The effect of perioperative dexamethasone dosing on post-tonsillectomy hemorrhage risk.

OBJECTIVES: Dexamethasone is currently recommended for routine prophylaxis against postoperative nausea and vomiting after tonsillectomy procedures. However, some studies have raised concern that dexamethasone use may lead to higher rates of post-tonsillectomy hemorrhage. Our objective was to determine whether higher doses of dexamethasone administered perioperatively during tonsillectomy procedures are associated with an increased risk of secondary post-tonsillectomy hemorrhage. METHODS: We conducted a retrospective review of 9843 patients who underwent tonsillectomy and received dexamethasone at our institution from January 2010 to October 2014. We compared the dose of dexamethasone administered to patients who did and did not develop secondary post-tonsillectomy hemorrhage using Mann Whitney U tests. Multivariable logistic regression models were used to evaluate the association between dexamethasone dose and post-tonsillectomy hemorrhage after adjustment for demographic and clinical characteristics. RESULTS: A total of 280 (2.8%) patients developed secondary post-tonsillectomy hemorrhage. Patients who developed hemorrhage tended to be older (median (interquartile range) 7 (4-11) vs. 5 (3-8) years), p < 0.001) and had undergone tonsillectomy more often for chronic tonsillitis but less often for tonsillar or adenotonsillar hypertrophy or sleep disturbances. Dexamethasone dose was significantly lower on average in patients who experienced secondary post-tonsillectomy hemorrhage (median (interquartile range) 0.19 (0.14, 0.23) mg/kg vs. 0.21 (0.17, 0.30), p < 0.001). Multivariable modeling demonstrated that the dose of dexamethasone was not significantly associated with post-tonsillectomy hemorrhage after adjustment for age. CONCLUSIONS: There does not appear to be a dose-related increase in the risk of post-tonsillectomy hemorrhage for patients receiving dexamethasone during tonsillectomy procedures.

Evaluation of an imaging protocol using ultrasound as the primary diagnostic modality in pediatric patients with superficial soft tissue infections of the face and neck.

OBJECTIVE: To determine the clinical impact of an initiative to use ultrasound (US) as the primary diagnostic modality for children with superficial face and neck infections versus use of computed tomography (CT). METHODS: Children with a diagnosis of lymphadenitis, face or neck abscess, or face and neck cellulitis were retrospectively evaluated by the otolaryngology service. Patients were separated into two groups based on implementation of a departmental initiative to use US as the primary diagnostic modality. The pre-implementation cohort consisted of patients treated prior to the initiative (2006-2009) and the current protocol cohort consisted of patients treated after the initiative was started (2010-2013). Demographics, use of US or CT, necessity of surgical intervention, and failure of medical management were compared. RESULTS: Three hundred seventy three children were evaluated; 114 patients were included in the pre-implementation cohort and 259 patients were included in the current protocol cohort for comparison. Patients presenting during the current protocol period were more likely to undergo US (pre-implementation vs. current protocol, p-value) (12% vs. 49%, p < 0.0001) and less likely to undergo CT (66% vs. 41%, p < 0.0001) for their initial evaluation. There were no differences in the percentage of children who underwent prompt surgical drainage, prompt discharge without surgery, or trial inpatient observation. There were also no differences in the rate of treatment failure for patients undergoing prompt surgery or prompt discharge on antibiotics. For those patients who underwent repeat evaluation following trial medical management, US was used more frequently in the current protocol period (4% vs. 20%, p = 0.002) with no difference in CT use, selected treatment strategy, or treatment failure rates. CONCLUSION: Increased use of US on initial evaluation of children with superficial face and neck infections resulted in decreased CT utilization, without negatively impacting outcome. Decreasing pediatric radiation exposure and potential long-term effects is of primary importance.

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.

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.

Pancreaticoduodenectomy outcomes in the pediatric, adolescent, and young adult population.

BACKGROUND: Pancreatic malignancy and chronic pancreatitis are rare in the pediatric, adolescent, and young adult (AYA) population, making pancreas resections an infrequent procedure in this demographic. Only case reports and small case series exist in the literature describing surgical outcomes and complications in this population. The aim of this study was to review the surgical outcomes of pediatric/AYA patients undergoing pancreaticoduodenectomy (PD) at our institution. METHODS: All pediatric/AYA adult patients (≤30 years) undergoing PD over a 15-year period (1998-2013) from a large academic institution were included. We provide adult (>30 years) data from our same institution for observational comparison. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data. RESULTS: Twenty-two patients with a median age of 25 years (range, 11-30 years) underwent PD. The most common postoperative histologic diagnoses were chronic pancreatitis (6, 27.3%), solid pseudopapillary neoplasm (5, 22.7%), and adenocarcinoma (4, 18.2%). Complications were 31.8% in the pediatric/AYA cohort and 58.6% in the adult cohort. The most common postoperative complication was intraabdominal abscess, which occurred in three patients (13.6%). Thirty-day mortality was 0% for pediatric/AYA patients. There were no recurrences or disease-related deaths in patients with solid pseudopapillary neoplasm. Pediatric patients with adenocarcinoma had a median survival of 10.2 mo (interquartile range, 9-21), in contrast to adults of 57.8 mo (interquartile range, 11-132). CONCLUSIONS: This is the largest series of PD procedures reported in the pediatric/AYA population. The procedure appears to be safe, with no 30-day mortalities and an acceptable complication rate.

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.

Outcomes in pediatric patients with recreational vehicle related forceful head impact.

PURPOSE: To compare outcomes in pediatric patients suffering forceful head impact during recreational vehicle use to patients with forceful head impact from other mechanisms. METHODS: Retrospective cohort study of all patients 3-18 years old who suffered forceful head impact (any traumatic mechanism strong enough to result in a face or skull fracture) in our institutional trauma registry between January 2011 and September 2013. RESULTS: Out of 252 events involving forceful head impact, 64 events were a result of riding a recreational vehicle. Although there is no difference in rates of temporal bone fractures, recreational vehicle accidents have higher rates of otic capsule violation (21% vs. 5%) and higher rates of hearing loss (30% vs 16%) compared to patients with forceful head impact from other mechanisms. All incidents of otic capsule violation and sensorineural hearing loss in recreational vehicle accidents were associated with a temporal bone fracture. CONCLUSION: Despite the increasing use of head protective gear while operating a recreational motor vehicle there is still heightened risk for temporal bone fractures and subsequent hearing loss. The comparative associations in this study suggest that helmets used with recreational vehicles do not protect the temporal bone thus leaving vital structures within the otic capsule at risk for damage and long term consequences. When treating these patients Otolaryngologists should be aware of the elevated risk of otic capsule violation and late hearing loss with temporal bone fractures.

Outcomes following neuromuscular blockade in patients receiving tracheostomies.

OBJECTIVE: The purpose of this study is to determine whether the use of neuromuscular blockade agents (NMBAs) in pediatric patients following tracheostomy is associated with increased rates of complications or a prolonged length of stay. METHODS: This was a single-center retrospective chart review of pediatric patients undergoing tracheostomy placement between 2010 and 2013 who were admitted to the pediatric or neonatal intensive care units and did or did not receive NMBA within 7 days post-procedure. RESULTS: Out of 114 included patients, 26 (23%) received NMBAs during the postoperative period. Patients receiving NMBAs were more likely to have cardiac disease and preoperative respiratory failure but less likely to have neurologic disease. Patients receiving NMBAs had a longer median postoperative length of stay (33 vs. 23 days, p=0.043) and were more likely to have postoperative ileus (12% vs. 3%, p=0.037). CONCLUSION: In patients undergoing tracheostomy placement, use of NMBAs is associated with prolonged postoperative hospital courses. NMBAs are not associated with a higher likelihood of postoperative complications.

High failure rate of nonoperative management of acute appendicitis with an appendicolith in children.

BACKGROUND: The purpose of this study was to investigate the feasibility of nonoperative management of acute appendicitis in children with an appendicolith identified on preoperative imaging. STUDY DESIGN: We performed a prospective nonrandomized trial of nonoperative management of uncomplicated acute appendicitis with an appendicolith in children aged 7 to 17years. The primary outcome was the failure rate of nonoperative management, defined as having undergone an appendectomy. Early termination was set to occur if the lower limit of the 95% confidence interval of the failure rate was greater than 20% at 30days or 30% at 1year. RESULTS: Recruitment for this study was halted after enrollment of 14 patients (N=5 nonoperative; N=9 surgery). The failure rate of nonoperative management was 60% (3/5) at a median follow-up of 4.7months (IQR 1.0-7.6) with a 95% CI of 23%-88%. None of the three patients that failed nonoperative management had complicated appendicitis at the time of appendectomy, while six out of nine patients who chose surgery had complicated appendicitis (0/3 vs. 6/9, p=0.18). The trial was stopped for concerns over patient safety. CONCLUSIONS: Nonoperative management of acute appendicitis with an appendicolith in children resulted in an unacceptably high failure rate.

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.

Effectiveness of Patient Choice in Nonoperative vs Surgical Management of Pediatric Uncomplicated Acute Appendicitis.

IMPORTANCE: Current evidence suggests that nonoperative management of uncomplicated appendicitis is safe, but overall effectiveness is determined by combining medical outcomes with the patient's and family's perspective, goals, and expectations. OBJECTIVE: To determine the effectiveness of patient choice in nonoperative vs surgical management of uncomplicated acute appendicitis in children. DESIGN, SETTING, AND PARTICIPANTS: Prospective patient choice cohort study in patients aged 7 to 17 years with acute uncomplicated appendicitis presenting at a single pediatric tertiary acute care hospital from October 1, 2012, through March 6, 2013. Participating patients and families gave informed consent and chose between nonoperative management and urgent appendectomy. INTERVENTIONS: Urgent appendectomy or nonoperative management entailing at least 24 hours of inpatient observation while receiving intravenous antibiotics and, on demonstrating improvement of symptoms, completion of 10 days of treatment with oral antibiotics. MAIN OUTCOMES AND MEASURES: The primary outcome was the 1-year success rate of nonoperative management. Successful nonoperative management was defined as not undergoing an appendectomy. Secondary outcomes included comparisons of the rates of complicated appendicitis, disability days, and health care costs between nonoperative management and surgery. RESULTS: A total of 102 patients were enrolled; 65 patients/families chose appendectomy (median age, 12 years; interquartile range [IQR], 9-13 years; 45 male [69.2%]) and 37 patients/families chose nonoperative management (median age, 11 years; IQR, 10-14 years; 24 male [64.9%]). Baseline characteristics were similar between the groups. The success rate of nonoperative management was 89.2% (95% CI, 74.6%-97.0%) at 30 days (33 of 37 children) and 75.7% (95% CI, 58.9%-88.2%) at 1 year (28 of 37 children). The incidence of complicated appendicitis was 2.7% in the nonoperative group (1 of 37 children) and 12.3% in the surgery group (8 of 65 children) (P = .15). After 1 year, children managed nonoperatively compared with the surgery group had fewer disability days (median [IQR], 8 [5-18] vs 21 [15-25] days, respectively; P < .001) and lower appendicitis-related health care costs (median [IQR], $4219 [$2514-$7795] vs $5029 [$4596-$5482], respectively; P = .01). CONCLUSIONS AND RELEVANCE: When chosen by the family, nonoperative management is an effective treatment strategy for children with uncomplicated acute appendicitis, incurring less morbidity and lower costs than surgery. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01718275.

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.

Using the maxillary-nasal angle to evaluate congenital nasal pyriform aperture stenosis.

IMPORTANCE: Congenital nasal pyriform aperture stenosis (CNPAS) is a rare cause of nasal airway obstruction in newborns. The decision to operate is made clinically. Although pyriform aperture width is used for diagnosing CNPAS, it does not fully characterize stenosis of the nasal cavity. OBJECTIVE: To determine the utility of additional metrics for evaluating CNPAS. DESIGN, SETTING, AND PARTICIPANTS: The medical records of 13 patients with CNPAS treated from 2007 through 2012 at a single tertiary pediatric facility were retrospectively examined. Data on patient demographic characteristics, known genetic abnormalities, and hospital courses were extracted. Computed tomographic images were evaluated for pyriform aperture width; maxillary-nasal angle (MNA), defined as the angle between the anterior maxilla and anterior-posterior nasal axis; and choanal width. INTERVENTIONS: Medical management and surgical management. MAIN OUTCOMES AND MEASURES: Pyriform aperture width, MNA, and choanal width. RESULTS: Six of 13 patients underwent medical management, and 7 patients underwent surgical treatment. For patients who were managed medically as compared with those managed surgically, the evaluation revealed a larger pyriform aperture width (median [interquartile range {IQR}], 5.6 [5.4-6.1] vs 4.6 [4.5-4.7] mm; P = .03) and MNA (median [IQR], 70° [63°-73°] vs 59° [59°-64°]; P = .048) but no significant difference in choanal width (median [IQR], 11.0 [9.6-12.2] vs 11.9 [10.3-11.9] mm; P = .76). CONCLUSIONS AND RELEVANCE: The MNA, when used in conjunction with pyriform aperture width, provides additional pertinent information to supplement clinical decision making in the evaluation of patients with CNPAS. These measurements may be helpful in identifying patients who should undergo surgical intervention, although additional studies would be required to allow predictive use of the MNA.

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.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Using quality improvement methods to change surgical practice: a case example of pediatric soft-tissue abscesses.

BACKGROUND: Surgical treatments of soft-tissue abscesses (STAs) include packing and ring drain (RD) and straight drain (SD) placement. Potential benefits of SDs include a single incision, less scarring, and no need for a follow-up appointment. We used a multidisciplinary quality improvement (QI) process to promote surgeon adoption of an STA drainage technique to improve efficiency and quality of care. SUBJECTS AND METHODS: Outcome measures included the proportion of STAs drained using SDs, the number of postoperative clinic visits, the proportion of patients requiring follow-up with a pediatric surgeon and other providers, and the postoperative complication rate, defined as need for an additional drainage procedure. RESULTS: After beginning the QI initiative, the proportion of STAs drained by SDs increased from 23% to 78% (P < .00001) and the proportion of patients requiring a surgical follow-up clinic appointment decreased from 71% to 32% (P < .00001). The mean number of surgical clinic visits per patient decreased from 0.79 to 0.39 visits per patient (P < .00001). Complication rates were similar between drain types (RD: 2.4%; SD: 1.7%; P = .57). This QI initiative produced a rapid sustained shift in surgeon practice with increased use of SDs, decreased number of follow-up visits, and no increase in complications.

Prediction of symptom improvement in children with biliary dyskinesia.

BACKGROUND: Rates of cholecystectomy for biliary dyskinesia are rising. Our objective was to identify clinical determinants of symptom improvement in children undergoing cholecystectomy for biliary dyskinesia. METHODS: This retrospective cohort study included patients undergoing cholecystectomy for biliary dyskinesia from 2006-2013 who had their gallbladder ejection fraction (EF) measured by either cholecystokinin-stimulated hepatobiliary iminodiacetic acid scan and/or fatty meal ultrasound. Patients presenting from 2010-2013 were interviewed >1 y after cholecystectomy to determine symptom improvement, complete symptom resolution, and any postoperative clinical interventions related to biliary dyskinesia. Sensitivity and positive predictive values for the diagnostic tests for symptom improvement were calculated. Multivariable logistic regression models were used to identify preoperative characteristics associated with symptom improvement. RESULTS: Of the 153 included patients, 76% were female, 89% were Caucasian, and 39% were obese. At postoperative evaluation, symptom improvement was reported by 82% of the patients and complete symptom resolution in 56%. For both the hepatobiliary iminodiacetic acid and fatty meal ultrasound, the sensitivity of the test to predict symptom improvement increased with higher EF, whereas the positive predictive values remained around 80%. Of the 41 patients who participated in phone interview for long-term follow-up, 85% reported symptom improvement and 44% reported complete symptom resolution. Factors associated with symptom improvement included a shorter duration of pain, a history of vomiting, and a history of epigastric pain. CONCLUSIONS: Despite not identifying an EF level that predicted symptom improvement, over 80% of patients undergoing cholecystectomy for biliary dyskinesia reported symptom improvement. These results support continuing to offer cholecystectomy to treat biliary dyskinesia in children.

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.

Feasibility of a nonoperative management strategy for uncomplicated acute appendicitis in children.

BACKGROUND: For decades, urgent operation has been considered the only appropriate management of acute appendicitis in children. The purpose of this study was to investigate the feasibility of nonoperative management of uncomplicated acute appendicitis in children. STUDY DESIGN: A prospective nonrandomized clinical trial of children with uncomplicated acute appendicitis comparing nonoperative management with urgent appendectomy was performed. The primary result was 30-day success rate of nonoperative management. Secondary outcomes included comparisons of disability days, missed school days, hospital length of stay, and measures of quality of life and health care satisfaction. RESULTS: Seventy-seven patients were enrolled during October 2012 to October 2013; 30 chose nonoperative management and 47 chose surgery. There were no significant differences in demographic or clinical characteristics. The immediate and 30-day success rates of nonoperative management were 93% (28 of 30) and 90% (27 of 30). There was no evidence of progression of appendicitis to rupture at the time of surgery in the 3 patients for whom nonoperative management failed. Compared with the surgery group, the nonoperative group had fewer disability days (3 vs 17 days; p < 0.0001), returned to school more quickly (3 vs 5 days; p = 0.008), and exhibited higher quality of life scores in both the child (93 vs 88; p = 0.01) and the parent (96 vs 90; p = 0.03), but incurred a longer length of stay (38 vs 20 hours; p < 0.0001). CONCLUSIONS: Nonoperative management of uncomplicated acute appendicitis in children is feasible, with a high 30-day success rate and short-term benefits that include quicker recovery and improved quality of life scores. Additional follow-up will allow for determination of longer-term success rate, safety, and cost effectiveness.