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Objectives The purpose of our study was to describe children with life-threatening bleeding. Design We conducted a prospective observational study of children with life-threatening bleeding events. Setting Twenty-four childrens hospitals in the United States, Canada, and Italy participated. Subjects Children 0-17 years old who received greater than 40 mL/kg total blood products over 6 hours or were transfused under massive transfusion protocol were included. Interventions Children were compared according bleeding etiology: trauma, operative, or medical. Measurements and main results Patient characteristics, therapies administered, and clinical outcomes were analyzed. Among 449 enrolled children, 55.0% were male, and the median age was 7.3 years. Bleeding etiology was 46.1% trauma, 34.1% operative, and 19.8% medical. Prior to the life-threatening bleeding event, most had age-adjusted hypotension (61.2%), and 25% were hypothermic. Children with medical bleeding had higher median Pediatric Risk of Mortality scores (18) compared with children with trauma (11) and operative bleeding (12). Median Glasgow Coma Scale scores were lower for children with trauma (3) compared with operative (14) or medical bleeding (10.5). Median time from bleeding onset to first transfusion was 8 minutes for RBCs, 34 minutes for plasma, and 42 minutes for platelets. Postevent acute respiratory distress syndrome (20.3%) and acute kidney injury (18.5%) were common. Twenty-eight-day mortality was 37.5% and higher among children with medical bleeding (65.2%) compared with trauma (36.1%) and operative (23.8%). There were 82 hemorrhage deaths; 65.8% occurred by 6 hours and 86.5% by 24 hours. Conclusions Patient characteristics and outcomes among children with life-threatening bleeding varied by cause of bleeding. Mortality was high, and death from hemorrhage in this population occurred rapidly.

OBJECTIVE: This study aims to determine if outpatient opioid prescriptions are associated with future substance use disorder (SUD) diagnoses and overdose in injured adolescents five years following hospital discharge. SUMMARY BACKGROUND DATA: Approximately, 1 in 8 adolescents are diagnosed with an SUD and 1 in 10 experience an overdose in the five years following injury. State laws have become more restrictive on opioid prescribing by acute care providers for treating pain, however, prescriptions from other outpatient providers are still often obtained. METHODS: This was a retrospective cohort study of patients ages 12–18 admitted to two level I trauma centers. Demographic and clinical data contained in trauma registries were linked to a regional database containing five years of electronic health records and prescription data. Regression models assessed whether number of outpatient opioid prescription fills after discharge at different time points in recovery were associated with a new SUD diagnosis or overdose, while controlling for demographic and injury characteristics, as well as depression and PTSD diagnoses. RESULTS: We linked 669 patients (90.9%) from trauma registries to a regional health information exchange database. Each prescription opioid refill in the first 3 months after discharge increased the likelihood of new SUD diagnoses by 55% (OR:1.55, CI:1.04–2.32). Odds of overdose increased with ongoing opioid use over 2–4 years post-discharge (p=0.016–0.025). CONCLUSIONS: Short-term outpatient opioid prescribing over the first few months of recovery had the largest effect on developing an SUD, while long-term prescription use over multiple years was associated with a future overdose.

Purpose Limited data are available describing the long-term results of pediatric patients undergoing aortic repair secondary to trauma. Therefore, this descriptive investigation was completed to abrogate this deficit. Methods A retrospective review of an urban level 1 pediatric trauma database maintained at a high-volume dedicated children’s hospital between 2008-2018 was completed to capture all cases of severe traumatic aortic injury and associated demographics, mechanisms, injury severity, treatment, and clinical outcomes. Results In the prespecified interval, 2189 children (age Conclusion Traumatic aortic injury is exceedingly rare in children and primarily of blunt etiology. Of the patients who survive the scene, operative repair seems to be associated with excellent perioperative and long-term survival.

BACKGROUND –: Injured adolescents have a 56% increased risk of developing a substance use disorder (SUD) within 3 years of their injury. The transition from medical prescription opioid use to nonmedical use in adolescent trauma patients has not been longitudinally studied long-term. The aim of this study is to describe 5-year patterns of opioid use in a cohort of injured adolescents as well as the proportion of patients experiencing overdose and SUD diagnoses. METHODS –: Our retrospective cohort study consisted of 736 patients 12–18 years old who were admitted for trauma from 2011–2013. We examined up to 5 years of regional health information exchange data containing information on prescription fills as well as diagnoses from inpatient, outpatient, and emergency department encounters. RESULTS –: At 1 year, over 20% of adolescents filled more than 2 opioid prescriptions after being discharged for their injury; and at 4 years, over 13% had received more than 8 opioid fills. Over the 5 year period, 11% received an opioid antagonist injection, 14% received an SUD diagnosis, and 8% had an overdose diagnosis. Relatively few patients had diagnoses for other mental health conditions including depression (5.5%), post-traumatic stress disorder (PTSD) (2.1%), and chronic pain (3.6%). CONCLUSIONS –: Opioid usage remains high for multiple years in a subset of the adolescent trauma population. Mental health diagnosis rates were substantially lower in injured adolescents than what has been reported in adults. However, overdose and SUD diagnoses occur in over 1 in 10 adolescents within 5 years of their injury. LEVEL OF EVIDENCE: Prognostic and Epidemiological Study, Level IV

Purpose Traumatic abdominal wall hernia (TAWH) is a rare consequence of blunt abdominal trauma (BAT). We examined a series of patients suffering TAWH to evaluate its frequency, rate of associated concurrent intraabdominal injuries (CAI) and correlation with CT, management and outcomes. Methods A Level 1 pediatric trauma center trauma registry was queried for children less than 18 years old suffering TAWH from BAT between 2009 and 2019. Results 9370 patients were admitted after BAT. TAWH was observed in 11 children, at incidence 0.1%. Eight children (73%) were male, at mean age 10 years, and mean ISS of 16. Six cases (55%) were because of MVC, three (27%) impaled by a handlebar or pole, and two (18%) dragged under large machinery. Seven (64%) had a CAI requiring operative or interventional management. Patients with CAI were similar to those without other injury, with 20% and 50% CT scan sensitivity and specificity for detection of associated injury, respectively. Five patients had immediate hernia repair with laparotomy for repair of intraabdominal injury, three had delayed repair, two have asymptomatic unrepaired TAWH, and one resolved spontaneously. Conclusions Children with TAWH have high rates of CAI requiring operative repair. CT scans have low sensitivity and specificity for detecting associated injuries. A high suspicion of injury and low threshold for exploration must be maintained in TAWH cases. Level of evidence IV

The utility of measuring the pediatric adjusted shock index (SIPA) at admission for predicting severity of blunt injury in pediatric patients has been previously reported. However, the utility of following SIPA after admission is not well described.The trauma registry from a level-one pediatric trauma center was queried from January 1, 2010 to December 31, 2015. Patients were included if they were between 4 and 16years old at the time of admission, sustained a blunt injury with an Injury Severity Score≥15, and were admitted less than 12h after their injury (n=286). Each patient's SIPA was then calculated at 0, 12, 24, 36, and 48h after admission and then categorized as elevated or normal at each time frame based upon previously reported values. Trends in outcome variables as a function of time from admission for patients with an abnormal SIPA to normalize as well as patients with a normal admission SIPA to abnormal were analyzed.In patients with a normal SIPA at arrival, 18.4% of patients who developed an elevated SIPA at 12h after admission died, whereas 2.4% of patients who maintained a normal SIPA throughout the first 48h of admission died (p0.01). Among patients with an elevated SIPA at arrival, increased length of time to normalize SIPA correlated with increased length of stay (LOS) and intensive care unit (ICU) LOS. Similarly, elevation of SIPA after arrival in patients with a normal initial SIPA correlated to increased LOS and ICU LOS.Patients with a normal SIPA at time of arrival who then have an elevated SIPA in the first 24h of admission are at increased risk for morbidity and mortality compared to those whose SIPA remains normal throughout the first 48h of admission. Similarly, time to normalize an elevated admission SIPA appears to directly correlate with LOS, ICU LOS, and other markers of morbidity across a mixed blunt trauma population. Whether trending SIPA early in the hospital course serves only as a marker for injury severity or if it has utility as a resuscitation metric has not yet been determined.Prognostic.Level II.

Background Literature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. Methods Admitted pediatric patients from 1/2012–12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single children’s hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. Results There were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. Conclusion APR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program.

Objectives Injuries associated with bicycles can generally be categorized into 2 types: injuries from falling from/off bicycles and injuries from striking the bicycle. In the second mechanism category, most occur as a result of children striking their body against the bicycle handlebar. The purpose of this study was to evaluate the presentation, body location, injury severity, and need for intervention for pediatric handlebar injuries at a single level one pediatric trauma center and contrast these against other bicycle-related injuries in children. Methods This work is a retrospective review of the trauma registry over an 8-year period. Individual charts were then reviewed for patients' demographic factors, injury details, and other clinical/radiographic findings. Each patient was then categorized as either having a handlebar versus nonhandlebar injury. Additionally, each patient's injuries were classified according to affected body "zone(s)" and the need for intervention in relation to these injuries. During the course of chart review, several unique radiographic and history/physical findings were noted and are also reported. Results During the study period, 385 patients were identified that met study criteria. Bicycle handlebars were involved in 27.8% (107/385) of injuries and 72.2% (278/385) were nonhandlebar injuries. There were differences in injury severity score, Head Abbreviated Injury Scale, length of stay between patients with handlebar versus nonhandlebar injuries, respectively. There were also differences in incidence of injuries across most body zones between patients with handlebar versus nonhandlebar injuries. There was statistically significant difference in need for intervention for abdominal solid organ injuries among handlebar versus nonhandlebar injuries mechanisms (21.6% vs 0%; P = 0.026), respectively. Sixteen patients with a handlebar injury underwent abdominal computed tomography (CT), which found only pericolic/pelvic free fluid or were negative for any disease and had normal/mildly elevated liver function test results at the time of arrival with otherwise normal laboratory workup results. Two patients required laparotomy for bowel injury and presented with peritonitis less than 12 hours after injury. The remaining patients did not have peritonitis on examination and were discharged without operative intervention 12 to 24 hours after injury without further event. Conclusions The bicycle handlebar is a unique mechanism of injury. The location, need for intervention, and the nature of the injury can vary significantly compared to other bicycle injuries. Handlebar injuries are more likely to cause abdominal and soft tissue injuries, whereas nonhandlebar injuries are more likely to cause extremity and skull/neck/central nervous system injuries. Because more than 20% of the reported handlebar injuries did not involve the abdomen or thoracoabdominal/extremity soft tissue as well as the variable presentation of handlebar injuries, it is imperative for the physician to consider this mechanism in all bicycle injuries. In addition, even within the same area of the body, handlebar injuries can be very different compared to nonhandlebar (i.e., orthopedic vs vascular injuries in the extremities). Physical examination and observation remain paramount when laboratory and radiographic workups are equivocal.

Background Currently there is limited knowledge on compliance with follow-up care in pediatric patients after abdominal trauma. The Indiana Network for Patient Care (INPC) is a large regional health information exchange with both structured clinical data (e.g., diagnosis codes) and unstructured data (e.g., provider notes). The objective of this study is to determine if regional health information exchanges can be used to evaluate whether patients receive all follow-up care recommended by providers. Methods We identified 61 patients treated at a Pediatric Level I Trauma Center who were admitted for isolated abdominal injuries. We analyzed medical records for two years following initial hospital discharge for injury using the INPC. The encounters were classified by the type of encounter: outpatient, emergency department, unplanned readmission, surgery, imaging studies, and inpatient admission; then further categorized into injury- and non-injury-related care, based on provider notes. We determined compliance with follow-up care instructions given at discharge and subsequent outpatient visits, as well as the prevalence of complications and sequelae. Results After reviewing patient records, we found that 78.7% of patients received all recommended follow-up care, 6.6% received partial follow-up care, and 11.5% did not receive follow-up care. We found that 4.9% of patients developed complications after abdominal trauma and 9.8% developed sequelae in the two years following their initial hospitalization. Conclusions Our findings suggest that health information exchanges such as the INPC are useful in evaluation of follow-up care compliance and prevalence of complications/sequelae after abdominal trauma in pediatric patients. Level of evidence Level IV.

Objective The purpose of this investigation was to determine our limb-related contemporary pediatric revascularization perioperative and follow-up outcomes after major blunt and penetrating trauma. Methods A retrospective review was performed of a prospectively maintained pediatric trauma database spanning January 2010 to December 2017 to capture all level I trauma activations that resulted in a peripheral arterial revascularization procedure. All preoperative, intraoperative, and postoperative continuous variables are reported as a mean ± standard deviation; categorical variables are reported as a percentage of the population of interest. Results During the study period, 1399 level I trauma activations occurred at a large-volume, urban children's hospital. The vascular surgery service was consulted in 2.6% (n = 36) of these cases for suspected vascular injury based on imaging or physical examination. Our study population included only patients who received an arterial revascularization, which was performed in 23 of the 36 consultations (1.6% of total traumas; median age, 11 years). These injuries were localized to the upper extremity in 60.9% (n = 14), lower extremity in 30.4% (n = 7), and neck in 8.7% (n = 2). The mean Injury Severity Score in the revascularized cohort was 14.0 (±7.6). Bone fractures were associated with 39.1% of the vascular injuries (90% of blunt injuries). Restoration of in-line flow was achieved by an endovascular solution in one patient and open surgery in the remainder, consisting of arterial bypass in 59.1% and direct repair in 40.9%. Within 30 days of the operation, we observed no deaths, no infections of the arterial reconstruction, and no major amputations. One patient required perioperative reintervention by the vascular team secondary to the development of a superficial seroma without evidence of graft involvement. Mean follow-up in our cohort was 43.3 (±35.4) months. During this phase, no additional deaths, amputations, chronic wounds, or limb length discrepancies were observed. All vascular repairs were patent, and all but one patient reported normal function of the affected limb at the latest clinic visit. Conclusions Traumatic peripheral vascular injury is rare in the pediatric population but is often observed secondary to a penetrating force or after long bone fracture. However, contemporary perioperative and long-term outcomes after surgical revascularization are excellent as demonstrated in this institutional case series.

Missed injuries contribute to increased morbidity in trauma patients. A retrospective chart review was conducted of pediatric trauma patients from 2010 to 2013 with a documented missed injury. A significant percentage of missed injuries were identified (3.01% during July 2012 to December 2013 vs 0.39% during January 2010 to July 2012) with the addition of acute care trained pediatric nurse practitioners to the trauma service at a pediatric trauma center. The increase is thought to be due to improvement in charting, consistent personnel performing tertiary examinations, and improved radiology reads of outside films. Language: en

Laparoscopic cholecystectomy is accepted therapy for children with ill-defined abdominal pain and impaired gallbladder emptying (biliary dyskinesia). Follow-up shows poor clinical response in many of these patients. The purpose of this report is to identify clinical and radiographic predictors of successful outcome after cholecystectomy for biliary dyskinesia.The authors retrospectively reviewed records of 51 children after laparoscopic cholecystectomy for biliary dyskinesia (1990 to 2003). Clinical symptoms, radiographic findings, and pathology were evaluated. Subjective clinical improvement is stratified using an established patient satisfaction score. Logistic regression analysis determines statistically independent predictors of successful outcome.Thirty-eight of 51 (75%) patients were available for follow-up. Twenty-seven of 38 (71%) patients reported complete resolution of symptoms. Nausea was the only symptom predictive of successful outcome by univariate analysis (odds ratio, 5.00). A cholecystokinin-stimulated, gallbladder ejection fraction less than 15% also predicts successful outcome (odds ratio, 8.00). Children with an ejection fraction greater than 15% did not have predictable resolution of symptoms. When present with pain and nausea, gallbladder emptying less than 15% has a positive predictive value of 93% and a negative predictive value of 81%.Together, nausea, pain, and decreased gallbladder emptying (15%) most reliably predict which children will benefit from cholecystectomy for biliary dyskinesia.

Background. The goal of this study was to review current injury characteristics, severity, intervention, and outcome of duodenal injuries from a single, pediatric trauma facility. Methods. A retrospective review was performed of duodenal injuries in children less than 16 years of age from 1990 to 2000. Results. Twelve children had duodenal injuries as a result of blunt abdominal trauma. Six injuries were the result of motor vehicle crashes. Nonaccidental trauma (2) and contact injury (4) provided the remaining cases. Diagnosis was achieved by abdominal computed tomography. Severity of duodenal injury included grade I (1), II (8), and III (3). Seven patients had associated visceral or neurologic injuries. Average Injury Severity Score was 18. Duodenal repair was required in 9 of the 10 patients explored. Treatment included observation (3); primary repair, alone, (2) or with proximal decompression (4); and pyloric exclusion with gastrojejunostomy (3). Exclusion techniques had fewer complications (0% vs 57%) and fewer hospital days (19 vs 23). Conclusions. Blunt abdominal trauma remains the most prevalent mechanism for pediatric duodenal injuries. Patients undergoing pyloric exclusion for severe duodenal trauma had a lesser morbidity and a shorter hospital stay in this small series. Pyloric exclusion remains an alternative for the treatment of severe duodenal injuries in selected children. (Surgery 2002;132:748-53.)

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1–11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.

Purpose Esophageal atresia is known to be associated with a variety of additional congenital anomalies in multiple organ systems. Emphasis on cardiovascular anomalies has been focused on aortic arch and intrinsic cardiac malformations. Persistent left superior vena cava (PLSVC) is the most common venous thoracic anomaly in the general population and creates a problem when central venous access is required. This review was undertaken to define the incidence of PLSVC in infants with esophageal atresia and to determine if any subgroup of associated anomalies poses additional risk. Methods A retrospective, institutional review board–approved review of all children treated for esophageal atresia from 1993 to 2002 at Riley Hospital for Children was undertaken. Of 118 children, 89 had sufficient data for inclusion. Charts were reviewed for gestational age, weight, type of atresia, echocardiogram, and associated anomalies. Statistical analysis was performed using the Fisher's Exact test. Results Of 89 children, 8 (9.9%; confidence interval, 4%-17%) had PLSVC compared with the reported incidence of 0.3% in the general population. Presence of additional organ system anomalies did not significantly increase relative risk for PLSVC. Conclusion The incidence of PLSVC is significantly increased in children with esophageal atresia when compared with the general population. This increased incidence of PLSVC is not influenced by the presence of cardiac or other associated anomalies. This finding should be kept in mind when central venous access is required in this patient population.

Child passenger safety has been a major public health victory, but there is still work to be done. This case presentation is about a 5-year-old boy who placed the shoulder portion of the lap-shoulder seat belt behind his back who was recently killed in a motor vehicle crash. This article reviews what trauma nurses need to know about the latest improvements in child passenger safety practices. Also presented are important resources for trauma nurses to share with families to improve travel safety.

In November 1987 we began to practice delayed repair of acutely symptomatic congenital diaphragmatic hernia (CDH) following medical and/or extracorporeal membrane oxygenation (ECMO) stabilization. We reviewed 23 consecutive patients with CDH symptomatic at birth treated over the ensuing 212 years. The mean age at admission, age at repair, and interval from admission to repair were 4.9, 37.0, and 32.6 hours, respectively. Overall survival was 52% (1223). ECMO was used in 14 patients with 7 survivors (50%); 4 of these patients underwent repair prior to ECMO and 10 while on ECMO. The patients were retrospectively grouped into three classes based on postductal arterial blood gas (ABG) response to conventional medical management: class A (n = 8), able to achieve and sustain adequate oxygenation (PO 2 > 60 mm Hg) and hyperventilation (PCO 2 2 2 2 2 > 40 mm Hg). The interval from admission to repair was 13.6, 53.5, and 25.4 hours for classes A, B, and C, respectively. Two class A (25%), nine class B (90%), and three class C patients (60%) were placed on ECMO. Survival rates were 88%, 50%, and 0% for classes A, B, and C, respectively. We propose the following management protocol. Class A patients are stable and can be repaired at any convenient point after admission without prerepair ECMO; few will need it afterward. Patients in class B are fairly stable, and a period of time can be spent trying to improve their oxygenation with maximal conventional medical management; without improvement, ECMO is instituted, and they undergo repair on bypass. Class C patients are unstable and should be placed on ECMO as soon as possible with later repair, understanding that their prognosis is poor.

It is controversial whether treatment with corticosteroids reduces stricture formation in the esophagus after the ingestion of caustic material.We conducted a prospective study over an 18-year period in which 60 children (median age, 2 years) with esophageal injury from the ingestion of caustic material were assigned randomly to treatment either with or without corticosteroids. The corticosteroids were given initially as prednisolon (2 mg per kilogram of body weight per day intravenously) and then as prednisone orally to complete a three-week course. All patients were evaluated by esophagoscopy within 24 hours of the ingestion. Those with moderate or severe esophageal injury had repeat esophagoscopy and barium swallow at follow-up.Esophageal strictures developed in 10 of the 31 children treated with corticosteroids and in 11 of the 29 controls (P not significant). Four children in the steroid group and seven in the control group eventually required esophageal replacement (P not significant). All but 1 of the 21 children with strictures had severe circumferential burns on initial esophagoscopy.There appears to be no benefit from the use of steroids to treat children who have ingested a caustic substance. The development of esophageal stricture was related only to the severity of the corrosive injury.

Background/Methods A 32-year retrospective review from 1972 to 2004 analyzed complications and long-term outcomes in children with total colonic aganglionosis (TCA) as they relate to the procedure performed. Results Thirty-six patients (27 boys, 9 girls) had TCA. The level of aganglionosis was distal ileum (26), mid–small bowel (8), midjejunum (1), and entire bowel (1). Enterostomy was performed in 35 of 36. Eight developed short bowel syndrome. Twenty-nine (81%) had a pull-through at 15 ± 6 months (modified Duhamel 20, Martin long Duhamel 4, and Soave 5). Six had a Kimura patch. Postoperative complications (including enterocolitis) were more common after long Duhamel and Soave procedures. Seven (19%; 2 with Down's syndrome) died (3 early, 4 late) from pulmonary emboli (1), sepsis (1), fluid overload (1), viral illness (1), liver failure (1), arrhythmia (1), and total bowel aganglionosis (1). Mean follow-up was 11 ± 9 years (range, 6 months-29 years). Twenty-four (83%) of 29 patients exhibited growth by weight of 25% or more, 21 (91%) of 23 older than toddler age had 4 to 6 bowel movements per day, and 17 (81%) of 21 were continent. In 5 of 6, the Kimura patch provided functional benefit with proximal disease. Conclusion Long-term survival was 81%. The highest morbidity occurred with long Duhamel or Soave procedures. The modified Duhamel is our procedure of choice in TCA. Bowel transplantation is an option for TCA with unadapted short bowel syndrome.

Background/Purpose Recognition of appendicitis in the child with hematologic malignancy may be difficult particularly in the setting of neutropenia and multiple medications causing an altered inflammatory response. Typhilitis may produce a similar constellation of clinical findings causing further diagnostic confusion. This review compares the relative frequency of these two conditions in children with hematologic malignancy with a focus on the clinical presentation, distinguishing features, surgical management, and outcome for patients with appendicitis. Methods This institutional review board–approved retrospective study evaluated 464 pediatric patients treated for hematologic malignancy at our institution from 1997 to 2003. From this cohort, we identified all children with a diagnosis of appendicitis or typhilitis. Data include demographics, clinical presentation, laboratory studies, and computed tomography (CT) scan findings. Groups were compared using the Fisher exact test. Significance was defined as P Results Eight (1.7%) of 464 children were diagnosed with typhilitis and 7 (1.5%) with appendicitis. There were no demographic differences between patients with appendicitis and typhilitis. Distinguishing clinical features in children with typhilitis included presence of fever and diarrhea. Clinical presentation in children with appendicitis was atypical in 5 of 7 cases yielding an incorrect preoperative diagnosis in all 5. Radiographic evaluation by CT scan accurately defined typhilitis, but not appendicitis. An operation was performed on all 7 children with appendicitis with no operative morbidity or mortality. Conclusions Appendicitis and typhilitis occur with similar frequency in children with leukemia and lymphoma. Typhilitis is accurately diagnosed with clinical findings of fever, diarrhea, abdominal pain, and typical CT scan findings. Appendicitis tends to present with atypical findings, but can be successfully managed with standard surgical care.

Background Information concerning long-term operative outcomes in patients with cystic fibrosis (CF) is relatively sparse in the operative literature. Methods A retrospective review of CF patients with operative conditions was performed (1972-2004) at a tertiary children's hospital to analyze outcomes including long-term morbidity and survival. Results A total of 226 patients with CF presented with an operative diagnosis (113 men, 113 women). A total of 422 operations were performed in 213 patients (94%). The mean age at operation was 4.1 ± 6.2 years (range, 1 d to 26 y) and 109 were neonates. Fifteen of 42 (36%) babies with simple meconium ileus (MI) were treated nonoperatively with hypertonic enemas, 27 of 42 and all 45 patients with complicated MI required operation, including 15 with jejunoileal atresia (17%). Seventeen of 27 (63%) patients with meconium ileus equivalent had MI as neonates; 7 of 27 (26%) required operation. Eight of 9 (89%) with fibrosing colonopathy required operation. Organ transplantation was required in 21 patients. Follow-up evaluation was possible in 204 of 213 (96%) patients. The duration of follow-up evaluation was 14.9 ± 8.5 years (range, 2 mo to 35 y). Operative morbidity was 11% at 1 year, 2% at 2 to 4 years, 1% at 5 to 10 years, and less than 1% at more than 10 years. There were 24 deaths (11%); 22 followed CF-related pulmonary complications and included 8 of 16 (50%) children with pneumothorax. Conclusions Long-term survival in CF patients has improved significantly (89%), with many surviving into the fourth decade. MI may predispose to late complications including meconium ileus equivalent and fibrosing colonopathy. Pneumothorax in CF patients is an ominous predictor of mortality. Children with CF are living longer and are good candidates for operation, but require long-term follow-up evaluation because of ongoing exocrine dysfunction.

Background Duodenal atresia and stenosis is a frequent cause of congenital, intestinal obstruction. Current operative techniques and contemporary neonatal critical care result in a 5% morbidity and mortality rate, with late complications not uncommon, but unknown to short-term follow-up. Methods A retrospective review of patients with duodenal anomalies was performed from 1972 to 2001 at a tertiary, children's hospital to identify late morbidity and mortality. Results Duodenal atresia or stenosis was identified in 169 patients. Twenty children required additional abdominal operations after their initial repair with average follow-up of 6 years (range, 1 month to 18 years) including fundoplication (13), operation for complicated peptic ulcer disease (4), and adhesiolysis (4). Sixteen children underwent revision of their initial repair: tapering duodenoplasty or duodenal plication (7), conversion of duodenojejunostomy to duodenoduodenostomy (3), redo duodenojejunostomy (3), redo duodenoduodenostomy (2), and conversion of gastrojejunostomy to duodenoduodenostomy (1). There were 10 late deaths (range, 3 months to 14 years) attributable to complex cardiac malformations (5), central nervous system bleeding (1), pneumonia (1), anastomotic leak (1), and multisystem organ failure (2). Conclusions Late complications occur in 12% of patients with congenital duodenal anomalies, and the associated late mortality rate is 6%, which is low but not negligible. Follow-up of these patients into adulthood is recommended to identify and address these late occurrences.

Splenectomy is frequently required in children with various hematologic disorders. The reported advantages of laparoscopic splenectomy (LS) include less pain, shorter hospital stay, and improved cosmesis. This report evaluates the outcome of children undergoing LS at a single children's facility. One hundred twelve children underwent LS by the lateral approach between August 1995 and February 2001. Indications for LS were hereditary spherocytosis in 58, idiopathic thrombocytopenic purpura in 21, sickle cell disease in 19, and other conditions in 14. LS alone was completed in 89 children and LS and cholecystectomy (LSC) in 20. Three required conversion to open splenectomy. Accessory spleens were identified in 19. Complications included ileus (four), acute chest syndrome (four), bleeding (two), pneumonia (one), and diaphragm perforation (one). There was no mortality. An accessory spleen was missed in one child with recurrent anemia. Average operative time for LS was 106 minutes and for LSC 135 minutes. Operative time for LS decreased with experience but the difference was not significant. Average length of stay was 1.51 days (range 1-11) and was longer in sickle cell disease (2.47 days) versus hereditary spherocytosis (1.29 days) and idiopathic thrombocytopenic purpura (1.16 days). We conclude that LS is safe and effective in children with hematologic disorders and is associated with minimal morbidity, zero mortality, and a short length of stay.

Background/Purpose: Pulmonary infiltrates in recipients of stem cell transplantation often present as diagnostic dilemmas. Although lung biopsy may establish the diagnosis of parenchymal disease, it remains unclear whether such a procedure results in a significant change in the patient's treatment and outcome. This study evaluates the efficacy of lung biopsy in recipients of stem cell transplantation. Methods: The medical records of 15 stem cell transplant recipients who underwent 18 lung biopsies were reviewed. The indications for stem cell transplantation were leukemia in 10 patients, lymphoma in 2, histiocytosis in 1, neuroblastoma in 1, and Ewing's sarcoma in 1. The results of the lung biopsies were correlated to the clinical management and outcomes. Results: The overall mortality rate was 67% (10 patients). Eight of the 9 patients who required mechanical ventilatory support at the time of lung biopsy died. The pathologic diagnoses were pneumonitis in 6 biopsies, fibrosis in 6, brochiolitis obliterans organizing pneumonia in 3, hemorrhage in 2, and infarction in 1. Therapy was changed in 1 patient who improved after a course of steroids for bronchiolitis obliterans organizing pneumonia. Lung biopsy cultures were positive in 6 patients but rarely resulted in changes in antibiotic therapy. Conclusions: Results of very few lung biopsies performed in stem cell transplant recipients redirected therapy. Furthermore, the ultimate outcome of these patients were not improved by the results of lung biopsies. J Pediatr Surg 36:1302-1303. Copyright © 2001 by W.B. Saunders Company.

Background/Purpose: Minimal access surgery (MIS, Nuss Procedure) is gaining acceptance rapidly as the preferred method for pectus excavatum repair. This shift in operative management has followed a single institution's evaluation of the procedure. This report describes an additional experience with the Nuss procedure. Methods: Twenty-one patients with pectus excavatum underwent repair by the Nuss Procedure. The patients ranged in age from 5 to 15 years (average, 8.2 years). There were 19 boys and 2 girls. Results: In 1 patient (age 5 years) the MIS procedure was aborted because of persistence of chest wall asymmetry. The other 20 patients had completion of their procedure without intraoperative complication. The operating times ranged from 45 to 90 minutes; however, there was an additional anesthetic set-up time (average, 45 minutes). All cases utilized a single support bar (11 to 17 inches). Patients underwent extubation in the operating room and were admitted to a ward bed with an epidural catheter in place for pain control and received intravenous analgesia. The hospital stay ranged from 4 to 11 days and averaged 4.9 days. Early postoperative complications included ileus (n = 1), bilateral pleural effusion (n = 2), atelectasis (n = 1), fungal dermatitis (n = 1), pneumothorax (n = 1), and flipped pectus bar (n = 2). Delayed complications included flipped pectus bar (n = 2), marked pectus carinatum requiring bar removal (n = 1), mild carinatum (n = 1), mild bar deviation (n = 1), progressive chest wall asymmetry (n = 3) with 1 requiring bar removal and open pectus repair, pleural effusion (n = 1), and chronic persistent pain requiring bar removal (n = 1). The length of follow-up is 3 to 20 months with an average of 12.3 months. Conclusions: The Nuss Procedure is quick, minimally invasive, and a technically easy method to learn; however, our data indicate there is a significant learning curve. Although previous reports suggest that few complications occur, we believe further assessment of patient selection regarding age, presence of connective tissue disorder, and severe chest wall asymmetry are still needed. Long-term follow-up also will be required to assure both health professionals and the public that this is the procedure of choice for patients with pectus excavatum. J Pediatr Surg 35:246-251. Copyright © 2000 by W.B. Saunders Company.

The majority of childhood injuries requiring admission are due to traffic-related injury, falls, and burns. Many of these injuries are preventable. In the case of the unpreventable, unintentional injury, the natural history of the injury and outcome can be altered by adherence to established safety standards. New standards also need to be set. There is definitely room for improvement in vehicular restraint systems for the smaller and younger passengers. It is known that wearing bicycle helmets, using safety belts, securing firearms in the home, and controlling hot water heater temperature levels will prevent or lessen injury in children. This information is being promulgated to communities by activities such as the National SAFE KIDS Campaign, a program of Children's National Medical Center sponsored by Johnson & Johnson Family of Companies and the National Safety Council. This campaign emphasizes important aspects of childhood injury: scope, causes, and prevention. Questions about the most devastating of childhood injuries, child abuse and assault related to violent crime, are more complex and the answers elusive. The study of patterns of injury in children highlights the need to implement new strategies aimed at prevention. At the same time, valuable information is obtained about specific injuries and responses seen in children that set them apart from adults.

Injuries are the leading cause of death in children 1 to 14 years old and result in permanent disabilities for thousands of children each year. Blunt trauma accounts for more than 60% of childhood injuries. Head trauma is most common, but the most severely injured children have multisystem injuries, frequently of the extremities, chest, and abdomen. The child's response to injury differs from that of the adult, and specific patterns are seen with blunt injury; recognition of these patterns is essential for proper management. The general surgeon coordinates the total care of the injured child, including the efforts of a variety of medical specialists, to provide cohesive and efficient care.