Outcomes of patent ductus arteriosus ligation in very low birth weight premature infants: A retrospective cohort analysis.

INTRODUCTION: Patent ductus arteriosus (PDA) can be a significant hemodynamic problem in preterm infants leading to increased morbidity and mortality. PDA ligation is therefore considered an urgent procedure in infants who have failed medical therapy. However, there is controversy regarding optimal timing and decision to operate. This study aimed to evaluate the outcomes and efficacy of PDA ligation in very low birth weight premature infants. METHODS: We performed a retrospective review of our institution's database and included very low birth weight premature infants (<1500 g) who underwent PDA ligation from 2008 to 2019 among 6 centers within the Southern California Kaiser Permanente network system. Indications for PDA ligation were variable but included congestive heart failure, respiratory failure, necrotizing enterocolitis, renal failure, and contraindications to medical therapy. PDA ligations were performed via thoracotomy incisions with ligations using a clip or tie. The primary outcome measure was mortality, and secondary outcomes included various postoperative morbidities. RESULTS: A total of 449 patients met criteria and were included in the study. The mean birth weight was 735 g (125 g-1460 g), and mean gestational age was 25 weeks (21-36 weeks). The mean operating room time was 28 min (9-84 min). 97% of PDAs were clipped, and 3% were tied. Comorbidities at the time of operation included bronchopulmonary dysplasia (59%), retinopathy of prematurity (39%), intraventricular hemorrhage (28%), and necrotizing enterocolitis (10%). There were 2 (0.4%) operative deaths, 15 (3%) deaths within 30 days, and 20 (4%) deaths within 1 year. Other postoperative outcomes included recurrent laryngeal nerve injury (1%), chylothorax (1%), pneumothorax (0.4%), and 3 (0.6%) reoperations. DISCUSSION: Very low birthweight premature infants with hemodynamically and clinically significant PDA are complicated patients. The risks of surgical ligation must be weighed against the potential clinical benefits. The mortality rate in our patient group within our hospital system is lower than those reported in the literature. Surgical ligation appears to be a safe and acceptable option for treatment of this complex problem, especially when medical therapy fails. Further studies are needed to elucidate specific independent risk factors that are associated with morbidity and mortality to further improve outcomes. LEVEL OF EVIDENCE RATING: Level II TYPE OF STUDY: Prognosis study.

Same day discharge after pediatric laparoscopic appendectomy in community hospitals.

INTRODUCTION: Same-day discharge (SDD) protocols after pediatric laparoscopic appendectomy have not been well studied in a community hospital setting, especially when hospitals with low inpatient pediatric censuses are increasingly closing their pediatric units. This study evaluates the outcomes of a SDD protocol after pediatric appendectomy that was implemented across an integrated healthcare system in which hospitals experienced closure of pediatric units. METHODS: Patients between ages 6 to 13 years-old who underwent laparoscopic appendectomy for uncomplicated appendicitis from January 1st 2015 to December 31st 2020 were reviewed. During the study period, an inter-hospital SDD protocol was introduced at nine hospitals, four of which closed their pediatric units. RESULTS: There were 1293 patients in the pre-protocol cohort and 953 patients in the post-protocol cohort. There were 588 (45.5%) patients who underwent SDD in the pre-protocol cohort, compared with 804 (84.4%) patients in the post-protocol cohort (p<0.00001). Postoperative narcotics were prescribed to 358 (27.7%) patients in the pre-protocol cohort, compared to 482 (50.6%) patients in the post-protocol cohort (P<0.00001). There was no difference in the 30-day emergency department visit rate or 30-day readmission rate between the two cohorts. A subgroup analysis comparing the surgical outcomes at community hospitals with and without pediatric units after implementation of the SDD protocol showed no difference. CONCLUSION: Same-day discharge after laparoscopic appendectomy for uncomplicated appendicitis in community hospitals, even after pediatric unit closure, is safe and feasible. The decrease in postoperative LOS and the increase in SDD are not associated with higher complication rates.

Use of Structured Presentation Formatting and NSQIP Guidelines Improves Quality of Surgical Morbidity and Mortality Conference.

BACKGROUND: Surgical Morbidity and Mortality (M&M) conference lacks a standardized structure across institutions. We compared implementation of structure and National Surgical Quality Improvement Program's (NSQIP) definitions to organize our M&M and identify cases for discussion versus the usually used method at many centers of case identification by an attending surgeon or resident. METHODS AND MATERIALS: A prospective study was performed, over a 10-wk period, to compare the identification of adverse events and the educational value of our M&M conference before and after implementation of structured NSQIP-defined presentations. Chart review was performed by a trained surgical clinical reviewer and trained NSQIP resident of all cases over the study period to identify NSQIP-defined occurrences. All presented M&Ms were evaluated for adequate reporting of adverse events and areas for improvement on a three-point scale. Surveys were administered before and after intervention to assess educational value to resident and faculty on a five-point Likert scale. Survey and presentation data were compared using Student's t-tests. P-values <0.05 were considered significant. RESULTS: Before intervention, 15% of NSQIP-defined occurrences were identified compared with 81% after intervention (P < 0.01). Thirty-three percent of deaths (1 of 3) before intervention were identified versus 100% (4 of 4) identified after intervention. Surveys obtained from faculty, residents, and students of individual presentations found improved clarity and educational content in cases presented (2.6-2.8) and improved identification of etiology (2.5-2.8), learning points (2.1-2.7), and opportunities for prevention of future adverse events (2.1-2.6) (all P < 0.01). Residents and faculty overall found that the postintervention model better identified adverse events (3.0-3.7, P = 0.02), opportunities for prevention (2.8-3.3, P = . 04), and promoted improved transparency (2.9-3.8, P < 0.01). Eighty-five percent of participants supported the changes in M&M conference. CONCLUSIONS: Incorporation of a clearly defined structure using NSQIP definitions for morbidity and identification of every mortality in our M&M conference standardized identification of adverse events thus improving conference quality. Consideration of the use of this structure should be given to other surgical departmental M&Ms.