Association of Operative Approach With Postoperative Outcomes in Neonates Undergoing Surgical Repair of Esophageal Atresia and Tracheoesophageal Fistula.

INTRODUCTION: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). METHODS: In this retrospective study, neonates undergoing EA/TEF repair from 2013 to 2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson's chi-square or Fisher's exact tests were used as appropriate. RESULTS: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time. Pre-match, neonates undergoing open repair were more likely to be premature, lower weight, ventilator dependent, and have cardiac risk factors with higher severity. Post-match, the groups were similar and included 340 neonates per group. MIS repair was associated with longer median operative time (209 vs. 174 min, p < 0.001) and increased overall post-operative intervention rates (7.6% vs. 2.9%, p = 0.01). There were no differences in composite morbidity (24.4% vs. 25.0%, p = 0.86) outside of reintervention. CONCLUSION: MIS approach for neonates with EA/TEF appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short- and long-term outcomes. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Extracorporeal life support use in patients with bronchopulmonary dysplasia: A single center case series.

PURPOSE: Preterm pediatric patients with bronchopulmonary dysplasia (BPD) represent a subgroup previously deemed high risk candidates for ECLS (extracorporeal life support) due to suspected high mortality or increased post ECLS morbidity. The aim of this study was to determine outcomes for patients with an established history of BPD who subsequently required ECLS. METHODS: A single center retrospective review was performed between 01/2010-06/2022 for patients less than 2 years of age, born prematurely (<32 weeks) with a subsequent diagnosis of BPD, and who required ECLS for respiratory failure. Demographic and clinical data, including ECLS data, were collected. Speech, language, feeding/swallowing, cognitive, hearing, vision, or motor function deficits were obtained with a median follow up of 42 months following discharge. RESULTS: Nineteen patients met criteria. The median birth weight and gestational age was 0.86 kg (IQR 0.73, 1.0) and 26 weeks (IQR 25, 27), respectively. The median chronological age at cannulation was 12.1 months. The most common etiologies for respiratory failure requiring ECLS were viral (68.4%) and bacterial (21.1%) pneumonia. Survival to decannulation was 78.9% (15/19) and survival to hospital discharge was 63.2% (12/19). Amongst survivors to discharge, 42% (5/12) required new or additional home oxygen and 50% (6/12) were noted to have neurodevelopmental/behavioral concerns on follow up at 1 year with 25% (3/12) with concerns beyond a year. CONCLUSION: Patients with underlying BPD who require ECLS have comparable mortality and long-term neurodevelopmental outcomes to non-BPD patients with respiratory failure. This information can be useful when considering ECLS candidacy and providing family counseling.

The Association of Social Determinants of Health With Short Term Pediatric Gastrostomy Tube Outcomes.

INTRODUCTION: Social determinants of health (SDH) have been found to be important contributors to postoperative outcomes, especially those related to procedures that require significant postoperative resources. The association between short-term gastrostomy tube (GT) outcomes and SDH in the pediatric population is unknown. METHODS: A retrospective review was performed of all patients less than 18 y old who received a GT between January 2018 and December 2020 at a single institution. Data including demographics, area deprivation index (ADI), and perioperative information were collected. Patient characteristics were compared in those that did and did not have an unexpected emergency department (ED) visit within 6 wk of discharge from GT placement. Statistical analysis was performed using Wilcoxon sum-rank, Chi-squared test, and Fisher's exact test where applicable, and univariable and multivariable logistic regression. RESULTS: Of the 541 children who underwent GT placement, 112 (20.7%) returned to the ED within 6 wk postdischarge. In univariable analysis, Black children had 1.64 the odds of an unexpected ED visit compared to White children (95% confidence interval [CI] 1.04-2.60, P = 0.03). When controlling for ethnicity, primary language, insurance, ADI and comorbidities, Black children had 1.80 the odds of an unexpected ED visit compared to White children (95% CI 1.10-2.97, P = 0.02). Final model fit which added a race by ADI interaction term revealed Black children had 2.52 the odds of an unexpected ED visit compared to White children in the low (1-6) ADI group (95% CI 1.41-4.60, P = 0.002). Within advantaged neighborhoods (ADI 1-6), the probability of unplanned ED visits for White children was 17.3% (95%CI 8.9% - 31.1%), which was significantly lower than that for Black children (34.6%, 95% CI 18.8% - 54.7%; P value = 0.006). CONCLUSIONS: Race and neighborhood disadvantage can be associated with unexpected ED visits within 6 wk of discharge from GT placement in the pediatric population. For procedures that require significant postdischarge resources it is important to study the effect of SDH on return to the healthcare system as they can be an important driver of disparities in outcomes.

Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections.

Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.

Pediatric ECLS Neurologic Management and Outcomes.

Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.

Neonatal Carotid Artery and Internal Jugular Vein Management Practices at Extracorporeal Membrane Oxygenation Decannulation: No Standard Approach.

BACKGROUND: There are currently no commonly accepted standardized guidelines for management of cervical vessels at neonatal extracorporeal membrane oxygenation (ECMO) decannulation. This study investigates neonatal ECMO decannulation practices regarding management of the carotid artery and internal jugular vein, use of post-repair anticoagulation, and follow-up imaging. METHODS: A survey was distributed to the 37 institutions in the Children's Hospitals Neonatal Consortium. Respondents reported their standard approach to carotid artery and internal jugular vein management (ligation or repair) at ECMO decannulation by their pediatric surgery and cardiothoracic (CT) surgery teams as well as post-repair anticoagulation practices and follow-up imaging protocols. RESULTS: The response rate was 95%. Pediatric surgeons performed most neonatal respiratory ECMO cannulations (88%) and decannulations (85%), while all neonatal cardiac ECMO cannulations and decannulations were performed by CT surgeons. Pediatric surgeons overwhelmingly ligate both vessels (90%) while CT surgeons typically repair both vessels at decannulation (83%). Of the responding centers that repair, 28% (7) have a standard anticoagulation protocol after neck vessel repair. While 52% (13) of centers routinely image cervical vessel patency at least once post repair, most do not subsequently repeat neck vessel imaging. CONCLUSIONS: Significant practice differences exist between pediatric and CT surgeons regarding the approach to cervical vessels at neonatal ECMO decannulation. For those centers that do repair the vessels there is little uniformity in post-repair anticoagulation or imaging protocols. There is a need to develop standardized cervical vessel management guidelines for neonatal ECMO patients and to study their impact on both short- and long-term outcomes. LEVEL OF EVIDENCE: IV.

Changes in pediatric injuries sustained while engaged in activities where helmet usage is recommended during the COVID-19 pandemic.

BACKGROUND: Unintentional injuries, including traumatic brain injuries (TBI), are the leading cause of pediatric morbidity and mortality in the USA. Helmet usage can reduce TBI incidence and severity; however, the epidemiology of pediatric TBI and helmet use is ever evolving. With lifestyle changes potentially accelerated by the pandemic, we predicted a decrease in helmet utilization with an associated increase in TBI during the pandemic compared to the pre-pandemic period. RESULTS: There were 1093 patients that presented with AWHUR injuries from 2018 to 2020 with an annual increase from 263 patients in 2018 up to 492 in 2020. The most frequently implicated mechanisms included bicycles (35.9%), ATVs (20.3%), skateboards (11.6%), scooters (8.3%), and dirt bikes (7.4%). Unhelmeted patients increased from 111 (58.7%) in 2018 to 258 (64.8%) in 2020. There was not a significant difference in the proportion of injuries that were unhelmeted from 38.9% in 2018-2019 to 35.2% in 2020 (p = 0.30), as well as the proportion of head injuries from 2018 to 2019 (24.3%) to 2020 (29.3%) (p = 0.07). A significant increase was seen in neurosurgical consultation from 17 (6.5%) in 2018 to 87 (17.7%) in 2020 (p = 0.02). Notably, there was an increase in the percentage of publicly insured patients presenting with injuries from AWHUR during 2020 (p < 0.001); this group also had suboptimal helmet usage. CONCLUSION: This study found an increase in patients presenting with injuries sustained while engaged in AWHUR in relation to the COVID-19 pandemic. Concerningly, there was a trend toward decreased helmet utilization and increased injury severity markers. Further analysis is needed into the communities impacted the most by AWHUR injuries.

Global Pediatric Surgery in the Era of COVID-19.

There is a tremendous unmet need regarding the surgical care of children in low- and middle-income countries. The rapid spread of coronavirus disease 2019 (COVID-19), and the resultant redistribution of health care resources required to combat it, has created even more unique difficulties in the provision of safe, timely, and affordable surgical care of children globally. The downstream effects of potential diminished surgical capacity may even more significantly affect the morbidity and mortality of children. The full effects of these changes are yet to be seen. The COVID-19 pandemic has also created unique opportunities that can be built on moving forward. It is critical that the focus on global surgical needs, particularly for children, continues to be a priority to mitigate the challenges caused by the COVID-19 pandemic. [Pediatr Ann. 2022;51(8):e316-e318.].

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging.

Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P < 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P < 0.0001). The cost of imaging per 100 patients increased from $24,255 to $31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis.

The morbidity of open tumor biopsy for intraabdominal neoplasms in pediatric patients.

PURPOSE: Tumor biopsy is often essential for diagnosis and management of intraabdominal neoplasms found in children. Open surgical biopsy is the traditional approach used to obtain an adequate tissue sample to guide further therapy, but image-guided percutaneous core-needle biopsy is being used more often due to concerns about the morbidity of open biopsy. We used a national database to evaluate the morbidity associated with open intraabdominal tumor biopsy. METHODS: We identified all patients undergoing laparotomy with tumor biopsy in the National Surgical Quality Improvement Project-Pediatric (NSQIP-P) database from 2012 to 2018 and measured the frequency of complications in the 30 days postoperatively. We tested associations between patient characteristics and outcomes to identify risk factors for complications. RESULTS: We identified 454 patients undergoing laparotomy for biopsy of an intraabdominal neoplasm. Median postoperative hospital stay was 7 days (IQR 4-12) and operative time was 117 min (IQR 84-172). The overall complication rate was 12.1%, with post-operative infection (6%) and bleeding (4.2%) being the most common complications. Several patient characteristics were associated with bleeding, but the only significant association on multivariable analysis was underlying hematologic disorder. CONCLUSION: Open abdominal surgery for pediatric intraabdominal tumor biopsy is accompanied by significant morbidity. Postoperative infection was the most common complication, which can delay initiation of further therapy, especially chemotherapy. These findings support the need to prospectively compare percutaneous image-guided core-needle biopsy to open biopsy as a way to minimize risk and optimize outcomes for this vulnerable population.

Inter-rater Reliability of Sacral Ratio Measurements in Patients with Anorectal Malformations.

BACKGROUND: Anorectal malformations (ARMs) are a spectrum of congenital anomalies with varying prognosis for fecal continence. The sacral ratio (SR) is a measure of sacral development that has been proposed as a method to predict future fecal continence in children with ARM. The aim of this study was to quantify the inter-rater reliability (IRR) of SR calculations by radiologists at different institutions. MATERIALS AND METHODS: x-Rays in the anteroposterior (AP) and lateral planes were reviewed by a pediatric radiologist at each of six different institutions. Subsequently, images were reviewed by a single, central radiologist. The IRR was assessed by calculating Pearson correlation coefficients and intraclass correlation coefficients from linear mixed models with patient and rater-level random intercepts. RESULTS: Imaging from 263 patients was included in the study. The mean inter-rater absolute difference in the AP SR was 0.05 (interquartile range, 0.02-0.10), and in the lateral SR was 0.16 (interquartile range, 0.06-0.25). Overall, the IRR was excellent for AP SRs (intraclass correlation coefficient [ICC], 81.5%; 95% confidence interval, 75.1%-86.0%) and poor for lateral SRs (ICC, 44.0%; 95% CI, 29.5%-59.2%). For both AP and lateral SRs, ICCs were similar when examined by the type of radiograph used for calculation, severity of the ARM, presence of sacral or spinal anomalies, and age at imaging. CONCLUSIONS: Across radiologists, the reliability of SR calculations was excellent for the AP plane but poor for the lateral plane. These results suggest that better standardization of lateral SR measurements is needed if they are going to be used to counsel families of children with ARM.

Reducing resource utilization for patients with uncomplicated appendicitis through use of same-day discharge and elimination of postoperative antibiotics.

BACKGROUND: There is controversy over certain aspects of post-appendectomy care for children with uncomplicated appendicitis. Some institutions have embraced the practice of same-day discharge after appendectomy, while others are hesitant due to concerns about increased readmissions or emergency department (ED) visits. Similarly, some surgeons have transitioned to treating gangrenous appendicitis with a single perioperative dose, while others are concerned about increased risk of infection in this population. METHODS: We developed a pathway for the management of patients undergoing appendectomy for uncomplicated acute appendicitis which included same-day discharge and elimination of postoperative antibiotics for patients with gangrenous appendicitis. We compared outcomes for children treated at our institution before and after implementation of the protocol. RESULTS: We identified 575 patients undergoing appendectomy for uncomplicated appendicitis (307 pre- and 268 post-protocol). We observed a significant decrease in postoperative length-of stay (10.6 to 2.6 h, p < 0.0001). There were no increases in postoperative complications, such as superficial (2.6% vs 1.1%, p = 0.19) or organ-space surgical-site infection (1.6% vs 0.4%, p = 0.14), percutaneous drain placement (1.3% vs 0%, p = 0.06), postoperative ED visits (5.5% vs 5.2%, p = 0.87) or readmission (3.3% vs 1.5%, p = 0.17). CONCLUSIONS: These findings suggest that incorporating same-day discharge for simple appendicitis and eliminating postoperative antibiotics for children with gangrenous appendicitis does not increase complication rates. Implementation of similar pathways across institutions has the potential to significantly reduce resource utilization for children undergoing appendectomy for uncomplicated appendicitis. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Standardized pathway for feeding tube placement reduces unnecessary surgery and improves value of care.

BACKGROUND: Children requiring gastrostomy tubes (GT) have high resource utilization. In addition, wide variation exists in the decision to perform concurrent fundoplication, which can increase the morbidity of enteral access surgery. We implemented a hospital-wide standardized pathway for GT placement. METHODS: The standardized pathway included mandatory preoperative nasogastric feeding tube (FT) trial, identification of FT medical home, and standardized postoperative order set, including feeding regimen and parent education. An algorithm to determine whether concurrent fundoplication was indicated was also created. We identified children referred for GT placement from 2015 to 2018 and compared concurrent fundoplication rates and outcomes pre- and postimplementation. RESULTS: We identified 332 patients who were referred for GT. Of these, 15 avoided placement. Concurrent fundoplication decreased postpathway (48% vs 22%, p < 0.0001). After adjusting for reflux and cardiac disease, prepathway patients were 3.5 times more likely to undergo concurrent fundoplication. ED visits (46% vs 27%, p = 0.001) and postoperative LOS (median (IQR) 10 days (5-36) to 5.5 days (1-19), p = 0.0002) decreased. CONCLUSIONS: A standardized pathway for GT placement prevented unnecessary GT placement and fundoplication with reduction in postoperative LOS and ED visits. This approach can significantly reduce resource utilization while improving outcomes. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.

Development of a multi-institutional registry for children with operative congenital lung malformations.

INTRODUCTION: The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection. METHODS: After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative. RESULTS: Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%). CONCLUSION: This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients. LEVEL OF EVIDENCE: Level II.

Robot-assisted repair of a urogenital sinus with an anorectal malformation in a patient with McKusick-Kaufman syndrome.

INTRODUCTION: A urogenital sinus (US) and an anorectal malformation (ARM) are a rare constellation of anomalies, and the optimal surgical approach is unclear. Open and laparoscopic approaches have been described for US and ARM, but no data exist to support robotic assistance in children. CASE: A 20-month-old Amish female presented to the study center with fever and abdominal pain. Abdominal ultrasound showed a large fluid-filled vagina, urinalysis was positive, and she was admitted for antibiotic therapy. Magnetic resonance imaging (MRI) confirmed hydrocolpos. An examination under anesthesia including cystoscopy demonstrated a short perineal body, an anteriorly displaced anus by muscle stimulation, and no vaginal opening. An ultrasound-guided, percutaneous vaginostomy tube was placed, and 650 cc of pus was drained. Vaginal and urine cultures grew similar strains of Escherichias coli. After a course of antibiotics, she underwent a robot-assisted mobilization of the intra-abdominal vagina and uterus, posterior sagittal anorectoplasty, vaginal pull-through, and a diverting colostomy. There were no intra-operative complications. Her Foley catheter was removed on post-operative day #3, and she voided spontaneously and was discharged in good condition. She remained in the hospital for ostomy teaching, but pain control and diet were not barriers to discharge after 12 h. CONCLUSION: Robotic mobilization of the intra-abdominal vagina in a pediatric patient with US and ARM is technically feasible and can be accomplished safely. Further comparative studies to other approaches are lacking. In this case, the robot allowed for good visualization, intra-operative collaboration between multiple specialties for complex patients with aberrant anatomy, and easy dissection in a narrow pre-pubertal pelvis and would be an approach that the study group uses in future cases.

Current operative management of congenital lobar emphysema in children: A report from the Midwest Pediatric Surgery Consortium.

PURPOSE: The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium. METHODS: After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015). RESULTS: Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0). CONCLUSIONS: Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion. LEVEL OF EVIDENCE: Level III.

Evaluation of a water-soluble contrast protocol for nonoperative management of pediatric adhesive small bowel obstruction.

BACKGROUND/PURPOSE: We examined outcomes before and after implementing an enteral water-soluble contrast protocol for management of pediatric adhesive small bowel obstruction (ASBO). METHODS: Medical records were reviewed retrospectively for all children admitted with ASBO between November 2010 and June 2017. Those admitted between November 2010 and October 2013 received nasogastric decompression with decision for surgery determined by surgeon judgment (preprotocol). Patients admitted after October 2013 (postprotocol) received water-soluble contrast early after admission, were monitored with serial examinations and radiographs, and underwent surgery if contrast was not visualized in the cecum by 24 h. Group outcomes were compared. RESULTS: Twenty-six patients experienced 29 admissions preprotocol, and 11 patients experienced 12 admissions postprotocol. Thirteen (45%) patients admitted preprotocol underwent surgery, versus 2 (17%) postprotocol patients (p = 0.04). Contrast study diagnostic sensitivity as a predictor for ASBO resolution was 100%, with 90% specificity. Median overall hospital LOS trended shorter in the postprotocol group, though was not statistically significant (6.2 days (preprotocol) vs 3.6 days (postprotocol) p = 0.12). Pre- vs. postprotocol net operating cost per admission yielded a savings of $8885.42. CONCLUSIONS: Administration of water-soluble contrast after hospitalization for pediatric ASBO may play a dual diagnostic and therapeutic role in management with decreases in surgical intervention, LOS, and cost. TYPE OF STUDY: Retrospective comparative study. LEVEL OF EVIDENCE: Level III.

Prevalence of Untreated Surgical Conditions in Rural Rwanda: A Population-Based Cross-sectional Study in Burera District.

IMPORTANCE: In low- and middle-income countries, community-level surgical epidemiology is largely undefined. Accurate community-level surgical epidemiology is necessary for surgical health systems planning. OBJECTIVE: To determine the prevalence of surgical conditions in Burera District, Northern Province, Rwanda. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study with a 2-stage cluster sample design (at village and household level) was carried out in Burera District in March and May 2012. A team of surgeons randomly sampled 30 villages with probability proportionate to village population size, then sampled 23 households within each village. All available household members were examined. MAIN OUTCOMES AND MEASURES: The presence of 10 index surgical conditions (injuries/wounds, hernias/hydroceles, breast masses, neck masses, obstetric fistulas, undescended testes, hypospadias, hydrocephalus, cleft lip/palate, and clubfoot) was determined by physical examination. Prevalence was estimated overall and for each condition. Multivariable logistic regression was performed to identify factors associated with surgical conditions, accounting for the complex survey design. RESULTS: Of the 2165 examined individuals, 1215 (56.2%) were female. The prevalence of any surgical condition among all examined individuals was 12% (95% CI, 9.2-14.9%). Half of conditions were hernias/hydroceles (49.6%), and 44% were injuries/wounds. In multivariable analysis, children 5 years or younger had twice the odds of having a surgical condition compared with married individuals 21 to 35 years of age (reference group) (odds ratio [OR], 2.2; 95% CI, 1.26-4.04; P = .01). The oldest group, people older than 50 years, also had twice the odds of having a surgical condition compared with the reference group (married, aged >50 years: OR, 2.3; 95% CI, 1.28-4.23; P = .01; unmarried, aged >50 years: OR, 2.38; 95% CI, 1.02-5.52; P = .06). Unmarried individuals 21 to 35 years of age and unmarried individuals aged 36 to 50 years had higher odds of a surgical condition compared with the reference group (aged 21-35 years: OR, 1.68; 95% CI, 0.74-3.82; P = .22; aged 36-50 years: OR, 3.35; 95% CI, 1.29-9.11; P = .02). There was no statistical difference in odds by sex, wealth, education, or travel time to the nearest hospital. CONCLUSIONS AND RELEVANCE: The prevalence of surgically treatable conditions in northern Rwanda was considerably higher than previously estimated modeling and surveys in comparable low- and middle-income countries. This surgical backlog must be addressed in health system plans to increase surgical infrastructure and workforce in rural Africa.

Indications and outcomes for tunneled central venous line placement via the axillary vein in children.

PURPOSE: To assess the indications, safety and outcomes of tunneled central venous catheters (CVCs) placed via a cutdown approach into the axillary vein in children, an approach not well described in this population. METHODS: A retrospective cohort study was performed on pediatric patients who received CVCs via open cannulation of the axillary vein or one of its tributaries between January 2006 and October 2016 at two hospitals. RESULTS: A total of 24 axillary CVCs were placed in 20 patients [10 male (42%); mean weight 7.0 kg (SD 2.9); mean age 10 months (SD 6)]. The most common indications for axillary vein access included neck or chest wall challenges (tracheostomies or chest wall wounds) (n = 18). The median duration of line placement was 140 days (IQR 146). The most common indications for removal were completion of therapy (n = 7, 39%) and infection (n = 5, 28%). There were no early complications. Long-term complications included infection (n = 5) or catheter malfunction (n = 3). CONCLUSIONS: Tunneled CVC placement via a cutdown approach into the axillary vein or its tributary can be an effective alternative approach to obtain long-term vascular access in children. Outcomes may be comparable to lines placed in traditional internal jugular and subclavian vein locations.

Laparoscopic Excision of Congenital Hepatic Cysts in the Pediatric Population: A Case Series and Literature Review.

PURPOSE: Congenital hepatic cysts are rare. Surgical excision is indicated for symptoms, complications, and to rule out malignancy. Laparoscopic management in the pediatric population has not been extensively documented. We present a series involving laparoscopic excision of pediatric congenital hepatic cysts and review the literature. METHODS: Data were collected over 15 years from two pediatric surgeons at three medical centers. Presence of a hepatic cyst excised laparoscopically was the only inclusion criterion. Data were collected on the cyst size, type, pathology, and location, as well as on length of hospital stay, complications, and 1 year recurrence rate. RESULTS: Four patients were identified: a 7-week-old male presenting with feeding intolerance due to a hepatic cyst; a 6-year-old male presenting with a hepatic cyst identified by ultrasound during evaluation for appendicitis; a male neonate diagnosed at birth with a left thoracic cyst that communicated through the diaphragm with a hepatic cystic lesion; and a 14-year-old male presenting with a 25 cm × 11 cm hepatic cyst. All lesions were excised laparoscopically. CONCLUSION: Our series is the largest documenting complete laparoscopic excision of congenital solitary hepatic cysts in the pediatric population. Laparoscopic excision is a safe and effective approach for the pediatric population.