Factors Associated with Torsion in Pediatric Patients with Ovarian Masses.

BACKGROUND: Management of ovarian torsion has evolved toward ovarian preservation regardless of ovarian appearance during surgery. However, patients with torsion and an ovarian neoplasm undergo a disproportionately high rate of oophorectomy. Our objectives were to identify factors associated with ovarian torsion among females with an ovarian mass and to determine if torsion is associated with malignancy. METHODS: A retrospective review of females aged 2-21 y who underwent an operation for an ovarian cyst or neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariate logistic regression was used to assess factors associated with torsion. Imaging data were assessed for sensitivity, specificity, and predictive value in identifying ovarian torsion. RESULTS: Of 814 girls with an ovarian neoplasm, 180 (22%) had torsion. In risk-adjusted analyses, patients with a younger age, mass size >5 cm, abdominal pain, and vomiting had an increased likelihood of torsion (P < 0.01 for all). Patients with a mass >5 cm had two times the odds of torsion (odds ratio: 2.1; confidence interval: 1.2, 3.6). Imaging was not reliable at identifying torsion (sensitivity 34%, positive predictive value 49%) or excluding torsion (specificity 72%, negative predictive value 87%). The rates of malignancy were lower in those with an ovarian mass and torsion than those without torsion (10% versus 17%, P = 0.01). Among the 180 girls with torsion and a mass, 48% underwent oophorectomy of which 14% (n = 12) had a malignancy. CONCLUSIONS: In females with an ovarian neoplasm, torsion is not associated with an increased risk of malignancy and ovarian preservation should be considered.

Pediatric Extracorporeal Membrane Oxygenation Mortality Is Related to Extracorporeal Membrane Oxygenation Volume in US Hospitals.

BACKGROUND: Our objective was to examine extracorporeal membrane oxygenation (ECMO) utilization and determine whether pediatric-specific and overall ECMO volumes are associated with mortality rates. METHODS: State Inpatient Databases from 17 states were queried for ECMO admissions during 2008-2014. Hospitals in which >90% of their ECMO patients were ≤18 y old were considered pediatric ECMO centers. Hospital overall ECMO volumes were calculated as the average annual number of admissions, of any age, and categorized as <6, 6-14, 15-30, and >30. Multivariable analyses were conducted to examine the impact of ECMO volume on pediatric in-hospital mortality. RESULTS: There were 4546 pediatric ECMO admissions across 84 hospitals. Most patients were neonates (59.9%), and the most common indication for ECMO was neonatal respiratory failure (20.1%). Approximately 35% of hospitals offering pediatric ECMO averaged <6 annual ECMO admissions. Centers with >30 annual ECMO admissions had significantly lower mortality than hospitals with lower ECMO volume. Among the high-volume centers, pediatric ECMO centers had significantly lower mortality rates than high-volume nonpediatric ECMO centers (17.4% versus 38.2%). CONCLUSIONS: A high proportion of hospitals performing pediatric ECMO have a low number of annual ECMO admissions. Pediatric centers with high volume had the lowest risk-adjusted mortality rates for pediatric ECMO.

Disparities in Radiation Burden from Trauma Evaluation at Pediatric Versus Nonpediatric Institutions.

BACKGROUND: Computed tomography (CT) imaging protocols and prescribing practices vary across institutions. Pediatric trauma patients imaged at a pediatric trauma center (PTC) may receive less radiation than patients imaged at non-PTCs before transfer. Our objective was to determine differences in radiation exposure from imaging performed at a PTC versus non-PTCs. METHODS: This retrospective analysis included patients <18 y old who underwent CT imaging from January 2013 to August 2015 during a trauma-related encounter. Radiation doses from CT scans were estimated and compared between scans performed at our PTC and non-PTCs before patient transfer using propensity score-weighted median regression. RESULTS: Of 3530 CT scans, 3021 were performed at our PTC and 509 at non-PTCs. Patients imaged at non-PTCs were older and had higher injury severity (all P < 0.05). Patients imaged at non-PTCs more frequently had neck CT (29.0% versus 7.3%) and chest CT (8.3% versus 2.7%), less frequently had abdomen/pelvis CT (19.5% versus 27.9%, all P < 0.01), and had similar rates of head CT (83.9% versus 80.9%, P = 0.18). After propensity weighting, CT scanning was more frequent at non-PTCs and patients received higher cumulative radiation exposure overall (median effective dose 2.36 versus 1.57 mSv, P < 0.001) and for each body region imaged (17% more for head, 191% for neck, 81% for chest, and 33% for abdomen/pelvis). CONCLUSIONS: Pediatric trauma patients imaged at a PTC receive lower radiation burden from CT imaging than patients initially imaged at adult institutions. Broader adoption of pediatric dosing protocols or deferring noncritical CT scans until transfer may mitigate these disparities.

Can ultrasound reliably identify complicated appendicitis in children?

BACKGROUND: The ability of ultrasound to identify specific features relevant to nonoperative management of pediatric appendicitis, such as the presence of complicated appendicitis (CA) or an appendicolith, is unknown. Our objective was to determine the reliability of ultrasound in identifying these features. METHODS: We performed a retrospective study of children who underwent appendectomy after an ultrasound at four children's hospitals. Imaging, operative, and pathology reports were reviewed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound for identifying CA based on pathology and intraoperative findings and an appendicolith based on pathology were calculated. CA was defined as a perforation of the appendix. Equivocal ultrasounds were considered as not indicating CA. RESULTS: Of 1027 patients, 77.5% had simple appendicitis, 16.2% had CA, 5.4% had no evidence of appendicitis, and 15.6% had an appendicolith. Sensitivity and specificity of ultrasound for detecting CA based on pathology were 42.2% and 90.4%; the PPV and NPV were 45.8% and 89.0%, respectively. Sensitivity and specificity of ultrasound for detecting CA based on intraoperative findings were 37.3% and 92.7%; the PPV and NPV were 63.4% and 81.4%, respectively. Sensitivity and specificity of ultrasound for detecting an appendicolith based on pathology were 58.1% and 78.3%; the PPV and NPV were 33.1% and 91.0%, respectively. Results were similar when equivocal ultrasound and negative appendectomies were excluded. CONCLUSIONS: The high specificity and NPV suggest that ultrasound is a reliable test to exclude CA and an appendicolith in patients being considered for nonoperative management of simple appendicitis.

Surgical site infection after stoma closure in children: outcomes and predictors.

BACKGROUND: Surgical site infection (SSI) is a burdensome complication following intestinal stoma closure, with reported rates ranging from 0% to 40%. We aimed to identify risk factors for SSI in children undergoing stoma closure. MATERIALS AND METHODS: Using 2012-2014 NSQIP Pediatric data, we identified patients aged 0-18 years undergoing stoma closure. Demographic, clinical, and 30-day outcome characteristics between children with and without SSI were compared. A multivariable logistic model was used to identify predictors of SSI. RESULTS: Among 2110 children who underwent stoma closure, 7.6% developed SSI. Patients who developed SSI had significantly longer time in the operating room, longer anesthesia times, longer total operation times, and longer lengths of stay (all P ≤ 0.01). Patients who developed SSI postoperatively had significantly higher rates of postoperative complications, including need for postoperative ventilation, sepsis, need for nutritional support on discharge, unplanned reoperation, unplanned readmission, postoperative lengths of stay >30 days, and transfusion within 72 hours after the start of surgery (all P ≤ 0.018). There was a significant relationship between operation time and SSI probability. Specifically, operation time greater than 105 minutes was associated with a higher SSI risk. On adjusted multivariable analyses, age, cardiac risk factors, Hirschsprung disease, and operation time greater than 105 minutes were independently predictive of SSI. CONCLUSIONS: Longer operation time, age, Hirschsprung disease, and cardiac risk factors are associated with an increased risk for SSI after stoma closure. Studies of perioperative adjuncts to reduce SSI in high-risk children based on expected procedure length and other preoperative characteristics are warranted.

Perioperative blood transfusion and complications in children undergoing surgery for solid tumors.

BACKGROUND: The objective was to assess whether perioperative blood transfusion (PBT) is associated with postoperative complications in children undergoing surgery for a solid tumor. METHODS: Using 2012-2014 National Surgical Quality Improvement Program Pediatric data, we identified patients aged 0-18 years who underwent surgery (biopsy or resection) for solid tumors. We compared demographic, clinical, and 30-day outcome characteristics between children who did and did not receive a PBT within 72 hours after surgery. Propensity score-matched analyses were used to estimate the effect of PBT on postoperative complications, in the overall cohort, the subgroup undergoing resection, and the subgroup with liver tumors. RESULTS: Of 961 patients who underwent surgery for solid tumors, 27.8% required PBT. Patients requiring PBT were more likely to have preoperative risk factors, including ventilator dependence, hematologic disorders, chemotherapy, sepsis, transfusion before surgery, and an American Society of Anesthesiologists class ≥3 (all P ≤ 0.01). In propensity score-matched analyses, PBT was not associated with overall complication risk (odds ratio [OR]: 1.50, P = 0.07) but was associated with an increased risk of postoperative mechanical ventilation (OR: 3.78, P < 0.001). Of the 750 patients undergoing tumor resection, 36.3% required PBT. After propensity matching, PBT was associated with overall postoperative complications (OR: 1.76, P = 0.02). Of 163 patients with liver tumors, 52.8% required PBT. After propensity matching, PBT was not associated with postoperative complications (OR: 2.00, P = 0.09). PBT was associated with a longer postoperative length of stay in all three analyses (all P < 0.01). CONCLUSIONS: PBT was associated with higher risks for postoperative complications in children undergoing surgery for solid tumors.

Management of benign ovarian lesions in girls: a trend toward fewer oophorectomies.

PURPOSE OF REVIEW: The management of benign ovarian lesions in girls is currently a controversial topic in the pediatric surgical literature. The purpose of this review is to highlight the epidemiology of benign ovarian masses, outline preoperative risk stratification strategies, review the indications and importance of ovary-sparing surgery (OSS), and discuss the impact of management algorithms. RECENT FINDINGS: Efforts across the United States and Canada to promote OSS have improved awareness about the role and safety of OSS for the management of benign ovarian masses in pediatric and adolescent girls. Preoperative risk stratification techniques by a multidisciplinary team can improve the preoperative identification of lesions with a high likelihood of benign disease. SUMMARY: Avoiding oophorectomy may be associated with a number of benefits to individual patients and the overall population. The implementation of a management algorithm to guide the treatment of pediatric and adolescent girls with ovarian lesions can reduce the rate of inappropriate oophorectomies.

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.

Variability in same-day discharge for pediatric appendicitis.

BACKGROUND: Recent single-institutional data point to the feasibility of same-day discharge (SDD) after appendectomy for nonperforated appendicitis and its potential as a quality-of-care indicator. Opportunities for SDD are greatest the sooner the appendectomy is performed after admission. We examine a national database to assess the pattern of SDD utilization among children who underwent appendectomy on the day of admission and potential limitations to SDD. METHODS: The 2009 Kids Inpatient Database (KID) was queried for children with a diagnosis of acute appendicitis who had appendectomy. Exclusion criteria included those children with perforated appendicitis or those in whom the procedure code was missing. Day from admission to procedure day and total length of stay (LOS) were then analyzed by demographics, type of procedure (laparoscopic versus open), children's hospital designation, and hospital region. After stratifying all patients undergoing appendectomy on day of admission into two groups by LOS (≤1 d, SDD versus >1 d, non-SDD), a multivariate analysis was then performed to determine the predictors of SDD. RESULTS: A total of 38,959 records, representing a weighted estimate of 56,077 patients with a diagnosis of nonperforated appendicitis, met the inclusion criteria. Median age was 14 y with interquartile range of 10-17 y. Median LOS was 1 d (interquartile range, 1-2 d), and the majority (71.8%) had laparoscopic appendectomy. On adjusted analysis, laparoscopic cases were 50% less likely to be non-SDD compared with their open counterparts (odds ratio [OR], 0.50; 95% confidence interval [CI], 0.47-0.53). Compared with Caucasians, significantly more Hispanics (OR, 1.44; 95% CI, 1.36-1.56) and African Americans (OR, 1.57; 95% CI, 1.42-1.73) were non-SDD. Hospitals in the midwest and south were more likely to be non-SDD. CONCLUSIONS: SDD is increasingly used for children with nonperforated appendicitis, but there is significant variability in the utilization of SDD for different ethnicities and hospital regions. These variations need to be further investigated to better delineate its potential role as a quality-of-care indicator.

Epidemiologic trend in elderly domestic injury.

BACKGROUND: The elderly constitute about 12% of the American population, with a projected increase of up to 25% in 2050. Elderly domestic injuries have been recognized as a major cause of morbidity and mortality. The objective of this study is to determine the 4-y national trend in elderly domestic injury, and we hypothesize that the home remains a significant source of injury. METHODS: Data on elderly patients ≥ 65 y was extracted from the National Trauma Data Bank's National Sample Project (NSP). Elderly patients with home injuries were compared with non-home injuries. Subsets of hospitalized patients were analyzed for trends in injury site over a 4 y period. Multivariate analysis was performed to determine the predictors of hospitalization and in-hospital mortality. RESULTS: A total of 98,288 patients, representing a weighed estimate of 472,456 elderly patients were analyzed. Forty-two percent of all injuries in the study population occurred at home, followed by motor vehicle crashes (MVC) at 25%. Home injuries as a proportion of annual injuries increased from 37% in 2003 to 40% in 2006. Majority (57%) were admitted to the floor and 14% to the intensive care unit (ICU). On multivariate analysis, African-Americans and Asians were less likely to be hospitalized (odds ratio (OR) 0.57 and 0.50, respectively, with females 47% less likely than males to die after hospitalization (P < 0.001). CONCLUSIONS: Home injuries remain the most significant source of elderly hospitalizations after trauma. With a rapidly growing elderly population, there is a need to recognize this specific location of injury and create directed preventive measures to avert elderly domestic injuries.

Does BMI affect perioperative complications following total knee and hip arthroplasty?

BACKGROUND: Orthopedic surgeons are reluctant to perform total knee (TKA) or hip (THA) arthroplasty on patients with high body mass index (BMI). Recent studies are conflicting regarding the risk of obesity on perioperative complications. Our study investigates the effect of BMI on perioperative complications in patients undergoing TKA and THA using a national risk-adjusted database. METHODS: A retrospective analysis was performed using the 2005-2007 American College of Surgeons-National Surgical Quality Improvement Program ACS-NSQIP dataset. Inclusion criteria were patients between 18 and 90 y of age who underwent TKA or THA. Patients were stratified into five BMI categories: normal, overweight, obese class I, obese class II, and morbidly obese. Demographic characteristics, length of stay, co-morbidities, and complication rates were compared across the BMI categories. RESULTS: A total of 1731 patients met the inclusion criteria, with 66% and 34% undergoing TKA and THA, respectively. A majority were female (60%) and >60 y (70%) in age. Of the patients who underwent TKA, 90% were either overweight or obese, compared with 77% in those undergoing THA. The overall preoperative comorbidity rate was 73%. The complication and mortality rates were 7% and 0.4%, respectively. When stratifying perioperative complications by BMI categories, no differences existed in the rates of infection (P = 0.368), respiratory (P = 0.073), cardiac (P = 0.381), renal (P = 0.558), and systemic (P = 0.216) complications. CONCLUSIONS: Our study demonstrates no statistical difference in perioperative complication rates in patients undergoing TKA or THA across BMI categories. Performing TKA or THA on patients with high BMI may increase mobility leading to improved quality of life.

Laparoscopic appendectomy in children with complicated appendicitis: ethnic disparity amid changing trend.

BACKGROUND: Laparoscopic appendectomy (LA) has gained acceptance in the treatment of uncomplicated appendicitis in the pediatric population. The role of LA versus open appendectomy (OA) in complicated (perforated) appendicitis has remained controversial. METHODS: A 10-y review of the Nationwide Inpatient Sample (HCUP-NIS) and 3 y of non-overlapping data from the Kids' Inpatient Database (KID) (2000, 2003, and 2006) was performed on pediatric patients (age <18 y) with complicated appendicitis. Patients were classified based on gender, race, insurance status, and type of appendectomy performed. Multivariate regression was conducted adjusting for age, race, gender, and type of appendectomy, with mortality and length of hospital stay (LOS) as outcomes. RESULTS: An estimated 72,787 patients met the inclusion criteria with a median age of 11 y. The majorities of the patients were male (59.9%), Caucasian (38.1%), and insured (89.7%). Twenty-nine percent underwent LA while 71% had OA. Proportion of LA increased from 9.9% in 1999 to 46.6% in 2007. On multivariate analysis, African-Americans were less likely to undergo LA compared with Caucasians (OR: 0.80, CI = 0.69-0.92, P = 0.002) despite an increased odds of undergoing LA over the last decade from 1998 to 2007 in the entire study population (OR 6.27, 95% CI 4.73-8.30, P = 0.000). Increasing age and gender were also associated with likelihood of receiving LA (OR: 1.08, CI = 1.06-1.10 and OR 1.25, 95% CI 1.18-1.31, P < 0.001). CONCLUSIONS: LA is gradually gaining acceptance over the years as an alternative to OA for complicated appendicitis, However, minority difference still exists in choice of procedure. There is a need to further investigate this disparity as it may be related to access to skilled laparoscopic pediatric surgeons.

Gastric prolapse with pseudocysts following laparoscopic adjustable gastric banding.

INTRODUCTION: Laparoscopic adjustable gastric banding (LAGB) is a reversible method of surgical gastric restriction. Following LAGB, the adverse event most commonly necessitating subsequent reoperation is prolapse of the gastric corpus or fundus above the band. A review of the medical literature reveals no reports of nonpancreatic pseudocysts being associated with this adverse event. Nonpancreatic pseudocysts, encountered during revisional bariatric surgery should be considered a cause of irreducible gastric prolapse. CASE REPORT: We report the case of a 41-year-old Caucasian female who underwent laparoscopic surgery to revise an adjustable gastric band and to repair an anterior gastric prolapse. Intraoperatively, 2 pseudocysts were found on the gastric fundus above the band in association with the gastric prolapse. The pseudocysts were resected, the gastric prolapse was reduced, and the band was left in place. The patient recovered uneventfully. CONCLUSION: Nonpancreatic pseudocysts may be associated with gastric prolapse in patients who have undergone LAGB. These pseudocysts can often be excised laparoscopically without violating the gastric lumen. This atypical presentation of gastric prolapse may pose a diagnostic and therapeutic challenge as these patients may.

Update on pediatric metabolic and bariatric surgery.

The prevalence of childhood obesity has risen sharply over the last several decades and poses a significant threat to the health and well-being of today's youth. Childhood-onset obesity is associated with a number of cardiometabolic consequences, which contribute to diminished quality of life. Metabolic and bariatric surgery offers a powerful treatment paradigm with positive long-term health effects. A growing body of literature supports the notion that earlier intervention in younger patients results in long-term health benefits. The development of a multidisciplinary care model and best practice guidelines are central to providing optimal care for this vulnerable patient population. Although the outcomes of metabolic and bariatric surgery in pediatric patients are reassuring and support the ongoing utilization of this important treatment paradigm, a number of significant challenges remain regarding access to care. As the literature continues to support earlier intervention for youth with severe obesity, future efforts should address these challenges to ensure that eligible patients are referred in timely fashion.

The pediatric surgery match by the numbers: Defining the successful application.

BACKGROUND: Pediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match. METHODS: After IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014-2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis. RESULTS: This training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p < 0.01). Matched applicants had more total publications (median: 12 vs. 7, p < 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p < 0.01). Training in multiple programs negatively impacted the chance to match (p < 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p < 0.01). CONCLUSIONS: The likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased. TYPE OF STUDY: Retrospective Comparative Study. LEVEL OF EVIDENCE: Level III.

Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms.

PURPOSE: The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms. METHODS: A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated. RESULTS: Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively). CONCLUSIONS: Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population. TYPE OF STUDY: Retrospective Cohort Review. LEVEL OF EVIDENCE: Level III.

Factors Associated With Management of Pediatric Ovarian Neoplasms.

BACKGROUND: Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions. METHODS: A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy. RESULTS: Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001). CONCLUSIONS: The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.

Variability in outcomes after gastroschisis closure across U.S. children's hospitals.

BACKGROUND: In patients undergoing gastroschisis closure, the effects of timing of closure and patient and hospital-level characteristics on length of stay (LOS) and time to enteral autonomy are unknown. STUDY DESIGN: Using the Pediatric Health Information System, we compared neonates who underwent early (within 1day of birth) versus delayed (>1day after birth) gastroschisis closure from 2005 to 2013. We evaluated the relationship between time to closure and both LOS and days on total parenteral nutrition (TPN). RESULTS: Of 4459 neonates with gastroschisis, 43.9% underwent early closure and 56.1% underwent delayed closure. Delayed closure, complicated gastroschisis, government insurance, lower birth weight, older age at closure, and complex chronic conditions were associated with longer LOS and days on TPN (all p<0.05). There was significant inter-hospital variability in both outcomes, after adjusting for patient- and hospital-level characteristics, including hospitals' gastroschisis and neonatal volumes, median age at closure, and percentages of complicated and delayed gastroschisis patients, (p<0.01). CONCLUSION: Delayed gastroschisis closure is associated with longer LOS and duration of TPN, even after excluding complicated cases. Furthermore, after controlling for hospital volume, rate of complicated gastroschisis, and timing of closure, the persistent inter-hospital variability suggests that practice variability is partially responsible for these differences. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: III.

Reducing the Number of Anesthetic Exposures in the Early Years of Life: Circumcision and Myringotomy as an Example.

Evidence suggests multiple anesthetics in early childhood may increase risk for neurodevelopmental injury. We evaluated proportions of children undergoing circumcision and myringotomy, concomitantly with or prior to circumcision, and compared costs between groups. The Pediatric Health Information System was queried for males aged 6 to 36 months who underwent circumcision in 2009-2014. Relative to circumcision, the proportion who underwent myringotomy previously, concomitantly, or both, was calculated. Of 29 789 patients who underwent circumcision, 822 also underwent myringotomy; 342 (41.6%) underwent myringotomy on a previous day, and 480 (58.4%) underwent myringotomy at time of circumcision. Total hospital costs were lower for concomitant procedures (median $2994 vs $4609, P < .001. In total, 58.4% of patients who underwent circumcision and myringotomy did so concomitantly. Combined procedures resulted in significantly reduced costs and potentially minimized neurocognitive risk. Ideally, both referring pediatricians and surgical specialists should inquire about other surgical needs to optimize the availability of concomitant procedures.

Complications in children with ulcerative colitis undergoing ileal pouch-anal anastomosis.

Total colectomy with ileal pouch-anal anastomosis (IPAA) is considered the standard procedure for the surgical management of ulcerative colitis. Despite the widespread utility of the procedure, as many as 75% of patients who undergo IPAA, experience at least 1 complication. This review highlights difficult intraoperative scenarios and complications of pouch surgery in children, including intraoperative, postoperative, and functional complications. Intraoperative scenarios include insufficient mesenteric length and positive leak tests. Postoperative complications include surgical site infection, anastomotic leak, stricture, fistula, pouchitis, small bowel obstruction, and pouch failure. Less common complications include afferent limb syndrome, pouch prolapse, and superior mesenteric artery syndrome. Functional complications include incontinence, impaired quality of life, infertility, and sexual dysfunction. Despite complications, most patients are satisfied with their outcomes and report an improvement in their lifestyle.