It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone.

BACKGROUND: Published data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design. METHODS: Patients aged 6-17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24-48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms <48 h, WBC<18, appendiceal diameter <11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures. RESULTS: Among 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected "pragmatic" challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL™ scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03). CONCLUSIONS: These data corroborate findings from non-randomized studies suggesting 70-90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success. LEVEL OF EVIDENCE: 1; randomized controlled trial.

Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.

OBJECTIVE: The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge. BACKGROUND: Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children. STUDY DESIGN: We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation. RESULTS: Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29-3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ±â€Š39 vs 47 ±â€Š27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2. CONCLUSIONS: Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

Simple preoperative radiation safety interventions significantly lower radiation doses during central venous line placement in children.

PURPOSE: The purpose of this study was to reduce radiation exposure during pediatric central venous line (CVL) placement by implementing a radiation safety process including a radiation safety briefing and a job-instruction model with a preradiation time-out. METHODS: We reviewed records of all patients under 21 who underwent CVL placement in the operating room covering 22 months before the intervention through 10 months after 2013-2016. The intervention consisted of a radiation safety briefing by the surgeon to the intraoperative staff before each case and a radiation safety time-out. We measured and analyzed the dose area product (DAP), total radiation time pre- and postintervention, and the use of postprocedural chest radiograph. RESULTS: 100 patients with valid DAP measurements were identified for analysis (59 preintervention, 41 postintervention). Following implementation of the radiation safety process, there was a 79% decrease in median DAP (61.4 vs 13.1 rad*cm2, P < 0.001) and a 73% decrease in the median radiation time (28 vs 7.6 s, P < 0.001). Additionally, there was a significant reduction in use of confirmatory CXR (95% vs 15%, P < 0.01). CONCLUSION: A preoperative radiation safety briefing and a radiation safety time-out supported by a job-instruction model were effective in significantly lowering the absorbed doses of radiation in children undergoing CVL insertion. TYPE OF STUDY: Case-control study. LEVEL OF EVIDENCE: Level III.

Increased capture of pediatric surgical complications utilizing a novel case-log web application to enhance quality improvement.

PURPOSE: Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications. METHODS: We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application. RESULTS: 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events). CONCLUSIONS: This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI. TYPE OF STUDY: Diagnostic study/Retrospective study. LEVEL OF EVIDENCE: Level III - case control study.

A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance.

PURPOSE: Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS: Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS: Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION: Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.

Acute Urinary Retention Caused by an Ovarian Teratoma-A Unique Pediatric Presentation and Review.

BACKGROUND: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. CASE REPORT: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations.

Managing radiation exposure in children--reexamining the role of ultrasound in the diagnosis of appendicitis.

PURPOSE: To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children. METHODS: A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate. RESULTS: Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%). CONCLUSIONS: US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.

Evisceration of small bowel after cauterization of an umbilical mass.

The omphalomesenteric duct (OMD), a temporary structure essential to fetal development, normally involutes completely by week 8 or 9 of gestation. On occasion, the OMD persists, the clinical presentations of which vary widely. We describe a case of a 6-week-old male with a patent OMD remnant that was initially treated as an umbilical granuloma, which then potentially allowed for prolapse of the small bowel through the umbilical ring. The patient required resection of the incarcerated bowel but had an otherwise uneventful and complete recovery.

Well-differentiated pancreatic neuroendocrine carcinoma in tuberous sclerosis--case report and review of the literature.

Neuroendocrine tumors of the pancreas are rare in children. They usually occur in the setting of genetic syndromes such as multiple endocrine neoplasia type 1, von Hippel-Lindau disease, and neurofibromatosis 1. These tumors have also been reported in the tuberous sclerosis complex (TSC), but the incidence is low in comparison with other syndromes. Only 9 cases have been described to date, and it is not yet well understood if any connection exists between TSC and pancreatic endocrine tumors. TSC is characterized by mutations in TSC1 and TSC2 genes, which activate the AKT-mTOR oncogenic cascade. Recent molecular studies in pancreatic endocrine tumors showed activation of the same pathway, which points toward a common molecular pathway between these two entities. We present a case of well-differentiated neuroendocrine carcinoma of the pancreas in a child with TSC and discuss the genetic aspects of this disease.

Complicated peptic ulcer disease in three patients with familial dysautonomia.

Familial dysautonomia (FD) is an autosomal recessive disorder characterized by autonomic and sensory neuropathy. Owing to pervasive dysfunction, the disease has protean clinical manifestations, affecting the ocular, gastrointestinal, pulmonary, orthopedic, vasomotor, and neurologic systems. The gastrointestinal perturbations, including dysphagia, gastroesophageal dysmotility, gastroesophageal reflux, and vomiting crises, are among the earliest signs. Here, we present the first 3 instances of gastric ulcers in patients with FD and discuss their common presenting features and the special management that was required.

An unusual form of duplicate bladder exstrophy.

Duplicate bladder exstrophy is a rare variant of the exstrophy/epispadic lesions in which an external patch of exstrophic bladder presents in addition to a closed bladder in a more normal anatomical position, diastasis of the pubis and rectus muscles, and often a form of epispadias. We describe an anomaly of this variant with a fistula to the closed bladder. Careful examination with fluoroscopy and cystoscopy is helpful in defining the anatomy in these variants.

Management and outcomes for children with pyloric stenosis stratified by hospital type.

BACKGROUND: Access to health care has been a source of controversy and public attention in health policy. The issues of access to and utilization of the healthcare system by infants and children is less well documented. Moreover, the impact on outcomes of race, ethnicity, and economic status in infants is vaguely addressed. METHODS: We performed a retrospective analysis of children who had undergone pyloromyotomy from July 31, 1998 to July 31, 2008 at our public hospital and university teaching hospital. Data abstracted included gestational age at delivery, birth weight, gender, race, insurance status, age at presentation, symptom duration, preoperative ultrasound (US), operative date, laboratory evaluations, as well as preoperative, postoperative, and total length of stay (LOS). RESULTS: The mean total preoperative LOS was twice as long at our public hospital than our private hospital (1.78 d versus 0.85 d, P=0.003). Similarly, the mean total length of stay was 0.87 d longer at our public hospital (3.87 d versus 3 d), which trended toward significance (P=0.06). Significantly, 72% (27/33) patients at the private hospital had their US either as an out-patient or on the day of admission, while only 58% (28/48) had an US performed as expeditiously at the public hospital (P=0.03, chi(2) analysis). CONCLUSIONS: Care at our public hospital leads to delayed diagnosis and treatment, resulting in longer preoperative and total LOS in infants with pyloric stenosis, most likely related to the timing of the preoperative US. Efforts should be made to encourage patients to use the outpatient clinic facilities for their ill infants, or for physicians at public hospitals to expedite the US process once the diagnosis of pyloric stenosis is entertained.

Management and outcomes for children with acute appendicitis differ by hospital type: areas for improvement at public hospitals.

BACKGROUND: Access to health care is a well-recognized issue in health policy, but use once patients have entered the health care system is uncommonly addressed. METHODS: We performed a retrospective review of children between 2 and 17 years of age with pathologically confirmed appendicitis at our public city hospital and private university hospital and compared management and outcomes. RESULTS: Among patients with acute appendicitis, the median length of stay was a day longer in the public hospital (2 days vs 1 day, P = <.001) despite a similar complication rate (12% vs 11%). More computed tomography (CT) scans were performed at the public hospital (36% vs 21%, P = .02) with a trend toward less use of ultrasound (US) (54% vs 65%, P = .13). CONCLUSIONS: Children at the public city hospital have a longer length of stay and undergo more expensive imaging. These findings may provide areas for improvement to optimize the care of children with appendicitis at government-funded institutions.

A reinforced suture line prevents recurrence after fundoplication in patients with familial dysautonomia.

BACKGROUND/PURPOSE: Long-term follow-up of fundoplication in patients with familial dysautonomia (FD) has revealed a high rate of recurrent gastroesophageal reflux. This may be because of the unique characteristics of patients with FD which include autonomic denervation accompanied by cyclic vomiting and retching. We reviewed our results with adaptations to the Nissen fundoplication to determine which would be most effective in preventing the need for reoperation. METHODS: We reviewed the records of 108 patient with FD who underwent fundoplication by a single pediatric surgeon from November 1978 to July 1, 2004. Patients were divided into 4 groups based on the operative technique: standard Nissen fundoplication, Nissen with a posterior gastropexy, Nissen with posterior gastropexy and a superior anchoring suture, and Nissen with a reinforced suture line in addition to the previous modifications. Demographic data and surgical outcomes were abstracted. RESULTS: Patients who underwent a Nissen fundoplication with a reinforced suture line were significantly less likely to require a reoperation for recurrent reflux than any other patients (P = .05, Fisher's Exact test) despite the fact that they were younger than patients who underwent a standard Nissen alone. CONCLUSION: The addition of a reinforced suture line to the standard Nissen fundoplication decreases the failure rate for patients with gastroesophageal reflux and FD. A reinforced suture line may be an attractive modification for patients where the fundoplication may be under continued physical stress caused by autonomic perturbations, or other conditions such as uncontrolled seizures or progressive neurologic decline.

Calcified catheter "cast" masquerading as a retained catheter fragment after removal of an implanted venous access device.

Calcified catheter "cast" found on radiologic studies after central venous catheter removal is a rare complication that has been reported twice. Both cases were associated with thrombus. In this case report, we present a 15-year-old boy with acute lymphoblastic leukemia who demonstrated on CT scan a radiopacity in his left brachiocephalic vein after removal of an implanted venous access device. This was initially thought to be a retained catheter fragment. Diagnostic studies, including venogram, excluded the presence of a retained catheter fragment. Additional procedures to retrieve a nonexistent catheter fragment were thus avoided. Therefore, a catheter "cast" should be considered as part of the differential diagnosis when calcification is found on an imaging study after removal of an implantable venous access device to prevent an unwarranted surgical exploration.

Short-term results in 53 US obese pediatric patients treated with laparoscopic adjustable gastric banding.

BACKGROUND: Obesity in the adolescent population has reached epidemic proportions. Although diet and behavior modification can help a minority of teenagers, most of these patients go on to become obese adults. Recently, surgical intervention for morbid obesity has gained increasing support. To date, this has only included gastric bypass procedures. However, this procedure carries at least a 1% mortality rate even in the hands of the most experienced surgeons. Therefore, our center has been using laparoscopic adjustable gastric banding (LAGB) to treat adolescents with morbid obesity. This analysis is a report of our short-term results in our first 53 patients. METHODS: All adolescents aged 13 to 17 years who had undergone LAGB at our institution and had been entered into our prospectively collected database since 2001 were reviewed. Data collected preoperatively included age, sex, race, and body mass index (BMI). Postoperatively recorded data included length of stay, operative morbidity, need for reoperation, as well as percentage of excess weight loss (%EWL) and BMI at 3-month intervals. RESULTS: Fifty-three teenagers aged 13 to 17 years (mean, 15.9 years) underwent LAGB at our institution since September 2001. Of these, 41 were female and 12 were male. The mean preoperative weight was 297 +/- 53 lb and the mean initial BMI was 47.6 +/- 6.7 kg/m2. The %EWL was 37.5 +/- 17.0 at 6 months, 62.7 +/- 27.6 at 1 year, and 48.5 +/- 15.6 at 18 months of follow-up. There were no intraoperative complications. Two patients had band slips that required laparoscopic repositioning, and 2 patients developed a symptomatic hiatal hernia that required laparoscopic repair. All of these procedures were performed as outpatient procedures. A fifth patient developed a wound infection requiring incision and drainage. Other complications included mild hair loss in 5 patients, iron deficiency in 4 patients, nephrolithiasis and cholelithiasis in 1 patient, and gastroesophageal reflux in 1 patient. CONCLUSIONS: Laparoscopic adjustable gastric banding is not only a safe operation for morbidly obese pediatric patients, but also represents an effective treatment strategy with a %EWL of approximately 50% at both 1 year and 18 months of follow-up. Because of the minimal morbidity and complete absence of mortality of the LAGB, it is the optimal surgical option for pediatric patients with morbid obesity.

Laparoscopic neo-os creation in an adolescent with uterus didelphys and obstructed hemivagina.

Uterus didelphys is a rare congenital anomaly with a well-documented association with obstructed hemivagina and ipsilateral renal agenesis. Treatment of this anomaly includes drainage of hematocolopos and excision of the vaginal septum, which has traditionally used a scalpel or scissors, often with hymenotomy. Recently, a less invasive approach using hysteroscopic resection has been reported, allowing improved visualization with preservation of the hymenal ring. In this article, we present an alternative minimally invasive approach using a combination of laparoscopy and vaginoscopy in the case of a 10-year-old girl. This approach allows for treatment in cases wherein vaginoscopy provides inadequate visualization with the advantage of enabling full evaluation for associated complications affecting future fertility including endometriosis, pelvic infection, and pelvic adhesions.

Thymoma in Children: Report of Two Cases and Review of Literature.

Thymoma is an uncommon tumor of childhood. Stage of the tumor is an independent prognostic factor for survival. Surgery is the treatment of choice for stage I and stage II tumors. Chemotherapy is reserved for patients with refractory or metastatic disease. Thymomas are moderately radiosensitive. However, radiation therapy is not an attractive option for children due to its side-effects on developing organs. The authors describe 2 children with completely encapsulated thymoma who were successfully treated with surgery alone. Both patients remain free of disease 3 years after surgery. One of the patients also has nevus sebaceous. The authors also discuss the possible association between the two disease entities.

Thymoma in children: report of two cases and review of literature.

Thymoma is an uncommon tumor of childhood. Stage of the tumor is an independent prognostic factor for survival. Surgery is the treatment of choice for stage I and stage II tumors. Chemotherapy is reserved for patients with refractory or metastatic disease. Thymomas are moderately radiosensitive. However, radiation therapy is not an attractive option for children due to its side-effects on developing organs. The authors describe 2 children with completely encapsulated thymoma who were successfully treated with surgery alone. Both patients remain free of disease 3 years after surgery. One of the patients also has nevus sebaceous. The authors also discuss the possible association between the two disease entities.