, 85%), descending colon (7, 9%), and transverse colon (5, 6%). There were 13 (15%) early complications and 43 (51%) late complications. Hirschsprung associated enterocolitis, defined by our group with a very nonrigorous criteria thereby including those patients with low suspicion, comprised 95% (41 patients) of the late complications. 70 of the 84 (83%) patients were eligible for a telephone interview, and we achieved 30 (43%) interviews with a median follow-up of 108 months. Patients scored into the following categories according to the Templeton fecal continence scoring system: good (14 patients, 47%), fair (8 patients, 26.5%), and poor (8 patients, 26.5%). The mean Rintala fecal continence score was 14.3 (+/- 4.6, range 0-16), thereby placing our patients in the highest category of “good”. Templeton quality of life scores placed patients into the following categories: good (24 patients, 80%), fair (5 patients, 17%), and poor (1 patient, 3%). The mean Bai quality of life score was 10.9 (+/- 1.9, range 0-12). Conclusion: Hirschsprung patients undergoing the Georgeson procedure at our institution have good long-term quality of life and fecal continence. Critical evaluation of those selected patients with poorer outcomes scores may provide insight into ways of improving the operation and both short and long-term postoperative care of these difficult patients.
- [Show abstract] [Hide abstract] ABSTRACT: This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables. This retrospective cohort study included all gastroschisis patients treated at a single tertiary children's hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission. Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01). Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.
- [Show abstract] [Hide abstract] ABSTRACT: Many different techniques for laparoscopic inguinal hernia repair have been introduced recently, using either an intraperitoneal [1–3] or an extraperitoneal [4–6] approach. One of the main challenges is to obtain a complete circumferential closure of the sack at the level of the internal ring without injury to the adjacent vas deferens or spermatic vessels. In an effort to separate these structures from the peritoneum before passing a suture around the base of the sack, we developed the hydrodissection-lasso technique, which is performed using a single-incision endosurgical approach. With the patient in Trendelenburg position, an 8-mm skin incision is made in the umbilicus, and a 5-mm trocar is placed in the inferior aspect for the endoscope. A 3-mm Maryland grasper is placed directly through the fascia in the upper part of the incision. Using a 22-gauge needle inserted percutaneously over the internal inguinal ring, saline is injected into the subperitoneal plane circumferentially, hydrodissecting the peritoneum off the vas deferens and vessels and creating a safe space through which the suture can pass without compromising these structures. A 2-mm stab incision is made directly over the internal inguinal ring, and a lasso technique is used to pass two strands of braided polyester suture around the hernia sack, as demonstrated in the video. Both sutures are tied tightly, leaving the knots under the skin. No direct or indirect manipulation of the vas deferens or vessels takes place during any part of the procedure. In contrast to other described techniques , the hydrodissection-lasso technique can be used for all indirect inguinal hernias in both girls and boys, and hydrodissection itself may be a useful adjunct to any of the other aforementioned techniques. Although an age limit for exclusive high ligation of the hernia sack for indirect inguinal hernias has not been established, the recurrence rate may be higher for adults if the procedure is not combined with inguinal floor reconstruction . At this time, we therefore limit the proposed technique to prepubertal patients. We have performed the described procedure for 22 patients without any recurrences during a maximum follow-up period of 12 months (Table 1). The patients had minimal postoperative pain. There were no complications except for a transient genitofemoral nerve paresis experienced by one girl in whom the hydrodissection was performed using 1% lidocaine instead of the usual normal saline solution. Although the sack was not resected, there were no cases of postoperative hydroceles. To evaluate whether this novel technique is an adequate long-term solution, a prospective clinical trial comparing standard open and single-incision endosurgical inguinal hernia repair using hydrodissection should be performed.
- [Show abstract] [Hide abstract] ABSTRACT: To identify technical difficulties during single-incision pediatric endoscopic surgery (SIPES) cases and to highlight solutions. After IRB approval, all SIPES cases were prospectively collected, and the surgeons involved were polled for technical difficulties encountered and their operative solutions. Over a period of 13 months, 224 pediatric SIPES cases were performed in 223 pediatric patients (92 female, 131 male) aged 3 weeks to 19 years. Among these were 130 appendectomies, 32 pyloromyotomies, 32 cholecystectomies, 11 inguinal hernia repairs, 6 Nissen fundoplications and 4 laparoscopic-assisted endorectal pullthrough procedures. Eighteen procedures (8%) employed a primary extra-umbilical instrument in addition to the transumbilical trocar(s). Thirty procedures (13%) begun via a single-site technique required additional trocars for completion. None required laparotomy. Intraoperative complications are discussed. The main challenges of SIPES are: (1) variable umbilical anatomy, (2) large size of current proprietary multitrocar devices, (3) trocar crowding, (4) intra-abdominal exposure, (5) fewer degrees of freedom, (6) clashing instruments, (7) in-line endoscope viewing, and (8) limited number of working ports. We discuss coping strategies to address these issues. Many of the drawbacks of SIPES can be overcome by specific techniques, which can make SIPES procedures more broadly feasible and applicable within pediatric endosurgery.
- [Show abstract] [Hide abstract] ABSTRACT: This study attempted to evaluate the association of early hypoalbuminemia with the risk of intestinal failure in gastroschisis patients. Neonates with gastroschisis treated at a tertiary children's hospital over a 10-year period were initially categorized into groups based on the lowest serum albumin measurement during the first 7 days of life. Based on preliminary analysis, patients with serum albumin <1.5 g/dL were considered to have early severe hypoalbuminemia. Intestinal failure was defined as inability of the patient to wean from parenteral nutrition (PN) during the initial hospital admission, thus requiring home PN. Logistic regression modeling was performed to adjust for sex, gestational age, birth weight, and concomitant intestinal complications. One hundred and thirty-five gastroschisis patients were included, of whom 21% had early severe hypoalbuminemia. Patients with early severe hypoalbuminemia had a significantly higher risk of intestinal failure compared to those with higher albumin levels (26 vs. 8%, p = 0.015). On multivariable logistic regression modeling, early severe hypoalbuminemia was strongly associated with intestinal failure (OR 6.4, 95% CI 1.8-23.3, p = 0.005). Early severe hypoalbuminemia appears to be an independent risk factor for long-term intestinal compromise rather than merely an indicator of overall illness. Further interventional studies are needed to determine whether clinical protocols utilizing judicious fluid administration, exogenous albumin, and early enteral feeding can improve clinical outcomes in gastroschisis.
- [Show abstract] [Hide abstract] ABSTRACT: Single-incision pediatric endosurgical (SIPES) pyloromyotomy is frequently used for the treatment of hypertrophic pyloric stenosis at our center. Our initial SIPES approach mirrored the conventional, triangulated laparoscopic pyloromyotomy. Because an increased number of perforations were noted on our initial analysis, a more straightforward Cross-technique SIPES pyloromyotomy was developed. This study compares the current Cross-technique SIPES pyloromyotomy to the previous standard SIPES operation. The Cross-technique entails grasping the antrum with the surgeon's left hand instrument, retracting toward the left lower quadrant, and thereby orienting the pylorus obliquely toward the right upper quadrant. The serosal incision and muscular spreading is accomplished using a right-hand instrument that crosses over the left hand grasper. Demographic variables, operative times, estimated blood loss (EBL), complications, conversion rate, and postoperative length of stay were compared. Twenty-nine Cross-technique patients were compared with 23 in the standard group. The Cross-technique was faster than the standard procedure (21 ± 5 vs. 27 ± 12 min, p = 0.03) and EBL was lower (1.3 ± 0.5 vs. 1.7 ± 0.6 ml, p = 0.02). There were two mucosal perforations requiring conversions to triangulated 3-access-site laparoscopy in the standard, and one conversion to open surgery in the Cross-technique group. Patients who underwent cross-technique pyloromyotomy weighed less (3.6 ± 0.6 vs. 4.0 ± 0.5 kg, p = 0.012), but there were no differences in age, gender ratio, conversion rate, or length of stay. There was one postoperative wound infection in the cross-technique, but none in the standard group. No patients required reoperation. All participating surgeons felt that the cross-technique was more ergonomic and easier to perform than the standard SIPES technique. The Cross-technique appears superior to standard SIPES pyloromyotomy and should be preferentially used for single-incision endosurgical pyloromyotomy for hypertrophic pyloric stenosis.
- [Show abstract] [Hide abstract] ABSTRACT: Laparoscopic Nissen fundoplication has been traditionally performed with extensive esophageal dissection to create 2 to 3 cm of intraabdominal esophagus. Retrospective data have suggested that minimal esophageal mobilization may reduce the risk of postoperative herniation of the wrap into the lower mediastinum. To compare complete esophageal dissection to leaving the phrenoesophageal attachment intact, we conducted a 2-center, prospective, randomized trial. After obtaining permission/assent, patients were randomized to circumferential division of the phrenoesophageal attachments (MAX) or minimal mobilization with no violation of the phrenoesophageal membrane (MIN). A contrast study was performed at 1 year. The primary outcome variable was postoperative wrap herniation. One hundred seventy-seven patients were enrolled in the study (MIN, n = 90; MAX, n = 87) from February 2006 to May 2008. There were no differences in demographics or operative time. Contrast studies were performed in 64 MIN and 71 MAX patients, respectively. The transmigration rate was 30% in the MAX group compared with 7.8% in the MIN group (P = .002). The reoperation rate was 18.4% in the MAX group and 3.3% in the MIN group (P = .006) Minimal esophageal mobilization during laparoscopic fundoplication decreases postoperative wrap transmigration and the need for a redo operation.
- [Show abstract] [Hide abstract] ABSTRACT: The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution. Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls. One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25). Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.
- [Show abstract] [Hide abstract] ABSTRACT: Bleeding is a dreaded complication of extracorporeal membrane oxygenation (ECMO). At our institution, we use a bleeding protocol (BP) with or without ε-amino caproic acid (ACA) for certain prophylactic or therapeutic indications. Subjectively, we have felt that placing a child on bleeding protocol shortens the circuit life because of clot formation. In this study, we evaluated the impact of BP with and without ACA on the survival time of the ECMO circuit. A retrospective analysis of all ECMO patients treated in our institution from 2000 to 2008 was performed. An event was defined as a change of the ECMO circuit for thrombosis. The times until occurrence of an event were noted for children off (standard) or on bleeding protocol (BP) and ACA (BP+ACA). Survival curves were generated for each of these study groups and compared using the log rank test. A total of 164 patients were treated with ECMO during the study period. 32 events were noted in the standard, 20 in the BP, and 25 in the BP+ACA group. Mean survival time of the circuit was 10.5 ± 3.8 days for the standard, 8.6 ± 3.4 days for the BP, and 9.9 ± 4.6 days for BP+ACA protocols. The corresponding Kaplan-Meier survival curves are shown. The log rank test showed no significant differences between groups (standard vs. BP p=0.12; standard vs. BP+ACA p=0.92). We found no evidence that instituting a bleeding protocol with or without aminocaproic acid shortens circuit times. Clotting of the ECMO unit should not be a major concern when placing a patient on a bleeding protocol.
- [Show abstract] [Hide abstract] ABSTRACT: Over the last 15 years, the laparoscopic-assisted endorectal pull-through procedure first described by Georgeson has become the standard treatment for Hirschsprung disease in many centers around the world. We report the first six patients who were operated using a single-incision endosurgical approach. Six infants (one female) diagnosed with Hirschsprung disease underwent laparoscopic endorectal pull-through via a single 1 cm horizontal skin incision in the umbilicus. Firstly, laparoscopic seromuscular leveling biopsies of the rectum and sigmoid were obtained. The affected rectosigmoid colon and rectum was then mobilized distally beyond the peritoneal reflection, facilitating the subsequent perineal dissection, pull-through, and coloanal anastomosis. Operative variables were compared between single-incision and conventional laparoscopic endorectal pull-through. The patients' average age and weight was 28 days and 3.8 kg, respectively. Operative time ranged from 90 to 220 min, with a mean estimated blood loss of 3.7 ml. There were no intraoperative complications. Postoperatively, all six patients recovered uneventfully and were discharged home on full feeds after a median of 7 days. On follow-up, the patients had virtually no appreciable scar, were feeding well, stooling, and gaining weight appropriately. The results were similar to those of conventional laparoscopic endorectal pull-through. Although technically challenging, laparoscopic-assisted endorectal pull-through in infants with Hirschsprung disease can be performed safely through a single umbilical incision with good postoperative results and excellent cosmesis.
- [Show abstract] [Hide abstract] ABSTRACT: Single-incision pediatric endosurgical (SIPES) appendectomy has been reported in few pediatric surgical centers. We have adopted the technique recently and have offered it to all patients in whom appendectomy was indicated. The purpose of this study was to report our experience with SIPES appendectomy for acute appendicitis, perforated appendicitis, and interval appendectomy, and to compare the results with those from patients who underwent conventional laparoscopic appendectomy 1 year previously. After IRB approval, data on all SIPES appendectomies performed in our hospital were prospectively collected, including operative time, intra- and postoperative complications, conversion rate, blood loss, and hospital length of stay. Cases were stratified into three categories: acute appendicitis, perforated appendicitis, and interval appendectomy. They were compared to patients operated on in 2007 using conventional laparoscopic (three-trocar) appendectomy. During the study period, 75 SIPES appendectomies were undertaken. Mean age was 11 years (range = 2-19 years) and mean weight was 45 kg (range = 12-132 kg). All SIPES appendectomies were completed laparoscopically, and additional trocars were placed in 20% of cases. SIPES interval appendectomies took the longest and had the highest conversion rate (33%). Follow-up data was available in 63 patients (82%) at a median of 3 weeks. There were three wound infections in the SIPES group (4%) and one in the 151 control patients. Compared to historic controls, operative time was shorter with SIPES compared to conventional laparoscopy for acute appendicitis (37 ± 12.3 vs. 44.1 ± 20.3 min, p = 0.01, 95% CI = 32-42 min). SIPES appendectomy is a very good alternative to the conventional laparoscopic approach, especially for acute appendicitis. It is technically more challenging for perforated appendicitis and interval appendectomy. Yet, with appropriate consideration and skill, scarless appendectomy is achievable.
- [Show abstract] [Hide abstract] ABSTRACT: The pediatric appendicitis score (PAS) has been used as a diagnostic tool for the assessment of acute abdominal pain. Our institution has utilized this scoring system as part of a clinical pathway for acute appendicitis. We sought to discover if the PAS could also serve as a prognostic indicator. Patients treated within the clinical pathway were divided into three groups (A, B, and C) based on the PAS assigned on admission. Data pertaining to intraoperative findings and length of hospital stay were collected prospectively. In 4 months, 112 patients were enrolled in the study (median age 10.5, range 1-18). 69 of these patients underwent early laparoscopic appendectomy. For group A, 75% had simple appendicitis and 5% were complex. For group B, 68.4% patients had simple appendicitis and 26.3% were complex. For group C, 27.3% were simple and 63.6% were complex. Mean length of hospital stay increased from 1.63 ± 0.34 for patients in group A to 5.9 ± 1.37 for patients in group C. Our observational data suggests that the PAS may be a prognostic tool for acute appendicitis. It thereby may impact on preoperative management and postoperative clinical pathways. A larger cohort is necessary to validate our findings.
- [Show abstract] [Hide abstract] ABSTRACT: Laparoscopic pyloromyotomy has become the standard treatment for hypertrophic pyloric stenosis. Single-incision laparoscopic surgery is an emerging operative approach that utilizes the umbilical scar to hide the surgical incision. To describe our initial experience with single-incision laparoscopic pyloromyotomy in 15 infants. Laparoscopic pyloromyotomy was performed through a single skin incision in the umbilicus, using a 4-mm 30 degrees endoscope and a 5-mm trocar. The 3-mm working instruments were inserted directly into the abdomen via separate lateral fascial stab incisions. All patients were prospectively evaluated. The procedure was performed in 15 infants (13 male) with mean age of 45 +/- 16 days and mean weight of 4.04 +/- 0.5 kg. All procedures were completed laparoscopically, and one case was converted to a conventional triangulated laparoscopic work configuration after a mucosal perforation was noted. The perforation was repaired laparoscopically. On average, operating time was 29.8 +/- 13.6 min, and postoperative length of stay was 1.5 +/- 0.8 days. All patients were discharged home on full feeds. Follow-up was scheduled 2-3 weeks after discharge, and no postoperative complications were noted in any of the patients. Single-incision laparoscopic pyloromyotomy is a safe and feasible procedure with good postoperative results and excellent cosmesis. The main challenge is the spatial orientation of the instruments and endoscope in a small working space. This can be overcome by a more longitudinally oriented working axis than used in the conventional angulated laparoscopic configuration.
- [Show abstract] [Hide abstract] ABSTRACT: Laparoscopic cholecystectomy has become the standard, in most pediatric surgery centers. In the search for a less-invasive procedure, a single-incision laparoscopic approach has been reported in adults and very few children. The aim of this study was to present our initial experience of cholecystectomy, using single-incision pediatric endosurgery (SIPES), including the technique, the intraoperative challenges, and the outcome. All pediatric patients who underwent a SIPES cholecystectomy from March through September 2009 were prospectively evaluated. Twenty-five children underwent a SIPES cholecystectomy. The most frequent indications were symptomatic cholelithiasis in 17 patients (68%) and biliary dyskinesia in 5 (20%). Five patients had sickle-cell anemia. The mean operative time was 73 minutes (range, 30-122). Median hospital stay was 1 day. In 17 patients (68%), a percutaneous 2-mm grasper was used to retract the gallbladder over the liver. No complications were noted, and no conversion to an open procedure was required. In 5 patients, additional trocars were added. On follow-up, 3 days to 2 months later, no complications were noted. No patients were readmitted, and there were no wound infections. Cholecystectomy, when using the SIPES approach in children, is a safe, reasonable alternative to conventional laparoscopy, leaving an inconspicuous scar. Whether SIPES offers any further benefit to the patient, besides improved cosmesis, should be evaluated in future studies.
- [Show abstract] [Hide abstract] ABSTRACT: To determine the independent impact of acute kidney injury (AKI) and renal replacement therapy (RRT) in infants and children who receive extracorporeal membrane oxygenation. Despite continued expertise/technological advancement, patients who receive extracorporeal membrane oxygenation have high mortality. AKI and RRT portend poor outcomes independent of comorbidities and illness severity in several critically ill populations. Retrospective cohort study. The primary variables explored are AKI (categorical complication code for serum creatinine > 1.5 mg/dL or International Statistical Classification of Diseases and Related Health Problems, Revision 9 for acute renal failure), and RRT (complication/Current Procedural Terminology code for dialysis or hemofiltration). Multiple variables previously associated with mortality in this population were controlled, using logistic stepwise regression. Decision tree modeling was performed to determine optimal variables and cut points to predict mortality. Critically ill neonates (0-30 days old) and children (> 30 days but < 18 yrs old) in the Extracorporeal Life Support Organization registry. None. Neonatal mortality was 2175 (27.4%) of 7941. Nonsurvivors experienced more AKI (413 [19%] of 2175 vs. 225 [3.9%] of 5766, p < .0001), and more received RRT (863 [39.7%] of 2175 vs. 923 [16.0%] of 5766, p < .0001) than survivors. Pediatric mortality was 816 (41.6%) of 1962. Pediatric nonsurvivors similarly experienced more AKI (264 [32.3%] of 816 vs. 138 [12.0%] of 1146, p < .0001) and RRT (487 [58.9%] of 816 vs. 353 [30.8%] of 1146, p < .0001) than survivors. After adjusting for confounding variables, the adjusted odds ratio for neonatal group was 3.2 (p < .0001) post AKI and 1.9 (p < .0001) given RRT. Similarly, the pediatric adjusted odds ratio for mortality was 1.7 (p < .001) post AKI and 2.5 (p < .0001) given RRT. AKI and RRT were essential in the neonatal and pediatric mortality decision trees. After adjusting for known predictors of mortality, AKI and RRT independently predict mortality in neonates and children, who receive extracorporeal membrane oxygenation. Ascertainment of AKI risk factors, testing novel therapies, and optimizing the timing/delivery of RRT may positively impact survival.
- [Show abstract] [Hide abstract] ABSTRACT: Anecdotally, laparoscopy has been used for the diagnosis and therapy of pediatric abdominal trauma, but only few studies have been published. We performed a systematic analysis of our experience concerning indications, procedures, and outcomes using laparoscopy in pediatric abdominal trauma patients. Our trauma database was searched for patients who underwent laparoscopy after being admitted for abdominal trauma. Cases were grouped into diagnostic and therapeutic procedures. Success was defined as attaining the correct diagnosis or as the ability to repair the injury by laparoscopy. Of 4,836 pediatric trauma admissions over a period of 12 years, 92 had open or laparoscopic abdominal explorations for blunt (n = 47) and penetrating (n = 35) injuries. In 21 patients, diagnostic laparoscopic procedures were performed, and 5 of these children also underwent a therapeutic laparoscopy. Nineteen patients were treated in the acute setting and two in a delayed fashion. Overall, 19 of 21 laparoscopies correctly diagnosed the injury, and all the 5 laparoscopic therapeutic procedures were successful. There was a significant difference in success rate of diagnostic laparoscopy between acute and delayed cases (p < 0.01). Retrospectively, laparotomy was avoided in 13 of 21 patients overall and in 10 of 10 patients with penetrating trauma (p = 0.02). Laparoscopy is useful in the management of the hemodynamically stable pediatric patient with abdominal trauma but may be less valuable in cases with delayed presentation. Many intraabdominal injuries are amenable to laparoscopic repair. In patients with penetrating trauma, laparoscopy avoided laparotomy is more likely than in those with blunt abdominal trauma. Laparoscopy is currently underutilized in the management of pediatric abdominal trauma.
Article: Hirschsprung's Disease
Sacred Heart Medical CenterSpokane, Washington, United States
Children's Hospital of AlabamaBirmingham, Alabama, United States