Intussusception - Soft Tissue Abscess - Pilonidal Cyst - Bleeding Meckel's...
With Dr. Nick Bruns & Dr. Ian Glenn · hosted by Dr. Todd Ponsky · StayCurrentMD
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Single Ventricle / HLHS 37 items
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Cincinnati changed practice 6-8 months ago to discharge intussusception patients home from the ER after a 4-hour observation period if they tolerate feeds and are hemodynamically stable.
The repeat enema study after initial reduction does not actually reduce the intussusception again; it proves the first reduction was successful because the edema has now resolved.
Ultrasound after intussusception reduction is difficult to interpret due to inflammation, so a contrast enema is preferred for confirmation.
One surgeon previously removed the appendix during operative intussusception reduction but now leaves it in due to concern about appendiceal stump dehiscence if reoperation is needed.
For intussusception in a 6-year-old, one approach is to attempt radiologic reduction, then work up for lead point electively and perform resection in a non-inflamed setting.
Many soft tissue abscesses are drained in the emergency department by ED physicians with sedation, not in the operating room.
Vessel loops are used as wicks for abscess drainage instead of traditional packing by some surgeons.
Admission criteria for soft tissue abscess include cellulitis, fever, and leukocytosis in some combination; if the child appears sick, admission is warranted.
Antibiotics are prescribed for soft tissue abscess only if cellulitis is present; otherwise patients go home without antibiotics.
In a retrospective review of abscess I&D cases discharged same-day from the OR, treatment failure (readmission or repeat I&D within 2 weeks) occurred in only 0.9% of patients.
Among patients with leukocytosis (white count up to 35), only 2 out of 138 had treatment failure after same-day discharge, and only one febrile patient had treatment failure.
For pilonidal disease, one surgeon operates after the second recurrence, though tries to delay as long as possible.
For recurrent pilonidal disease or large draining sinuses, formal excision with off-midline layered closure and drain placement is performed.
Physical exam findings such as deep gluteal fold and excessive hair are high-risk factors that may influence timing and type of pilonidal surgery.
For severe recurrent pilonidal disease, open excision with wet-to-dry dressing changes or wound vac is used.
The key to preventing pilonidal recurrence is post-operative management: keeping the patient prone on bed rest until the wound heals, as it is primarily a wound healing problem from sitting on the surgical site.
Plastic surgeons perform flap procedures for recurrent pilonidal disease and keep patients prone post-operatively.
Some surgeons have sent patients for laser hair removal without complaints, though ensuring adequate treatment area and obtaining insurance reimbursement remain challenges.
After a negative Meckel scan in a child with hematochezia, one approach is colonoscopy with intent to proceed to laparoscopy if negative, ideally under the same anesthetic.
Starting a PPI for suspected Meckel diverticulum bleeding will stop the bleeding temporarily; it should never be an emergency operation.
For a bleeding Meckel diverticulum, if there is an ulcer at the base, segmental small bowel resection is performed rather than simple diverticulectomy.
One position is that stapling off a bleeding Meckel removes the acid source, so the ulcer will heal without needing bowel resection, similar to vagotomy for peptic ulcer disease.
The ectopic gastric mucosa in Meckel diverticulum is almost always at the tip of the diverticulum.
When performing Meckel diverticulectomy by pulling the diverticulum out through the umbilicus, marking the bowel edge with a marker while it is relaxed (not under tension) helps avoid narrowing the bowel lumen.
In a series of 48 intussusception patients discharged from the ED, only one recurred within 48 hours and that patient did not require operation, only repeat reduction.
When contrast fills the appendix but does not reflux into small bowel after intussusception reduction, this is attributed to ileocecal edema; the recommendation is to observe and repeat the study in a few hours.
Age over 5 years is the inflection point for pathologic lead point in intussusception, with 30-60% of cases in this age group having a lead point depending on the series.
A study at ABSA showed that packing abscesses did not make a difference in outcomes, yet surgeons continue to use packing or wicks.
The Bascom technique involves excising pits with an 11 blade at skin level under local anesthesia, allowing healing by secondary intention; 70% of patients do not recur, though there is no control group.
The Karydakis flap is superior to excision alone for pilonidal disease and comparable to the modified Limberg flap; the modified elliptical rotation flap has comparable short-term results.
One patient reported laser hair removal for pilonidal disease was the most painful thing he had experienced and discontinued treatment after half a session.
Bill Gazetta taught at the fellows course that ulcers in Meckel bleeding are in the Meckel diverticulum itself, not in the adjacent small bowel.