Gangrenous appendicitis: No longer complicated.

BACKGROUND: Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections. METHODS: In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions. RESULTS: Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. CONCLUSIONS: Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.

Using quality improvement methodology to improve ovarian salvage for benign ovarian masses.

PURPOSE: Most ovarian masses in children are benign and potentially amenable to ovarian salvage surgery (OSS). Despite the common use of OSS among pediatric and adolescent gynecologists (PAG) in recognition of reproductive and hormonal health advantages, this technique is not commonly performed by pediatric surgeons. The aim of this quality improvement (QI) initiative was to improve our institutional rate of OSS for benign ovarian masses. METHODS: Baseline data were obtained retrospectively from surgical procedures performed for benign ovarian masses between January 2012 and February 2016. Designed interventions to improve the rate of OSS included the development of an ovarian mass algorithm, standardization of radiologic templates, multidisciplinary analyses of ovarian procedures, and implementation of a training model for performing OSS. Procedures performed for benign ovarian masses from March 2016 to February 2017 comprised the process stage. RESULTS: Our institutional baseline OSS rate was 28.8%. After implementation of the institutional algorithm, a single oophorectomy was performed for a benign mass, increasing the OSS rate to 96%. There have been no missed ovarian malignancies. CONCLUSIONS: Utilizing preoperative risk assessment, QI methodology and multidisciplinary collaboration resulted in improved OSS rates for benign ovarian masses with no evidence of missed ovarian malignancies. LEVEL OF EVIDENCE: Level II. This is a prospective comparative study, with comparison to a retrospective cohort. This is a quality improvement initiative without randomization.

Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery.

BACKGROUND: Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Previous studies have shown that perioperative bundles reduce SSIs, but few have focused on pediatric GI operations. We hypothesized that a GI bundle would decrease SSI rates, length of stay (LOS), and hospital charges. METHODS: After establishing baseline SSI rates, a GI bundle was created and implemented in November 2014. We prospectively collected data including demographics, procedure type, LOS, inpatient charges, bundle compliance, and SSI development. We analyzed SSI rates, LOS, and charges using process control charts. RESULTS: The baseline SSI rate for all GI operations was 3.4%, which increased to 7.1%, then decreased to 4.7%. Midgut/hindgut and stoma closure SSI rates decreased from 11.3% to 8.0% (p<0.05) and 21.4% to 7.9%, respectively (p<0.05). Although overall LOS and charges were unchanged, average LOS for midgut/hindgut surgeries and stoma closures decreased from 20.3 to 13.6days (p=0.015) and 12.6 to 7.9days (p=0.04), respectively. Stoma closure charges decreased from $94,262 to $50,088 (p=0.01). CONCLUSIONS: Our perioperative GI bundle decreased SSI rates, primarily among midgut/hindgut operations. Bundle usage decreased LOS and charges most effectively in stoma closures. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: Level 2.