Transversus Abdominis Plane Block VS. Local Wound Infiltration for Elective Minimally Invasive Cholecystectomy in Children: A Prospective Randomized Trial.

BACKGROUND: The efficacy of transversus abdominis plane (TAP) block versus local anesthetic wound infiltration (LWI) in pediatric laparoscopic surgery is largely unknown. The objective of this study was to prospectively analyze this in minimally invasive cholecystectomy. We hypothesized that TAP block would be superior to LWI in terms of pain control and post-operative complications. METHODS: We conducted a prospective, randomized, single-blinded, controlled trial between 2017 and 2022 after obtaining Institutional Review Board (IRB) approval. After randomization, patients received a standard amount of ropivacaine via either 1) ultrasound-guided TAP block after general anesthesia induction or 2) local injection at port insertion by the operating surgeon. We collected data including operative time, pain scores, and medication usage post-operatively. We used descriptive statistics to report all endpoints and compared data with t-tests and Fisher's exact tests. A p-value less than 0.05 was considered statistically significant. RESULTS: We enrolled 85 patients (43 LWI, 42 TAP). Mean [standard deviation] age and body mass index (BMI) in the LWI and TAP groups were 14.8 [1.9] and 14.7 [2] years and 29.9 [7.2] and 27.4 [8.2] kilogram/meter2 (kg/m2) respectively. We did not find any significant differences in postoperative opioid use, pain scores, and gastrointestinal symptoms. TAP patients had significantly longer time between anesthesia-start and procedure-start (p < 0.001), although total time under anesthesia was not significantly different (p = 0.540). CONCLUSION: There are no significant differences between equal administration of local anesthetic by TAP block and surgeon administered LWI during minimally invasive cholecystectomy. TYPE OF STUDY: Randomized clinical trial. LEVEL OF EVIDENCE: Level II.

Trauma injury, severity, and outcomes among pediatric American Indian/Alaska Natives in the North Central United States.

BACKGROUND: There is a disproportionately higher trauma morbidity between American Indian/Alaska Native (AI/AN) and non-AI/AN children. OBJECTIVE: To characterize and compare trauma in AI/AN and non-AI/AN children presenting to a Regional Pediatric Level II Trauma Center (Adult Level I Trauma Center). METHOD: A retrospective observational study of all children <20 years presenting from 2012-2018. Descriptive data were analyzed along with T-tests to determine if demographic and clinical characteristics were different for AI/AN and non-AI/AN children. RESULTS: AI/AN children are more likely to be referred from outside hospitals [OR 5.61, 95% CI 3.79, 8.29], to have penetrating injuries [OR 3.87, 95% CI 1.88, 7.99] and have higher likelihood of both minor [OR 1.48, 95% Cl 1.06, 2.07] and major [OR 1.99, 95% Cl 1.37, 2.87] trauma activation on arrival. More AI/AN children suffer violent injuries [OR 3.12, 95% CI 1.90, 5.01], utilized Intensive Care Unit (ICU) [OR 1.54 95% CI 1.10, 2.14], had prolonged length of stay (LOS) [OR 1.52, 95% Cl 1.28, 1.80], and were less likely discharged home [OR 0.65, 95% Cl 0.44, 0.96]. CONCLUSIONS: AI/AN pediatric trauma patients suffer higher morbidity compared to non-AI/AN pediatric trauma patients. This study provides data which supports the need for future interventions to decrease the burden of injury noted among AI/AN children. STUDY TYPE: Treatment STUDY TYPE AND LEVEL OF EVIDENCE: Retrospective comparative study; Level III.

Identifying Adverse Events in Pediatric Surgery: Comparing Morbidity and Mortality Conference with the NSQIP-Pediatric System.

BACKGROUND: Recent improvements to morbidity and mortality (M&M) conference have focused on the case review system. However, case selection occurs by physician reporting, which is limited by selection bias. We compared the effectiveness of our M&M conference with the NSQIP-Pediatric (NSQIP-P) system for identifying adverse events. STUDY DESIGN: Complications from January 2010 to September 2015 were compared between M&M and NSQIP-P. Only M&M patients meeting NSQIP-P criteria were compared with patients from the NSQIP-P system; exclusions were studied separately. Complication rates in M&M conference before and after a 2012 format change designed to increase case reporting were also compared. RESULTS: Detection of mortality in M&M conference and NSQIP-P was not different. Morbidity events identified by NSQIP-P were significantly higher than M&M conference during the entire study period (194 vs 100 occurrences/1,000 cases) (p < 0.0001). Morbidity occurrences in M&M conference increased with the 2012 improvements, however, they still remained less than that identified by NSQIP-P (226 vs 141 occurrences/1,000 cases) (p < 0.0001). Of 863 patients presented in M&M conference, 210 were excluded from direct comparison because they did not meet NSQIP-P criteria. These included 62 deaths and 287 occurrences of morbidity. Their analysis in M&M conference resulted in 32 action initiatives directed at system failures. CONCLUSIONS: The NSQIP-P identified more complications than M&M. The M&M conference improvements increased reported cases, but they still remained lower than NSQIP-P. However, M&M conference identified events resulting in systems changes that would not have been identified by NSQIP-P. Although NSQIP-P captures occurrences to compare large patient cohorts, M&M analyzes singular failures and initiates direct interventions. Integration of these systems can optimize their usefulness in quality improvement.

The trauma registry compared to All Patient Refined Diagnosis Groups (APR-DRG).

BACKGROUND: Literature has shown there are significant differences between administrative databases and clinical registry data. Our objective was to compare the identification of trauma patients using All Patient Refined Diagnosis Related Groups (APR-DRG) as compared to the Trauma Registry and estimate the effects of those discrepancies on utilization. METHODS: Admitted pediatric patients from 1/2012-12/2013 were abstracted from the trauma registry. The patients were linked to corresponding administrative data using the Pediatric Health Information System database at a single children's hospital. APR-DRGs referencing trauma were used to identify trauma patients. We compared variables related to utilization and diagnosis to determine the level of agreement between the two datasets. RESULTS: There were 1942 trauma registry patients and 980 administrative records identified with trauma-specific APR-DRG during the study period. Forty-two percent (816/1942) of registry records had an associated trauma-specific APR-DRG; 69% of registry patients requiring ICU care had trauma APR-DRGs; 73% of registry patients with head injuries had trauma APR-DRGs. Only 21% of registry patients requiring surgical management had associated trauma APR-DRGs, and 12.5% of simple fractures had associated trauma APR-DRGs. CONCLUSION: APR-DRGs appeared to only capture a fraction of the entire trauma population and it tends to be the more severely ill patients. As a result, the administrative data was not able to accurately answer hospital or operating room utilization as well as specific information on diagnosis categories regarding trauma patients. APR-DRG administrative data should not be used as the only data source for evaluating the needs of a trauma program.

Development of a multi-institutional clinical research consortium for pediatric surgery.

BACKGROUND: Multicenter clinical research studies in pediatric surgery have been largely limited to relatively small case-series and retrospective reviews because of the rarity of many of the diseases we treat and difficulty coordinating and executing multi-institutional studies. Creation of a collaborative research network can provide the needed patient population and infrastructure to perform high quality multi-institutional studies. METHODS: In 2013, eleven academic pediatric surgery centers within the United States formed a research consortium to develop and conduct multicenter clinical research projects to advance the practice of pediatric surgery. RESULTS: We present our process for creating, developing, and maintaining this consortium including initial regional geographic limitation, charter development with by-laws and procedures for adopting studies, and research infrastructure including a central website for study monitoring and central reliance institutional review board process. CONCLUSION: Our model could be reproduced or adapted by other institutions to develop or strengthen other research collaboratives. LEVEL OF EVIDENCE: Type of study: retrospective, IV.

Controversies in nutritional support for critically ill children.

Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.

Mortality increases with recurrent episodes of nonaccidental trauma in children.

BACKGROUND: Nonaccidental trauma (NAT) is a leading cause of childhood traumatic injury and death. Our objectives were to compare the mortality rates of children who experience recurrent episodes of NAT (rNAT) with children who experience a single episode of NAT and to identify factors associated with rNAT and increased mortality from rNAT. METHODS: Patients of NAT and rNAT in the Ohio State Trauma Registry were identified by matching date of birth, race, and sex between records of patients younger than 16 years between 2000 and 2010 with an DRG International Classification of Diseases--9th Rev. e-code for child abuse (E967-E967.9). Statistical comparisons were made using Fisher's exact and Wilcoxon rank-sum tests. RESULTS: A total of 1,572 patients of NAT were identified, with 53 patients meeting criteria for rNAT. Compared with patients with single-episode NAT, patients with rNAT were more commonly male (66% vs. 52%, p = 0.05), were white (83% vs. 65%, p = 0.02), were evaluated at a pediatric trauma center (87% vs. 69%, p = 0.008), and had higher mortality (24.5% vs. 9.9%, p = 0.002). Compared with rNAT patients who did not die, those who died with rNAT had a longer interval from initial episode to second episode (median [interquartile range], 527 days [83-1,099] vs. 166 days [52-502]; p = 0.07) and were older during their second episode (1 year [<6 months to 3 years] vs. <6 months [<6 months to 1 year]; p = 0.06). At initial presentation, lower-extremity fractures (p = 0.09) and liver injuries (p = 0.06) were reported more commonly in nonsurvivors of rNAT. CONCLUSION: Mortality is significantly higher in children who experience rNAT. Therefore, it is critically important to effectively intervene with appropriate resources and follow-up after a child's initial episode of NAT to prevent a future catastrophic episode.

Increased use of enoxaparin in pediatric trauma patients.

PURPOSE: Venous thromboembolism (VTE) in pediatric trauma patients has been reported from 0.7 to 4.2 patients per 1000 admissions. There are no clear guidelines for prophylactic anticoagulation in children. The purpose of this study was to examine the use of enoxaparin in pediatric trauma patients. METHODS: The Pediatric Health Information System database was queried from 2001 to 2008 for patients 0 to 18 years with a primary diagnosis of trauma based on International Classification of Diseases, Ninth Revision, codes. Patients who received enoxaparin and/or diagnosed with VTE were identified using pharmacy and International Classification of Diseases, Ninth Revision, codes. Logistic regression was used to identify patient and hospital characteristics associated with VTE and enoxaparin use. RESULTS: Among 260,078 pediatric trauma patients, 3195 were prescribed enoxaparin (1.23%), 2915 (1.12%) of whom were given enoxaparin without a diagnosis of VTE. The incidence of VTE remained stable (0.23%-0.28%), whereas the use of enoxaparin increased (0.75%-1.54%), especially in patients without VTE (0.65%-1.43%). Venous thromboembolism was significantly associated with pelvic fractures, intensive care unit stay, and central venous catheters (P = .017, P < .001, P < .001). CONCLUSIONS: Despite a stable VTE incidence, the use of enoxaparin significantly increased in pediatric trauma patients, suggesting that use of pharmacologic thromboprophylaxis is increasing in pediatric trauma centers.

Extracorporeal membrane oxygenation as a lifesaving modality in the treatment of pediatric patients with burns and respiratory failure.

PURPOSE: Several case series have described successful utilization of extracorporeal membrane oxygenation (ECMO) for the treatment of pediatric burn patients with respiratory failure. This study examines the Extracorporeal Life Support Organization registry experience in the treatment of these patients. METHODS: The Extracorporeal Life Support Organization registry was queried from 1999 to 2008 for all patients not older than 18 years who suffered a burn-related injury. RESULTS: Thirty-six patients met inclusion criteria. The mean age was 4.45 years, with an average weight of 20.9 kg. Survivors vs nonsurvivors had a shorter average time to ECMO (97 vs 126 hours, P = .890) and shorter average ECMO run times (193 vs 210 hours, P = .745). Seventeen patients underwent venovenous ECMO and 19 patients underwent venoarterial ECMO, with survival of 59% (n = 10) and 47% (n = 9), respectively (P = .493; odds ratio, 1.587; 95% confidence interval, 0.424-5.945). Overall survival was 53% (n = 19). Complications occurred in 28 patients (33 mechanical, 101 medical). The venoarterial group had 21 mechanical (n = 8) and 61 medical complications (n = 17), compared with the venovenous group with 12 mechanical (n = 8) and 40 medical complications (n = 11). CONCLUSIONS: Extracorporeal membrane oxygenation can be a lifesaving modality for pediatric burn patients with respiratory failure. Survival is comparable to the reported survival of non-burn-related pulmonary failure pediatric patients requiring ECMO.

Minimally invasive Heller's myotomy in children: safe and effective.

PURPOSE: The aim of the study was to review a single institution experience of minimally invasive Heller's myotomy in pediatric patients with achalasia. METHODS: An institutional review board-approved retrospective review from 1999 to 2005 identified patients 18 years old and younger who underwent a minimally invasive Heller's myotomy for achalasia. RESULTS: Twenty-six patients were identified with a mean age of 15 (range, 4-18 years). There were 11 female and 15 male patients. There were 3 intraoperative complications (2 esophageal mucosal injuries and 1 aspiration). There was no mortality. All 26 surgeries were completed laparoscopically. Two patients had Dor fundoplication, whereas 23 patients had Toupet fundoplication. Average length of hospital stay was 2.7 days (range, 1-4 days) excluding the 3 patients with intraoperative complications and 3.5 days for all patients (range, 1-17 days). Postoperative follow-up ranged from 0 to 75 months (mean, 20 months). Postoperatively, one patient developed reflux symptoms (incidence 4%). Seven patients (27%) had recurrence of symptoms at a mean of 13 months (range, 1-66 months) after their operation. CONCLUSIONS: Laparoscopic Heller's myotomy with fundoplication is a safe and effective treatment of symptomatic achalasia in the pediatric population. Complications were low in this group of patients and comparable to other published reports in the literature.

Rare but serious complications of central line insertion.

Discussions on the complications of central venous catheterization in children typically focus on infectious and the more common mechanical complications of pneumothorax, hemothorax, or thrombosis. Rare complications are often more life-threatening, and inexperience may compound the problem. Central venous catheter complications can be broken down into early or late, depending on when they occur. The more serious complications are typically mechanical and occur early, but delayed presentations of pericardial effusions, cardiac tamponade, and pleural effusions may be of equal severity, and delay in diagnosis can be catastrophic. Careful insertion techniques, as well as continued vigilance in the correct position and function of central venous catheters, are imperative to help prevent serious complications.

Sclerotherapy for the treatment of postmastectomy seroma.

BACKGROUND: Seroma is a common complication after mastectomy. We review our experience with sclerotherapy for postmastectomy seroma management. METHODS: Patients who underwent outpatient sclerotherapy for postmastectomy seroma were reviewed. Ninety-five percent ethyl alcohol or povidone iodine, which was administered by way of percutaneous catheter, was the initial sclerosant, and dwell time was 20 to 30 minutes. Povidone iodine solution was instilled 2 to 3 times daily. Catheters were removed when output reached <30 mL/d or when cavity size was <20 ml by sinogram. RESULTS: Sixteen patients (18 seromas) had sclerotherapy initiated at median of 34 days after surgery. Mean number of treatment days was 3 (median duration 16). Seven patients (44%) developed infection during treatment, which was associated with increased duration. Three seromas recurred and were successfully treated with single aspiration. COMMENTS: Sclerotherapy is a feasible treatment for chronic seroma after mastectomy. Longer treatment duration was associated with infection; antibiotic prophylaxis should be considered. Research is necessary to determine optimal regimens and superiority over other approaches.

Outcome of adrenocortical tumors in children.

PURPOSE: This study reviews adrenocortical tumors in children to determine factors that significantly affect outcome. METHODS: An institutional review board-approved retrospective review from 1976 to 2005 identified 23 patients younger than 19 years old with histologic confirmation of adrenocortical carcinoma (ACC) and adenomas. RESULTS: The mean age of the 23 children was 9.0 +/- 1.6 years; girls predominated (female-to-male ratio = 1.9:1) as did cancers (ACC 16, adenoma 7); tumor hormone production (74%); and advanced stage for disease (66%). All malignancies were more than 2.5 cm. Adrenalectomy, including en bloc resection of adjacent structures (35%) achieved grossly negative margins in 70% of patients. Three patients received chemotherapy or chemoradiation as primary treatment without surgery. There was no perioperative mortality; morbidity was 10% (pneumothorax, acute renal failure, chylous ascites, and thrombocytosis). Surgical cure without adjuvant therapy was achieved for all adenomas and ACC stages I and II. For ACC stage III and IV, median survival was 21 months, 5-year survival was 0%. All advanced-staged ACC received adjuvant therapy. Surgically negative margins conferred a survival advantage. CONCLUSIONS: Children, especially females with ACC present with large advanced-staged tumors. Surgically negative margins with or without en bloc resection improves survival. The high percentage of children with functioning tumors suggests earlier detection is possible.

Pediatric endoscopic injuries: incidence, management, and outcomes.

BACKGROUND: Endoscopy has assumed a significant role in the management of gastrointestinal disorders. However, endoscopic-related injuries are poorly reported. METHODS: Review of our surgical database (1980-2006) identified all patients age 18 years or younger with an endoscopic-related injury managed at our institution. RESULTS: A total of 3269 colonoscopies were performed; there were 3 iatrogenic perforations (incidence, 0.09%). All were managed operatively: 2 underwent fecal diversion, and 1 was repaired primarily. There was 1 postoperative complication (internal hernia) and no deaths related to colonoscopic perforation. Nine thousand three hundred eight esophagogastroduodenoscopy (EGD) procedures were performed, resulting in 6 iatrogenic injuries (0.06%): bleeding (2), perforation (2), and mucosal tears (2) (0.02% each). All EGD-related injuries occurred in the esophagus except for 1 duodenal perforation which was managed operatively by primary repair. Both patients with bleeding complications underwent repeat endoscopy and cautery with satisfactory results. The other 3 patients were managed conservatively without complication. Three hundred eighty-nine endoscopic retrograde cholangiopancreatogram procedures were performed with 2 iatrogenic injuries (0.5%): 1 bleed and 1 perforation (0.25% each). Both were managed conservatively without complication. CONCLUSION: Endoscopic injuries are uncommon. Colonoscopic perforations require prompt surgical intervention. Esophagogastroduodenoscopy- and endoscopic retrograde cholangiopancreatogram-related injuries are amenable to conservative therapy in clinically stable patients devoid of peritonitis.