Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial.

Importance: Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial. Objective: To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia. Design, Setting, and Participants: A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023. Interventions: In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age. Main Outcomes and Measures: The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period. Results: Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup). Conclusions and Relevance: Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit. Trial Registration: ClinicalTrials.gov Identifier: NCT01678638.

Enhancing Hospital Reimbursement Through a Pediatric Surgery Resident Orientation Program: A Focus on Accurate Diagnosis Code Documentation for Acute Appendicitis.

BACKGROUND: The usage of specific ICD-10 diagnosis codes significantly influences hospital reimbursement compared to non-specific codes. This study hypothesized that a formal orientation program for pediatric surgery residents would enhance the selection of accurate and specific diagnosis codes for acute appendicitis such as K35.30 for "Acute appendicitis with localized peritonitis" rather than K35.80 for "Unspecified acute appendicitis," thereby improving hospital reimbursement. METHODS: We implemented a comprehensive orientation for pediatric surgery residents at our institution in late 2020, a component of which emphasized the importance of having specific ICD-10 diagnosis codes. We conducted a retrospective analysis of laparoscopic appendectomy billing data for pediatric patients, comparing the use of specific versus unspecified diagnosis codes and associated hospital reimbursement rates before (2020) and after (2022) the program's initiation. Patients without payment were excluded. Statistical significance was determined by a two-tailed p-value of ≤0.05. RESULTS: Analysis of 267 patient records showed a significant increase in the use of the specific diagnosis code (K35.30) from 3.6% in 2020 to 87.5% in 2022 (p < 0.0001). Adjusted for inflation and billing changes, mean hospital reimbursement per case increased by $661 (from $4414 to $5,075, p = 0.027), totaling an additional $84,616 in 2022, just for a single subset of appendicitis patients. CONCLUSIONS: A targeted resident orientation program significantly improves the use of specific ICD-10 codes for acute appendicitis, leading to increased hospital reimbursement. Such programs represent a valuable approach for enhancing the financial outcomes of pediatric surgical care while reinforcing the importance of accurate medical documentation. STUDY DESIGN: Retrospective. LEVEL OF EVIDENCE: III.

A Review of the Use of Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Malignancy in Pediatric Patients.

Hyperthermic intraperitoneal chemotherapy (HIPEC) can directly target microscopic peritoneal disease, has achieved regular consideration in the treatment of several adult cancer types, and is more recently being studied in pediatrics. This review paper provides an overview of the use of this modality in pediatrics in order to identify medication choice, discuss post-operative morbidity and mortality, and evaluate impact on overall survival. Four databases were searched including Scopus, PubMed, Embase, and CINAHL and ultimately 37 papers documenting the use of this modality comprising 264 pediatric patients were included. Malignancies treated include desmoplastic small round cell tumor, rhabdomyosarcoma, angiosarcoma, colorectal carcinoma, and mesothelioma, with several rarer tumor types. Cisplatin was the most commonly used drug for HIPEC at varying concentrations for 30-90 min in duration at temperatures of approximately 41-42 °C. Reported toxicities were generally self-limited and there was no post-operative mortality. The impact on overall survival versus systemic chemotherapy and debulking surgery is uncertain due to lack of clinical trials and very small sample size across tumor subsets and the overall pediatric population. The relationship between degree of tumor burden and extent of surgical debulking needs to be further clarified. Future directions include prospective clinical trials, establishment of patient databases to facilitate standardization of HIPEC in pediatric patients, and additional approaches to optimize HIPEC.