Charge Awareness Affects Treatment Choice: Prospective Randomized Trial in Pediatric Appendectomy.

OBJECTIVE: To determine whether charge awareness affects patient decisions. BACKGROUND: Pediatric uncomplicated appendicitis can be treated with open or laparoscopic techniques. These 2 operations are considered to have clinical equipoise. METHODS: In a prospective, randomized clinical trial, nonobese children admitted to a children's hospital with uncomplicated appendicitis were randomized to view 1 of 2 videos discussing open and laparoscopic appendectomy. Videos were identical except that only one presented the difference in surgical materials charges. Patients and parents then choose which operation they desired. Videos were available in English and Spanish. A postoperative survey was conducted to examine factors that influenced choice. The trial was registered at ClinicalTrials.gov (NCT 01738750). RESULTS: Of 275 consecutive cases, 100 met enrollment criteria. In the group exposed to charge data (n = 49), 63% chose open technique versus 35% not presented charge data (P = 0.005). Patients were 1.8 times more likely to choose the less expensive option when charge estimate was given (95% confidence interval, 1.17-2.75). The median total hospital charges were $1554 less for those who had open technique (P < 0.001) and $528 less for the group exposed to charge information (P = 0.033). Survey found that 90% of families valued having input in this decision and 31% of patients exposed to charge listed it as their primary reason for their choice in technique. CONCLUSIONS: Patients and parents tended to choose the less expensive but equally effective technique when given the opportunity. A discussion of treatment options, which includes charge information, may represent an unrealized opportunity to affect change in health care spending.

Treatment and outcome of traumatic biliary injuries in children.

BACKGROUND/PURPOSE: Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome. METHODS: We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002-2012. RESULTS: Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4-15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage. CONCLUSION: Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.

Fecal continence following complex anorectal trauma in children.

BACKGROUND: Complex injuries involving the anus and rectum are uncommon in children. We sought to examine long-term fecal continence following repair of these injuries. METHODS: We conducted a retrospective review using our trauma registry from 2003 to 2012 of children with traumatic injuries to the anus or rectum at a level I pediatric trauma center. Patients with an injury requiring surgical repair that involved the anal sphincters and/or rectum were selected for a detailed review. RESULTS: Twenty-one patients (21/13,149 activations, 0.2%) who had an injury to the anus (n=9), rectum (n=8), or destructive injury to both the anus and rectum (n=4) were identified. Eleven (52%) patients were male, and the median age at time of injury was 9 (range 1-14) years. Penetrating trauma accounted for 48% of injuries. Three (14%) patients had accompanying injury to the urinary tract, and 6 (60%) females had vaginal injuries. All patients with an injury involving the rectum and destructive anal injuries were managed with fecal diversion. No patient with an isolated anal injury underwent fecal diversion. Four (19%) patients developed wound infections. The majority (90%) of patients were continent at last follow-up. One patient who sustained a gunshot injury to the pelvis with sacral nerve involvement is incontinent, but remains artificially clean on an intense bowel management program with enemas, and one patient with a destructive crush injury still has a colostomy. CONCLUSIONS: With anatomic reconstruction of the anal sphincter mechanism, most patients with traumatic anorectal injuries will experience long-term fecal continence. Follow-up is needed as occasionally these patients, specifically those with nerve or crush injury, may require a formal bowel management program.