A multi-institutional approach for decreasing narcotic prescriptions after laparoscopic appendectomy.

Background: Appendicitis is a common indication for surgical hospital admission. Uncomplicated appendicitis is typically treated with surgical intervention, most commonly a laparoscopic appendectomy. As with many procedures, narcotic utilization is highly varied among surgeons for postoperative pain control.

Post operative pediatric appendicitis nurse-driven discharge: Patient outcomes and nursing perspectives.

Background: Nurse-driven discharge pathways following pediatric appendectomies have proven effective in children's hospitals; studies in general hospital settings are lacking. Additionally, despite the central role of nursing in such pathways, nursing perspectives aren't investigated in the literature.

Methods: Data from all pediatric acute uncomplicated appendicitis patients who underwent laparoscopic appendectomy in the 12 months following institution of a nurse-driven discharge pathway (intervention, n = 67) were compared to those treated in the preceding year (control, n = 64).

Does the implementation of a pediatric appendicitis pathway promoting ultrasound work outside of a children's hospital?

Background: Efficacy of care pathways for pediatric appendicitis is well established in children's hospitals, but not in community Emergency Departments (EDs).

Methods: A diagnostic pathway combining the Pediatric Appendicitis Score (PAS) with selective ultrasound was implemented. The charts of 2201 pediatric patients seen at four general EDs before and after implementation were retrospectively reviewed, identifying 611 children seriously considered for appendicitis.

Use and accuracy of diagnostic imaging in the evaluation of pediatric appendicitis.

Background: There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined.

Methods: For patients ≤18 years old undergoing appendectomy, we evaluated diagnostic imaging performed, patient characteristics, hospital type, and imaging/pathology concordance (2008-2012) using data from Washington State's Surgical Care and Outcomes Assessment Program.

Impact of maternal substance abuse and smoking on children with gastroschisis.

Background/purpose: Conflicting information exists regarding the effects of maternal substance abuse on gastroschisis. The objectives of this study are to determine if maternal smoking is associated with an increased risk of gastroschisis and whether substance abuse is associated with the severity of gastroschisis.

Methods: The Canadian Pediatric Surgery Network (CAPSNET) database was evaluated for associations between maternal substance abuse and the severity of the gastroschisis.

Gastroschisis closure--does method really matter?

Background/purpose: Management of gastroschisis varies. This study aims to determine which aspects of practice influence outcomes.

Methods: All cases of simple gastroschisis (N = 99) in the Canadian Pediatric Surgery Network database were analyzed looking at methods of preoperative bowel protection, timing of closure, and closure techniques; and outcome measures included time to onset of enteral feeds, duration of parenteral nutrition (PN), and length of stay (LOS).

Laparoscopically supervised PEG at time of Nissen fundoplication: a safe option.

Background/purpose: Children with gastroesophageal reflux disease (GERD) often have associated feeding difficulties that warrant the insertion of a feeding gastrostomy at the time of the antireflux procedure. Options for gastrostomy tube insertion at the time of laparoscopic Nissen fundoplication (LNF) include laparoscopic gastrostomy, percutaneous endoscopic gastrostomy (PEG), and classic open gastrostomy. The complication rate of PEG may be decreased if it is placed under laparoscopic supervision.

Two cases of thoracoscopic resection of esophageal duplication in children.

We report two cases of thoracoscopic resection of esophageal duplication cysts. Both patients underwent successful thoracoscopic excision. They were discharged on postoperative day 2 and 4, respectively.

Primary thoracoscopic repair of diaphragmatic hernia with pericostal sutures.

The surgical management of congenital diaphragmatic hernias has traditionally been via laparotomy or thoracotomy. Although laparoscopic and thoracoscopic repairs have been described, most reports are in older infants. We describe a method for primary thoracoscopic repair applied in the immediate neonatal period when no posterolateral rim of diaphragm exists.

Laparoscopy in the management of antenatally detected liver masses.

Antenatally detected liver masses that are not clearly benign on postnatal investigation pose a management dilemma. Unless the diagnosis is clear, observation alone is risky. Improvements in radiological diagnosis permit confirmation of the benign nature of these masses in some instances, but it is usually difficult to distinguish them from malignant lesions.

Life-threatening abdominal wall hematoma in a chronic renal failure patient after a single dose of enoxaparin.

We present a patient with chronic renal insufficiency who developed a massive posttraumatic abdominal wall hematoma after a single therapeutic dose of enoxaparin administered during workup of chest pain. Surgical evacuation of the hematoma was required to control life-threatening hemorrhage. Low-molecular-weight heparin use is not without risk and mandates appropriate indication and accurate dosing.