Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease.

OBJECTIVES: To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD). STUDY DESIGN: Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD. RESULTS: Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13). CONCLUSIONS: Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.

Diverting Ileostomy for the Treatment of Severe, Refractory, Pediatric Inflammatory Bowel Disease.

OBJECTIVES: Diverting ileostomy is used as a temporizing therapy in patients with perianal Crohn disease; however, little data exist regarding its use for colonic disease. The primary aim of the present study was to determine the role of diversion in severe refractory colonic inflammatory bowel disease (IBD) in a pediatric population. METHODS: Retrospective study of patients who underwent diverting ileostomy at The Children's Hospital of Philadelphia from 2000 to 2014 for the management of severe, refractory colonic IBD. Clinical variables were compared in the 1 year before ileostomy and 1 year after diversion. Surgical and disease outcomes including changes in diagnosis were reviewed through 2015. RESULTS: Twenty-four patients underwent diverting ileostomy for refractory colonic disease. Initial diagnoses were Crohn disease in 10 (42%), ulcerative colitis in 1 (4%), and IBD-unclassified in 13 patients (54%). Comparing data before and after surgery, there were statistically significant improvements in height and weight velocities, height velocity z score, blood transfusion requirement, hemoglobin, and hospitalization rates. Chronic steroid use decreased from 71% to 22%. At the conclusion of the study, 10 patients had undergone subsequent colectomy, 7 had successful bowel reanastomosis, and 7 remain diverted. Seven patients (29%) had a change in diagnosis. There were 13 surgical complications in 7 subjects, including prolapse reduction, stoma revision, and resection of ischemic bowel. CONCLUSIONS: In pediatric patients with refractory colonic IBD, diverting ileostomy can be a successful intervention to induce clinical stability. Importantly, diversion is a steroid-sparing therapy and allows additional time to clarify the diagnosis.

Fast-track management is safe and effective after bowel resection in children with Crohn's disease.

BACKGROUND: "Fast-track" management (FT) challenges traditional postoperative tenets in order to minimize discomfort and optimize inpatient care. We examined the outcomes of consecutively performed laparoscopic-assisted ileocecectomy for Crohn's disease (CD), with particular focus on FT's effects in patients with underlying bowel inflammation. METHODS: We retrospectively reviewed all patients undergoing isolated laparoscopic-assisted ileocecectomy for CD at our institution between 12/2000 and 12/2010, excluding patients with multiple areas of surgical CD, bladder involvement, or age >18years. RESULTS: Seventy-one patients aged 8-18years underwent isolated laparoscopic-assisted ileocecectomy for CD, of which 45 met FT criteria. Individual practice patterns primarily determined which patients were FT-managed. FT management led to decreased length of stay (LOS), time to first stool, time to full diet, and intravenous narcotic use. No significant difference in complications or disease progression was observed between the two groups during 2-year follow up. CONCLUSIONS: Our results suggest that FT is safe and effective in patients with CD. In a chronically ill population, counseling patients and families to expect early discharge is critical to the success of this strategy. Despite CD-related GI pathology, FT patients realized benefits in terms of LOS, time to bowel function, and narcotic use without any increase in complications.