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.

Association of initial assessment variables and mortality in severe pediatric traumatic brain injury.

Background: Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality. Methods: Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression. Results: Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%. Conclusions: Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.

Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial.

Importance: Recurrence continues to be a significant challenge in the treatment and management of pilonidal disease. Objective: To compare the effectiveness of laser epilation (LE) as an adjunct to standard care vs standard care alone in preventing recurrence of pilonidal disease in adolescents and young adults. Design, Setting, and Participants: This was a single-institution, randomized clinical trial with 1-year follow-up conducted from September 2017 to September 2022. Patients aged 11 to 21 years with pilonidal disease were recruited from a single tertiary children's hospital. Intervention: LE and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone. Main Outcomes and Measures: The primary outcome was the rate of recurrence of pilonidal disease at 1 year. Secondary outcomes assessed during the 1-year follow-up included disability days, health-related quality of life (HRQOL), health care satisfaction, disease-related attitudes and perceived stigma, and rates of procedures, surgical excisions, and postoperative complications. Results: A total of 302 participants (median [IQR] age, 17 [15-18] years; 157 male [56.1%]) with pilonidal disease were enrolled; 151 participants were randomly assigned to each intervention group. One-year follow-up was available for 96 patients (63.6%) in the LE group and 134 (88.7%) in the standard care group. The proportion of patients who experienced a recurrence within 1 year was significantly lower in the LE treatment arm than in the standard care arm (-23.2%; 95% CI, -33.2 to -13.1; P < .001). Over 1 year, there were no differences between groups in either patient or caregiver disability days, or patient- or caregiver-reported HRQOL, health care satisfaction, or perceived stigma at any time point. The LE group had significantly higher Child Attitude Toward Illness Scores (CATIS) at 6 months (median [IQR], 3.8 [3.4-4.2] vs 3.6 [3.2-4.1]; P = .01). There were no differences between groups in disease-related health care utilization, disease-related procedures, or postoperative complications. Conclusions and Relevance: LE as an adjunct to standard care significantly reduced 1-year recurrence rates of pilonidal disease compared with standard care alone. These results provide further evidence that LE is safe and well tolerated in patients with pilonidal disease. LE should be considered a standard treatment modality for patients with pilonidal disease and should be available as an initial treatment option or adjunct treatment modality for all eligible patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03276065.

Clearance While Upright on Initial Diuretic Renography Predicts the Need for Surgery in Children With Congenital Hydronephrosis.

OBJECTIVE: To improve the predictive ability of diuretic renography (DR) for surgical intervention in children with congenital hydronephrosis (CH) and concern for ureteropelvic junction obstruction. METHODS: Children with CH born between 2007 and 2021 who underwent initial DR prior to 6months of life, had both clearance while upright (CUP) and T ½ reported, and did not have immediate surgical intervention after the first DR were retrospectively evaluated for surgical intervention during the period of clinical observation. Once the optimal cut-points were identified for CUP and T ½, they were used to calculate the sensitivity, specificity, positive predictive value, and negative predictive value. RESULTS: In total 65 patients were included in the final analysis with 33 (50.8%) undergoing surgical intervention (pyeloplasty) and 32 (49.2%) still on observation at last follow-up. The optimal cut-points for predicting surgical intervention were 28.1 minutes for T ½ and 22.4% for CUP. Applying the CUP cut-point of 22.4% we achieved a sensitivity of 60.6% (95% CI: 43.9-77.3), specificity of 96.9% (95% CI: 90.1-100.0), positive predictive value of 95.2% (95% CI: 86.1-100.0), and negative predictive value of 70.5% (95% CI: 57.0-83.9). CONCLUSION: A low CUP accurately predicts surgical intervention in children with CH who are initially observed. Although there is no singular measure on DR that can with absolute certainty predict future clinical course, our data do suggest there is utility in incorporating CUP (if <22.4%) into the decision process. Further research is necessary to help guide the management of children with intermediate CUP values.

Assessing Alternative Approaches for Wound Closure in a National Pediatric Learning Health System.

INTRODUCTION: Our objective was to perform a feasibility study using real-world data from a learning health system (LHS) to describe current practice patterns of wound closure and explore differences in outcomes associated with the use of tissue adhesives and other methods of wound closure in the pediatric surgical population to inform a potentially large study. METHODS: A multi-institutional cross-sectional study was performed of a random sample of patients <18 y-old who underwent laparoscopic appendectomy, open or laparoscopic inguinal hernia repair, umbilical hernia repair, or repair of traumatic laceration from January 1, 2019, to December 31, 2019. Sociodemographic and operative characteristics were obtained from 6 PEDSnet (a national pediatric LHS) children's hospitals and OneFlorida Clinical Research Consortium (a PCORnet collaboration across 14 academic health systems). Additional clinical data elements were collected via chart review. RESULTS: Of the 692 patients included, 182 (26.3%) had appendectomies, 155 (22.4%) inguinal hernia repairs, 163 (23.6%) umbilical hernia repairs, and 192 (27.8%) traumatic lacerations. Of the 500 surgical incisions, sutures with tissue adhesives were the most frequently used (n = 211, 42.2%), followed by sutures with adhesive strips (n = 176, 35.2%), and sutures only (n = 72, 14.4%). Most traumatic lacerations were repaired with sutures only (n = 127, 64.5%). The overall wound-related complication rate was 3.0% and resumption of normal activities was recommended at a median of 14 d (interquartile ranges 14-14). CONCLUSIONS: The LHS represents an efficient tool to identify cohorts of pediatric surgical patients to perform comparative effectiveness research using real-world data to support medical and surgical products/devices in children.

Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies.

BACKGROUND: This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches. METHODS: The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes. RESULTS: 12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5). CONCLUSIONS: MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes. MINI-ABSTRACT: In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair. LEVEL OF EVIDENCE: III.

Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients.

BACKGROUND: The Affordable Care Act Medicaid expansion has increased insurance coverage and reduced some disparities in care and outcomes among trauma patients, but its impact on subsets of trauma patients with particular mechanisms of injury are unclear. This study evaluated the association of the Affordable Care Act Medicaid expansion with insurance coverage, trauma care, and outcomes among young adults hospitalized for firearm- or motor vehicle crash-related injuries. MATERIALS AND METHODS: We used statewide hospital discharge data from 5 Medicaid expansion and 5 nonexpansion states to compare changes in insurance coverage and outcomes among firearm and motor vehicle crash trauma patients aged 19-44 from before (2011-2013) to after (2014-2017) Medicaid expansion. We examined difference in differences overall, by race/ethnicity, and by zip-code-level median income quartile. RESULTS: Medicaid expansion was associated with a decrease in the proportion of young adult motor vehicle crash and firearm trauma patients who were uninsured (motor vehicle crash: difference in differences - 12.7 percentage points, P < .001; firearm: difference in differences - 30.7 percentage points, P < .001). Medicaid expansion was also associated with increases in the percentage of patients discharged to any rehabilitation (motor vehicle crash: difference in differences 1.78 percentage points, P = .001; firearm: difference in differences 2.07 percentage points, P = .02) and inpatient rehabilitation (motor vehicle crash: difference in differences 1.21 percentage points, P = .001; firearm: difference in differences 1.58 percentage points, P = .002). Among patients with firearm injuries, Medicaid expansion was associated with a reduction in in-hospital mortality (difference in differences - 1.55 percentage points, P = .002). CONCLUSION: In its first 4 years, the Affordable Care Act Medicaid expansion increased insurance coverage and access to rehabilitation among young adults hospitalized for firearm- or motor vehicle crash-related injuries while reducing inpatient mortality among firearm trauma patients.

The Potential Clinical and Economic Value of a Human Papillomavirus Primary Screening Test That Additionally Identifies Genotypes 31, 45, 51, and 52 Individually.

BACKGROUND: Although current human papillomavirus (HPV) genotype screening tests identify genotypes 16 and 18 and do not specifically identify other high-risk types, a new extended genotyping test identifies additional individual (31, 45, 51, and 52) and groups (33/58, 35/39/68, and 56/59/66) of high-risk genotypes. METHODS: We developed a Markov model of the HPV disease course and evaluated the clinical and economic value of HPV primary screening with Onclarity (BD Diagnostics, Franklin Lakes, NJ) capable of extended genotyping in a cohort of women 30 years or older. Women with certain genotypes were later rescreened instead of undergoing immediate colposcopy and varied which genotypes were rescreened, disease progression rate, and test cost. RESULTS: Assuming 100% compliance with screening, HPV primary screening using current tests resulted in 25,194 invasive procedures and 48 invasive cervical cancer (ICC) cases per 100,000 women. Screening with extended genotyping (100% compliance) and later rescreening women with certain genotypes averted 903 to 3163 invasive procedures and resulted in 0 to 3 more ICC cases compared with current HPV primary screening tests. Extended genotyping was cost-effective ($2298-$7236/quality-adjusted life year) when costing $75 and cost saving (median, $0.3-$1.0 million) when costing $43. When the probabilities of disease progression increased (2-4 times), extended genotyping was not cost-effective because it resulted in more ICC cases and accrued fewer quality-adjusted life years. CONCLUSIONS: Our study identified the conditions under which extended genotyping was cost-effective and even cost saving compared with current tests. A key driver of cost-effectiveness is the risk of disease progression, which emphasizes the need to better understand such risks in different populations.

Predictors of Ventriculoperitoneal Shunt Failure in Children Undergoing Initial Placement or Revision.

BACKGROUND: Ventriculoperitoneal (VP) shunt placement, the mainstay of treatment for hydrocephalus, can place a substantial burden on patients and health care systems because of high complication and revision rates. We aimed to identify factors associated with 30-day VP shunt failure in children undergoing either initial placement or revision. METHODS: VP shunt placements performed on patients in the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric were identified. RESULTS: VP shunts were placed in 3,984 patients either as an initial placement (n = 1,093) or as a revision (n = 2,891). Compared to the initial-placement group, the revision group was significantly more likely to experience shunt failure (14 vs. 8%, p < 0.0001). In the initial-placement group, congenital hydrocephalus was independently associated with shunt failure (OR 1.83; 95% CI 1.01-3.31, p = 0.047). In the revision group, cardiac risk factors (OR 1.38; 95% CI 1.00-1.90, p = 0.047), a chronic history of seizures (OR 1.33; 95% CI 1.04-1.71, p = 0.022), and a history of neuromuscular disease (OR 0.61; 95% CI 0.41-0.90, p = 0.014) were independently associated with shunt failure. CONCLUSIONS: Identifying the factors associated with VP shunt failure may allow the development of interventions to decrease failures. Further refinement of the collected variables in the NSQIP Pediatric specific to neurosurgical procedures is necessary to identify modifiable risk factors.

Variation in Practice Patterns for the Management of Newborn Spina Bifida in the United States.

OBJECTIVE: To survey variations in recommended initial management of newborn spina bifida (SB). METHODS: Members of an international pediatric urology ListServe and of the Pediatric Urology Nurse Specialists organization were surveyed on practice patterns for newborn SB. Pediatric urologists, nurse practitioners, and physician assistants practicing in the United States were included. RESULTS: A total of 63 practitioners (48% pediatric urologists and 52% nurse practitioners or physician assistants) were included. Most practice at tertiary hospitals (94%) and about half use a protocol (56%). Recommended in-hospital screening tests include renal ultrasound (95%), voiding cystourethrogram (52%), catheterized bladder volumes (56%), and renal function tests (37%). Urodynamics are deferred until follow-up by 71%. Fifty percent of practitioners initiate clean intermittent catheterization (CIC) on all newborns, whereas 43% wait for symptoms. The majority of those who start CIC continue until residual volumes are below a threshold. Few recommend prophylactic antibiotics routinely (13%), or in patients on CIC (19%), but most recommend it for urinary reflux (62% grades 1-2, 79% grade 3, and 87% grades 4-5). Anticholinergics are deferred until after urodynamics (68%). Practicing at an institution with a pediatric urology fellowship program or an SB treatment protocol was associated with differing diagnostic work-up and urologic management. CONCLUSION: There is variability in management of newborn SB among pediatric urology providers at tertiary care centers that may be influenced by institutional factors such as the presence of a pediatric urology fellowship or the presence of a protocol to care. This highlights the need for prospective multicenter projects to better understand how variations in management affect patient outcomes.

Sacral nerve stimulation allows for decreased antegrade continence enema use in children with severe constipation.

BACKGROUND: Sacral nerve stimulation (SNS) can be beneficial for children with constipation, but no studies have focused on children with constipation severe enough to require antegrade continence enemas (ACEs). Our objective was to evaluate the efficacy of SNS in children with constipation treated with ACE. METHODS: Using a prospective patient registry, we identified patients <21years old who were receiving ACE prior to SNS placement. We compared ACE/laxative usage, PedsQL Gastrointestinal Symptom Scale (GSS), Fecal Incontinence Quality of Life Scale (FIQL), Fecal Incontinence Severity Index (FISI), and Vancouver Dysfunctional Elimination Syndrome Score (DES) at baseline and progressive follow-up time intervals. RESULTS: Twenty-two patients (55% male, median 12years) were included. Median ACE frequency decreased from 7 per week at baseline to 1 per week at 12months (p<0.0001). Ten children (45%) had their cecostomy/appendicostomy closed. Laxative use, GSS, FIQL, and DES did not change. FISI improved over the first 12months with statistical significance reached only at 6months (p=0.02). Six (27%) children experienced complications after SNS that required further surgery. CONCLUSIONS: In children with severe constipation dependent on ACE, SNS led to a steady decrease in ACE usage with nearly half of patients receiving cecostomy/appendicostomy closure within 2years. LEVEL OF EVIDENCE: IV.

Comparing laparoscopic versus open Ladd's procedure in pediatric patients.

BACKGROUND/PURPOSE: The objective of this study was to perform a comparative analysis of laparoscopic versus open Ladd's procedure on 30-day postoperative outcomes. METHODS: All elective Ladd's procedures performed on patients with intestinal malrotation in the 2013-2014 National Surgical Quality Improvement Program Pediatric were identified. A propensity score-matched analysis was used to account for baseline differences between groups, and generalized estimating equations (GEEs) were used to compare 30-day outcomes between open versus laparoscopic groups. RESULTS: Fifty-eight (18.6%) patients underwent laparoscopic Ladd's while 253 (81.4%) underwent an open technique. After propensity score matching, 53 laparoscopic cases (38.1%) and 86 open cases (61.9%) were identified and compared for outcomes. Total length of stay was shorter for the laparoscopic group compared to the open group (6 vs. 4days, p<0.001). Postoperative length of stay was shorter for the laparoscopic group as well (5 vs. 4days, p<0.001). Postoperative complications occurred in 5 laparoscopic cases (9.4%) and in 18 open cases (20.9%), but did not meet statistical significance (p=0.08). One laparoscopic patient (1.9%) and 8 open patients (9.3%) required hospitalization beyond 30days, but this also did not meet significance (p=0.08). CONCLUSIONS: In a matched analysis, laparoscopic Ladd's led to shorter hospital stays than open Ladd's in the initial 30-day postoperative period. Short-term benefits of laparoscopic Ladd's lend support for using additional resources to perform multi-institutional studies to compare differences in long-term outcomes between laparoscopic and open Ladd's. TYPE OF STUDY: Therapeutic LEVEL OF EVIDENCE: III.

Laparoscopic pyloromyotomy decreases postoperative length of stay in children with hypertrophic pyloric stenosis.

OBJECTIVE: To determine the impact of laparoscopic versus open pyloromyotomy on postoperative length of stay (LOS). MATERIALS AND METHODS: The 2013 National Surgical Quality Improvement Project Pediatric database was queried for all cases of pyloromyotomy performed on children <1year old with congenital hypertrophic pyloric stenosis. Demographics, clinical, and perioperative characteristics for patients with and without a prolonged postoperative LOS, defined as >1day, were compared. Logistic regression modeling was performed to identify factors associated with a prolonged postoperative LOS. RESULTS: Out of 1143 pyloromyotomy patients, 674 (59%) underwent a laparoscopic procedure. Patients undergoing open pyloromyotomy had a longer operative time (median 28 vs. 25min, p<0.001) but shorter duration of general anesthesia (median 72 vs. 78min, p<0.001). Patients undergoing open pyloromyotomy more frequently had a prolonged postoperative LOS (32% vs. 26%, p=0.019). Factors independently associated with postoperative LOS >1day included open pyloromyotomy (odds ratio, 95% confidence interval, p-value) (1.38, 1.03-1.84, p=0.030), cardiac comorbidity (3.64, 1.45-9.14, p=0.006), pulmonary comorbidity (3.47, 1.15-10.46, p=0.027), lower weight (1.005 per 100g decrease, 1.002-1.007, p<0.001), longer preoperative LOS (1.35 per additional day, 1.13-1.62, p=0.001), longer operative time (1.11 per additional 5min, 1.05-1.17, p<0.001), higher preoperative blood urea nitrogen (1.04 per additional mg/dl, 1.01-1.07, p=0.012), and higher serum sodium (1.08 per additional mg/dl, 1.03-1.14, p=0.004). CONCLUSIONS: Compared to laparoscopic pyloromyotomy, open pyloromyotomy is independently associated with a higher likelihood of a prolonged postoperative LOS.

Tracheostomy Placement in Children Younger Than 2 Years: 30-Day Outcomes Using the National Surgical Quality Improvement Program Pediatric.

IMPORTANCE: Analysis of the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric demonstrated that the highest contribution to composite morbidity in otolaryngology is seen in children younger than 2 years undergoing tracheostomy. OBJECTIVE: To determine predictive factors for complications following tracheostomy placement in patients younger than 2 years that, if targeted for reduction in quality initiatives, might result in improved surgical outcomes. DESIGN, SETTING, AND PARTICIPANTS: The NSQIP Pediatric reports predefined 30-day postoperative outcomes for surgical cases from participating institutions for quality improvement. All 206 cases of elective tracheostomy performed in children younger than 2 years from 2012 to 2013 among 61 participating institutions and documented in the NSQIP Pediatric public use file were included. Data analysis was conducted from December 1, 2014, to June 30, 2015. INTERVENTIONS: Surgical placement of tracheostomy in children younger than 2 years. MAIN OUTCOMES AND MEASURES: Demographics and clinical and perioperative characteristics for children who did and did not experience a major complication from elective tracheostomy were compared. Continuous variables were compared using Wilcoxon rank sum tests and categorical variables were compared using Pearson χ2 tests or Fisher exact tests where appropriate. A logistic regression model was fit to identify adjusted odds ratios (aORs) with 95% CIs of preoperative factors predictive of occurrence of a major complication. RESULTS: Of the 206 children younger than 2 years who underwent tracheostomy, 50 (24.3%) experienced a major complication within 30 days. The most common complications were pneumonia (16 [7.8%]), postoperative sepsis (12 [5.8%]), death (12 [5.8%]), and deep or organ space surgical site infections (8 [3.9%]). Neonatal age (aOR, 2.38; 95% CI, 1.06-5.37; P = .04), intraventricular hemorrhage (aOR, 2.72; 95% CI, 1.01-7.32; P = .048), and comorbid cardiac risk factors (relative to none: minor risk factors, aOR, 2.94; 95% CI, 1.19-7.24; major or severe risk factors, aOR, 1.31; 95% CI, 0.44-3.84; P = .04 for all cardiac risk factors) were independently predictive of major complications. CONCLUSIONS AND RELEVANCE: Young children undergoing tracheostomy tube placement have high rates of morbidity. This analysis identifies the need for additional procedure-specific outcome variables and improved variable definitions to incorporate into a detailed module for NSQIP Pediatric that will more effectively promote national, specialty-specific targeted quality improvement efforts.

Preoperative risk assessment in children undergoing major urologic surgery.

BACKGROUND: Preoperative risk assessment is standard in adult surgery, but often these risk assessments cannot be applied to children. Previous studies emphasize the differences between pediatric and adult populations and variability by surgical procedure types. OBJECTIVE: We investigated preoperative risk factors for several outcomes in children undergoing major urologic surgery using the National Surgical Quality Improvement Program (NSQIP) Pediatric. STUDY DESIGN: A cohort of 2-18-year-old children who underwent major urologic surgery was identified by Current Procedure Terminology (CPT) codes in the 2012-2013 NSQIP-Pediatric. The NSQIP-Pediatric prospectively collects standardized and validated data from 61 sites on preoperative, operative, and 30-day postoperative variables. Urologic surgeries involving dissection of the peritoneal or extraperitoneal space were included. Patients undergoing pure genitourinary surgery were analyzed separately from those with bowel involvement to improve homogeneity. Postoperative outcomes including hospital length of stay and 30-day infective complications, non-infective complications, unplanned reoperation and readmissions were evaluated by fitting multivariable logistic regression models. RESULTS: A total of 2601 patients were identified, of whom 399 (15.3%) underwent bowel-involved surgery and 2202 (84.7%) underwent pure genitourinary surgery. Patients in the bowel-involved group were significantly older with more comorbidity. Postoperative complications, unplanned return to operating room, hospital length of stay and readmission rates were all significantly worse in the bowel-involved group. In the pure genitourinary group, older age and white race improved some outcomes, while American Society of Anesthesia (ASA) class ≥ 3, total operation time, obesity, pulmonary risk factors, preoperative renal disease, developmental delay, structural central nervous system abnormality, and supplemental nutrition independently predicted at least one negative outcome (Table). DISCUSSION: Consistent with previous research on reconstructive surgery, we identified a significant difference in patient age, surgery details, comorbidity, and increased complications for patients undergoing urologic surgery with bowel involvement compared with pure genitourinary surgery. Focusing solely on pure genitourinary surgery, we identified predictors of outcomes. Identification of these factors in pediatric urology is novel and only recently possible with the availability of the NSQIP-Pediatric. CONCLUSION: Using the NSQIP-Pediatric, we confirmed differences in complication rates for major urologic surgeries, with and without bowel involvement in a national sample. Preoperative risk characteristics were also identified for patients undergoing pure genitourinary surgery. Further investigation into these relationships is necessary to better elucidate their clinical significance with the goal of improving surgical planning, postoperative care, and family counseling.

Laparoscopic bowel resection for pediatric inflammatory bowel disease.

BACKGROUND: To compare 30-d outcomes between laparoscopic and open intestinal resection performed on pediatric patients with ulcerative colitis and Crohn disease. MATERIALS AND METHODS: We identified all proctocolectomies performed on patients with ulcerative colitis and all intestinal resections with primary anastomosis performed on patients with Crohn disease in the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program Pediatric. We compared demographic, clinical, and 30-d outcome characteristics between patients who underwent an open or laparoscopic resection. RESULTS: Of the 140 patients with ulcerative colitis who underwent proctocolectomy, 103 (74%) were performed laparoscopically. Patients undergoing laparoscopic colectomy had shorter postoperative length of stay (LOS) and fewer incisional complications. On multivariate analysis, open versus laparoscopic proctocolectomy is not an independent predictor of postoperative LOS for patients with ulcerative colitis. Of the 188 patients with Crohn disease who underwent an intestinal resection, 122 (65%) underwent laparoscopic resection. In comparison with patients undergoing open resection, patients undergoing laparoscopic resection had similar rates of complications but a shorter postoperative LOS. CONCLUSIONS: For children with ulcerative colitis, laparoscopic proctocolectomy is not independently associated with a difference in postoperative LOS. In unadjusted analyses, laparoscopic bowel resections for children with Crohn disease may be associated with a shorter postoperative LOS compared with that of open procedures. Additional accrual of cases within the American College of Surgeons National Surgical Quality Improvement Program Pediatric will allow for risk-adjusted analyses of outcomes, including factors independently associated with incisional complications.

A comparison of injuries sustained from recreational compared to organized motorized vehicle use in children.

PURPOSE: To examine the injury severity and patterns of injury for pediatric motorized recreational vehicle (MRV) drivers injured during organized events (OE) compared to recreational use (RU). METHODS: All pediatric MRV injuries between 2006 and 2012 in our institutional trauma registry were studied for mechanism of injury, initial evaluation, and treatment. Injuries with an Abbreviated Injury Scale ≥2 were categorized by body region and diagnosis. RESULTS: Out of 589 collisions, 92 (16%) occurred during an OE. Compared to RU drivers, OE drivers were more likely to wear helmets (92% vs. 40%, p<0.001) and other protective equipment (79% vs. 6%, p<0.001). There was no difference in rates of hospital admission, rates of surgical intervention, injury severity scores, rates of intensive care unit admission, or lengths of stay. There were no differences in injuries by body region or injury type, except that dislocations were more common in OE drivers (2% vs. 0%, p=0.038). CONCLUSION: Despite higher rates of helmet and protective gear use, pediatric MRV drivers participating in OEs sustain similarly severe injuries as drivers using MRVs recreationally. No differences were observed in body regions involved or outcomes. Public perception that OE use of MRV for children is safe should be addressed.

Comparison of 30-day outcomes between thoracoscopic and open lobectomy for congenital pulmonary lesions.

OBJECTIVE: To compare postoperative length of stay and 30-day outcomes between thoracoscopic and open lobectomy performed on a nonemergency basis for congenital pulmonary lesions using a validated national database. MATERIALS AND METHODS: We identified all nonemergency lobectomies performed on patients with congenital pulmonary lesions in the 2012 National Surgical Quality Improvement Program (NSQIP) Pediatric database and compared demographic, clinical, and 30-day outcome characteristics between patients who underwent an open or thoracoscopic lobectomy. Logistic regression with Firth's penalized likelihood bias-reduction method was used to determine predictive risk factors for a postoperative length of stay (LOS) of >3 days. RESULTS: Of 101 patients included, 40 (39%) underwent thoracoscopic lobectomy. In comparison with patients undergoing thoracoscopic lobectomy, patients undergoing open lobectomy were significantly more likely to be admitted prior to surgery, be American Society of Anesthesiologists Class ≥ 3, receive oxygen support prior to surgery, and have other congenital anomalies or cardiac risk factors. Both groups had similar total operative times (open versus thoracoscopic, 150 versus 173 minutes; P=.216). Patients undergoing open lobectomy had longer postoperative LOS (4 versus 3 days; P=.001) and more often received an intraoperative or postoperative transfusion (12% versus 0%; P=.003). The procedure type was not an independent risk factor for postoperative LOS >3 days in the multivariable analysis. CONCLUSIONS: Patients undergoing thoracoscopic lobectomy have fewer comorbidities at baseline, receive fewer perioperative transfusions, and have a shorter postoperative LOS. Accrual of additional patients within the NSQIP Pediatric database will allow for further risk-adjusted analyses to control for differences in baseline characteristics between patients undergoing open and thoracoscopic resections.