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Appendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old. A retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period. One thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1–1.9 years, 60% 2–2.9 years, 64% 3–3.9 years, and 49% 4–4.9 years), but the youngest children had fewer postoperative abscesses. In children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. A retrospective review was conducted of all children (<18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean ± standard error of mean. Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management.

Although blunt cerebrovascular injuries (BCVIs) are a well-recognized sequela of trauma in adults, there have been few reports in children. The investigators questioned whether adult screening protocols are appropriate in the pediatric population. The purpose of this study was to describe the incidence, injury patterns, and stroke rates of pediatric patients sustaining BCVIs. Pediatric patients (aged ≤ 18 years) diagnosed with BCVIs at a regional level I trauma center and a pediatric level I trauma center since 1996 were reviewed. Forty-five patients sustained BCVIs (60% male; mean age, 13 ± .7 years; mean Injury Severity Score, 23 ± 2). Three patients exsanguinated, and 10 presented with stroke; neurologic changes occurred 17 ± 6 hours after injury (range, 1–72 hours). Screening indications were present in 30%. Thirty-two asymptomatic patients were diagnosed. All but 1 received antithrombotic agents; 1 patient had neurologic deterioration despite heparinization. Comparing asymptomatic patients with those with stroke, there was a significant difference in age (15 vs 11 years). More than two-thirds of patients presenting with stroke did not have screening indications according to adult protocols. With the availability of noninvasive diagnostic imaging such as computed tomographic angiography, broader screening guidelines for children should be instituted.

We hypothesize that in children with Crohn's disease (CD) isolated to a single site, resection leads to clinical improvement, decreased medication requirements, and improved growth. A retrospective review was conducted of children with CD isolated to the terminal ileum undergoing operative intervention at Children's Hospital Colorado between 2002 and 2013. Twenty-six patients underwent ileocecetomy (mean age at diagnosis 14.1 ± 2.6 years; mean age at resection 15.7 ± 2.5 years; median follow-up 2 ± 1.5 years). Twenty-two (84.6%) patients reported clinical improvement and 17 (65.4%) were able to decrease the number or dosage of medications. Average weight increased from the 29th to the 45th percentile (P = .09) at 1 year and to the 56th percentile (P = .02) at 3 years post resection. Average body mass index increased from the 30th to the 48th and 49th percentile at 1 and 3 years (P < .05 for both), respectively. Height increased from the 39th percentile at the time of resection to the 51st percentile at 3 years (P = nonsignificant). Surgical resection of an isolated ileal segment in adolescents with CD allows for catch-up growth and reduction in medication requirements.

Adolescents with blunt solid organ injuries (BSOI) are cared for at both pediatric trauma centers (PTC) and adult trauma centers (ATC). Over the past decade, treatment strategies have shifted towards non-operative management with reported favorable outcomes. The aim of this study was to compare management strategies and outcomes between PTC and ATC. We queried the 2016–2018 Trauma Quality Improvement Program (TQIP) datasets to identify adolescents between the ages of 16 and 19 with BSOI. Characteristics were stratified by center type (pediatric or adult) for comparative analyses. Separate logistic regressions were used to assess the association of hospital type, location of injury, age, gender, weight, Glascow Coma Score (GCS), Injury Severity Score (ISS), and intensive care unit (ICU) admissions for outcomes of interest. Among the 3,011,310 patients enrolled in the 2016–2018 TQIP datasets, 106,892 (3.5%) had a BSOI ICD9/10 code. Of those, 9,193 (8.6%) were between 16 and 19 years of age and included in this analysis. Within this cohort, 6,073 (66.1%) were managed at an ATC and 3,120 (33.9%) were managed at a PTC. While statistically different, there were no clinically relevant differences for age, weight, and sex between groups. A significantly higher ISS and lower GCS score were observed among those admitted to ATC compared to PTC. ICU admissions were more frequent at ATC. Number of blood transfusions by 4 h after presentation were also higher among those admitted to an ATC. Despite a lower ISS and higher GCS at presentation, mortality was higher among those treated at a PTC with an odds ratio (95% confidence interval) of 2.42 (1.31–4.53). After excluding adolescents with a traumatic brain injury, a common cause of mortality among adolescent trauma patients, these differences in outcomes persisted. Our data suggest that adolescents with BSOI managed at a PTC are less likely to receive blood transfusions by 4 h of admission or be admitted to the ICU than those managed at an ATC. However, this more conservative approach may come at the expense of higher overall mortality. Further work is needed to understand these differences and determine if PTC need to be more aggressive in managing BSOI. •Adolescents suffering a BSOI admitted to an ATC are more likely to be admitted to the ICU and receive blood than those admitted to a PTC.•Mortality associated with adolescent BSOI appears to be higher among those treated at a PTC compared to those treated at an ATC.•Further studies are needed to determine if a more conservative approach to the management of BSOI in adolescents affects survival.

Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. A retrospective review of all children undergoing appendectomy over a 5-year period was performed. We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy. In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.

BackgroundDespite advancements in medical therapy for ulcerative colitis (UC), a significant proportion of children progress to colectomy with ileal pouch-anal anastomosis (IPAA). Procedural related complications between two- and three-stage operations in children have not been well described.MethodsWe performed a retrospective review of patients who underwent a colectomy for UC or inflammatory bowel disease unclassified between 2008 and 2018.ResultsForty-nine children underwent an IPAA at the time of colectomy (two stage) or during a subsequent operation (three stage). Preoperative hemoglobin and albumin concentrations were lower among those undergoing three-stage procedures. The rate of early complications (≤30 days) was similar between the two groups (p = 0.46); however, late complications (>30 days) were more commonly associated with three-stage procedures (p = 0.03). Time with a stoma was 3.2 months longer among those who underwent a three-stage procedure. While three-stage procedures were more often performed during the first half of the study period (2008–2012), two-stage procedures became more common during the second half (2013–2018). During this transition to favor two-stage procedures, complication rates did not significantly change.ConclusionAlthough three-stage procedures were thought to be associated with fewer complications, we found comparable complication rates as we transition to two-stage procedures.

Background Minimally invasive surgical (MIS) techniques have become an established part of the care of the adult oncology patient. As surgeons have become more experienced with these advances in technique, MIS has recently seen an expanding role in the diagnosis and treatment of pediatric malignancies. We hypothesize that MIS techniques can be used to provide reliable diagnosis and safe therapeutic resection of many pediatric malignancies. Procedure We performed a retrospective review of all patients who underwent a minimally invasive operation for diagnosis or treatment of a malignant solid tumor at the Children’s Hospital Colorado over a ten-year period. Results A total of 105 minimally invasive procedures were performed in 98 patients, 61 % of which were male. The majority of cases, 78 (74 %) were thoracoscopic procedures and the remaining 27 (26 %) were laparoscopic procedures. Twenty-one (27 %) thoracoscopic procedures were performed for complete resection of primary tumor or metastases, with only three cases (14 %) converted to open thoracotomy. Tumors that were successfully removed thoracoscopically include neuroblastomas ( n  = 8), metastatic disease ( n  = 7), and a schwannoma. Of the 28 laparoscopic procedures, nine were performed for tumor resection with one case converted to open. Tumors that were successfully removed laparoscopically include 6 adrenal neuroblastomas and one pseudopapillary pancreatic tumor. There were no major surgical complications. No port site or surgical site recurrences were reported. Conclusions MIS techniques can be used safely and effectively for the diagnosis and resection of pediatric malignancies and treatment decisions can be made accurately based on tissue obtained.

Abstract Extrahepatic liver (EL) rests are rare, with a reported annual incidence of 0.24–0.47. While reports often note EL incidentally found on pathologic specimens of aberrant tissue, there has been a case report of hepatocellular carcinoma arising from one of these rests, highlighting the importance of surgical resection. EL has been reported to cause symptoms such as abdominal pain, intraperitoneal bleeding and compression of adjacent organs. Most commonly, it has been identified in the gallbladder, likely due to proximity of the gallbladder to the native liver. The paucity of diagnostic tests makes the preoperative diagnosis challenging. We present a case of a 12-year-old female presenting with severe epigastric pain secondary to incapsulated EL tissue attached to the stomach via a narrow stalk. By describing this case, we hope to improve the diagnosis and management of abdominal masses with unclear etiology.