Pediatric Appendicitis Transfers From Adult Centers: Can Alvarado Scores Help Determine Which Patients Need a CT?

BACKGROUND: Acute appendicitis is possible for any pediatric patient with abdominal pain. At our tertiary care center, patients are transferred for surgical management with unnecessary or excessive imaging. We hypothesize that using the Alvarado score (AS) to clinically stage patients will identify patient groups that could be transferred prior to imaging. METHODS: Retrospective review of pediatric patients transferred to our hospital for suspected appendicitis between 11/2020 and 3/2022 was performed. Variables collected included AS, imaging, and pathology. Alvarado score was calculated for each patient, and patients were grouped into low score, intermediate score, and high score groups. Positive predictive values (PPVs) were calculated for patients who underwent CT. RESULTS: 196 patients (age 2-17, 58% male) were transferred with suspected appendicitis. CT was obtained in 67% of patients and was not significantly different between groups. The low-score group (n=35) had a rate of appendicitis of 14% and the PPV of CT was 33%. The intermediate-score group (n = 74) had a rate of appendicitis of 62% and the PPV of CT was 88%. In the high-score group (n = 87), the rate of appendicitis was 92% and PPV of CT was 98%. DISCUSSION: Our data show that patients with low, intermediate, and high AS undergo CT at similar rates. We suggest that patients in the low score and high score groups may not benefit from reflexive CT given the likelihood of appendicitis based on the Alvarado score. We propose that CT in these groups be performed at the discretion of the pediatric center in order to expedite transfer and spare children excess radiation.

Gastroschisis: A State-of-the-Art Review.

Gastroschisis, the most common type of abdominal wall defect, has seen a steady increase in its prevalence over the past several decades. It is identified, both prenatally and postnatally, by the location of the defect, most often to the right of a normally-inserted umbilical cord. It disproportionately affects young mothers, and appears to be associated with environmental factors. However, the contribution of genetic factors to the overall risk remains unknown. While approximately 10% of infants with gastroschisis have intestinal atresia, extraintestinal anomalies are rare. Prenatal ultrasound scans are useful for early diagnosis and identification of features that predict a high likelihood of associated bowel atresia. The timing and mode of delivery for mothers with fetuses with gastroschisis have been somewhat controversial, but there is no convincing evidence to support routine preterm delivery or elective cesarean section in the absence of obstetric indications. Postnatal surgical management is dictated by the condition of the bowel and the abdominal domain. The surgical options include either primary reduction and closure or staged reduction with placement of a silo followed by delayed closure. The overall prognosis for infants with gastroschisis, in terms of both survival as well as long-term outcomes, is excellent. However, the management and outcomes of a subset of infants with complex gastroschisis, especially those who develop short bowel syndrome (SBS), remains challenging. Future research should be directed towards identification of epidemiological factors contributing to its rising incidence, improvement in the management of SBS, and obstetric/fetal interventions to minimize intestinal damage.

"Next Day" Examination Reduces Radiation Exposure in Cervical Spine Clearance at a Level 1 Pediatric Trauma Center: Preliminary Findings.

BACKGROUND: Safe and effective clearance of the pediatric cervical spine presents a challenging problem due to a myriad of reasons, which has often led to further imaging studies such as computed tomographic (CT) scans being performed, exposing the pediatric patient to significant radiation with a potential increased cancer risk. The goal of this study is to develop an effective algorithm for cervical spine clearance that minimizes radiation exposure. METHODS: A cervical spine clearance protocol had been utilized in our institution from 2002 to 2011. In October 2012, the protocol was revised to provide indications for appropriate imaging by utilizing repeat "next day" physical examination. In 2014, the protocol was again revised with the desired goal of decreasing the use of CT scans through increased involvement of the Spine Service. A retrospective review was commenced using information from the Trauma Database from 2011 to 2014. Three groups were analyzed according to which protocol the patients were evaluated under: 2011, 2012, and 2014 protocols. RESULTS: During the study period, 762 patients underwent cervical spine clearance; 259 (2011 protocol), 360 (2012 protocol), and 143 (2014 protocol). The average age of all patients was 8.8 years, with 28% of patients younger than 5 years of age. There were no missed or delayed diagnoses of cervical spine injury. The use of CT scans decreased during the study period from 90% (2011 protocol) to 42% (2012 protocol) to 28.7% (2014 protocol). There was an increase in time to removal of the cervical collar at 13 to 24 hours from 8% (2011 protocol) to 22% (2012 protocol) to 19% (2014 protocol). This was not associated with an increase in hospital length of stay, which averaged 2.51 days (2011 protocol), 2.45 days (2012 protocol), and 2.27 days (2014 protocol). CONCLUSIONS: Repeat "next day" clinical examinations and increased involvement of the Spine Service decreased radiation exposure without compromising the diagnosis of cervical spine injury or increasing the length of stay at a Level One Pediatric Trauma Center in this pilot study. LEVEL OF EVIDENCE: Level 4-case series.

Use of Etomidate for Rapid Sequence Intubation (RSI) in Pediatric Trauma Patients: An Exploratory National Survey.

Objective, To survey the pediatric trauma programs to ascertain if and how etomidate is being used for rapid sequence intubation (RSI) in pediatric trauma patients. Design, A 25 question survey was created using REDCaps. A link to the survey was emailed to each of the pediatric and adult trauma programs that care for pediatric patients. Setting, Pediatric trauma programs and adult trauma programs caring for pediatric patients. Intervention, None. Measurements and Main Results, A total of 16% of programs responded (40/247). The majority of the centers that responded are urban, academic, teaching Level 1 pediatric trauma centers that provide care for > 200 pediatric trauma patients annually. The trauma program directors were the most likely to respond to the survey (18/40). 33/38 respondents state they use etomidate in their RSI protocol but it is not used in all pediatric trauma patients. 26/38 respondents believe that etomidate is associated with adrenal suppression and 24/37 believe it exacerbates adrenal suppression in pediatric trauma patients yet 28 of 37 respondents do not believe it is clinically relevant. Conclusions, Based on the results of the survey, the use of etomidate in pediatric trauma patients is common among urban, academic, teaching, level 1 pediatric trauma centers. A prospective evaluation of etomidate use for RSI in pediatric trauma patients to evaluate is potential effects on adrenal suppression and hemodynamics is warranted.

Vacuum-assisted closure: a novel method of managing surgical necrotizing enterocolitis.

PURPOSE: Necrotizing enterocolitis (NEC) requiring surgical intervention is associated with mortality rates approaching 50%. We evaluated outcomes of patients that underwent surgical treatment for NEC with vacuum-assisted closure (VAC) of the abdomen as compared with traditional laparotomy, bowel resection, and ostomy creation. METHODS: A retrospective review identified 26 patients from 2007 to 2012 with NEC. Overall, 17 patients were treated with laparotomy, and 9 were treated with laparotomy and VAC (LapVac). Age, weight, preoperative and postoperative mean airway pressure, length of bowel resected, duration on total peripheral nutrition, time until initiation of feeds, and length of stay were assessed. A Student's t-test was used for statistical analysis. RESULTS: Nine LapVac patients underwent a total of 1.2 ± 1.3 VAC changes and had open abdomens for 13.1 ± 19.1 days. LapVac and traditional laparotomy patients had similar outcomes with respect to amount of bowel resected, time on a ventilator, time to initiation of feeds, and length of hospital stay. Two of nine patients (22%) in the LapVac group were placed in continuity without the need for an ostomy. We identified a subset of patients in the LapVac group that demonstrated signs of abdominal compartment syndrome (ACS), exhibiting mean airway pressures greater than 15 cm H2O preoperatively. Patients with ACS treated with VAC therapy had shorter time to initiation of feeds (p=0.047) and shorter lengths of stay (p=0.0395) as compared with traditional laparotomy. CONCLUSION: Our data demonstrate that use of the wound VAC is a safe approach in the management of premature infants with NEC requiring surgical intervention with outcomes comparable to standard surgical management. Use of the wound VAC may allow the establishment of bowel continuity and abdominal closure without the need for an ostomy. VAC therapy may also hasten the recovery of NEC patients with concomitant ACS by eliminating the compartment syndrome. Larger studies are required to confirm this theory.

The psychological sequelae of violent injury in a pediatric intervention.

PURPOSE: Pediatric trauma centers have unique potential to prevent violent injury and its psychological sequelae. Hospital-based violence intervention programs (HVIPs) are proliferating across the U.S., but little is known about the psychological needs of pediatric patients who participate in them. The purpose of this study was to describe the prevalence of symptoms of posttraumatic stress and exposure to community violence among pediatric HVIP participants. METHODS: We conducted a cross-sectional analysis of psychosocial needs assessment data that were collected for 48 participants. The Child Trauma Screening Questionnaire (CTSQ) and modified Survey of Children's Exposure to Community Violence were used to assess primary outcomes. RESULTS: The sample was 62.5% male and had a mean age of 14.5 years. Twenty-three percent reported previously sustaining a violent injury resulting in medical care, and 47.8% had witnessed a shooting. The majority (66.0%) had a CTSQ score at/above the threshold for probable PTSD diagnosis. The mean CTSQ score was 5.9 and hyperarousal (3.3) symptoms were more common than re-experiencing symptoms (2.6). CONCLUSION: Pediatric HVIPs and trauma centers should consider integrating PTSD screening and trauma-focused psychoeducation into the practice and protocols. Future research should evaluate the impacts of these interventions.

Are general surgeons behind the curve when it comes to disaster preparedness training? A survey of general surgery and emergency medicine trainees in the United States by the Eastern Association for the Surgery for Trauma Committee on Disaster Preparedness.

PURPOSE: We think that general surgeons are underprepared to respond to mass casualty disasters. Preparedness education is required in emergency medicine (EM) residencies, yet such requirements are not mandated for general surgery (GS) training programs. We hypothesize that EM residents receive more training, consider themselves better prepared, and are more comfortable responding to disaster events than are GS residents. METHODS: From February to May 2009, the Eastern Association for the Surgery of Trauma-Committee on Disaster Preparedness conducted a Web-based survey cataloging training and preparedness levels in both GS and EM residents. Approximately 3000 surveys were sent. Chi-squared, logistic regression, and basic statistical analyses were performed with SAS. RESULTS: Eight hindered forty-eight responses were obtained, GS residents represented 60.6% of respondents with 39% EM residents, and four residents did not respond with their specialty (0.4%). We found significant disparities in formal training, perceived preparedness, and comfort levels between resident groups. Experience in real-life disaster response had a significant positive effect on comfort level in all injury categories in both groups (odds ratio, 1.3-4.3, p < 0.005). CONCLUSION: This survey confirms that EM residents have more disaster-related training than GS residents. The data suggest that for both groups, comfort and confidence in treating victims were not associated with training but seemed related to previous real-life disaster experience. Given wide variations in the relationship between training and comfort levels and the constraints imposed by the 80-hour workweek, it is critical that we identify and implement the most effective means of training for all residents.

Vacuum-assisted closure in the treatment of extensive lymphangiomas in children.

BACKGROUND: The management of lymphangiomas in children is a complex problem with frequent recurrence and infection. Vacuum-assisted closure (VAC) devices have been shown to accelerate the healing of open wounds. We hypothesized that VAC therapy might decrease complications after resection of lymphangiomas. METHODS: A retrospective review was performed on 13 children (August 2005 to April 2010) who were patients undergoing lymphangioma resection with postoperative VAC therapy. Patient demographics, size and location of the lymphangioma, VAC duration and number of changes, hospital stay, complications, need for further surgery, and length of follow-up were recorded. RESULTS: Thirteen children (mean age, 8 years; mean weight, 34 kg) underwent 15 operations for lymphangiomas followed by postoperative VAC therapy. Locations included the head and neck, thorax and abdomen, and lower extremity. The mean VAC duration was 19 days, and they underwent a mean of 2.6 VAC changes. Six children had operative closure of the wound at a mean of 15 days postoperative. The remaining patients underwent closure by secondary intention. There were no recurrences. Complications included VAC device malfunctions requiring intervention and wound infections. Mean follow-up was 289 days. CONCLUSION: Postoperative VAC therapy for the treatment of lymphangiomas can be an effective adjunct to surgical treatment by decreasing risks of recurrence and infection.

Single-incision thoracoscopic surgery in children: equivalent results with fewer scars when compared with traditional multiple-incision thoracoscopy.

BACKGROUND: Single-incision pediatric endosurgery is gaining popularity, especially for abdominal operations. Several reports in the literature support the feasibility of the single-incision approach in pediatric laparoscopy. Here we compare our experience with single-incision thoracoscopic surgery (SITS) to traditional multiple-incision video-assisted thoracoscopic surgery (VATS) in children. METHODS: A chart review of all patients who underwent SITS at our institution was performed. The same number of demographically matched VATS case controls were selected from a pool of patients operated on during the same time period. Operative time, time until chest tube removal, length of stay, complications, and any need for further intervention were recorded. Statistical analysis was done by Student's t-test using Instat 3. RESULTS: Fourteen SITS procedures were performed during the study period. These patients were compared with 14 VATS case controls. Both groups were similar with regard to age, weight, sex, and procedures performed. The mean operative time in the SITS group was 84 ± 43 minutes versus 64 ± 30 in the VATS group (P=.18). Days until chest tube removal was 4 ± 2.2 in the SITS group and 2.8 ± 1.4 in the VATS group (P=.09). Length of hospital stay was 5.5 ± 4.4 days in the SITS group versus 7.2 ± 8.6 in the VATS group (P=.51). There were no intraoperative complications and no procedure conversions in either group. One SITS patient who underwent a wedge resection and mechanical pleurodesis for a spontaneous pneumothorax was readmitted for a recurrent pneumothorax and required a reoperation. CONCLUSIONS: Our experience demonstrates that there are no statistically significant differences in operative time, time until chest tube removal, and length of hospital stay when comparing SITS to VATS in children. We believe that SITS is an equivalent procedure that allows for fewer scars when compared with traditional multiple-incision VATS in children.

Prophylactic antibiotics do not decrease the incidence of wound infections after laparoscopic pyloromyotomy.

PURPOSE: Although laparoscopic pyloromyotomy is considered to be a clean case, many surgeons administer prophylactic preoperative antibiotics. The aim of this study was to evaluate the impact of prophylactic antibiotics on the wound infection rate after laparoscopic pyloromyotomy. METHODS: We conducted a retrospective review of all patients who underwent laparoscopic pyloromyotomy at our institution between August 2002 and December 2009. Data included patient age, sex, weight, serum HCO(3) at admission and at operation, and if the patient received prophylactic antibiotics. The rate of wound infection or other wound complications, including suture granuloma, umbilical granuloma, umbilical hernia, skin dehiscence, and omental evisceration, was determined. RESULTS: Two hundred ninety-nine patients underwent 301 consecutive laparoscopic pyloromyotomies. Sixty-four percent (n = 194) of patients returned for follow-up and were included in the study. Fifty-seven percent (group A, n = 111) received antibiotics, and 43% (group B, n = 84) did not. There were 3 wound infections in each of the equally matched groups (group A, 2.7%; group B, 3.5%; P = .73). Other wound complications occurred in 4.5% of patients (n = 5) in group A and 8.3% of patients (n = 7) in group B (P = .27). CONCLUSION: The use of prophylactic antibiotics does not significantly decrease the rate of wound infection or other wound complications after laparoscopic pyloromyotomy.

Early experience with single-incision thoracoscopic surgery in the pediatric population.

INTRODUCTION: Single-incision pediatric endosurgery is gaining popularity in children. We have recently applied the single-incision approach for thoracoscopic procedures. We report our initial experience with single-incision thoracoscopic surgery in the pediatric population. METHODS: A retrospective chart review of the first 10 single-incision thoracoscopic operations done at our institution was conducted. The patients' mean age and weight and the median operative time, postoperative length of stay, and time until discontinuation of chest tubes were determined. RESULTS: The 10 procedures were performed in eight patients (two patients each had bilateral procedures). The procedures performed included wedge resection and mechanical pleurodesis for spontaneous pneumothorax (n = 7), wedge biopsies for lymphoma (n = 1) and chronic granulomatous disease (n = 1), and resection of an apical extrapulmonary neuroblastoma (n = 1). All of the procedures were completed without intraoperative complication or significant blood loss. In each case, multiple trocars and/or unsheathed instruments were passed through a single small incision, which was subsequently used for the chest tube(s). The mean patient age was 13.5 years (range 3-18 years). The mean weight was 47 kilograms (range 16-63 kg). The median operative time was 64 minutes (range 50-201 minutes). The median postoperative length of stay was 7 days (range 3-19 days). The median time until chest tube removal was 3 days (range 2-15 days). The mean follow-up was 7 months (range 3-12 months). One patient developed a recurrent pneumothorax and persistent air leak after having undergone a wedge resection and pleurodesis for a spontaneous pneumothorax and required a reoperation. CONCLUSION: Single-incision thoracoscopic surgery is a feasible alternative to the traditional multiple-incision approach in the pediatric population. The in-line positioning of the camera and instruments often proves to be an advantage rather than a hindrance.

A comparison of laparoscopic and open Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit population.

INTRODUCTION: The aim of this study was to compare outcomes after laparoscopic and open techniques for Nissen fundoplication and gastrostomy placement in the neonatal intensive care unit (NICU) population. METHODS: The medical records for NICU inpatients who underwent laparoscopic and open Nissen fundoplication and gastrostomy placement from August 2002 to August 2008 were reviewed after Institutional Review Board approval. Each technique was compared with regard to operative time, estimated blood loss, postoperative 24-hour narcotic requirements, time to goal feeds, and complication rates. Analysis of variance was used to determine statistical significance. Data are quoted as mean +/- SEM. RESULTS: Fifty-seven NICU patients underwent fundoplication and gastrostomy placement (25 laparoscopic and 32 open). The time to goal feeds was significantly shorter for the laparoscopic group (4.3 +/- 0.4 vs 6.1 +/- 0.6 days, P = .04). The 24-hour postoperative narcotic requirement was significantly lower in the laparoscopic group (0.24 +/- 0.05 vs 0.55 +/- 0.08 mg/kg, P = .007). Operation times (111 +/- 5 [open] vs 113 +/- 5 minutes, P = .76) and estimated blood loss (13 +/- 2 [open] vs 11 +/- 1 mL, P = .33) were comparable for both groups. CONCLUSION: Laparoscopic and open techniques for Nissen fundoplication with gastrostomy placement are safe and appropriate treatment methods with equivalent operating times for the treatment of gastroesophageal reflux in the NICU population.

Ruptured abdominal aortic aneurysm in an 11-year-old boy.

We present a case of a ruptured aortic aneurysm in an 11-year-old boy presenting with loss of consciousness. The presentation, management, pathology, and gravity of this condition are discussed.