Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease.

OBJECTIVE: To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications. BACKGROUND: H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications. METHODS: A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary children's hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed. RESULTS: We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation. CONCLUSIONS: There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered. THE LEVEL OF EVIDENCE RATING: Level IV.

The Impact of Socioeconomic Status on Appendiceal Perforation in Pediatric Appendicitis.

OBJECTIVE: To assess the impact of socioeconomic status (SES) on pediatric appendicitis outcomes using the validated Agency for Healthcare Research and Quality (AHRQ) SES Index and incorporating block-group data. STUDY DESIGN: We reviewed all patients <18 years old who underwent appendectomy for acute appendicitis from 2009-2013 at our institution. Patient addresses were geocoded and linked to 2010 US Census SES block-group data to determine composite AHRQ SES Index scores based on 7 publically reported SES variables. The primary outcome was appendiceal perforation, and the impact of SES scores, age, race, and insurance status on perforation rates were assessed through regression analyses. RESULTS: Of 1501 patients, 510 (34%) had perforated appendicitis. On bivariate analysis, components of the SES Index associated with an increased perforation rate included lower household income, lower percentage of adults with college education, and higher percentage of adults with <12th grade education (all P < .05). On multivariate analysis, age ≤ 10 years (OR 1.7, 95% CI 1.4-2.2) and public insurance (OR 1.5, 95% CI 1.2-2.0) were associated with increased odds of perforation. CONCLUSIONS: This study used the AHRQ SES scoring system to evaluate SES and its influence on appendiceal perforation. Among our cohort of pediatric patients, the risk of perforation was multifactorial, and younger age and public insurance were stronger predictors of perforation than SES.

Surgical resident education in patient safety: where can we improve?

BACKGROUND: Effective communication and patient safety practices are paramount in health care. Surgical residents play an integral role in the perioperative team, yet their perceptions of patient safety remain unclear. We hypothesized that surgical residents perceive the perioperative environment as more unsafe than their faculty and operating room staff despite completing a required safety curriculum. MATERIALS AND METHODS: Surgeons, anesthesiologists, and perioperative nurses in a large academic children's hospital participated in multifaceted, physician-led workshops aimed at enhancing communication and safety culture over a 3-y period. All general surgery residents from the same academic center completed a hospital-based online safety curriculum only. All groups subsequently completed the psychometrically validated safety attitudes questionnaire to evaluate three domains: safety culture, teamwork, and speaking up. Results reflect the percent of respondents who slightly or strongly agreed. Chi-square analysis was performed. RESULTS: Sixty-three of 84 perioperative personnel (75%) and 48 of 52 surgical residents (92%) completed the safety attitudes questionnaire. A higher percentage of perioperative personnel perceived a safer environment than the surgical residents in all three domains, which was significantly higher for safety culture (68% versus 46%, P = 0.03). When stratified into two groups, junior residents (postgraduate years 1-2) and senior residents (postgraduate years 3-5) had lower scores for all three domains, but the differences were not statistically significant. CONCLUSIONS: Surgical residents' perceptions of perioperative safety remain suboptimal. With an enhanced safety curriculum, perioperative staff demonstrated higher perceptions of safety compared with residents who participated in an online-only curriculum. Optimal surgical education on patient safety remains unknown but should require a dedicated, systematic approach.

The utility of the contrast enema in neonates with suspected Hirschsprung disease.

BACKGROUND/PURPOSE: The contrast enema (CE) is commonly utilized for suspected Hirschsprung disease (HD) patients. We set out to determine the utility of the CE in the newborn for clinically suspicious HD. METHODS: All CEs performed for suspicion of HD in neonates from January 2004 to December 2013 were reviewed by two pediatric radiologists who were blinded to the original interpretations and final diagnoses. A standardized scoring sheet was utilized to document essential radiographic findings. Definitive diagnoses were determined by pathology. Descriptive statistics, likelihood ratios, and interrater agreement were determined. RESULTS: 158 CEs were reviewed. Interrater agreement was 89% with kappa (95% CI) of 0.63 (0.47-0.76). Common indications for CE were similar between non-HD and HD groups. The positive, inconclusive, and negative likelihood ratios (95% CI) were 38 (10-172), 3.2 (1.3-9.1), and 0.15 (0.06-0.47), respectively, leading to posttest probabilities for positive, inconclusive, and negative tests of 83%, 32%, and 2.5%, respectively. CONCLUSIONS: Although radiographic positive CE for HD portends a high probability of HD, inconclusive studies still represent a significant increased risk. In clinically suspicious infants for HD, those with inconclusive studies may benefit from a lower threshold to perform follow-up rectal biopsy.