Search

Background: Pediatric renal trauma is rare and lacks sufficient population-specific data to generate evidence-based management guidelines. A nonoperative approach is preferred and has been shown to be safe. However, bleeding risk assessment and management of collecting system injury are not well understood. We introduce the Multi-institutional Pediatric Acute Renal Trauma Study (Mi-PARTS), a retrospective cohort study designed to address these questions. This article describes the demographics and contemporary management of pediatric renal trauma at Level I trauma centers in the United States., Methods: Retrospective data were collected at 13 participating Level I trauma centers on pediatric patients presenting with renal trauma between 2010 and 2019. Data were gathered on demographics, injury characteristics, management, and short-term outcomes. Descriptive statistics were used to report on demographics, acute management, and outcomes., Results: In total, 1,216 cases were included in this study. Of all patients, 67.2% were male, and 93.8% had a blunt injury mechanism. In addition, 29.3% had isolated renal injuries, and 65.6% were high-grade (American Association for the Surgery of Trauma Grades III-V) injuries. The mean Injury Severity Score was 20.5. Most patients were managed nonoperatively (86.4%), and 3.9% had an open surgical intervention, including 2.7% having nephrectomy. Angioembolization was performed in 0.9%. Collecting system intervention was performed in 7.9%. Overall mortality was 3.3% and was only observed in patients with multiple injuries. The rate of avoidable transfer was 28.2%., Conclusion: The management and outcomes of pediatric renal trauma lack data to inform evidence-based guidelines. Nonoperative management of bleeding following renal injury is a well-established practice. Intervention for renal trauma is rare. Our findings reinforce differences from the adult population and highlights opportunities for further investigation. With data made available through Mi-PARTS, we aimed to answer pediatric specific questions, including a pediatric-specific bleeding risk nomogram, and better understanding indications for interventions for collecting system injuries., Level of Evidence: Prognostic and Epidemiological; Level IV., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Efficient transfer of adult trauma patients to the intensive care unit (ICU) is associated with decreased emergency department (ED) length of stay (ED LOS) and improved patient outcomes. While well studied in adults, quality improvement (QI) initiatives focused on the rapid transfer of pediatric trauma patients are lacking. We report the effect of institutional system changes directed at expediting the transfer of pediatric trauma patients to the pediatric ICU (PICU)., Methods: This initiative commenced in 2013. Preliminary data regarding ED LOS for pediatric trauma patients were collected from January through December 2012 as the pre-implementation cohort. Using the plan-do-study-act (PDSA) framework of QI, the first PDSA cycle was implemented in January 2013. In subsequent PDSA cycles, we implemented the mandatory attendance of the PICU charge nurse and the PICU attending physician to all highest-level pediatric trauma activations. Throughout, ED LOS was collected and mapped on a run chart. ED LOS and variance were compared between all cycles of implementation., Results: One hundred and fifty-one pediatric patients arrived or were upgraded to the highest-level pediatric trauma activation and admitted to the PICU from 2012 through 2019. We observed a decrease in median ED LOS of 105 minutes between the pre- and post-implementation groups. With each PDSA cycle, we observed a decrease in median ED LOS and variation., Conclusion: The inclusion of the PICU charge nurse and attending physician at highest-level pediatric trauma activations facilitated more rapid access to the PICU with decreased ED LOS., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons., Methods: A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency., Results: A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases., Conclusion: Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Injury to the kidney from either blunt or penetrating trauma is the most common urinary tract injury. Children are at higher risk of renal injury from blunt trauma than adults, but no pediatric renal trauma guidelines have been established. The authors reviewed the literature to guide clinicians in the appropriate methods of management of pediatric renal trauma., Methods: Grading of Recommendations Assessment, Development and Evaluation methodology was used to aid with the development of these evidence-based practice management guidelines. A systematic review of the literature including citations published between 1990 and 2016 was performed. Fifty-one articles were used to inform the statements presented in the guidelines. When possible, a meta-analysis with forest plots was created, and the evidence was graded., Results: When comparing nonoperative management versus operative management in hemodynamically stable pediatric patient with blunt renal trauma, evidence suggests that there is a reduced rate of renal loss and blood transfusion in patients managed nonoperatively. We found that in pediatric patients with high-grade American Association for the Surgery of Trauma grade III-V (AAST III-V) renal injuries and ongoing bleeding or delayed bleeding, angioembolization has a decreased rate of renal loss compared with surgical intervention. We found the rate of posttraumatic renal hypertension to be 4.2%., Conclusion: Based on the completed meta-analyses and Grading of Recommendations Assessment, Development and Evaluation profile, we are making the following recommendations: (1) In pediatric patients with blunt renal trauma of all grades, we strongly recommend nonoperative management versus operative management in hemodynamically stable patients. (2) In hemodynamically stable pediatric patients with high-grade (AAST grade III-V) renal injuries, we strongly recommend angioembolization versus surgical intervention for ongoing or delayed bleeding. (3) In pediatric patients with renal trauma, we strongly recommend routine blood pressure checks to diagnose hypertension. This review of the literature reveals limitations and the need for additional research on diagnosis and management of pediatric renal trauma., Level of Evidence: Guidelines study, level III.

Background: Injury is one of the most prevalent potentially emotionally traumatic events that children experience and can lead to persistent impaired physical and emotional health. There is a need for interventions that promote full physical and emotional recovery and that can be easily accessed by all injured children. Based on research evidence regarding post-injury recovery, we created the Cellie Coping Kit for Children with Injury intervention to target key mechanisms of action and refined the intervention based on feedback from children, families, and experts in the field. The Cellie Coping Kit intervention is parent-guided and includes a toy (for engagement), coping cards for children, and a book for parents with evidence-based strategies to promote injury recovery. This pilot research trial aims to provide an initial evaluation of the impact of the Cellie Coping Kit for Children with Injury on proximal targets (coping, appraisals) and later child health outcomes (physical recovery, emotional health, health-related quality of life)., Method / Design: Eighty children (aged 8-12 years) and their parents will complete a baseline assessment (T1) and then will be randomly assigned to an immediate intervention group or waitlist group. The Cellie Coping Kit for Injury Intervention will be introduced to the immediate intervention group after the T1 assessment and to the waitlist group following the T3 assessment. Follow-up assessments of physical and emotional health will be completed at 6 weeks (T2), 12 weeks (T3), and 18 weeks (T4)., Discussion: This will be one of the first randomized controlled trials to examine an intervention tool intended to promote full recovery after pediatric injury and be primarily implemented by children and parents. Results will provide data on the feasibility of the implementation of the Cellie Coping Intervention for Injury as well as estimations of efficacy. Potential strengths and limitations of this design are discussed., Trial Registration: Clinicaltrials.gov, NCT03153696 . Registered on 15 May 2017.

Introduction: Nonaccidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. The skeletal survey (SS) and follow-up skeletal survey (FUSS) are essential in the evaluation of selected NAT patients. We identified that our clinically indicated FUSS completion rate was suboptimal. We hypothesized that implementing an intervention of postdischarge follow-up in our pediatric surgery clinic would improve FUSS completion rates., Methods: A follow-up clinic for NAT patients was established in July 2013. A retrospective review was performed of all suspected NAT cases younger than 2 years old seen at Kentucky Children's Hospital between November 2012 and February 2014. The study population was divided into pre (Group 1) and postintervention (Group 2). Bivariate analysis was performed., Results: Group 1 consisted of 50 patients (58% male; median age, 9 months). Forty-7 (94%) had an SS; fractures were identified in 37 (74%) patients. Only 20 patients (40%) had FUSS; of those, 4 had newly identified fractures. Group 2 consisted of 52 patients (54% male; median age, 7 months). All 52 children (100%) had an SS; fractures were identified in 35 (67%) patients. Forty-seven patients (90%) had FUSS. Of those, 6 had new radiographic findings. Thirty-five patients (67%) were seen in our clinic. This improvement in FUSS (40% versus 90%) was statistically significant, P < 0.001., Conclusion: The decision to follow NAT patients in our clinic had significantly increased our rates of FUSS completion. This additional clinic follow-up also provided more evidence for NAT evaluation.

We studied pediatric bicycle accident victims (age ≤ 15 years) who were treated at our pediatric Level I trauma center during a 10-year period. Demographic data, injury severity, hospital course, and hospital cost data were collected. We compared the children who were helmeted to those who were unhelmeted. Our study cohort consisted of 516 patients. Patients were mostly male (70.2%) and white (84.7%); the median age was nine years. There were 101 children in the helmet group and 415 children in the unhelmeted group. Helmeted children were more likely to have private insurance (68.3% vs 35.9%, P < 0.001). Unhelmeted children were more likely to sustain multiple injuries (40% vs 25.7%, P = 0.008), meet our trauma activation criteria (45.5% vs 16.8%, P < 0.001), and be admitted to the hospital (42.4% vs 14.9%, P < 0.001). Helmeted children were less likely to sustain brain injuries (15.8% vs 25.8%, P = 0.037), skull fractures (1% vs 10.8%, P = 0.001), and facial fractures (1% vs 6%, P = 0.040). Median hospital costs were more expensive in the unhelmeted group. Helmet usage was suboptimal. Although most children sustained relatively minor injuries, the unhelmeted children had more injuries and higher costs than those who used helmets. Injury prevention programs are warranted.

We initiated a multidisciplinary Child Protection Team (CPT) as a subgroup of our pediatric multidisciplinary trauma peer review committee. Meetings are held monthly. Nonaccidental trauma (NAT) patients from the preceding month are reviewed. The meeting has two parts. During the open part, detectives and child protective services (CPS) workers are invited to discuss specific cases. The closed part focuses on improvement of specific processes and future outcomes. Attendance is recorded and minutes are kept. We sought to review accomplishments of this group. We retrospectively reviewed the minutes from our CPT meetings conducted between February 2014 and April 2015. We tracked attendance, cases reviewed, process improvement projects, and corrective action plans. Meeting attendance was very good-78 per cent. During the 15-month study period, we had 141 suspected NAT patients; 96 were reviewed at our meetings. CPS workers attended 53 per cent of the meetings; 13 investigations were discussed. We established a clinical practice guideline for the evaluation of NAT patients. We created a mechanism to improve compliance with follow-up skeletal surveys. Six corrective letters were sent to individuals notifying them of care concerns and opportunities for improvement. Equipment needs were identified, and we obtained a digital camera and speaker phone. We have conducted multiple educational sessions to increase awareness. Our CPT meeting has improved the care of our NAT patients and provided better communication between our hospital staff and CPS workers. We have improved inhospital processes for our NAT patients. We have provided educational opportunities to outside care providers.

Non-accidental trauma (NAT) victims account for a significant percentage of our pediatric trauma population. We sought to better understand the injury patterns and outcomes of NAT victims who were treated at our level I pediatric trauma center. Trauma registry data were used to identify NAT victims between January 2008 and December 2012. Demographic data, injury severity, hospital course, and outcomes were evaluated. One hundred and eighty-eight cases of suspected NAT were identified. Children were mostly male and white. The median age was 1.1 years; the median Injury Severity Score was 9. Traumatic brain injuries, lower extremity fractures, and skull fractures were the most common injuries. Twenty-seven per cent required medical procedures; most were performed by orthopedic surgery. Twenty-four per cent required admission to the pediatric intensive care unit. The median length of stay was two days. The mortality rate was 9.6 per cent. We generated a hot spot map of our catchment area and identified areas of our state where NAT occurs at increased rates. NAT victims sustain significant morbidity and mortality. Due to the severity of injuries, pediatric trauma surgeons should be involved in the evaluation and management of these children. Much work is needed to prevent the death and disability incurred by victims of child abuse.

Therapeutic reduction of intussusception by air or contrast enema may require surgery if the bowel is irreducible or perforates. There is no standard for the involvement of a pediatric surgeon in the workup of the condition. A regional survey of clinical practices was therefore undertaken to attempt to establish a consensus as to when the presence of a pediatric surgeon is required. Distributed to pediatric surgeons at 32 institutions, a questionnaire asked the process of imaging and reduction of infants with intussusception and the extent of pediatric surgical involvement. Surgeons at 29 institutions responded (91%). Ultrasound was used in diagnosis in 16 (55%), 13 (45%) requiring a positive ultrasound diagnosis of intussusception before attempting reduction. Three-fourths (22 [76%]) required surgeon notification that enema reduction was taking place, and one-fourth (seven [24%]) required prior surgical consultation. Only three (10%) required the presence of a surgery team member. Most (21 [72%]) did not demand one, and five (18%) indicated that surgical presence was desirable but not a necessity. There is no consensus for pediatric surgical involvement before and during reduction of an intussusception.

Complicated necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are major causes of mortality. We hypothesized that peritoneal drainage (PD) is more efficacious in SIP. Newborn infants with intestinal perforation treated with PD at our institution between 2007 and 2012 were divided into two groups: Group 1, infants with complicated NEC (n = 19), and Group 2, infants with SIP (n = 15). In Group 1, median birth weight was 705 g; median gestational age was 25.9 weeks. Median age at PD was 24 days. Six required laparotomy. Median time from PD to enteral feeds was 22.5 days. In Group 2, median birth weight was 685 g; median gestational age was 25.3 weeks. Median age at PD was 5 days. Two required laparotomy. Median time from PD to enteral feeds was 16 days. In Group 1, eight patients survived to discharge; median length of hospital stay (LOS) was 104.5 days. In Group 2, eight survived; median LOS was 109.5 days. Neither outcome was statistically significant (P = 0.73 and 0.878, respectively). Management of premature infants with intestinal perforation remains challenging. Mortality is high. Between our cohorts, there were no differences in regard to PD as definitive therapy, survival, and LOS.

Objective: We compared outcomes among pediatric patients managed with minimally invasive (MI) packing techniques with those managed with traditional packing techniques for drainage of subcutaneous abscesses., Methods: After institutional review board approval, medical records of children requiring drainage of subcutaneous abscesses between January 2010 and June 2011 were reviewed. Data were collected on patient demographics, abscess location, surgical procedure, microbiology cultures, and hospital length of stay (LOS). The hospital accounting system was queried for direct and indirect costs. We compared LOS and cost data among groups managed with MI versus traditional packing techniques., Results: Incision and drainage was performed on 329 children (57.8% girls, 72% white, mean age of 43 months [range <1 to 218]). Of the total abscesses 198 (60.2%) were located in the groin/buttocks/perineum. Methicillin-resistant Staphylococcus aureus was identified in 74% of culture specimens. A total of 202 patients (61.4%) underwent packing and 127 (38.6%) underwent MI drainage. MI drainage ranged from 0% (0/110) in January to June 2010 to 34.6% (44/127) in the July to December 2010 transition period and reached 90.2% (83/92) in 2011 (P < 0.001). Median LOS decreased from 2 days (interquartile range 1-2) in the packing-only period to 1 day (interquartile range 1-2) in the predominantly MI period (P < 0.001). Hospital costs decreased with the transition to the MI technique (P < 0.001). MI drainage was associated with a $520 reduction in median direct costs and a $385 reduction in median indirect costs (P < 0.001)., Conclusions: Soft tissue infections requiring incision and drainage are common in the pediatric population, with the majority caused by methicillin-resistant Staphylococcus aureus. Infections requiring drainage most frequently occurred in the diaper area of girls younger than 3 years old. Changing to an MI technique significantly decreased the hospital costs and LOS in our patient population.

Chondromyxoid fibromas are benign tumors which are found most frequently in the metaphyses of long bones. They comprise less than 1% of primary bone neoplasms and display a hypermetabolic appearance on PET imaging. Oftentimes, they are misdiagnosed as chondrosarcomas and are excised due to concern for malignancy. We present a case of a condromyxoid fibroma originating from the second rib of a 15-year-old girl., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Our objective was to determine the accuracy of laparoscopic evaluation to detect a contralateral patent processus vaginalis (CPPV) at initial presentation for inguinal hernia (IH) repair and the rate of CPPV relative to age, sex, and initial hernia side. We performed a 5-year retrospective review of 1580 pediatric patients with unilateral IH in which surgeons selectively used laparoscopy to evaluate for a CPPV. There were 1205 boys and 303 girls; 980 (65%) presented with right IH (RIH) and 528 (35%) with left IH (LIH). Laparoscopic evaluation was performed in 459 (47%) patients presenting with RIH and 225 (43%) patients presenting with LIH. Laparoscopic evaluation was positive for CPPV in 32 per cent of patients with RIH and 42 per cent of patients with LIH (P = 0.0168). CPPV was associated with prematurity (P = 0.0003) and age younger than 6 months (P = 0.0001) but not with sex (P = 0.55). The future contralateral occurrence rate was 1.6 per cent and recurrence rate 0.2 per cent. This study supports the accuracy of CPPV evaluation by laparoscopy. Although the rate of CPPV decreases after 6 months of age, girls older than 2 years of age have a significantly higher rate of CPPV than boys, supporting laparoscopic evaluation in older girls.

Introduction: The impact of risk-taking behavior among adolescent blunt trauma patients is not fully appreciated. This study examined the relationship between adolescent risk-taking behaviors, the resultant injury severity, and outcome for blunt trauma., Methods: Between January 2000 and December 2005, data were collected on adolescent blunt trauma patients (12-18 years) admitted to either a Level I adult trauma center or large urban pediatric hospital. Five groups of risk-taking behavior were examined: ATV riders, drug and alcohol users, unhelmeted motorcyclists, unhelmeted extreme sports participants and unrestrained motor vehicle occupants. Demographic data, mechanism of injury, injury severity, hospital course and outcomes were evaluated for each group., Results: A total of 2030 adolescents were admitted following blunt trauma; 723 adolescents (36%) were engaged in risk-taking behavior at the time of their injury. Most patients were male (68%). Unrestrained MVA occupants were the most frequently encountered risk takers (37%); among this subset, most were unrestrained passengers (74%). Head injuries were frequent (22%) among risk takers. When compared to non-risk-takers, there were no significant age, race, gender, or ISS differences. However, a significantly higher number of positive head CT scans were found among risk-taking adolescents (22%, p < 0.05). Mortality was low (3%)., Conclusions: Risk-taking behavior is prevalent among adolescent blunt trauma patients. Improved injury prevention strategies are needed to discourage these behaviors during adolescence.

Background: Reports of somatic mutations found in hearts with cardiac septal defects have suggested that these mutations are aetiologic in pathologic cardiac development. However, the hearts in these reports had been fixed in formalin for over 22 years. Because of the profound implication of this finding, we attempted to replicate it using fresh frozen tissue obtained in the current era from 28 patients with septal defects who underwent cardiac surgery and who were enrolled in our congenital heart disease tissue bank., Methods: Our cohort included patients with atrial septal defects (ASD, n = 13), ventricular septal defects (VSD, n = 5), and atrioventricular canal defects (AVCD, n = 10). Cardiac tissue samples were collected both from diseased tissue located immediately adjacent to the defect and from anatomically normal tissue located at a site remote from the defect (right atrial appendage). Tissue samples were immediately frozen in liquid nitrogen and stored at -80 degrees C. Genomic DNA was isolated and amplified using the same methodology described in the previously published reports. 42 pathologic cardiac tissue samples were sequenced., Results: One non-synonymous germline sequence variant was identified in one patient. Two synonymous germline sequence variants were identified in two separate patients. A common single nucleotide polymorphism (SNP) was identified in 16 patients. Based on the incidence of somatic mutations described in the previously published reports, our study was adequately powered to replicate the previous studies. No evidence of somatic mutations was found in this study., Conclusion: Somatic mutations in NKX2-5 do not represent an important aetiologic pathway in pathologic cardiac development in patients with cardiac septal defects.

Purpose: We compared injury severity, hospital course, and outcomes between adolescent blunt trauma patients with and without positive toxicology screens., Methods: Trauma registry data were used to identify adolescent blunt trauma victims between 2000 and 2005. Demographics, injury severity, hospital course, and outcomes were evaluated. Patients with and without positive toxicology results were compared., Results: There were 9.3% that had positive toxicology results. The mean age of toxicology-positive patients was 17.2 years. The most commonly detected drugs were cannabinoids (40%), alcohol (30%), and polysubstances (23%). Toxicology-positive patients had significantly lower Glasgow Coma Scale (11.8 +/- 4.6 vs 13.7 +/- 3.3; P < .001), higher Injury Severity Score (16.7 +/- 11.2 vs 10.4 +/- 9.1; P < .001), and required more emergent operations (20.7% vs 12.8%; P < .001). Length of stay was longer (7.3 +/- 8.1 vs 4.8 +/- 7.2 days; P < .001). Functional Independence Measure scores were lower (10.5 +/- 2.2 vs 11.2 +/- 1.7; P < .001); mortality was higher (6.4% vs 2.6%; P < .001)., Conclusions: A significant number of adolescents had positive toxicology screens. Our data suggest that toxicology-positive patients were more severely injured, required more hospital care, and had worse outcomes than other adolescent blunt trauma victims.

The management of intestinal malrotation without midgut volvulus is controversial. Some advocate the Ladd procedure in all patients with malrotation, whereas others propose a more selective approach. We attempted the laparoscopic Ladd procedure on nine patients who were diagnosed with intestinal malrotation without volvulus. Patient records were retrospectively reviewed. Data were collected on patient presentation, operative procedure, hospital course, and outcome. The laparoscopic Ladd procedure was successfully completed in eight patients (aged 10 weeks to 25 years). One patient required conversion to an open procedure. Operative time averaged 111 minutes (range, 77-176 minutes). Hospital stay ranged from 3 to 5 days (average, 3.6 days). All patients were discharged home on a regular diet. There was one complication and no deaths. Eight patients had complete resolution of their symptoms. The laparoscopic Ladd procedure is a safe and effective procedure for infants, children, and adults who have intestinal malrotation without midgut volvulus. The operative times, hospital stay, and clinical outcomes were acceptable. We recommend that laparoscopic intervention be considered in patients with intestinal malrotation without volvulus. Intestinal malrotation occurs along a wide spectrum of anatomic variants and clinical presentations. The management of malrotation without midgut volvulus remains controversial. Most advocate performing the Ladd procedure on all patients found to have malrotation because there is no way to know which of these patients will develop catastrophic midgut volvulus. Some propose a more selective approach because of the morbidity associated with operative intervention. There have been a number of small series and case reports describing the use of laparoscopy to diagnose and correct malrotation. Proponents of this method point out its minimally invasiveness, patients' quick recoveries, and successful outcomes. We describe our experience with the laparoscopic Ladd procedure and its long-term results.

The coexistence of colonic atresia and Hirschsprung's disease presents a diagnostic and therapeutic challenge. Colonic atresia is quickly recognized, and the majority of patients are diverted shortly after birth. The diagnosis of coincident Hirschsprung's disease usually is made after anastomotic failure after restoration of intestinal continuity. A recent compilation of these patients has suggested that Hirschsprung's disease may be predicted on the basis of nonfixation of the colon distal to the atresia. However, we recently cared for an infant with transverse colonic atresia and total colonic aganglionosis associated with normal orientation and fixation of the distal colon.

Background: We studied the etiology, treatment, and outcome of enterocutaneous fistulas in 106 patients to evaluate our current practice and the impact of newer therapies-octreotide, wound vacuum-assisted closure (VAC), and fibrin glue-on clinical outcomes. Review of the literature and our own 1990 study indicate a mortality rate of 5% to 20% for enterocutaneous fistula, and a healing rate of 75% to 85% after definitive surgery., Methods: We reviewed all cases of gastrointestinal-cutaneous fistula from 1997 to 2005 at 2 large teaching hospitals. We identified 106 patients with enterocutaneous fistula; patients with irritable bowel disease and anorectal fistulas were excluded., Results: The origin of the fistula was the small bowel in 67 patients, colon in 26, stomach in 8, and duodenum in 5. The etiology of the fistula was previous operation in 81 patients, trauma in 15, hernia mesh erosion in 6, diverticulitis in 2, and radiation in 2. Of the 106 patients in the study, 31 had a high output fistula (greater than 200 mL/day), 44 had a low output fistula, and, in 31 patients, the fistula output was low but there was no record of volume. Initial treatment was nonoperative except for patients with an abscess who needed urgent drainage. In 24 patients, the effect of octreotide was monitored: in 8 patients, fistula output declined; in 16 patients, octreotide was of no benefit. Fibrin glue was used in 8 patients and was of benefit to 1. The wound VAC was used in 13 patients: 12 patients still required operative repair of the fistula, whereas the fistula was healed in 1 patient. The main benefit of the VAC system was improved wound care in all patients before definitive surgery. Total parenteral nutrition was used in most patients to provide nutritional support. Operative repair was performed in 77 patients and was successful in 69 (89%), failing in 6 patients with persistent cancer or infection. Nonoperative treatment was used in 29 patients and resulted in healing in 60%. Of 106 patients, 7 (7%) died of fistula complications. The cause of death was persistence or recurrence of cancer in 4 patients and persistent sepsis in 3., Conclusion: Enterocutaneous fistula continues to be a serious surgical problem. The wound VAC and fibrin glue had anecdotal successes (n = 2), and one-third of patients responded to octreotide. We believe that octreotide should be tried in most patients and that the wound VAC has a role in selected patients. Although 7% overall mortality is lower than in previous studies, the number managed without operation (27%) remains the same. In addition to early control of sepsis, nutritional support, and wound care, a well-timed operation was the most effective treatment.