LATE PRESENTING CONGENITAL DIAPHRAGMATIC HERNIA:  A 21-YEAR SINGLE CENTER REVIEW   J Baerg MD, V Kanthimathinathan MD, D Moores MD Loma Linda University Children’s Hospital, Loma Linda, CA   Aim:  To describe the  outcome of children with late presenting congenital diaphragmatic hernia (CDH) and compare the most recent decade (2000-2009) to the previous decade (1989-1999) for changes in the clinical practice.   Methods:  After IRB approval, patients who presented  with CDH between 30 days and 18 years, between January 1989 and December 2009, were reviewed retrospectively.  Outcome data were collected by telephone survey in 2010. Data were compared by Fisher exact test and t-test. P<0.05 was  significant.   Results:  During the study period, 31 children (22/31(71%) males) presented between 45 days and 13 years (median:  9 months). Morgagni hernia was present in 14/31(45%) and Bochdalek in 17/31(55%).  There were 20/31(64%) left-sided, 8/31(26%) right-sided and 3/31(10%) bilateral.  Acute symptoms were present in 24/31(77%), chronic symptoms in 5/31(17%), and 2/31(6%) had an incidental diagnosis of CDH.  There were 10/31(32%) misdiagnosed as pneumonia, one patient having undergone a prior thoracotomy for empyema at another center.  There was 1/31(3%) misdiagnosed as a chest mass, who required extensive intestinal resection after strangulation in a left Bochdalek hernia.  Between 1989-1999, 14/31(45%) open repairs were performed, 2/14(14%) with patch.  Between 2000-2009, 17/31(55%) repairs were performed, 7/17(41%) laparoscopic.  Blood loss (p=0.04), post-op ventilation (p=0.004) and hospital stay (p= 0.04) were significantly higher between 1989-1999.  Operative times were significantly longer (p=0.005) between 2000-2009.  Telephone follow-up was complete for 27/31(87%) and ranged from 1-20 years (median: 7 years).  All survived, none had surgery for recurrence, malrotation or bowel obstruction. The child with bowel strangulation is alive at 18 years with short bowel on TPN.   Conclusion:  Patients with repaired, late presenting CDH survive  without sequellae, unless misdiagnosis occurs.  Clinical practice is improving.   The most recent decade demonstrates significant improvements in length of stay, operative blood loss and use of postoperative ventilation.  The increased operative times reflect the learning curve of laparoscopic repairs.     LATE PRESENTING CONGENITAL DIAPHRAGMATIC HERNIA:  A 21-YEAR SINGLE CENTER REVIEW   J Baerg MD, V Kanthimathinathan MD, D Moores MD Loma Linda University Children’s Hospital, Loma Linda, CA   Aim:  To describe the  outcome of children with late presenting congenital diaphragmatic hernia (CDH) and compare the most recent decade (2000-2009) to the previous decade (1989-1999) for changes in the clinical practice.   Methods:  After IRB approval, patients who presented  with CDH between 30 days and 18 years, between January 1989 and December 2009, were reviewed retrospectively.  Outcome data were collected by telephone survey in 2010. Data were compared by Fisher exact test and t-test. P<0.05 was  significant.   Results:  During the study period, 31 children (22/31(71%) males) presented between 45 days and 13 years (median:  9 months). Morgagni hernia was present in 14/31(45%) and Bochdalek in 17/31(55%).  There were 20/31(64%) left-sided, 8/31(26%) right-sided and 3/31(10%) bilateral.  Acute symptoms were present in 24/31(77%), chronic symptoms in 5/31(17%), and 2/31(6%) had an incidental diagnosis of CDH.  There were 10/31(32%) misdiagnosed as pneumonia, one patient having undergone a prior thoracotomy for empyema at another center.  There was 1/31(3%) misdiagnosed as a chest mass, who required extensive intestinal resection after strangulation in a left Bochdalek hernia.  Between 1989-1999, 14/31(45%) open repairs were performed, 2/14(14%) with patch.  Between 2000-2009, 17/31(55%) repairs were performed, 7/17(41%) laparoscopic.  Blood loss (p=0.04), post-op ventilation (p=0.004) and hospital stay (p= 0.04) were significantly higher between 1989-1999.  Operative times were significantly longer (p=0.005) between 2000-2009.  Telephone follow-up was complete for 27/31(87%) and ranged from 1-20 years (median: 7 years).  All survived, none had surgery for recurrence, malrotation or bowel obstruction. The child with bowel strangulation is alive at 18 years with short bowel on TPN.   Conclusion:  Patients with repaired, late presenting CDH survive  without sequellae, unless misdiagnosis occurs.  Clinical practice is improving.   The most recent decade demonstrates significant improvements in length of stay, operative blood loss and use of postoperative ventilation.  The increased operative times reflect the learning curve of laparoscopic repairs.      

  Aim:  To identify factors associated with residents who attained a predetermined level of competence in laparoscopic intracorporeal suturing. Methods:  IRB approval was obtained.  Data was gathered prospectively between July 1, 2009 and March 1, 2010.  A goal was set that residents would practice intracorporeal suturing in a simulator until they could perform one surgeon’s knot and five more throws in under 5 minutes.  Residents from 5 postgraduate years presented individually for a tutorial with one pediatric surgeon.  Residents first practiced the movements outside the simulator.  When they could produce the movements with a needle driver and forceps, they proceeded to the simulator.  They practiced individually with one pediatric surgeon until they could perform an intracorporeal suture.  Baseline times were recorded.  A survey about previous laparoscopic experience   was given to each resident.  Each was then instructed to continue to return to the simulator to practice until they could perform an intracorporeal suture  within the goal time of 5 minutes.  Besides this predetermined speed, they were instructed to practice until they did not drop the needle and could keep the instrument tips within an 8 by 8 cm area.  Logs to keep track of practice dates and times were administered. Data from surveys, official case logs, and practice time logs were analyzed by Pearson chi-square and student t-test.  P-values <0.05 were considered significant.  Results:  Forty residents presented for tutorials.  Fourteen (35%) reached the goal during the study period and they required between 1 and 21 (median: 1.5) practice sessions.                         * mean, SD Conclusion: Residents that achieved competence in laparoscopic intracorporeal suturing (as compared to those that did not) were 1) significantly more likely to have had 3 or more years of post-graduate training, 2) significantly more experienced with complex laparoscopic cases, and 3) sutured twice as fast at the time of their initial tutorial.     Met Goal n = 14(%)    Goal Not Met n =26(%) p Post Graduate Year 3- 5 12(86%) 2(8%) 0.01 Complex Lap. Cases* 23.4+/-19 9.5+/-12.5 0.01 Baseline Time (min)* 14.3+/-6.5 19.4+/-9.6 0.04  

 ABSTRACT:       INTRODUCTION:   We present a case of endoscopy-guided placement of a pleuro-peritoneal shunt in a patient with primary lymphedema, multiple abdominal lymphoceles, an episode of spontaneous bacterial peritonitis and  recurring symptomatic  pleural effusions.CASE:  A fifteen year-old boy with primary lymphedema, had undergone multiple thoracenteses and chest tubes for a left pleural effusion.  An incision was made in the posterior axillary line at the sixth intercostal space.  The pleural portion of the shunt was placed in good position guided by the five millimeter, thirty-degree camera.    The shunt and pump chamber were tunneled under the skin.  A 5mm incision was made in the left upper quadrant, a purse string suture was placed in the posterior rectus sheath and the 5mm port was inserted into the abdomen under direct vision.   Pneumoperitoneum was obtained to a pressure of 13 mm Hg and the camera was inserted.  Multiple lymphoceles and   adhesions were identified. With laparoscopic guidance, an area was dissected in which to place the shunt.  Immediate good shunt function was observed.DISCUSSION:  This previously unreported use of endoscopy to successfully place a pleuro-peritoneal shunt, allowed a patient to be discharged from hospital free of oxygen and external tubes.    Information was obtained about the patient’s abdomen  which will guide future therapy.

 

 Baerg,  Taylor   Pediatric Endosurgery & Innovative Techniques. December 1, 2003:445- 449.     Laparoscopic Technique of Simultaneous Gastrostomy Tube Placement and Inguinal Hernia Repair in a Neonate (peer reviewed)

 Baerg, Kaban, Tonita, Pahwa, Reid      J Pediatr Surg. 2003  May;38(5):771-4.    Gastroschisis: A sixteen-year review.  Peer reviewed and published.

 Meyers, Baerg      J Pediatr Surg. 2001 May;36(5):726-9. Farm accidents in children: Eleven Years of Experience.

Purpose:              We sought to identify significant associations between gastroesophageal reflux disease (GERD) and weight loss in neonatal intensive care unit (NICU) infants. Methods:              After Institutional Review Board approval, infants born between January 2004 and December 2006, investigated by 24-hour pH-probe before age six months, were reviewed retrospectively. GERD was present if the pH < 4 for over 5% of 24 hours.  We examined growth curves at the initial pH-probe, 6 months later, and December 2009.  At the six-month evaluation, we compared infants who lost to infants who gained.  Logistic regression identified subgroups associated with weight loss independent of GERD.  Results:             Follow-up was complete for 191, 48(25.1%) lost and 143(74.9%) gained.  GERD was present in 87/191(45.5%), 31(35.6%) underwent fundoplication, 56(64.4%) received anti-reflux medications. Weight loss occurred in 21/87(24.1%) and was not from GERD in 20/21(95.2%). Between 6-30 months (median:  10 months) after their initial probe, 5/31(16.1%) fundoplication patients were vomiting, but gaining weight.  A pH-probe confirmed GERD.             GERD was absent in 104/191(54.5%). Weight loss occurred in 27/104(26.0%) and was not from GERD in 20/27(74.1%). Between 6-31 months (median: 11 months) after a negative probe, 7/27(26.0%) were vomiting and losing weight.  A pH-probe confirmed GERD.             Infants unable to feed orally (OR:2.68(95%CI:  1.24-5.85)), or with a genetic syndrome (OR:13.56(95%CI:  4.56-40.29)), lost independent of GERD. Conclusions:              If treated, GERD is not associated with weight loss in NICU infants.  Despite a negative pH-probe, pediatricians should inquire about GERD symptoms, and restudy infants before weight loss occurs.  Infants with inability to feed orally or genetic syndromes lose weight, independent of GERD.   

 Chronic Intestinal Pseudo-obstruction in Children Joanne Baerg MD, Arvand Elihu MD    Loma Linda University Children’s Hospital       Background: The aim of this study was to report the presentation and outcome of 20 consecutive children with the syndrome of chronic intestinal pseudo-obstruction between 1995-2005.  Methods:IRB approval was obtained.  Charts of patients <17 years with recurrent signs of intestinal occlusion in the absence of identifiable obstruction were reviewed.  Hirschsprung’s disease was excluded.Results:Twelve girls (60%) and 8 boys (40%) were identified.  Twelve (60%) presented before one year (range: 3 months-10 years).  Three underwent ileostomy (15%).  Follow-up ranged from 1.5-17 years (mean -9years).  One boy suffered Munchausen’s by proxy.  The remaining 19 were categorized:  1)  Three (15%) had pathologic evidence of myopathy(2) and neuropathy (1).  2)  Twelve (60%) had non-specific intestinal failure, 8(66%) were neurologically impaired and had GERD.  The intestinal failure worsened after Nissen fundoplication in 3 (25%).  3)  Four (20%) actually had a slowly evolving mechanical obstruction which resolved after surgery.  Overall mortality was 20% (4/20).  Presently, 10 (50%) tolerate enteral feeds and 6 (30%) require parenteral nutrition.   Conclusion:Three children (15%) had pathologic evidence of pseudo-obstruction.  Intestinal failure can occur despite normal histology.  A slowly evolving mechanical obstruction can mimic pseudo-obstruction and should be eliminated from the diagnosis.  

 

 Baerg, Zuppan, Klooster                         J Pediatr Surg  2004; Jun  39(6): 800-3 Biliary Atresia: A Fifteen Year review of Clinical and Pathologic Features Associated with Liver Transplant  Published in peer reviewed journal.

 J. Curtis MD * resident in surgery (presenter) J. Baerg MD    (senior colleague)   Dept. of Pediatric Surgery, Loma Linda University Children’s Hospital Rm. 21111, Coleman Pavilion, 11175 Campus St. Loma Linda, CA                92354     Beware of “Innocuous” Air Rifle Injuries     Two toddlers, ages 3 and 5 respectively, sustained intentional close range air rifle injuries to the anterior abdominal wall. (0.177 caliber ball bearing and low velocity weapons- 280 feet per sec.)   One patient was left unsupervised with an older sibling and one was the victim of child abuse. Each presented with a 3mm opening on the anterior abdominal wall and no exit wound. Vital signs remained within normal limits throughout the assessment and no other injuries were noted. Triple contrast abdominal CT scans and serial abdominal X-rays of each patient remained completely unremarkable. In spite of normal investigations, serial abdominal exams revealed peritoneal irritation within a short period of time after arrival.  Laparotomy was performed in each case and findings will be described.  The cases illustrate the potential lethality of air rifles and the importance of accurate, frequent clinical exams over radiological studies in order to prevent missed injuries.     Address correspondence to Dr. Baerg Email:       jbaerg@som.llu.edu Phone:      909 558 4619, Fax:  909 558 0236