Biomedical subjects

Charles L Snyder

Publications and source records attributed to Charles L Snyder.

At least 19 recordsLinked to original sources

PubMed2007

Current management of umbilical abnormalities and related anomalies.

Prenatally, the umbilicus is of paramount importance, providing the gateway between the mother and the fetus. As the fetus becomes increasingly autonomous at the end of the second month of fetal life, the connections (vitelline, urachal) diminish in significance and involute. Disturbances in this process can result in a wide variety of abnormalities, ranging from relatively minor defects identified at birth (umbilical granulation tissue) to life-threatening complications quiescent until late adulthood (urachal carcinoma). This section will review the 'state of the art' in evaluation and management of these umbilical and related abnormalities.

Hernia, Umbilical↗

PubMed2006

Relative value units correlate with pediatric surgeons' operating time: when perceived myth becomes reality.

PURPOSE: In 1992, the Congress implemented a Medicare payment system based on relative value units (RVUs). Today, RVUs are increasingly used to determine surgeon reimbursement from Medicare, Medicaid, and private third-party payers. We questioned whether current RVU assignments accurately reflect the quantity of time that surgeons spend operating. METHODS: Over a 12-month period, 59 common pediatric operations were identified and classified as general surgery (n = 34), urology (n = 13), or minimally invasive (n = 10). Only operations performed as an outpatient or requiring less than one inpatient day of direct surgeon involvement were included. By regression analysis, correlation coefficients were generated comparing average operating time per procedure to the corresponding RVU generated. RESULTS: Of 59 specific operations, a total of 744 general surgery cases, 1155 urological cases, and 370 minimally invasive cases were performed. RVU efficiency was greatest in general surgery (1 RVU = 5.18 operating minutes), followed by minimally invasive operations (1 RVU = 6.80 minutes) and urological operations (1 RVU = 8.59 minutes). Regression analysis proved minimally invasive operations to correlate best with RVUs with R2 = 0.8376, followed by urology at R2 = 0.6753, and then general surgery at R2 = 0.649. CONCLUSIONS: The RVU has emerged as the most dominant factor influencing reimbursement of practicing pediatric surgeons. Despite common surgeon bias, RVUs do correlate with current operating times. These data prove important as surgeons analyze cost, negotiate contracts, and strategically plan for fiscal success.

Child↗

PubMed2006

A simple and more cost-effective antibiotic regimen for perforated appendicitis.

OBJECTIVE: Appendicitis is the most common abdominal emergency in children. When perforation is encountered, postoperative management is grounded upon the use of intravenous antibiotics. The 3-drug regimen of ampicillin, gentamicin, and clindamycin has long been the accepted standard by pediatric surgeons. Although effective and seemingly inexpensive, this regimen produces a cumbersome dosing schedule, which has inspired the search for a simpler regimen that does not compromise efficacy or expense. To this end, we have introduced a 2-drug regimen of ceftriaxone and Flagyl (Pharmacia Corporation, Chicago, Ill) with once-a-day dosing. METHODS: A retrospective review was conducted of the most recent 250 patients treated at our institution with perforated appendicitis. Patients treated since the implementation of this 2-drug regimen were compared with the recent historical cohort treated with triple antibiotic coverage. Parameters analyzed between the 2 groups included temperature curves for the first 5 postoperative days, abscess rate, length of hospitalization, length of intravenous antibiotic treatment, and medication charges. RESULTS: The 2-drug regimen was used in 57 patients (group 1) compared with 193 patients treated with triple antibiotic coverage (group 2). Maximum recorded temperature between the 2 groups was similar upon admission, but the mean maximum temperature in group 1 became significantly lower than group 2 from postoperative day 1 onward (P < .001). Postoperatively, an abscess developed in 8.8% of group 1 compared with 14.2% of group 2, which was not significantly different (P = .37). Mean length of stay was 6.8 days in group 1 and 7.8 days in group 2 (P = .03). Medication charges to the patient were 81.32 dollars per day in group 1 compared with 318.53 dollars per day in group 2, translating to 1186.05 dollars savings for 5 days. CONCLUSIONS: Once-a-day dosing with ceftriaxone and Flagyl provides adequate antibiotic coverage for the postoperative management of perforated appendicitis in children. This regimen allows patients to more rapidly defervesce compared with traditional triple antibiotic coverage; moreover, this simple regimen provides substantial advantages for administration and expense.

Adolescent↗

PubMed2006

Esophageal foreign bodies in the pediatric population: our first 500 cases.

BACKGROUND: Children with esophageal foreign bodies are frequently seen by pediatric surgeons. Choking and dysphagia are common presentations; however, esophageal perforation has been reported. Historically, rigid esophagoscopy with extraction of the foreign body has been the recommended treatment. Alternatively, Foley balloon extraction is a safe and effective approach. METHODS: Over a 16-year period, 555 children presented with an esophageal foreign body. Retrospective analysis of the medical record was undertaken. Statistics were by univariate analysis. RESULTS: Two hundred ninety-eight boys and 257 girls presented with a mean age of 3.24 years. Dysphagia (37%) and drooling (31%) were the most common symptoms. Foreign bodies were lodged in the superior esophagus in 73%, and 88% of the objects were coins. Balloon extraction with fluoroscopy was performed in 468 children. Eighty percent of the objects were successfully removed with a mean fluoroscopy time of 2.2 min, and 8% were advanced into the stomach. The overall success rate was 88%, with failures necessitating rigid esophagoscopy under general anesthesia. Children younger than 1 year were the most likely to fail (25% failure rate). Airway aspiration never occurred. Significant savings in patient charges were observed with this approach. CONCLUSIONS: Balloon extraction of pediatric esophageal foreign bodies is a safe and cost-effective procedure. This technique is applicable for infants, children, and adolescents. Experienced practitioners should be able to achieve greater than 80% success rate.

Adolescent↗

PubMed2006

Faulty bone morphogenetic protein signaling in esophageal atresia with tracheoesophageal fistula.

BACKGROUND: The organogenesis of esophageal atresia with tracheoesophageal fistula remains unclear. We have previously demonstrated that the fistula tract develops from a trifurcation of the embryonic lung bud and displays pulmonary lineage traits. Unlike the lung, the fistula grows without branching. Bone morphogenetic proteins (BMPs) are known to be important in lung branching. We studied possible BMP signaling defects as a potential cause for the absence of branching in the fistula tract. METHODS: Adriamycin was administered to pregnant rats on days 6-9 of gestation to induce tracheoesophageal fistula. Microdissection was performed at E13 and E17 isolating the foregut. Tissues were analyzed using immunohistochemistry for BMP ligand (BMP2, BMP4, BMP7) and receptor (BMPRIA, BMPRIB, BMPRII) expression. RESULTS: Immunohistochemistry revealed the presence of all 3 BMP ligands at E13, localized specifically to the esophageal mucosa but absent in the fistula and lung. At E17, the ligands were again present in the esophageal mucosa, and additionally in the fistula tract mucosa, but remained absent in the lung. At E17, all of the BMP receptors were also localized to the luminal surface of esophagus and fistula. However, in the lung epithelium, only BMPRII was found, whereas BMPRIA and BMPRIB remained absent. CONCLUSIONS: The normal expression pattern of BMP4 was increased at the branch tips and low between branches. Among other results, we show here a constant expression level of BMP ligands throughout the entire epithelium of the fistula tract. This diffuse expression suggests defective BMP signaling in the fistula tract and explains its nonbranching phenotype.

Abnormalities, Drug-Induced↗

PubMed2006

Open versus laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial.

BACKGROUND: Pyloric stenosis, the most common surgical condition of infants, is treated by longitudinal myotomy of the pylorus. Comparative studies to date between open and laparoscopic pyloromyotomy have been retrospective and report conflicting results. To scientifically compare the 2 techniques, we conducted the first large prospective, randomized trial between the 2 approaches. METHODS: After obtaining IRB approval, subjects with ultrasound-proven pyloric stenosis were randomized to either open or laparoscopic pyloromyotomy. Postoperative pain management, feeding schedule, and discharge criteria were identical for both groups. Operating time, postoperative emesis, analgesia requirements, time to full feeding, length of hospitalization after operation, and complications were compared. RESULTS: From April 2003 through March 2006, 200 patients were enrolled in the study. There were no significant differences in operating time, time to full feeding, or length of stay. There were significantly fewer number of emesis episodes and doses of analgesia given in the laparoscopic group. One mucosal perforation and one incisional hernia occurred in the open group. Late in the study, 1 patient in the laparoscopic group was converted to the open operation. A wound infection occurred in 4 of the open patients compared with 2 of the laparoscopic patients (P = 0.68). CONCLUSIONS: There is no difference in operating time or length of recovery between open and laparoscopic pyloromyotomy. However, the laparoscopic approach results in less postoperative pain and reduced postoperative emesis. In addition, there was a fewer number of complications in the laparoscopic group. Finally, patients approached laparoscopically will likely display superior cosmetic outcomes with long-term follow-up.

Follow-Up Studies↗

PubMed2006

Hernia uterus inguinale: a proposed algorithm using the laparoscopic approach.

The authors present a case of hernia uteri inguinale, or the presence of Mullerian duct structures in an inguinal hernia. This entity presents in phenotypic males presumably secondary to defects in the action of the Mullerian inhibiting substance and presents a pediatric surgeon with management dilemmas. The long-term complications associated with the gonads if left intact include the risk of malignancy and infertility. We describe the use of the laparoscopic technique in the management of this condition and propose an algorithm for the management of this condition.

Algorithms↗

PubMed2005

Bone morphogenetic protein expression patterns in human esophageal atresia with tracheoesophageal fistula.

The organogenesis of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains unknown. The fistula tract appears to develop from a non-branching trifurcation of the embryonic lung bud. The non-branching growth of the fistula differs from the other lung buds and suggests a deficiency in bone morphogenetic protein (BMP) signaling, since BMPs are critical to proper lung development and branching. With IRB approval, portions of newborn human proximal esophageal pouch and distal fistula samples were recovered at the time of surgical repair of EA/TEF. The tissues were processed for immunohistochemistry. Commercially available fetal tissues were used as controls. In control tissues, BMP ligands (BMP 2, 4, and 7) were all present in the esophagus but absent in the trachea. BMPRIA was absent in both tissues. BMPRIB was detected in trachea but not in esophagus and BMPRII was detected in esophagus but not in trachea. In the EA/TEF specimens, all BMP ligands were present in the proximal esophageal pouch but absent in the fistula tract. BMPRIA and BMPRIB were not detected in either tissue. However, BMPRII was found in both fistula tract and proximal pouch. The submucosa of the fistula appears to maintain a mixed (identical neither to lung, esophagus, or trachea) BMP signaling pattern, providing one mechanism which could potentially explain the esophageal dismotility and lack of lung branching seen in the fistula/distal esophagus.

Bone Morphogenetic Protein Receptors, Type I↗

PubMed2005

Surgical management of primary bladder diverticula in children.

PURPOSE: The aim of this study was to review the authors' surgical experience with primary bladder diverticula in the pediatric population, with special attention to associated urinary tract infections and voiding dysfunction. METHODS: A retrospective review yielded 21 pediatric patients with primary bladder diverticula treated surgically over a 13-year span. Patients with secondary diverticula were excluded. Charts were reviewed and patients were contacted in regards to several factors. Diverticula were diagnosed preoperatively by radiography on a voiding cystourethrogram. Diverticula, which were only found intraoperatively and not on VCUG, were not included in the study. RESULTS: Mean age at presentation was 8.16 years (range of 0.17-12.91 years). The sex predominance was male, 17 (81%) of 21. Mean follow-up was 44.2 months (range of 6-156 months). The diverticula were associated with ureters requiring reimplantation in 15 of 21 patients (72.4%); only 6 (28.6%) of 21 were isolated diverticula. Nineteen (90.5%) of 21 patients presented with infections, and all 19 (100%) have had complete resolution of infections. Of the total, a subset of 6 patients with isolated diverticula and no evidence of reflux had total resolution of their infections. Twelve patients presented with voiding dysfunction. Eight of these 12 patients had improvement of their voiding dysfunction with complete resolution in 2 patients. CONCLUSIONS: In this series, infections were eliminated with surgical excision of the primary diverticula. Surgical repair was also associated with improvement of voiding dysfunction.

Child↗

PubMed2005

Management of postoperative infections after the minimally invasive pectus excavatum repair.

PURPOSE: Pectus excavatum is frequently repaired using the minimally invasive placement of a substernal bar (Nuss procedure). Infectious complications after the Nuss procedure are potentially devastating. To date, the management of postoperative infectious complications has not been well described. METHODS: A retrospective review of all patients (N = 168) who underwent the Nuss procedure from January 1, 1997, to October 1, 2003, at our institution was performed. Six patients (4%) had postoperative infections, and their medical records were reviewed. RESULTS: Of the 6 patients, 5 underwent operative drainage for wound abscesses that developed 2 to 76 weeks postoperatively. The other patient developed cellulitis 12 months postoperatively and was treated effectively with antibiotics alone. Recurrent infections were treated in 3 of 6 patients, one of whom eventually required removal of the bar resulting in a mild, residual pectus excavatum defect. One of 6 patients has had the substernal bar removed electively. The remaining 4 continue to be without clinically apparent infection at this time and are over 1 year removed from their infection. CONCLUSIONS: Although uncommon, infectious complications after the Nuss procedure require complex management strategies. Despite recurrent infection in some cases, most infectious complications occurring after the minimally invasive repair can be effectively treated without having to remove the substernal bar.

Abscess↗

PubMed2005

Urachal anomalies in children: the vanishing relevance of the preoperative voiding cystourethrogram.

PURPOSE: Children with a wet, draining, or infected umbilicus are often referred to pediatric surgeons. Unfortunately, uniform guidelines regarding diagnostic imaging are lacking. Historically, the persistence of the urachus was attributed to intrauterine distal urinary obstruction. Today, many surgeons continue to advocate preoperative voiding cystourethrogram (VCUG). METHODS: Records of children with urachal abnormalities over the past 10 years were reviewed. Demographics, presentation, imaging, genitourinary anomalies, operations, length of stay, and complications were recorded. Statistical evaluation was by descriptive analysis. RESULTS: Fifty-six children were diagnosed with urachal anomalies. Age at operation was 2.5 years (1 day-13 years). Fifty percent of patients were less than 1 year. Ultrasound was used in 88% of cases. Voiding cystourethrogram (34%) and computed tomography (14%) were also used. Average hospitalization was 1.9 (0-13) days. Thirty-two percent underwent operations as outpatients. Seven percent developed wound infections. Eight children (14%) had genitourinary anomalies. However, no VCUG examination (n = 19) documented an obstructive process. CONCLUSIONS: The current study represents the largest reported series of symptomatic urachal anomalies in children. Disorders of the urachus are variable in presentation with the diagnosis reliably made by history and ultrasound alone. Further testing, including VCUG, is not warranted, adding additional cost, an invasive procedure, and inconvenience to the child.

Adolescent↗

PubMed2005

Management of complications after hypospadias repair.

OBJECTIVES: To review our experience with hypospadias complications (seen after 10%-15% of repairs) and to identify factors influencing outcome. METHODS: We reviewed the available medical records of 113 patients who underwent repeat operation for hypospadias complications. Of the 113 patients, 40% had undergone the initial repair at our institution (internal referral); 60% had undergone the initial repair elsewhere before referral (external referral). The variables potentially affecting outcome were reviewed, including the severity of the defect, concomitant disease, age at the initial operation and revisions, type of complications and treatment, and the number of revisions. Outcomes were compared on the basis of specialty and experience. RESULTS: Isolated hypospadias was present in 81% and other genitourinary abnormalities in 10%. External referral patients were older at the first revision (7.3 versus 4.2 years, P = 0.027). Complications included fistula (73%), stricture (12%), breakdown of repair (10%), and diverticulum formation (11%). Successful revision was independent of the initial defect. The first, second, and third revision was successful in 77%, 64%, and 67% of patients, respectively. The cumulative success rate was 77%, 92%, and 97% after each respective repair attempt. The success of the repair was independent of the patient's age at the initial operation/revision and of the interval from the initial repair to reoperation. Internal referral and external referral patients had similar results. Specific experience with the repair of hypospadias complications correlated with a successful outcome (P <0.001). CONCLUSIONS: Complications after hypospadias repairs are common, with fistula accounting for approximately 75%. The outcome in our series was independent of hypospadias severity, patient age at repair, number of revisions, stent use, and referral status. Repairs performed by an experienced pediatric urologist were associated with improved outcomes (P <0.001).

Child↗

PubMed2005

Trends in mode of delivery for gastroschisis infants.

Cesarean delivery for infants with gastroschisis has not been clearly demonstrated to produce superior outcomes compared with vaginal delivery; however, it not clear whether this has been translated into common clinical practice. Therefore, we analyzed the shifts in type of delivery during the last three decades at our institution. The medical records of all infants with gastroschisis treated at our hospital during the last 33 years were reviewed. Two groups, based on mode of delivery, were compared with regard to demographics, treatment, and outcome. A statistical analysis of changes in type of delivery was performed, and compared with the neonatal population as a whole. A total of 222 patients with gastroschisis were analyzed: 103 delivered via cesarean section and 119 delivered via vaginal birth. Logistic regression demonstrated a significant trend toward cesarean delivery over time (p=0.0001). The odds ratio indicated a 16% per year increase in the chance of cesarean delivery. There has been a significant trend toward cesarean delivery in patients with gastroschisis treated at our institution.

Apgar Score↗

PubMed2005

Synergistic endocrine induction by GLP-1 and TGF-beta in the developing pancreas.

OBJECTIVES: Glucagon-like peptide-1 (GLP-1) is known to stimulate glucose-dependent insulin production and secretion by pancreatic beta-cells. Preliminary evidence suggests that GLP-1 may also influence endocrine differentiation from pancreatic progenitor cells. Additionally, TGF-beta signaling can also control endocrine differentiation by both inhibiting proliferation and enhancing differentiation of endocrine progenitor cells to become mature beta-cells. Here we document synergy of these two signaling pathways in the differentiation of endocrine cells in the developing pancreas. METHODS: Embryonic pancreas was harvested from mice at day 11.5 and cultured for six days with GLP-1 agonist, exendin-4, and/or TGF-beta1 ligand. Also, a pan-neutralizing TGF-beta isoform antibody was used alone or with exendin-4 to study TGF-beta inhibition in this system. Pancreatic cultures were processed for immunohistochemistry. RESULTS: Exogenous TGF-beta1 and exendin-4 each individually enhanced both insulin and glucagon differentiation dose-dependently. However, when combined there was an additive effect to a 4.5-fold increase in insulin-positive differentiation. We also saw suppression of amylase-positive differentiation. Surprisingly, TGF-beta pan-neutralizing antibody also gave an augmentation of endocrine differentiation by 1.5 to 2-fold, but no synergistic effect was seen with exendin-4. CONCLUSION: We conclude that TGF-beta isoforms have a specific synergistic role with GLP-1 pathway signaling in early pancreatic development, toward endocrine differentiation and away from acinar differentiation.

Animals↗

PubMed2004

Thyroglossal duct infections and surgical outcomes.

PURPOSE: Thyroglossal duct cysts (TGDC) are the most common head and neck congenital anomalies in children and often present as infected neck masses. The authors reviewed their experience with TGDC to determine if preoperative infection was related to postoperative complications, including recurrence and postoperative infection. METHODS: The medical records of 99 patients undergoing excision of TGDC from January 1991 to July 2002 were reviewed. Factors thought to be associated with recurrence (age, history of infection, drainage, abscess, and operative procedure) were analyzed. RESULTS: Ninety-nine patients made up the study group. The mean age at operation was 5.0 years (range, 6 months to 16 years) with a male to female ratio of 1.6:1. TGDC recurred in 12.1% (12 of 99) of these patients. There was no gender difference for those with and without recurrence. The presence of an abscess or cellulitis preoperatively (22 of 99 patients) did not correlate with recurrence (NS). In addition, postoperative infection occurred in 13 of 99 patients and also was independent of preoperative infection. However, postoperative infection clearly was associated with an increased risk of TGDC recurrence. Seven of 87 patients without recurrence had a postoperative infection, whereas 6 of 12 of those who had a recurrence had a postoperative infection (P <.001). The mean follow-up was 3.7 years and was comparable for the 2 groups (recurrence v. resolution). Twelve patients successfully underwent a second procedure for recurrence. CONCLUSIONS: In this large series of TGDC, preoperative infection occurred in approximately 1 of 5 patients and was not predictive of recurrence. Although postoperative infection did not correlate with the presence of preoperative infection, it was clearly associated with a statistically significant incidence of recurrent disease.

Adolescent↗

PubMed2004

Aberrant fibroblast growth factor receptor 2 signalling in esophageal atresia with tracheoesophageal fistula.

BACKGROUND: Although the pathogenesis of esophageal atresia with tracheoesophageal fistula (EA/TEF) remains unknown, it has been shown that despite its esophageal appearance, the fistula tract originates from respiratory epithelium. The authors now hypothesize that defects in fibroblast growth factor (FGF) signaling contribute to the esophaguslike phenotype of the fistula tract. FGF2R is critical to normal lung morphogenesis and occurs in 2 isoforms (FGF2RIIIb and FGF2RIIIc), each with different ligand-binding specificity. To characterize FGF signaling in the developing EA/TEF, the authors analyzed levels of FGF2R splice variants in experimental EA/TEF. METHODS: The standard Adriamycin-induced EA/TEF model in rats was used. Individual foregut components from Adriamycin-treated and control embryos were processed for real-time, fluorescence-activated semiquantitative reverse transcriptase polymerase chain reaction on gestational days 12.5 and 13.5. RESULTS: Both fistula tract and Adriamycin-treated or normal esophagus showed significantly lower levels of FGF2RIIIb than either Adriamycin-treated lung buds (E12.5, P =.02; E13.5, P <.005) or normal lung buds (E12.5, P <.005; E13.5, P <.01). At E13.5, the fistula tract had lower levels of FGF2RIIIc than either treated (P <.01) or normal lung (P <.05). CONCLUSIONS: Levels of FGF2R in the developing fistula tract resemble that of distal esophagus rather than developing lung. This defect in FGF2RIIIb signaling may account for the nonbranching, esophaguslike phenotype of the fistula, despite its respiratory origin.

Animals↗

PubMed2004

An effective pyloromyotomy length in infants undergoing laparoscopic pyloromyotomy.

BACKGROUND: Traditional management of pyloric stenosis has consisted of open pyloromyotomy during which the surgeon is able to palpate and determine whether the hypertrophied pylorus has been completely divided. During the last decade, laparoscopic pyloromyotomy has become an increasingly popular approach for this condition. The purpose of this study was to determine whether there is an effective pyloromyotomy length that will allow the surgeon to feel confident that a complete pyloromyotomy was performed with the laparoscopic approach. METHODS: All infants undergoing laparoscopic pyloromyotomy from October 1999 through October 2003 at a single institution were retrospectively studied. Clinical variables collected included the patient's age, gender, electrolyte status on admission, the elapsed time from admission to operation, ultrasonographic dimensions of the hypertrophied pylorus, operative time, the length of the pyloromyotomy performed, the time to initial and to full feedings, and the duration of the postoperative hospitalization. RESULTS: One hundred seventy-one patients comprised the study group. The age (mean +/- standard deviation) at the time of operation was 5.2 +/- 2.8 weeks. The mean preoperative ultrasonic measurements for both pyloric thickness and pyloric length were 4.3 +/- 0.7 mm and 19.5 +/- 2.8 mm, respectively. The average pyloromyotomy incision length for this entire group was 1.9 +/- 0.21 cm. The mean operative time was 23.5 +/- 8.3 minutes. There were no mucosal perforations, no conversions to an open procedure, and no evidence for an incomplete pyloromyotomy. CONCLUSIONS: Laparoscopic pyloromyotomy is a safe and effective technique for infants with pyloric stenosis. A pyloromyotomy incision length of approximately 2 cm appears to be an effective measure of a complete pyloromyotomy.

Digestive System Surgical Procedures↗

PubMed2003

Evaluation of pectus bar position and osseous bone formation.

PURPOSE: Minimally invasive repair has become a popular approach for pectus excavatum (PE). The bar is secured to the thoracic wall and left for approximately 2 years. The authors have noticed an intense bone formation (BF) around some of these bars at removal. A review of children undergoing bar removal was performed to better understand this BF in relation to bar placement. METHODS: A retrospective review of children undergoing bar removal after PE repair since January 1998 was performed. Chart review included age at bar insertion and removal, bar insertion position (subcutaneous [SC] v submuscular [SM]), BF on Chest x-ray and at bar removal, operating time, and estimated blood loss (EBL). RESULTS: Thirty-six patients underwent bar removal during the study period (16 SC and 20 SM). Chest x-ray evaluation was possible in 27 patients (16 SM, 11 SC). No difference existed for length of time the bar was in place or age at insertion/removal between groups. EBL was higher in the SM (18.3 v 8.8 mL, not significant). BF was seen radiographically in 15 SM and 3 SC patients (P <.001). BF was encountered at removal in 19 SM patients and a single SC patient (P <.001). Operating time was statistically longer (P <.01) for the SM group (30.2 v 15.6 min). CONCLUSIONS: Bar position during repair of PE is important. SM positioning virtually always results in BF with increased EBL and statistically longer operating time at removal. Careful placement of the bar in the SC position without violating the fascia should be used to avoid these undesirable effects.

Blood Loss, Surgical↗