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Biomedical subjects

J Patrick Murphy

Publications and source records attributed to J Patrick Murphy.

13 recordsLinked to original sources
PubMed2007

Current management of the acute scrotum.

Pediatric surgeons and urologists are often asked to evaluate boys with acute scrotal pain and inflammation. Although there are myriad etiologies for this syndrome, testicular torsion should be at the top of the list. It is the one diagnosis that must be made accurately and rapidly if there is any hope for testicular salvage. The purpose of this article is to update/review the appropriate evaluation and management of the acute scrotum and to guide the clinician in distinguishing testicular torsion from the other conditions that commonly mimic this surgical emergency.

Acute Disease↗
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

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↗
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 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↗
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

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↗
PubMed2004

Incomplete bladder duplication presenting antenatally.

We report a case of an incomplete bladder duplication diagnosed by prenatal ultrasonography at 35 weeks of gestation. The patient was followed until bladder neck obstruction and high-grade vesicoureteral reflux of a solitary kidney prompted definitive repair at 6 months of age. Bladder duplication is a rare anomaly. To our knowledge this is the first documented case of an incomplete bladder duplication discovered antenatally.

Abnormalities, Multiple↗
PubMed2004

The use of stab incisions for instrument access in laparoscopic urological procedures.

PURPOSE: Traditional laparoscopic procedures use expensive cannulas to facilitate the insertion and removal of laparoscopic instruments. We report our experience with limited access stab incisions for the insertion of instruments into the peritoneal cavity during laparoscopic urological procedures to minimize the use of disposable cannulas. MATERIALS AND METHODS: All patients undergoing laparoscopic urologic procedures using stab incisions, as performed by us, from November 1999 through March 2003 were included. Procedures included nephrectomy, partial nephrectomy, varicocelectomy, nephroureterectomy, orchiopexy and adrenal procedures. A single cannula was used for telescope access. In select cases additional cannulas were used for unique instruments or specimen manipulation/extraction. Abdominal wall stab incisions were used for the remaining instruments. Stab incisions were closed with a Steri-Strip (3M Healthcare, St. Paul, Minnesota) at the skin level only. RESULTS: A total of 53 procedures were performed during the study period. Pneumoperitoneum was maintained in all cases. There were no complications associated with the use of stab incisions. A total of 105 cannulas were saved using our technique. At a cost to the patient of dollars 140 per cannula the overall cost saving was dollars 14,700 with an average saving of dollars 277 per case. CONCLUSIONS: Laparoscopic urological procedures can be performed effectively and safely with stab incisions for instrument access. There are significant cost savings related to the elimination of cannulas. We believe that our technique of stab incisions for instrument access is equivalent to the traditional cannula approach and should be used when possible.

Child↗