Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Disease severity, not operative approach, drives organ space infection after pediatric appendectomy.

OBJECTIVE: This study examines patient and operative factors associated with organ space infection (OSI) in children after appendectomy, specifically focusing on the role of operative approach. BACKGROUND: Although controversy exists regarding the risk of increased postoperative intra-abdominal infections after laparoscopic appendectomy, this approach has been largely adopted in the treatment of pediatric acute appendicitis. METHODS: Children aged 2 to 18 years undergoing open or laparoscopic appendectomy for acute appendicitis were selected from the 2012 American College of Surgeons Pediatric National Surgical Quality Improvement Program database. Univariate analysis compared patient and operative characteristics with 30-day OSI and incisional complication rates. Factors with a P value of less than 0.1 and clinical importance were included in the multivariable logistic regression models. A P value less than 0.05 was considered significant. RESULTS: For 5097 children undergoing appendectomy, 4514 surgical procedures (88.6%) were performed laparoscopically. OSI occurred in 155 children (3%), with half of these infections developing postdischarge. Significant predictors for OSI included complicated appendicitis, preoperative sepsis, wound class III/IV, and longer operative time. Although 5.2% of patients undergoing open surgery developed OSI (odds ratio = 1.82; 95% confidence interval, 1.21-2.76; P = 0.004), operative approach was not associated with increased relative odds of OSI (odds ratio = 0.99; confidence interval, 0.64-1.55; P = 0.970) after adjustment for other risk factors. Overall, the model had excellent predictive ability (c-statistic = 0.837). CONCLUSIONS: This model suggests that disease severity, not operative approach, as previously suggested, drives OSI development in children. Although 88% of appendectomies in this population were performed laparoscopically, these findings support utilization of the surgeon's preferred surgical technique and may help guide postoperative counsel in high-risk children.

Value Added from Same-day Discharge after Appendectomy for Children with Simple Appendicitis.

Same-day discharge of children after appendectomy for simple appendicitis is safe and associated with enhanced parent satisfaction. Our general pediatric surgeons aimed to improve the rate of same-day discharge after appendectomy for simple appendicitis. Methods: We implemented a clinical practice guideline in September 2019. A surgeon-of-the-week service model and the urgent operating room started in November 2019 and January 2020, respectively. Data for children with simple appendicitis from our academic medical center were gathered prospectively using National Surgical Quality Improvement Program-Pediatric. Patient outcomes before intervention implementation (n = 278) were compared with patients following implementation (n = 264). Results: The average monthly percentage of patients discharged on the day of surgery increased in the postimplementation group (32% versus 75%). Median postoperative length of stay decreased [16.5 hours (interquartile range, 15.9) versus 4.4 hours (interquartile range, 11.7), P < 0.001], and the proportion of patients discharged directly from the postoperative anesthesia care unit increased (22.8% versus 43.6%; P < 0.001). There were no differences in balancing measures, including the return to the emergency department and readmission. Fewer children were discharged home on oral antibiotics after implementation (6.8% versus 1.5%, P = 0.002), and opioid prescribing at discharge remained low (2.5% versus 1.1%, P = 0.385). Conclusions: Using quality improvement methodology and care standardization, we significantly improved the rate of same-day discharge after appendectomy for simple appendicitis without impacting emergency department visits or readmissions. As a result, our health care system saved 140 hospital days over the first 21 months.

Reduction of surgical site infections in pediatric patients with complicated appendicitis: Utilization of antibiotic stewardship principles and quality improvement methodology.

BACKGROUND: The rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy. METHODS: A quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation. RESULTS: From July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03). CONCLUSIONS: Utilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.

Opioid stewardship in pediatric surgery: Approaching zero.

INTRODUCTION: In response to the opioid epidemic, we hypothesized that adequate pain control can be achieved with few, if any, opioid prescriptions at discharge following pediatric surgical procedures. METHODS: All records for patients 0-15 years old who underwent pediatric surgical operations from December 2017 through May 2018 were reviewed. Opioids prescriptions, emergency department (ED) visits, and hospital readmissions were recorded. Postoperative pain was assessed on a scale from 0 to 10 via phone call within three days of discharge. RESULTS: 352 patients underwent 394 surgical procedures. Three patients were prescribed opioids at discharge. There were no pain-related readmissions. One patient returned to the ED owing to pain. 116 unique pain scores were obtained from 114 patients: score 0 (n = 69, 59%), 1-3 (n = 31, 27%), 4-5 (n = 11, 9%), 6-8 (n = 5, 4%), and 9-10 (n = 0, 0%). There was a positive association between pain and increasing age (r = 0.26, p = 0.005). No patients who underwent hernia repair reported a pain score greater than 3. CONCLUSIONS: Adequate pain control at discharge after pediatric general surgical procedures can be achieved for most children with scheduled nonopioid medications only. A limited supply of opioids for analgesia after discharge may benefit small subset of patients. This strategy would help reduce opioid prevalence in the community. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

Endovascular repair of a traumatic aortic transection in a pediatric patient.

Traumatic aortic rupture due to blunt trauma in the pediatric population is rare. The management of this unusual injury has largely been extrapolated from the adult literature and is evolving. Open surgical repair is the accepted treatment; however, endograft repair is a promising alternative, which can serve as a definitive or bridging technique in select patients who are high-risk surgical candidates. The authors report the successful deployment of an endograft limb to correct a traumatic pseudoaneurysm of the aorta in a high-risk pediatric patient.

Transluminal migration of ingested foreign body without peritonitis.

The authors present 2 cases of transluminal migration of an ingested foreign body into the peritoneal cavity without causing peritonitis. Clinical and radiologic features and surgical approach are described, focusing on the absence of an acute abdomen in transluminal migration and the use of laparoscopy in achieving extraction of the foreign object.

Temporary occlusion of the gastroesophageal junction: a modified technique for stabilization of the neonate with esophageal atresia and tracheoesophageal fistula requiring mechanical ventilation.

Management of newborn infants with esophageal atresia and tracheoesophageal fistula that require mechanical ventilation is challenging. Without rapid control of the fistula, these patients develop profound respiratory failure and massive distention of the gastrointestinal tract. We present the case of a newborn who upon intubation exhibited respiratory failure and cardiovascular collapse, and in whom traditional intra-operative techniques to gain control of the tracheoesophageal fistula were unsuccessful. We describe a technique that temporarily occludes the gastroesophageal junction, and allows for stabilization of the neonate and definitive repair of the tracheoesophageal fistula.

Use of Polyflex Airway stent in the treatment of perforated esophageal stricture in an infant: a case report.

Anastomotic stricture is a common sequela after primary repair of esophageal atresia with esophagoesophagostomy. Esophageal perforation secondary to dilatation of the stricture, and refractory stricture are not uncommon. We present a case using a Polyflex Airway stent (Boston Scientific, Natick, MA) as an alternative treatment of esophageal stricture and perforation in an infant.

Intraoperative colonic lavage in a premature infant: a case report.

Left-sided colonic obstruction in the neonate traditionally is managed with a multistaged defunctioning colostomy and resection. In adults, one-stage primary anastomosis has become increasingly popular with the use of on-table antegrade colonic lavage. In infants, and especially in premature neonates, enterostomies pose significant morbidity. O'Connor and Sawin reported a 68% complication rate in 50 infants with necrotizing enterocolitis who had survived until the time of enterostomal closure. This case discusses a modified application of on-table colonic lavage in the management of an obstructing sigmoid stricture in a premature infant.