Exchange of Extracorporeal Membrane Oxygenation Cannulas for Hemodialysis Catheters in Children Requiring Renal Replacement Therapy.

BACKGROUND: Pediatric patients requiring extracorporeal membrane oxygenation (ECMO) may require renal replacement therapy even after decannulation. However, data regarding transition from ECMO cannulation to a hemodialysis catheter in pediatric patients is not currently available. METHODS: Patients <18 years old who had an ECMO cannula exchanged for a hemodialysis catheter during decannulation at a tertiary care children's center from January 2011 to September 2022 were identified. Data was collected from the electronic medical record. RESULTS: A total of 10 patients were included. The cohort was predominantly male (80.0%, n = 8) with a median age of 1 day (IQR 1.0, 24.0). All ECMO cannulations were veno-arterial in the right common carotid artery and internal jugular vein. The median time on ECMO was 8.5 days (IQR 6.0, 15.0). One patient had the venous cannula exchanged for a tunneled hemodialysis catheter during decannulation, two were transitioned to peritoneal dialysis, and seven had the temporary hemodialysis catheter converted to a tunneled catheter by Interventional Radiology (when permanent access was required) at a median time of 10 days (IQR 8.0, 12.5). Of these 7 patients, 28.6% (n = 2) developed catheter-associated infection within 30 days of replacement, with one requiring catheter replacement. Transient bloodstream infection occurred in 10.0% (n = 1) within 30 days of ECMO cannula exchange. CONCLUSION: Venous ECMO cannula exchange for a hemodialysis catheter in children requiring renal replacement therapy after decannulation is possible as a bridge to a permanent hemodialysis or peritoneal catheter if renal function does not recover, while supporting vein preservation.

Hepatic artery thrombosis and use of anticoagulants and antiplatelet agents in pediatric liver transplantation.

BACKGROUND: Hepatic artery thrombosis (HAT) is a reported complication of 5%-10% of pediatric liver transplantations, rates 3-4 times that seen in adults. Early HAT (seen within 14 days after transplant) can lead to severe allograft damage and possible urgent re-transplantation. In this report, we present our analysis of HAT in pediatric liver transplant from a national clinical database and examine the association of HAT with anticoagulant or antiplatelet medication administered in the post-operative period. METHODS: Data were obtained from the Pediatric Health Information System database maintained by the Children's Hospital Association. For each liver transplant recipient identified in a 10-year period, diagnosis, demographic, and medication data were collected and analyzed. RESULTS: Our findings showed an average rate of HAT of 6.3% across 31 centers. Anticoagulant and antiplatelet medication strategies varied distinctly among and even within centers, likely due to the fact there are no consensus guidelines. Notably, in centers with similar medication usage, HAT rates continue to vary. At the patient level, use of aspirin within the first 72 h of transplantation was associated with a decreased risk of HAT, consistent with other reports in the literature. CONCLUSION: We suggest that concerted efforts to standardize anticoagulation approaches in pediatric liver transplant may be of benefit in the prevention of HAT. A prospective multi-institutional study of regimen-possibly including aspirin-following transplantation could have significant value.

Hypertrophic Pyloric Stenosis Protocol: A Single Center Study.

BACKGROUND: Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. METHODS: We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. RESULTS: The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. DISCUSSION: This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.

Duodenal Atresia Repair: A Single-Center Comparative Study.

BACKGROUND: The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. METHODS: Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. RESULTS: A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. CONCLUSION: The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.

Management of Primary Spontaneous Pneumothorax in Children: A Single Institution Protocol Analysis.

BACKGROUND: The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol. METHODS: A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed. RESULTS: Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01]. CONCLUSION: Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity. LEVEL OF EVIDENCE: IV. Retrospective study.

Institutional outcomes of blunt liver and splenic injury in the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium era.

BACKGROUND: The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium practice management guideline was created to standardize management of blunt liver or spleen injury across pediatric trauma centers. We describe our outcomes since guideline adoption at our institution and hypothesize that blunt liver or spleen injury may be managed more expeditiously than currently reported without compromising safety. METHODS: A retrospective cohort study was conducted on patients younger than 18 years presenting with blunt liver and/or splenic injuries from March 2016 to March 2021 at one participating center. RESULTS: A total of 199 patients were included. There were no clinically relevant differences for age, body mass index, or sex among the cohort. Isolated splenic injuries (n = 91 [46%]) and motor vehicle collisions (n = 82 [41%]) were the most common injury and mechanism, respectively. The overall median length of stay (LOS) was 1.2 days (interquartile range, 0.45-3.3 days). Intensive care unit utilization was 23% (n = 46). There was no statistically significant difference in median LOS among patients with isolated solid organ injuries, regardless of injury grade. There were no readmissions associated with non-operative management. CONCLUSION: The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium guideline fosters high rates of nonoperative management with low intensive care unit utilization and LOS while demonstrating safety in implementation, irrespective of injury grade. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Laparoscopic Gastrostomy in Infants During an Open Abdominal Procedure: A Novel Approach.

Introduction: Infants with intra-abdominal pathology necessitating open abdominal surgery may also require placement of a gastrostomy tube (GT). Use of laparoscopy provides better visualization for gastrostomy placement and lowers the risk of complications compared with an open approach. We describe a series of patients who underwent laparoscopic GT placement at the time of an open abdominal procedure. Methods: All patients who underwent an open abdominal procedure with concurrent laparoscopic gastrostomy from January 2010 to June 2020 were reviewed. Descriptive statistics were performed with categorical variables reported as proportions and continuous variables reported as medians with interquartile range [IQR]. Results: Twelve patients were included; 8 (67.5%) were male. The median age at time of surgery was 10 weeks [IQR 6, 14], with a median weight of 4.1 kg [IQR 3.4, 4.8]. Ten patients had the laparoscope placed through the open incision, whereas 2 had the laparoscope placed through a separate incision. Median operative time was 106 minutes [IQR 80, 125]. There were no intraoperative complications. Postoperative complications included surgical site infection in 5 (41.7%), leaking around the GT in 3 (25%), and malfunction of the tube in 1 (8.3%). One patient required reoperation 28 days postoperatively due to malfunction. Conclusion: Laparoscopic GT can be safely performed at the time of an open abdominal procedure, and frequently through the same incision, harnessing the benefits of a laparoscopic approach even when an open incision is needed.

Umbilical access in laparoscopic surgery in infants less than 3 months: A single institution retrospective review.

INTRODUCTION: Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO2) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years. METHODS: A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016 to 2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death. RESULTS: Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO2 embolism. CONCLUSION: In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO2 embolism exists, these complications are not exclusively associated with umbilical access technique.

Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection.

PURPOSE: COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI). METHODS: A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded. RESULTS: Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation. CONCLUSION: Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.

Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease.

INTRODUCTION: Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. METHODS: A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. RESULTS: Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode. CONCLUSION: Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.

Evaluation of a fluid resuscitation protocol for patients with hypertrophic pyloric stenosis.

INTRODUCTION: We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay. METHODS: A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded. RESULTS: Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p < .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p < .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p < .05). CONCLUSION: Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents. LEVEL OF EVIDENCE: III - Retrospective comparative study.

Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital.

OBJECTIVES: With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. MATERIALS AND METHODS: A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. RESULTS: A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. CONCLUSION: Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.

The impact of botulinum injection for hospitalized children with Hirschsprung-associated enterocolitis.

INTRODUCTION: Stasis from obstruction at the level of the internal anal sphincter (IAS) can lead to Hirschsprung-associated enterocolitis (HAEC) and may be improved by botulinum toxin (BT) injections. Our aim was to determine if BT injection during HAEC episodes decreased the number of recurrent HAEC episodes and/or increased the interval between readmissions. METHODS: A retrospective review was performed of patients admitted for HAEC from January 2010 to December 2019. Demographics and outcomes of patients who received BT were compared to patients who did not receive BT during their hospital stay. RESULTS: A total of 120 episodes of HAEC occurred in 40 patients; 30 patients (75%) were male, 7 (18%) had Trisomy 21 and 10 (25%) had long-segment disease. On multivariate analysis, patients who received BT during their inpatient HAEC episode had a longer median time between readmissions (p = 0.04) and trending toward an association with fewer readmissions prior to a follow-up clinic visit (p = 0.08). CONCLUSION: The use of BT in HD patients hospitalized for HAEC is associated with an increased time between recurrent HAEC episodes and trended toward fewer recurrent episodes. The use of BT should be considered in the management of patients admitted with HAEC.

Neonatal Renal Failure in the Setting of Anorectal Malformation: A Case Report and Literature Review.

Anorectal malformations (ARMs) can occur in isolation or in association with other anomalies, most commonly those of the genitourinary systems. Morbidity and mortality are highest among patients who develop end-stage renal disease (ESRD) either from severe congenital anomalies (dysplastic kidneys) or from repeated infections in those who have vesicoureteral reflux or persistent recto-urinary fistulas. We describe our management strategy for a patient born with an ARM and bilateral dysplastic kidneys to highlight the nuances and complex decision-making considerations required in taking care of this complex patient population. Our patient is a male twin born at 32 weeks' gestational age who was found to have bilateral dysplastic kidneys on prenatal ultrasound. On initial examination, an imperforate anus was identified along with a severe urethral stricture. Full workup also revealed sacral dysgenesis and confirmation of the dysplastic kidneys. On day of life 3, a laparoscopic diverting sigmoid colostomy was performed; urologic evaluation confirmed the severe urethral stricture, which required dilation to place an 8F council tip catheter. Due to his small size, peritoneal dialysis could not be initiated until five weeks of age. As full volumes could not be reached with peritoneal dialysis, he was soon transitioned to continuous renal replacement therapy. At five months of age, a laparoscopic-assisted posterior sagittal anorectoplasty (PSARP) was performed. As his urethral stricture had worsened, a suprapubic catheter had been placed for bladder decompression. Reversal of his colostomy was performed 15 days after PSARP. Unfortunately, the patient required three further surgical interventions due to abdominal wall and inguinal hernias contributing to filling and emptying dysfunction when utilizing peritoneal dialysis. He is currently 16 months of age and remains inpatient due to intermittent hemodialysis requirements along with autocycling of his peritoneal dialysis. He is working on developmental milestones, can pull to a stand, and is currently being evaluated for kidney transplantation. The development of ESRD in a neonate or infant with an ARM is rare and can be due to congenital dysplasia or agenesis of bilateral kidneys. While peritoneal dialysis is the preferred approach, catheter dysfunction can result from intra-abdominal adhesions or inadequate fluid removal from inguinal or abdominal wall hernias that form in the setting of increased intra-abdominal pressure required for peritoneal dialysis. Close collaboration is required between pediatric surgeons, nephrologists, and urologists to facilitate colonic and urologic reconstruction and manage catheter-related complications.

A single institution experience with Laparoscopic Hernia repair in 791 children.

INTRODUCTION: There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique. METHODS: A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis. RESULTS: 791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically. CONCLUSIONS: The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.

Tisagenlecleucel infusion in patients with relapsed/refractory ALL and concurrent serious infection.

BACKGROUND: Tisagenlecleucel, an anti-CD19 chimeric antigen receptor T (CAR-T) cell therapy, has demonstrated durable efficacy and a manageable safety profile in pediatric and young adult patients with relapsed/refractory B-cell acute lymphoblastic leukemia (B-ALL) in the ELIANA pivotal trial and real-world experience. Experience from investigator-led studies prior to ELIANA suggests that infections and inflammatory conditions may exacerbate the severity of cytokine release syndrome (CRS) associated with CAR-T cell therapy, leading to extreme caution and strong restrictions for on-study and commercial infusion of tisagenlecleucel in patients with active infection. CRS intervention with interleukin (IL)-6 blockade and/or steroid therapy was introduced late in the course during clinical trials due to concern for potential negative effect on efficacy and persistence. However, earlier CRS intervention is now viewed more favorably. Earlier intervention and consistency in management between providers may promote broader use of tisagenlecleucel, including potential curative therapy in patients who require remission and recovery of hematopoiesis for management of severe infection. MAIN BODY: Patient 1 was diagnosed with B-ALL at 23 years old. Fourteen days before tisagenlecleucel infusion, the patient developed fever and neutropenia and was diagnosed with invasive Mucorales infection and BK virus hemorrhagic cystitis. Aggressive measures were instituted to control infection and to manage prolonged cytopenias during CAR-T cell manufacturing. Adverse events, including CRS, were manageable despite elevated inflammatory markers and active infection. The patient attained remission and recovered hematopoiesis, and infections resolved. The patient remains in remission ≥1 year postinfusion.Patient 2 was diagnosed with pre-B-ALL at preschool age. She developed severe septic shock 3 days postinitiation of lymphodepleting chemotherapy. After receiving tisagenlecleucel, she experienced CRS with cardiac dysfunction and extensive lymphadenopathy leading to renovascular compromise. The patient attained remission and was discharged in good condition to her country of origin. She remained in remission but expired on day 208 postinfusion due to cardiac arrest of unclear etiology. CONCLUSIONS: Infusion was feasible, and toxicity related to tisagenlecleucel was manageable despite active infections and concurrent inflammation, allowing attainment of remission in otherwise refractory pediatric/young adult ALL. This may lead to consideration of tisagenlecleucel as a potential curative therapy in patients with managed active infections.

Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols.

PURPOSE: Previous reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis. MATERIAL AND METHODS: A retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value <.05 determined as significant. RESULTS: A total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation. CONCLUSION: Our evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted. LEVELS OF EVIDENCE: Therapeutic study; Level 3.

30 Years of Flipping the Coin-Heads or Tails?

INTRODUCTION: Swallowed coins are a frequent cause of pediatric emergency department visits. Removal typically involves endoscopic retrieval under anesthesia. We describe our 30-year experience retrieving coins using a Foley catheter under fluoroscopy ("coin flip"). MATERIALS AND METHODS: Patients younger than 18 years who underwent the coin flip procedure from 1988 to 2018 were identified. Failure of fluoroscopic retrieval was followed by rigid endoscopic retrieval in the operating room. Detailed subanalysis of patients between 2011 and 2018 was also performed. RESULTS: A total of 809 patients underwent the coin flip procedure between 1988 and 2018. Median age was 3.3 years; 51% were male. The mean duration from ingestion to presentation was 19.8 hours. Overall success of removal from the esophagus was 85.5%, with 76.5% of coins retrieved and 9% pushed into the stomach. All remaining coins were retrieved by endoscopy. Complication rate was 1.2% with nine minor and one major complications, a tracheal tear that required repair. In our recent cohort, successful fluoroscopic removal led to shorter hospital lengths of stay (3.2 vs. 18.1 hours, p < 0.001). CONCLUSION: Patients who present with a coin in the esophagus can be successfully managed with a coin flip, which can be performed without hospital admission, with rare complications.