Faculty Bibliography

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.

Umbilical anomalies are a rare presentation in the pediatric patient. The differential diagnosis includes anomalies resulting from urachal and vitelline duct derivatives such as urachal sinus, urachal cyst, urachal diverticulum, patent urachus, herniated Meckel's diverticulum, umbilico-enteric fistula, or umbilical polyp. In this article, a case presentation of an umbilical anomaly along with the differential diagnosis and management options are discussed. Based upon this review of the literature, the authors propose a management algorithm for treating children with umbilical anomalies.

Rectal prolapse (RP), although most frequently encountered in the frail elderly, may also occur in children. This condition is most troublesome in the premature infant with significant associated comorbidities. Pediatric RP most often can be managed conservatively with expectant and/or judicious use of laxative-based bowel regimens. In rare instances of intractable RP, surgical intervention ranging from simple (sclerotherapy, Thiersch wire) to complex (perineal or transabdominal bowel resection) becomes necessary. We describe a modification of the Altemeier technique using a novel sequential linear stapling technique to treat intractable RP in a 5.0-kg infant with severe coexisting life-threatening comorbidities. The child had resumption of bowel movements on postoperative Day 1 and has had no recurrences. Sequential linear stapling technique for perineal resection of intractable pediatric RP appears to be a safe and potentially attractive alternative.

Over the past decade, methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a global problem, prompting extensive surveillance efforts. A previous study of S. aureus isolates at our institution revealed alarming increases in the prevalence of MRSA with no sign of plateau. However, evidence of MRSA in pediatric surgical patients remains largely anecdotal, as there are no published reports of institutional MRSA surveillance in the pediatric surgical literature. We conducted a retrospective review of incision and drainage (I and D) procedures at our institution from 1998 through 2004. All I and D procedures performed at the University of Chicago Children's Hospital were identified and the patients' charts reviewed for pertinent information. A total of 99 I and D procedures were performed during the study period, ranging from 5 in 1998 to 32 in 2004. Among cultures with positive growth, 52 (65.8%) were MRSA, 14 (17.7%) were methicillin-sensitive S. aureus, and 13 (16.5%) were miscellaneous species. The number of MRSA isolates increases from 2 in 1998 to 20 in 2004, the largest increase occurring during the last 3 years of the study. A large proportion of MRSA isolates were resistant to antimicrobials from other classes, with over 70% being resistant to both erythromycin and cefazolin. A majority of MRSA isolates (71.4%) were obtained from patients with no record of prior hospitalization. Our analysis confirms a high prevalence of MRSA among soft-tissue infections requiring surgical drainage. In addition, a majority of MRSA isolates were resistant to multiple antimicrobials and were isolated from children without a previous documented exposure to the hospital milieu. Thus, pediatric surgeons should be aware of MRSA prevalence and resistance patterns in the local communities.

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of < 0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.

PURPOSE: It has been suggested that routine division of short gastric vessels (SGVs) results in a more 'floppy' Nissen fundoplication leading to improved outcomes, that is, less dysphagia and lower incidences of recurrent gastroesophageal reflux disease (GERD). The aim of this retrospective study was to assess whether laparoscopic Nissen fundoplication without division of SGVs (Rossetti modification) (laparoscopic Nissen-Rossetti fundoplication [LNRF]) is associated with acceptable clinical outcome in children. METHOD: The charts of 368 children who underwent LNRF between January 1996 and September 2004 by 1 primary surgeon were retrospectively reviewed. Children were divided into 2 groups: LNRF + gastrostomy (A) and LNRF alone (B). Mean follow-up period of all groups was 4.2 years. RESULTS: Laparoscopic Nissen-Rossetti fundoplication was completed in 99% (365/368). Mean operating time for group A was 74 minutes and 61 minutes for group B. None in group A required postoperative esophageal dilatation, and 9 in group B (22.5%) required 12 dilatations; 3.6% developed recurrent GERD, 3.7% in group A and 2.5% in group B. CONCLUSION: Laparoscopic Nissen-Rossetti fundoplication can be performed with acceptable long-term outcome in children, especially in the majority also requiring chronic gastrostomy access. Short-term, reversible dysphagia may be seen in a small percentage of children having fundoplication alone

Amniotic band syndrome (ABS) is a rare disorder in which bands of mesoderm that emanate from the chorionic side of the amnion and insert on the fetal body can generate a wide variety of disfiguring and disabling malformations. It usually is sporadic, and the incidence is approximately 1 in 15,000 live births, and affected children typically require involvement of several pediatric surgical subspecialties. The authors describe a case of ABS with extensive craniofacial anomalies.