Search

Purpose: The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery., Methods: A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR)., Results: LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge., Conclusions: Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB., Type of Study: Prognosis study LEVEL-OF-EVIDENCE RATING: Level II., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Pediatric mediastinal masses may be resected using an open or video-assisted thoracoscopic surgery (VATS) approach. We sought to define the preoperative imaging findings predicting amenability to VATS., Methods: This multicenter retrospective study of pediatric patients undergoing either VATS or open surgical mediastinal mass resection between 2008 and 2018 evaluated the preoperative imaging descriptors associated with VATS. Postoperative endpoints included length of stay (LOS), 30-day readmission, 90-day mortality and complication rates., Results: Mediastinal mass resection was performed in 33 patients. Median tumor size was 6 cm, and 51.5% had anterior mediastinal tumors. The 23 (69.7%) patients who underwent VATS were significantly older (144 months vs 32, P = 0.01) and larger (33.6 kg vs 13.8 P = 0.03). Preoperative imaging characteristics in VATS included "well circumscribed", "smooth margins" and "cystic", while the open surgery group were "heterogeneous" and "coarse calcification". The open group had more germ cell tumors (60.0% vs 13.0%, P = 0.16) but no difference in malignancy. VATS patients had shorter LOS (2 days vs 6.5, P = 0.24). Readmission, complication and mortality rates were similar., Conclusions: Pediatric patients with apparent malignancy frequently underwent open resection compared with the thoracoscopic group, although final malignant pathology was similar. Equivalent outcomes and shorter LOS should favor a minimally invasive approach., Level of Evidence: Level III., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE) in patients undergoing the modified Ravitch procedure., Methods: A retrospective review of 37 patients undergoing the modified Ravitch repair with either INC or TE from March 2009 to July 2021 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long term opioid use after discharge, and post-operative complications., Results: LOS decreased to 2.8 days in the INC group compared to 6 days in the TE group (p<0.0001). Surgical time and total OR time was increased in the INC group. The INC group experienced significantly lower hospital costs (p<0.01). Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long term opioid use in the INC group (p<0.0001)., Conclusions: INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings for patients undergoing the modified Ravitch procedure. We recommend that INC be included in the current practice for postoperative pain control in pectus disorder patients undergoing the modified Ravitch procedure., Competing Interests: Conflict of Interest The authors report no conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB)., Methods: In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR)., Results: The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation., Conclusions: The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital., Level-Of-Evidence: Level II., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier Inc.)

Purpose: The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE)., Methods: A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications., Results: LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group., Conclusions: INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.

Introduction: Cloaca malformation repair strategy is strongly dictated by common channel and urethral lengths. Mid to long common channel cloacas are challenging and often require laparotomy for dissection of pelvic structures. The balance of common channel and urethral lengths often dictates the approach for reconstruction. Laparoscopy has been utilized for rectal dissection but not for management of the urogenital (UG) structures. We hypothesized that laparoscopy could be applied to UG separation in reconstruction of cloaca malformations. Methods: Records were reviewed for 9 children with cloaca who underwent laparoscopic rectal mobilization and UG separation. Clinical parameters reviewed included demographics, relevant anatomic lengths, operative duration, transfusion requirements, and perioperative complications. Results: Repair was perfomed at a median (interquartile range) age of 12 (7, 15) months. Common channel length as measured by cystoscopy was 3.5 (3.3, 4.5) cm. There were no intraoperative complications. Transfusion requirements were minimal. Postoperative length of stay was 6 (5, 11) days. One patient developed a urethral web and 2 developed vaginal stenosis. One patient later underwent a laparotomy for obstruction due to a twisted rectal pull-through. Conclusions: Laparoscopic rectal mobilization and UG separation in long common channel cloaca are safe and well tolerated. Laparoscopy affords full evaluation of Mullerian structures and enables separation of the common UG wall, which may ultimately enhance long-term urinary continence.

Background: Morgagni hernias are rare, with a reported incidence of 2% to 5% of congenital diaphragmatic hernias., Objectives: To review a laparoscopic technique to repair Morgagni hernias in pediatric patients., Methods: Retrospective chart review of pediatric patients who underwent minimally invasive repair of a Morgagni hernia from November 2009 to September 2017 within a defined population., Results: During an 8-year period, 15 patients with Morgagni hernias were identified. Four patients with Morgagni hernias were excluded because they had open repairs. Eleven Morgagni hernias were repaired through a completely minimally invasive approach. Three repairs were completed using a soft-tissue patch (Gore-Tex patch, W L Gore & Associates Inc, Flagstaff, AZ). All minimally invasive repairs were completed with transfascial sutures using an endoscopic suturing device (Endo Close, Covidien/Medtronic, Fridley, MN) and 2-0 nonabsorbable synthetic sutures with extracorporeal knot tying. Median follow-up was 40 months (range = 2.6 months to 7.3 years). No patients had postoperative pectus excavatum defects. There were no recurrences., Conclusion: Morgagni hernias are amenable to minimally invasive repair with this simple technique. With large defects, synthetic patches should be used. Recurrences are rare, and morbidity is low.

Background: Reconstruction of complex chest wall deformities is a surgical challenge. A new technique can improve long-term outcomes and result in high patient satisfaction., Methods: A multicenter study was conducted on pediatric patients undergoing complex chest wall reconstruction between September 2015 and January 2018. The evolution of the technique using open reduction and internal fixation (ORIF) with SternaLock® and RibFix® to repair chest wall deformities is described., Results: Seventeen patients underwent complex chest wall reconstruction with ORIF. Eight patients had severe or recurrent pectus excavatum, five patients had pectus carinatum, and four patients had complex chest wall fractures or other anomalies causing significant chronic pain. Up to three SternaLock® plates and four RibFix® plates were used for each procedure. Median length of hospital stay after surgery was four days. Median follow-up time was 12 months (range 2-30). There were no postsurgical complications. There was 100% patient satisfaction in postoperative recovery and cosmesis., Conclusion: ORIF using SternaLock® and RibFix® is an effective method of reconstructing complex chest wall deformities. This technique improves physical stability without the requirement of a subsequent surgery and enhances overall patient satisfaction. High volume centers should integrate this novel approach for challenging chest wall reconstruction., Type of Study: Treatment study: case series., Level of Evidence: Level IV., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: The ability to use detailed, accurate current procedural terminology (CPT) codes is a key component of effective research. We examined the effectiveness of CPT codes to accurately reflect care in patients undergoing surgery for necrotizing enterocolitis (NEC)., Methods: A multicenter retrospective analysis of operations on patients with NEC was conducted across 4 institutions between 2011 and 2016. Correlation between operative dictation and CPT coding was analyzed., Results: A total of 124 patients with NEC diagnosis undergoing exploratory abdominal operations were identified. NEC was improperly diagnosed in 25 patients, who were excluded from further analysis. Of the 99 patients reviewed, the initial exploratory abdominal operation was coded inaccurately in 58 cases (59%). Within these, 15 (26%) had multiple coding errors such that the nature of the original operation was not discernable from the applied codes. Inaccurate codes often did not describe the presence of a mucous fistula (n=27, 44%), ostomy (n=24, 39%), or extra segments of bowel resected (n=9, 16%). The length of bowel resected is not currently described by any CPT codes., Conclusion: CPT coding for abdominal operations does not sufficiently reflect complexity of pediatric surgeries. This study highlights the significance of this inadequacy and its implications in future database studies in the era of electronic medical records., Level of Evidence: Level IV., Type of Study: Clinical research study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The likelihood of a lead point as the cause of ileocolic intussusception increases as children get older. This study looks at whether a different management strategy should be employed in older patients., Methods: 7 year multi-institutional retrospective study of intussusception in patients aged <12 years., Results: Ileocolic intussusception with complete data was found in 153 patients: 109 0-2 years, 34 3-5 years, and 10 6-12 years, respectively. Bloody stools occurred in 42/143 of 0-5 years and 0/10 of 6-12 years, p<0.001. Combined hydrostatic and/or surgical reduction was successful in 113/143 0-5 year olds vs 5/10 6-12 year olds, p<0.001. Enemas were safe but reduced only 1 patient over age 5. Resections were required in 29 patients (15 idiopathic, 14 lead points). Lead points were found in 4/109 children under 3 years, in 5/34 aged 3-5 years and 5/10 aged 6-12 years (p=0.04 vs 3-5 years and p <0.001 vs 0-5 years). Lead points consisted of 7 Meckel's diverticula and 7 others., Conclusion: Children older than 5 years are much more likely to have a pathologic lead point and early surgical intervention should be considered. In this study, enema reduction was safe but minimally beneficial in this age group., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Recurrent gastroesophageal reflux is a common complication after fundoplication procedures. We report our experience with laparoscopic redo Nissen fundoplications in pediatric patients with a history of open antireflux procedure. The medical records of all patients with a history of open antireflux procedure who underwent a subsequent laparoscopic redo Nissen fundoplication were reviewed. One hundred eighty laparoscopic Nissen fundoplications were performed between September 2004 and September 2012; 23 were redo procedures. Twelve patients had a history of prior open fundoplication. Average time between operations was 113.7±64 months. Seven patients presented with emesis, 4 with aspiration pneumonia, and 1 with clinical reflux. Eight had a history of cerebral palsy and/or seizure disorder. Laparoscopic revision was completed in 100% of the patients, with no intraoperative complications. Average operative time was 177.5±86 minutes. Seven patients were able to resume feeds on postoperative Day 1. Median length of stay was 3 days. Median follow-up was 21 months. One patient required a redo antireflux procedure 8 months later for persistent dysphagia. Thus laparoscopic revision Nissen fundoplication after a prior open antireflux procedure is feasible and safe.

Background/purpose: Choledocholithiasis is uncommon in the pediatric population. Techniques for common bile duct stone extraction are still not well established. This article aims to describe safe and applicable techniques for pediatric common bile duct exploration., Materials and Methods: This was a retrospective review of a prospectively maintained database of two pediatric surgeons for patients undergoing laparoscopic common bile duct exploration at two tertiary-care centers from April 2008 to March 2012., Results: For 39 patients under 15 years of age undergoing laparoscopic cholecystectomy, 10 cholangiograms were performed, and 8 were found to have filling defects. Seven patients underwent successful laparoscopic common bile duct exploration with documentation of stone clearance, and 1 patient was sent for postoperative endoscopic retrograde cholangiopancreatography with stone extraction. Eleven patients had cholecystectomy performed by single-incision laparoscopic surgery, but none of these had cholangiograms or common bile duct explorations. Various methods of stone clearance were used, including the use of saline flush, balloon catheters, nitinol stone extractors, and the aide of glucagon. Depending on patient size, a choledochosope or a ureteroscope was used. There were no complications and no conversions to open surgery., Conclusions: Laparoscopic common bile duct exploration is feasible in the pediatric population, using many of the instruments readily available in the standard operating room. With an armamentarium of tools and techniques, the method of stone extraction can be tailored to the patient and situation.

Context: Increasing popularity of strong magnets as toys has led to their ingestion by children, putting them at risk of potentially harmful gastrointestinal tract injuries., Objectives: To heighten physician awareness of the potential complications of magnetic foreign body ingestion, and to provide an updated algorithm for management of a patient who is suspected to have ingested magnets., Design: A retrospective review of magnet ingestions treated over a two-year period at our institutions in the Southern California Permanente Medical Group. Data including patient demographics, clinical information, radiologic images, and surgical records were used to propose a management strategy., Results: Five patients, aged 15 months to 18 years, presented with abdominal symptoms after magnet ingestion. Four of the 5 patients suffered serious complications, including bowel necrosis, perforation, fistula formation, and obstruction. All patients were successfully treated with laparoscopic-assisted exploration with or without endoscopy. Total days in the hospital averaged 5.2 days (range = 3 to 9 days). Average time to discharge following surgery was 4 days (range = 2 to 7 days). Ex vivo experimentation with toy magnetic beads were performed to reveal characteristics of the magnetic toys., Conclusions: Physicians should have a heightened sense of caution when treating a patient in whom magnetic foreign body ingestion is suspected, because of the potential gastrointestinal complications. An updated management strategy is proposed that both prevents delays in surgical care and avoids unnecessary surgical exploration.

Various parameters in 91 adult participants with vascular malformations and 91 controls were studied. The mean of the participants' platelet volumes was 8.5 fL and that of their controls was 9.1 (P < .001). The mean of the participants' platelet mass was 2145 µL/L of blood and that of their controls was 2351 (P = .006). The other parameters studied were not significantly different than the controls. It is suggested that the lower platelet volume might be related to a compensatory mechanism to keep the total body platelet mass stable despite the increased vasculature.

The hepatic portoenterostomy (HPE) is the accepted initial operation for biliary reconstruction for biliary atresia, but in a select group of patients with patent distal extrahepatic bile ducts (PDEBD), a hepatic portocholecystostomy (HPC) may also be considered. A10 year old boy presented with sudden onset of jaundice following a successful HPC at 2 months of age. Radiographic evaluation revealed excretion into a distended gallbladder with distal biliary obstruction. He underwent a successful Roux-en-Y cholecystojejunostomy and remains jaundice-free two years later. Cholecystojejunostomy is an effective salvage operation for patients who develop late distal biliary obstruction after an HPC., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: We conducted a study to determine whether hospital type (county [ie, safety-net] vs private) affects health care access (appendiceal perforation [AP] rates), treatment (laparoscopic appendectomy [LA] rates), and outcomes in children with appendicitis., Methods: A review of cases involving children who had appendicitis between 1998 and 2007 was performed. Data from county and private hospitals were compared. Outcomes were AP rates, LA rates, need for postoperative abscess drainage, length of hospitalization (LOH), and cost., Results: Multivariate analysis confirmed that among 7902 patients, (county = 682; private = 7220), county-hospital patients had lower incomes, higher AP rates, higher LA rates, lower postoperative abscess drainage rates, and longer LOH than did private-hospital patients. The longer LOH at the county institution led to higher costs. Within the county hospital, outcomes were similar across all ethnic groups and income levels., Conclusions: Children with appendicitis treated at a county hospital were of lower socioeconomic background and had higher AP rates, longer LOH, and higher costs than their counterparts at private hospitals, but were more likely to undergo LA and require less abscess drainage. Within the county hospital, ethnic and socioeconomic disparities were not apparent; thus, these differences between institutions might have been caused by underlying disparities in ethnicity, income, and health care access.

Background: Ultrasound guidelines for hypertrophic pyloric stenosis (HPS) have fixed minimum measurements and do not account for variation in patient weight or age. We sought to determine if preoperative pyloric measurements correlated with weight and age in patients with surgically proven HPS., Methods: A retrospective analysis was conducted of 189 patients with HPS treated at a single institution over a 5-year period (2005 to 2010). Pearson correlation and linear regression analyses were used to determine if there were statistically significant associations between these combinations of factors: age and pyloric muscle thickness, weight and pyloric muscle thickness, age and pyloric length, and weight and pyloric length., Results: Patients' mean age was 4.6 weeks (range, 1 to 17 weeks). Their mean weight was 3.9 kg (range, 2.5 to 8.0 kg). Mean pyloric muscle thickness was 0.42 cm (range, 0.18 to 0.86 cm), and mean pyloric length was 1.89 cm (range, 0.8 to 2.8 cm). Pearson correlation coefficient analysis showed a significant relationship between age and muscle thickness (r = 0.35, p < 0.001) as well as weight and muscle thickness (r = 0.24, p = 0.001). No significant relationship existed between pyloric length and age or weight. Linear regression analysis demonstrated similar results., Conclusion: In patients with HPS, pyloric muscle thickness was directly related to age and weight. Practitioners should be aware that smaller and younger infants with a clinical diagnosis of HPS may still truly have HPS even though the minimum diagnostic criterion for muscle thickness or length is not found on ultrasound.

Background/purpose: This study evaluated the optimal timing for repair, incarceration risk, and postoperative apnea rate in premature infants with inguinal hernias., Methods: This was a retrospective review of premature infants undergoing inguinal hernia repairs from 2006 to 2008., Results: One hundred seventy-two patients were identified. Mean gestational age was 30.7 weeks, and mean birth weight was 1428 g. At repair, mean postconceptional age was 46.6 weeks with mean weight of 3688 g. Elective repairs were performed on 127 patients. Thirty-five patients were discharged with a known hernia, and none developed incarceration. No postoperative apnea episodes occurred in any of these 127 patients. Forty-five patients had herniorrhaphy before discharge from the neonatal intensive care unit (NICU) with a median postoperative hospitalization of 8 days (2-51 days). Thirteen percent required prolonged (>48 hours) intubation after repair. Of 172 patients, 8 (4.6%) developed incarcerated hernia. Five incarcerations occurred in the NICU before discharge, and 3 patients had incarceration as their initial presentation., Conclusions: There is minimal risk of postoperative apnea for premature infants undergoing elective inguinal hernia repair. The risk of incarceration in premature infants discharged from the NICU with a known hernia is low. Herniorrhaphy before discharge from the NICU was associated with a prolonged hospital stay., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: The aim of the study was to determine whether equal access to health care eliminates racial and socioeconomic disparities in appendicitis outcomes., Methods: A review of patients younger than 18 years treated for appendicitis for a decade was performed. Outcomes were appendiceal perforation (AP) rate and length of hospitalization (LOH). Independent variables included racial status, annual median per capita income, and parental education level., Results: Seven thousand two hundred forty-seven patients were identified (mean age, 11.6 years; 62% male). The adjusted odds ratio (OR) for AP was similar in blacks, Hispanics, and Asians compared to whites. The OR for AP was similar in high- and medium-income families compared to low-income families. The OR for AP was similar in high and medium parental education levels compared to low parental education levels. The adjusted LOH was longer in blacks and similar in Hispanics and Asians compared to whites. The LOH was shorter in high- and similar in medium-income families compared to low-income families. The LOH was similar in all parental education levels., Conclusion: Lower socioeconomic background and minority status did not correlate with higher appendiceal perforation rates or a clinically longer LOH in children with equal access to care. The previously reported disparities in pediatric appendicitis outcome are preventable with equal access to care., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective., Methods: A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement., Results: Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13,080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20,440., Conclusion: Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Undetected perforation during laparoscopic pyloromyotomy can be fatal. Detecting a perforation at the time of laparoscopic pyloromyotomy is difficult. The purpose of this study was to determine whether air insufflation of the stomach reliably detects perforation during laparoscopic pyloromyotomy., Case Reports: Between 2007 and 2008, 71 patients underwent laparoscopic pyloromyotomy and 2 patients (3.3%) had perforation. Insufflating the stomach with air did not demonstrate the perforation in either case. Both perforations were detected by careful inspection of the myotomy; a small amount of mucus was seen at the perforation site. Both patients underwent open suture repair with an omental patch and had unremarkable postoperative courses., Conclusions: Air insufflation of the stomach during laparoscopic pyloromyotomy does not reliably rule out perforation. As with all procedures with potential complications, a high index of suspicion and careful inspection of the entire myotomy may help detect perforation.

Background: This study evaluated the educational value of pediatric surgery rotations, the likelihood of performing pediatric operations upon completing general surgery (GS) residency, and time and cost of training GS residents in pediatric surgery., Methods: A survey was administered to GS residents that evaluated the pediatric surgery rotation and anticipated practice intentions. A retrospective analysis (2005-2006) of operative times for unilateral inguinal hernia repair, bilateral inguinal hernia repair, and umbilical hernia repair was also performed. Procedure times were compared for operations performed by a pediatric surgeon with and without GS residents. Cost analysis was based on time differences., Results: General surgery residents (n = 19) considered the pediatric surgery rotation to have high educational value (4.7 +/- 0.6 of 5) with extensive teaching (4.6 +/- 0.7) and operative experience (4.4 +/- 0.8). Residents listed pediatric surgery exposure, operative technique, and observed work ethic as most valuable. Upon graduation, residents expect to perform pediatric operations 2 to 3 times annually. Thirty-seven percent of residents felt competent to perform appendectomy (patients >5 years), 32% appendectomy (3-5 years), 21% gastrostomy (>1 year), and 11% inguinal herniorrhaphy (>1 year). Operative times and costs were significantly higher in operative procedures performed with a GS resident., Conclusion: General surgery residents considered pediatric surgery as a valuable educational experience. Residents anticipate performing pediatric operations a few times annually. Training GS residents in pediatric surgery increased operative time and cost. This information may be useful in determining the appropriate setting for resident education as well as budget planning for pediatric surgical practices.

Purpose: Complete contrast enema reduction of intussusception is traditionally considered confirmed when contrast is seen refluxing into the terminal ileum. Operative intervention is typically indicated when the intussusception is not completely reduced. This study reviews the outcomes after symptomatic reduction of intussusception without requiring reflux of contrast into the terminal ileum., Methods: A retrospective review of all pediatric patients treated for intussusception between 1996 and 2006 was performed. Diagnostic modality, operative reports, and hospital records were reviewed., Results: One hundred sixty-eight patients were treated for intussusception during the study period. Median age was 9.9 months (59 days to 16.7 years). One hundred thirty-seven (81.5%) patients underwent contrast enema as the initial diagnostic/therapeutic modality. On contrast enema, 15 (10.9%) patients demonstrated reduction of the intussusception but without contrast refluxing into the terminal ileum. All 15 patients had improvement of symptoms. Six (40%) patients underwent operative intervention and were found to have a completely reduced intussusception. Two (13.3%) patients had repeat contrast enema the next day confirming complete reduction. The remaining 7 (46.7%) patients were observed without further radiographic studies, and all 7 patients were discharged the following day tolerating full feedings. There were no recurrent intussusceptions., Conclusion: Nonoperative management may be used in patients with reduced intussusception despite lack of contrast refluxing into the terminal ileum if symptoms resolve.

Purpose: Increasing health care expense and rising numbers of uninsured Americans have led many to propose a national health insurance. This study describes the process, rationale, and requirements in creating a regional pediatric surgical service in the setting of a single-payer system., Methods: Our health care system consists of 10 medical centers providing comprehensive care to more than 3 million members. All services are provided by salaried physicians/practitioners to prepaid members. Before July 2004, pediatric surgical care was performed at multiple medical centers with many services contracted out. Starting July 2004, a multidisciplinary, comprehensive pediatric perioperative plan was established. Implementation has occurred in steps; current status and preliminary results are reviewed., Results: Strict guidelines for pediatric anesthesia and requirements for support services, personnel, and equipment were defined. Pediatric surgery is now performed at 3 community medical centers and 1 tertiary, teaching hospital. Operative cases were assigned to each center based on age, complexity, level of postoperative care, and location. A single high-volume, center for complex care has been established. Access to care was excellent; more than 90% of outpatient consultations were seen within 2 weeks. Utilization of services was 94% in 2006 and 98% in 2007. Physician and patient satisfaction were high. Additional pediatric surgeons have been hired and nearly all care has been internalized. Given the proximity to a major children's hospital, specialty services have not been duplicated., Conclusion: Establishing a multidisciplinary, comprehensive pediatric perioperative plan provided standards for supporting pediatric surgical services at community hospitals. This regional service may be a model for the future of specialty care, especially in the setting of a single-payer system.

Hypothesis: Nissen fundoplication decreases the use of antireflux medications., Design: Retrospective cohort study using discharge abstract data and pharmacy data., Setting: Twelve regional Kaiser Permanente hospitals in southern California., Patients: Three hundred forty-two patients underwent Nissen fundoplication., Intervention: Nissen fundoplication., Main Outcome Measure: Use of antireflux medications., Results: The number of patients requiring antireflux medications decreased from 233 patients (68.1%) before Nissen fundoplication to 197 (57.6%) after Nissen fundoplication. Of the 233 patients, 176 (75.6%) were restarted on antireflux medications within 1 year after Nissen fundoplication. Use of antireflux medication decreased in neurologically healthy patients but was unchanged in neurologically impaired children., Conclusions: Use of antireflux medication decreased after Nissen fundoplication. Neurologically healthy children showed the biggest decrease in antireflux medication use after Nissen fundoplication.

Background/purpose: The aim of this report is to assess the technique and outcome of laparoscopic partial nephrectomy in infants and toddlers., Methods: From January 2001 to January 2005, 7 consecutive patients, ages 5 to 15 months, underwent laparoscopic partial nephrectomies. All patients had duplicated systems associated with ureteroceles (5), severe reflux (1), ectopic ureter (1), and nonfunctioning systems. Follow-up ranged from 4 to 51 months., Results: All procedures were completed successfully using 4 ports (2 x 5 and 2 x 3 mm) except one, which required an additional port. The distal ureter, renal parenchyma, and hilar vessels were all transected using the harmonic scalpel. The mean operating time was 179 minutes with minimal blood loss in each case. The average hospital stay was 2.4 days (range, 1-5 days). The first case in the series, initially attempted retroperitoneally, was converted to a transabdominal approach because of lack of space. All subsequent approaches were transabdominal. One patient required ureteral stump reexcision because of frequent urinary tract infections associated with a distal ureteral diverticulum., Conclusions: Laparoscopic partial nephrectomy can be performed safely. The harmonic scalpel divides the parenchyma bloodlessly. The cosmetic result is excellent. A transabdominal approach with division of the ureteral cuff flush with the bladder is recommended.

Urethral obstruction in the fetus is rare. Whereas proximal obstruction most often is caused by posterior urethral valves, causes of distal obstruction are less well recognized and can include urethral atresia, urethral webs, and anterior urethral valves. These latter abnormalities can lead to urinary retention, incontinence, enuresis, spontaneous bladder rupture, and megacystis. The authors present 3 fetuses (gestational age range, 18 to 20 weeks) in whom distal urethral obstruction was suspected by prenatal ultrasonography in the absence of a demonstrable lesion. All 3 experienced spontaneous resolution of the presumed obstruction. On follow-up, all are alive and well with no adverse genitourinary tract sequelae. No postpartum intervention was required.

One major problem for patients with myelomeningocele (MMC) is fecal incontinence. To prevent this problem, fetal surgery for repair of MMC has been recently undertaken. The strategy behind this surgery is to allow normal development of anal sphincter muscles. The purpose of this study was to determine whether fetal surgery for repair of MMC allows normal development of anal sphincter muscles. Myelomeningocele was surgically created in fetal sheep at 75 days of gestation. At 100 days of gestation, fetal surgery for repair of the MMC lesion was performed. Three repair methods were used: standard neurosurgical repair (4 fetal sheep), covering the MMC lesion with Alloderm (2 fetal sheep), and covering the MMC lesion with Gore-Tex (2 fetal sheep). After the sheep were delivered (140 days of gestation), external and internal anal sphincter muscles were analyzed histopathologically. In control fetal sheep (not repaired) anal sphincter muscles did not develop normally. In contrast, in fetal sheep that underwent repair of the MMC, the external and internal anal sphincter muscles developed normally. Histopathologically, in the external sphincter muscles, muscle fibers were dense. In the internal sphincter muscles, endomysial spaces were small, myofibrils were numerous, and fascicular units were larger than those in unrepaired fetal sheep. There was no difference in muscle development for the repair methods. Fetal surgery for repair of MMC allows normal development of anal sphincter muscles.

Fetal intervention for congenital diaphragmatic hernia was developed to lessen the high morbidity and mortality of pulmonary hypoplasia. Lung pathology and morphometry in patients treated with fetal intervention have not been described. We report clinical and autopsy findings, as well as basic lung morphometry in 16 cases of congenital diaphragmatic hernia with fetal intervention (12 cases tracheal occlusion; 4 cases hernia repair), and 19 cases of congenital diaphragmatic hernia without fetal intervention. All patients who underwent fetal intervention were born premature. Lung enlargement with increased lung-to-body weight ratio was observed with fetal tracheal occlusion, accompanied by lower than normal radial alveolar counts and increased alveolar size. Patients treated with tracheal occlusion also had early alveolar development (at 29.8, 30.6, and 30.9 wk postconceptual age) as well as mucous fluid pooling in airways and alveoli. All cases showed severe alveolar septal widening, more extensive in patients without fetal intervention. When grouped by postconceptual age, no statistically significant difference was found between patients with and without fetal intervention with respect to lung-to-body weight ratio, radial alveolar count, mean alveolar length, and relative arteriolar media thickness. Lung enlargement has been observed with fetal tracheal occlusion sonographically; our studies suggest that this is due in part to emphysema and mucous fluid pooling. The lung remains abnormal with low radial alveolar counts and increased alveolar size. Tracheal occlusion did not prevent development of lung pathology associated with pulmonary hypoplasia.

Despite intensive clinical and experimental efforts, mortality from CDH remains high. More than two decades of research in multiple centers has led to a better understanding of the pathophysiology, prognosis, and treatment options for fetuses that have CDH. It now appears that fetuses that have prenatally diagnosed CDH can be stratified into high- and low-risk groups based upon sonographic parameters. Fetuses that do not have liver herniation into the chest that have a favorable LHR have an excellent chance of survival with postnatal therapy. Prenatal diagnosis allows the time and place of delivery to be planned in advance so these infants can be treated in a tertiary care nursery that has maximal medical and surgical therapy. Fetuses that have liver herniation into the chest and an unfavorable LHR have a grim prognosis. These fetuses might benefit from in utero intervention. There is no role for open fetal repair of the diaphragmatic detect; however, fetoscopic temporary tracheal occlusion might improve lung growth and development and might decrease morbidity and mortality in these infants. The FETENDO strategy appears to work, and for the first time it offers hope to the fetus that has high-risk CDH, but its efficacy must be proven in a proper randomized, controlled trial.

Objective: As previously reported, high postnatal mortality seen in fetuses with congenital diaphragmatic hernia (CDH) with liver herniation and low lung-to-head ratio (LHR) appears to be improved in fetuses who undergo fetoscopic temporary tracheal occlusion (TO). To test whether further evolution of this technique produces results that justify a randomized controlled trial comparing prenatal intervention to postnatal care, the authors analyzed 11 additional cases and the cumulative experience with 19 cases., Methods: The authors analyzed retrospectively the outcome of 11 new and 8 previously reported cases of fetoscopic temporary tracheal occlusion. Various factors were studied including maternal morbidity, antenatal outcome, physiologic lung response, and neonatal course., Results: Temporary TO can be accomplished using 3 5-mm radially expanding uterine ports without hysterotomy. Obstetric morbidity included mild pulmonary edema in 6 cases, chorioamniotic separation and premature rupture of membranes in 12 patients, and preterm labor and delivery in all patients. Thirteen of 19 (68%) neonates survived for 90 days after delivery; one died in utero, and 5 died after birth. Late mortality included one death caused by sepsis and 2 by complications associated with tracheostomies. Morbidity from gastroesophageal reflux requiring Nissen fundoplication, tracheal injury requiring repair or tracheostomy, and recurrent hernias after diaphragmatic repair were characteristic in longterm survivors., Conclusions: Fetoscopic temporary TO may improve outcome in poor-prognosis fetuses with CDH. However, complications related to tracheal dissection, premature delivery and late morbidity are significant. This experience has led to simpler techniques for fetoscopic tracheal occlusion and to an National Institutes of Health-sponsored randomized controlled trial comparing fetoscopic tracheal occlusion with optimal postnatal care.

To determine whether fetal surgery in a fetus with myelomeningocele (MMC) allows normal development of rectal muscles and nerves, we analyzed the rectum after fetal surgery in a sheep model. An MMC lesion was surgically created in 13 fetal sheep at 75 days of gestation. One fetal sheep died after the lesion was created. Eight fetal sheep were repaired at 100 days of gestation; the others were not repaired, as a control (n=4). Three methods were used for fetal surgery of MMC: standard neurosurgical repair (4 fetal sheep), covering of the MMC lesion by Alloderm (2 fetal sheep), and covering of the MMC lesion by Gore-Tex (2 fetal sheep). At 140 days of gestation, fetal sheep were harvested and histo-pathological analysis was performed on the rectum using hematoxylin and eosin staining for muscles and S-100 protein staining for nerves. One fetal sheep treated by standard neurosurgical repair died before harvesting. The four untreated fetal sheep had hypoplastic longitudinal muscles of the rectum but well developed-circular muscles. In addition, the untreated fetuses had a hypoplastic submucosal nerve plexus but a well-developed intermuscular nerve plexus. In contrast, treated fetal sheep had well-developed longitudinal and circular muscles except for one sheep treated with standard neurosurgical repair. In addition, except for the same fetal sheep, treated fetal sheep had well-developed nerve plexuses. There was no difference in muscle and nerve development of the rectum among the three repair methods. Fetal surgery for repair of MMC allows normal development of rectal muscles and nerves.

The development of fetal surgery has led to promising therapeutic options for a number of congenital malformations. However, preterm labor (PTL) and premature rupture of membranes continue to be ubiquitous risks for both mother and fetus. To reduce maternal morbidity and the risk of prematurity, minimal access surgical techniques were developed and are increasingly employed. Congenital diaphragmatic hernia (CDH), obstructive uropathy, twin-to-twin transfusion syndrome (TTTS), and sacrococcygeal teratoma have already been successfully treated using minimal access fetal surgical procedures. Other life-threatening diseases as well as severely disabling but not life-threatening conditions are potentially amenable to treatment. The wider application of minimal access fetal surgery depends on a continued improvement in technology and a better understanding of complications associated with fetal intervention.

Purpose: The aim of this report is to assess the technique and outcome of thoracoscopic lobectomy for asymptomatic prenatally diagnosed lung lesions., Methods: From June 1999 to March 2002, 14 consecutive asymptomatic patients with a prenatal diagnosis of congenital cystic adenomatoid malformation or pulmonary sequestration, ages 3 to 15 months, underwent postnatal thoracoscopic lobectomy. Single-lung ventilation and controlled pneumothorax with low pressure (4 torr) and low flow (1.0 L/min) were used in all. Follow-up ranged from 4 to 35 months., Results: All procedures were completed successfully using 3 ports. Rather than using stapling devices or clips, pulmonary vessels were sealed and the fissure completed (when necessary) with the Ligasure thermal energy device. Eleven lesions were on the left (10 lower lobe), and 3 were in the right lower lobe. The mean operating time was 110 minutes. The average hospital stay was 38 hours. There were no intraoperative or postoperative complications., Conclusions: This is the first report of a completely thoracoscopic technique for pulmonary lobectomy in small children. Thoracoscopic lobectomy is a relatively quick and safe procedure, and the cosmetic result is excellent. Early resection obviates the risk of infection in these lesions., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Background/purpose: Neonates with large congenital diaphragmatic hernias (CDH) require prosthetic patch closure of the defect because of the paucity of native diaphragmatic tissue. As the child grows, patch separation can occur necessitating reoperation. Use of vascularized autologous tissue may decrease the incidence of reherniation as tissue incorporation and growth may be improved. The authors report our early experience using a local muscle advancement flap with microneural anastomosis for those children in whom reherniation develops after prosthetic patch placement., Methods: Seven patients with CDH (6 left and 1 right) whose synthetic diaphragmatic patch separated from the chest wall resulting in a clinically significant recurrent hernia were followed up with prospectively. After dissecting the ipsilateral latissimus dorsi off the chest wall and dividing the thoracodorsal neurovascular bundle (based on its lumbar blood supply), the synthetic patch was removed via an eighth intercostal incision. The muscle flap was placed into the hemithorax through the bed of the tenth rib and sutured in place over a Vicryl mesh scaffold. The thoracodorsal nerve was anastomosed to the phrenic nerve. Functional analysis of the flap was performed in 4 patients., Results: Age at placement of the muscle graft ranged from 2 months to 48 months (median, 24 months). There has been no evidence of reherniation after placement of the muscle graft. Long-term outcome and functional analysis of the flap was available in 4 patients (mean, 19 months). Two infants had fluoroscopic and sonographic evidence of nonparadoxical neodiaphragmatic motion. In one of these, electromyographic evidence of function was documented with a phrenic nerve conduction velocity of 22 meters per second. The third infant showed no evidence of neodiaphragmatic motion, and the fourth infant had paradoxical motion., Conclusions: This is the first direct documentation of phrenic nerve function in an infant with CDH. An innervated reversed latissimus dorsi (RLD) flap reconstruction for recurrent CDH provides an alternative to prosthetic patch repair. This technique offers the advantages of autologous vascularized tissue with potential phrenic nerve innervation and physiologic neodiaphragmatic motion., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Background/purpose: The management of the fetus with a large neck mass that obstructs the airway remains a clinical challenge. The authors review their experience with giant fetal cervical teratoma and discuss options for management., Methods: A retrospective review of all patients referred since 1994 for prenatal management of a fetal neck mass was performed. Variables examined included gestational age at diagnosis and delivery, size and location of the neck mass, presence of fetal hydrops, associated anomalies, management methods, operating time, and outcome., Results: Seven patients were identified with a prenatal diagnosis of giant cervical teratoma. Four patients had fetal hydrops; of these, 2 died in utero of hydrops, and a third fetus underwent elective termination. The remaining hydropic and previable fetus underwent fetal surgery for resection of the mass. The 3 nonhydropic patients underwent ex utero intrapartum treatment (EXIT) procedures for airway control. Endotracheal intubation was possible in one patient, and one received a tracheostomy. In the third fetus, neither intubation nor tracheostomy were possible, and resection of the neck mass was performed on placental support. There were no deaths in the surgical group., Conclusions: The management of fetal giant cervical teratoma includes a spectrum of options. For the rare previable fetus with hydrops, fetal resection may be indicated. In patients with airway obstruction, EXIT procedure provides the luxury of time to obtain airway control either by intubation, tracheostomy, or, if necessary, tumor resection on placental support., (Copyright 2003, Elsevier Science (USA). All rights reserved.)

Congenital diaphragmatic hernia (CDH) is one of the most common causes of neonatal morbidity and mortality. The clinical spectrum of CDH ranges from minimally affected infants who do well with modern neonatal care to severely affected infants who die despite all interventions. Two decades of research have led to advances in the prenatal diagnosis of CDH and have better defined the natural history of CDH. Fetuses with CDH now can be stratified into "low" and "high" risk groups based on sonographic parameters. "Low risk" fetuses have an excellent chance of survival with postnatal therapy. Prenatal intervention is reserved for "high risk" fetuses. Ongoing research is focused on improving both prenatal and postnatal treatment of these severely affected infants.

There are a growing number and variety of fetal disorders that may benefit from intervention prior to birth. Despite the diversity, there are common pathophysiologic denominators or patterns that tie together many seemingly disparate disorders. The purpose of this article was not to review disorders presented in other, accompanying articles but, rather, to present pathophysiologic patterns that common influence fetal surgery within a cohesive framework.

The impetus for the development of minimal access techniques for fetal surgery was the unusual occurrence with open hysterotomy of preterm labor, premature rupture of membranes, and the maternal complications resulting from tocolytic therapy. This strategy involves a constellation of techniques that allow surgical procedures to be performed inside the uterus without a hysterotomy. The unique requirements of this approach necessitated modifications of existing endoscopic techniques, development of novel fetoscopic instruments, and utilization of the expertise of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life-threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel techniques, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of intervention.

Background/purpose: Nonimmune hydrops in the fetus is a finding that often portends death. The association and prognosis of fetuses with congenital diaphragmatic hernia (CDH) and hydrops is not known., Methods: A retrospective review of all prenatally diagnosed cases and referrals of CDH was performed. Variables analyzed included gestational age at diagnosis and delivery, side of hernia, presence of associated anomalies and hydrops, and neonatal outcome., Results: Since 1993, 474 prenatal referrals for CDH have been made. One hundred seventy-five were evaluated; 15 fetuses had hydrops (9%). Five patients had CDH, hydrops, and associated lethal anomalies. In the remaining 10 patients, 6 of the diaphragmatic defects were right-sided and 4 were left-sided. All except one had a major portion of the liver herniated into the chest. Six fetuses had prenatal intervention. Five neonates died shortly after birth. There were 5 long-term survivors; all received prenatal intervention., Conclusions: The association of CDH and hydrops is rare but often results in fatality. Hydrops appears to be associated with liver in the hernia, right-sided lesions, and lethal anomalies. Fetal intervention can be performed successfully in patients with CDH and hydrops, and may improve long-term survival rate in this group., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Purpose: Fetal surgery is performed increasingly with minimal access approaches. The authors report their experience with fetal endoscopic procedures (fetendo) with emphasis on changing techniques and outcome trends., Methods: All fetal endoscopic cases performed at a single institution from January 1996 to August 2001 were reviewed (n = 66). Cases were examined with respect to year performed, type of operation, operative data, and outcome., Results: Twin-twin transfusion syndrome (26 cases) and congenital diaphragmatic hernia (35 cases) were the most common diseases treated. From 1996 to 2001, there was a decrease in average operating time (256 to 127 minutes [P =.0006]), number of ports utilized (3.8 to one [P =.00001]), pump volume (28.7 to 2.7 L [P =.00001]), and estimated blood loss (408 to 29 mL [P =.008]). In addition, port size changed from 10 mm to 5 mm. Chorioamniotic separation (31 of 66), premature rupture of membranes (32 of 66), chorioamnionitis (12 of 66), and fetal death (10 of 66) continued to be significant complications., Conclusions: Fetal endoscopic surgery over the last 6 years has evolved toward shorter operating time, the use of smaller and fewer ports, decreased pump fluid exchange, and decreased blood loss, with the types of cases centered on twin-twin transfusion syndrome and congenital diaphragmatic hernia., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: In rare instances in monochorionic twin pregnancies, one twin can have a discordant anomaly (eg, cystic hygroma). If this twin dies in utero, neurologic injury and death can occur in the surviving cotwin. To protect the normal twin, the authors developed an approach to separate the circulations and ablate the umbilical cord of the abnormal twin., Methods: From September 1998 to February 2001, 6 cases of discordant anomalous twins were diagnosed by prenatal ultrasound scan in which the anomaly was lethal or parents desired prenatal termination for this abnormal twin. All underwent surgical intervention with gestational ages varying from 19 to 24 weeks., Results: Depending on cord insertion site and placental anatomy, blood flow was interrupted to the anomalous fetus by either radiofrequency ablation (RFA; 2 cases), cord transection (1 case), or cord transection after laser ablation of communicating vessels (3 cases). Fetal death occurred in one normal twin 4 days postoperatively. Average age at delivery for the 5 surviving fetuses was 34.5 weeks' gestation. On follow-up, all surviving infants are neurologically intact., Conclusion: An otherwise normal monochorionic twin threatened by an anomalous cotwin can be salvaged successfully with a strategy tailored to interrupt the vascular connections between the 2 twins., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Background/purpose: This study was designed to assess the outcome and financial costs incurred for the treatment of gastroschisis., Methods: A retrospective analysis was conducted of all patients with gastroschisis at a single institution over the past decade (n = 69). Hospital costs were determined and standardized to December 2001 dollars., Results: Of the 69 patients, average gestational age at delivery was 35.9 weeks. Thirty-six patients had a primary fascial closure; 33 had a silo placed. The mean time to first feeding was 22 days and full feeding, 33 days. Average length of stay was 47 days. There were 3 deaths (2 shortly after birth, and one 131 days later owing to sepsis). The average cost of hospitalization and physician fees for patients with gastroschisis was $123,200. Using multivariate regression analysis, significant variables (P <.05) associated with cost of hospitalization were number of operative procedures, ventilatory days, male gender, and length of stay. Room expenses (43%), physician fees (15%), respiratory and pulmonary care (10%), and supply and devices (10%) made up the majority of costs., Conclusions: Cost of care associated with treatment for gastroschisis is high. Strategies designed to reduce cost must limit gastrointestinal, respiratory, and operative complications and reduce length of stay., (Copyright 2002, Elsevier Science (USA). All rights Reserved.)

Numerous laparoscopic operations have replaced the traditional open procedure in both adults and children. These new procedures have allowed access to body cavities without significantly traumatizing intervening tissue. The laparoscopically assisted anorectal pull-through (LAARP) for high anorectal malformations (ARM) uses fundamental concepts learned from decades of high ARM repair and incorporates modern technologic advancements in surgical instrumentation and techniques. This laparoscopic approach offers good visualization of an infant's deep pelvis with a reconstruction technique that minimizes trauma to important surrounding structures. The laparoscopic repair can be completed in one stage, 2 stages, or 3 stages. Currently, either the 2-stage or 3-stage operation is recommended. With the 3-stage approach, a temporary colostomy is created initially followed by LAARP in several weeks to months. The colostomy then is closed several months later., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: Pericardial teratomas are rare congenital tumors which invade the developing mediastinum, compressing the venous return to the heart, leading to hydrops. Tumors, with large cystic components, have been treated previously with in utero pericardiocentesis with some success. We present the first reported case of in utero open resection of a fetal pericardial teratoma., Methods: A 31-year-old G1P0 woman was found to have a fetus with a pericardial teratoma. Hydrops developed at 24 weeks' gestation. After counseling, open fetal resection was performed via a fetal median sternotomy., Results: Although the tumor was successfully removed, the hydrops did not resolve. In addition, over the course of 3 weeks, the mother developed maternal mirror syndrome which prompted an emergent cesarean section. Neonatal death ensued shortly after birth., Conclusions: The fetus with a pericardial teratoma complicated by hydrops is compromised. Treatment options include early delivery, aspiration of the pericardial effusion, and in utero operative resection., (Copyright 2002 S. Karger AG, Basel)

A growing number of the pediatric antireflux procedures are performed laparoscopically. Although there are no prospective randomized studies comparing conventional open surgery to laparoscopic surgery, there are retrospective and anecdotal data suggesting that the laparoscopic approach is at least as good and, in many cases, better than the open procedure. Once the significant learning curve is achieved, one may attain similar operative times with the benefit of magnification and enhanced visualization of the operative field compared to open surgery. The greatest benefits of laparoscopic antireflux surgery are the cosmetic result, a decrease in postoperative analgesia requirements, and an earlier return to normal daily life for both parents and their children., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: As the volume of fetal surgery cases has steadily increased, an increasing incidence of chorioamniotic membrane separation (CMS) has been noted. Due to the potential adverse consequences from this abnormality, we reviewed the last decade of experience with fetal intervention at our institution and examined the incidence and outcomes of fetuses given this diagnosis., Study Design: A retrospective chart review of 75 fetal surgery cases at our institution was performed. Variables analyzed included preoperative, operative, and outcome data. Postoperative ultrasounds were evaluated for the presence of CMS., Results: Excluding operative deaths, the incidence of CMS was 47%. There were significant differences (p<0.05) in time to delivery (7 vs 5 weeks), cases using a perfusion pump (80% vs 60%), and number of trocars (2.13 vs 1.54) in cases of CMS versus those without. Ultrasounds showed normal to high levels of amniotic fluid in 97% of cases. There was an increased incidence of premature rupture of membranes (63% vs 45%), preterm labor (57% vs 38%), and chorioamnionitis (29% vs 15%) with CMS, but no difference in mortality rate., Conclusion: CMS is a frequent finding following fetal surgery. It is associated with significant morbidity but is manageable with close follow-up in a hospital setting. Following fetal surgery, the finding of CMS can be a life-threatening complication that warrants further study to understand its etiology and prevention.

Fetal endoscopic surgery (FETENDO) involves many techniques that allow surgical procedures to be performed inside the uterus without an hysterotomy. The impetus for developing these minimal access techniques for fetal surgery is the unusual occurrence with an open hysterotomy of preterm labor, premature rupture of membranes, and maternal complications resulting from tocolytic therapy. The unique requirements of this approach necessitated a modification of existing endoscopic techniques, the development of novel fetoscopic instruments, and the inclusion of a wide variety of specialists. Technical expertise in the field and a natural evolution of techniques have given rise to innovative repairs previously not envisioned. Severe congenital diaphragmatic hernia, diseases of monochorionic twins, and obstructive uropathy have already been successfully treated using fetoscopic surgical techniques. Fetoscopic correction of many other non-life threatening anomalies continues to evolve. The future of fetoscopic surgical intervention depends on the continual evolution of novel approaches to disease, the elucidation of the pathophysiology and treatment of other fetal disorders, and a better understanding of treatment of complications of such intervention.

Intraabdominal coccidioidomycosis is a very rare entity and usually responds to medical therapy. Operative intervention is reserved for diagnosis or drainage of localized collections. With biliary coccidioidomycosis, medical treatment appears to be ineffective, and biliary tract drainage is necessary for optimal management. A case of coccidioidomycosis in the gallbladder and biliary tree is described and the literature reviewed., (Copyright 2001 by W.B. Saunders Company.)