Optimal timing of appendectomy in the pediatric population.

BACKGROUND: No consensus has been reached on optimal timing for performing appendectomies. We compared immediate and delayed appendectomies in pediatric patients presenting with suspected acute appendicitis to determine differences in postsurgical complications and perforation rates. METHODS: A retrospective cohort study was performed of all children who underwent appendectomy during a 4-y period. Cutoffs used were 6, 8, and 12 h from admission to operating room (OR). The Student t-tests and chi-square tests were performed to compare continuous and categorical variables, respectively. A logistic regression model was fitted to determine predictors of appendiceal perforation. P values <0.05 were considered significant. RESULTS: Analysis included 484 patients with mean elapsed time from admission to OR of 394 min, with 262 subjects in the immediate and 222 subjects in the delayed >6 h groups. Surgical site infections (SSIs), perforations, and small bowel obstructions were similar between groups, and no statistically significant differences were found for SSIs in the nonperforated delayed versus immediate groups (P = 0.964). Time from admission to the OR did not predict perforation (P = 0.921), although white blood cell count at the time of admission was a significant predictor of perforation (odds ratio, 1.08; P < 0.001). CONCLUSIONS: For suspected acute appendicitis, delaying appendectomy after admission for >6 h demonstrated no differences in SSI or perforation rates compared with immediate appendectomy. Waiting to perform an appendectomy until the following day has equal outcomes to immediate surgical procedure and may improve overall quality of patient care by limiting surgeon fatigue.

Surgeon-performed ultrasound: accurate, reproducible, and more efficient.

PURPOSE: A study previously performed at our institution demonstrated that surgeon-performed ultrasound (SPUS) was accurate compared to radiology department ultrasound (RDUS) when evaluating children with suspected appendicitis. The purpose of this study was to determine if these results were reproducible and if SPUS decreased time to definitive diagnosis. METHODS: A surgery resident performed examinations and ultrasounds on children with suspected appendicitis. Final diagnosis was confirmed by pathology. Results were compared to RDUS and combined with the previous study for a final comparison with RDUS. Mean time to diagnosis was recorded. Data were analyzed using Fisher exact and Student's t test. RESULTS: Fifty-eight patients underwent SPUS, of these 35 had RDUS. The accuracy of SPUS alone was 93% (54/58) and RDUS accuracy was 94% (33/35) (p = 1). When SPUS was combined with clinical examination accuracy increased to 95% (55/58). When results were combined with the previous study, overall accuracy of SPUS was 90% (101/112) compared to overall RDUS accuracy of 89 % (50/56). Mean time to diagnosis for RDUS was 135 min (n = 35), whereas mean time to diagnosis for SPUS was 30 min (n = 58; p = 0.0001). CONCLUSION: SPUS is accurate and reproducible in evaluating children with suspected appendicitis. SPUS potentially decreases time to definitive therapy and emergency department wait times.

Surgeon-performed bedside ultrasound to assess volume status: a feasibility study.

PURPOSE: Rapid assessment of volume status in children is often difficult. The purpose of this study was to evaluate the feasibility of surgeon-performed ultrasound to assess volume status in patients with hypertrophic pyloric stenosis. METHODS: Ultrasounds were performed on admission and before operation. The diameters of the inferior vena cava (IVC) and aorta (Ao) were measured and IVC/Ao ratios were calculated. Electrolytes were measured on admission and repeated if warranted. Logistic regression was used to associate the clinical outcome, defined as CO2 ≤30 mEq/L, with IVC/Ao ratios. Predictive capacity was estimated from the logistic regression for IVC/Ao ratios. Linear regression was used to estimate associations between CO2 values and IVC/Ao ratios. RESULTS: Thirty-one patients were enrolled. The IVC/Ao ratio is highly associated with actual CO2 values (P < 0.001) and the clinical outcome (P = 0.004). For every 0.05 unit increase in IVC/Ao ratio, predicted CO2 decreased 1.1 units. For every 0.05 unit increase in the IVC/Ao ratio, the odds of having a CO2 ≤30 mEq/L increased 48% [OR = 1.48, 95% CI (1.13,1.94)]. Predictive capacity is maximized at an IVC/Ao ratio of 0.75 as 83.9 % of subjects were correctly classified and specificity and PPV = 100%. CONCLUSIONS: Surgeon-performed ultrasound to determine IVC/Ao ratio is feasible. An IVC/Ao ratio of 0.75 predicted adequate resuscitation.

Can you see with CT? Is cervical spine computed tomographic imaging sufficient in pediatric trauma?

BACKGROUND: Traumatic cervical spine injury (CSI) is fundamentally different in children, and imaging recommendations vary; however, prompt diagnosis is necessary. METHODS: We conducted a retrospective cohort study, evaluating children who presented after traumatic injury from 7/1/2012 to 12/31/2019 receiving a cervical spine CT. Evaluation of the incidence and clinical significance of CSI undetected on CT subsequently diagnosed on MRI was conducted. Additionally, all with CSI underwent image review to evaluate for potential overlooked, but visible pathology. RESULTS: 1487 children underwent a cervical spine CT, revealing 52 with CSI. 237 underwent MRI due to an abnormal CT or continued clinical concern. Ultimately, three were discovered to have clinically significant CSI missed on CT. In all cases, retrospective review demonstrated a retroclival hematoma when soft tissue windows were formatted in sagittal and coronal views. CONCLUSIONS: A normal CT may be sufficient to rule-out clinically significant CSI. However, the presence of a retroclival hematoma must be evaluated.

An Evaluation of Pediatric Gastrocutaneous Fistula Closure Through the Punch Excision of Epithelized Tract Procedure.

BACKGROUND: Persistent gastrocutaneous fistulae frequently complicate gastrostomy tube placement. A minimally invasive technique for tract closure employing balloon catheter retraction and punch excision of the epithelized tract (PEET) was recently reported. We hypothesized the PEET technique of closure would lead to decreased complications without an increased incidence of recurrence. METHODS: We conducted a single-center retrospective cohort study evaluating children who underwent gastrocutaneous fistula (GCF) closure 1/1/2018-12/31/2021, comparing patients who underwent the PEET procedure to those repaired with layered closure. Procedure duration and outcomes were additionally compared to the 2018-2019 National Surgical Quality Improvement Program (NSQIP) Participant Use File (PUF) database. RESULTS: Sixty-two children underwent operative GCF closure, including 25 with PEET and 37 traditional layered closure. Procedural time was significantly decreased employing PEET (14 vs 26 minutes, P < .0001), less than half the national median by the NSQIP PUF database of 292 GCF closures (14 vs 34.5 minutes, P < .0001). Those repaired with the PEET method experienced no episodes of recurrence, surgical site infection, readmission, reoperation, or mortality within 30 days of the procedure. Conversely, in traditional closure, there was a 24.3% complication rate, including 7 surgical site infections, 1 readmission, and 2 unplanned reoperations. National procedural complication rate by NSQIP PUF was 5.5%, with a 4.8% rate of surgical site infection, .3% reoperation incidence, and .3% mortality. DISCUSSION: Our study suggests GCF closure employing the PEET procedure is a safe, more efficient method of tract closure than the traditional layered closure technique.

Elder child or young adult? Adolescent trauma mortality amongst pediatric and adult facilities.

BACKGROUND: While it is assumed adolescents receive comparable trauma care at pediatric trauma centers (PTC), adult trauma centers (ATC), and combined facilities (MTC), this remains understudied. METHODS: We conducted a retrospective cohort study through the NTDB evaluating patients 14-18 years of age who presented to an ACS-verified level 1 or 2 trauma facility between 1/1/2016 and 12/31/2019. Multiple logistic regression analyses were performed to compare mortality risk among trauma facility verification types. RESULTS: 91,881 adolescents presented after trauma over the four-years. Hypotension, severe TBI, firearm mechanism, and ISS >15 were associated with increased mortality. Compared to PTCs, the odds of trauma-related mortality were statistically higher at MTCs (OR 1.82, p = 0.004) and ATCs (OR 1.89-2.05, p = 0.001-0.002). CONCLUSIONS: Injured adolescents receiving care at ATCs and MTCs have higher mortality risk than those cared for at PTCs. Further evaluation of factors associated with this observed difference is warranted and may help identify opportunities to improve outcomes in injured adolescents.

Evaluation of white blood cell count at time of discharge is associated with limited oral antibiotic therapy in children with complicated appendicitis.

BACKGROUND: Variation exists for postoperative antibiotics in children with complicated appendicitis. We investigated the impact of white blood count (WBC) at discharge on oral antibiotic therapy, abscess rate, and readmission rate. MATERIAL/METHODS: We conducted a two year review of children with complicated appendicitis. In the pre-protocol group, total antibiotic therapy was ten days (IV and oral) and home oral antibiotics at discharge. In the post-protocol group, children with leukocytosis were prescribed oral antibiotics to complete seven days of total antibiotic therapy and children without leukocytosis were not prescribed oral home antibiotics. RESULTS: There was no difference between mean hospital days after operation (3.52 vs. 3.24, p = 0.5111), means days of inpatient intravenous antibiotics (3.13 vs. 2.58, p = 0.5438), post-operative abscess rates (20.7% vs. 19.6%, p = 0.9975), or readmission rate (13.4% vs. 12.4%, p = 1.000). The post-protocol group had a shorter average total antibiotic duration (4.24 vs. 9.52 days, p < 0.001) and were more likely to be discharged without oral antibiotics (71.1% vs 8.5%, p < 0.001). DISCUSSION: Limiting home antibiotics at discharge to children with leukocytosis significantly decreases home antibiotic use.

Review of bedside surgeon-performed ultrasound in pediatric patients.

PURPOSE: Pediatric surgeon performed bedside ultrasound (PSPBUS) is a targeted examination that is diagnostic or therapeutic. The aim of this paper is to review literature involving PSPBUS. METHODS: PSPBUS practices reviewed in this paper include central venous catheter placement, physiologic assessment (volume status and echocardiography), hypertrophic pyloric stenosis diagnosis, appendicitis diagnosis, the Focused Assessment with Sonography for Trauma (FAST), thoracic evaluation, and soft tissue infection evaluation. RESULTS: There are no standards for the practice of PSPBUS. CONCLUSIONS: As the role of the pediatric surgeon continues to evolve, PSPBUS will influence practice patterns, disease diagnosis, and patient management. TYPE OF STUDY: Review Article. LEVEL OF EVIDENCE: Level III.

Use of bedside abdominal ultrasound to confirm intestinal motility in neonates with gastroschisis: A feasibility study.

BACKGROUND: Optimal timing to begin feeds in neonates with gastroschisis remains unclear. We examined if bedside abdominal ultrasound for intestinal motility is a feasible tool to detect return of bowel function in neonates with gastroschisis. METHODS: Neonates born with uncomplicated gastroschisis who underwent closure received daily ultrasound exams. Full motility was defined as peristalsis seen in all quadrants. Average length of time between abdominal wall closure and start of enteral feeds, full ultrasound motility, and clinical characteristics was compared using Student's t-tests. RESULTS: Seventeen patients were enrolled. No differences were found between motility on ultrasound and bowel movements, gastric residuals, or nonbilious residuals. Mean time to enteral feeds (11.82days) was significantly delayed compared to documentation of full motility on ultrasound (8.94days; p=0.012), consistent bowel movements (8.41days; p=0.006), low gastric residuals (9.47days; p<0.001), and nonbilious residuals (9.18days; p<0.001). In the single subject in which feeds were started before full motility was seen on ultrasound, feeds were subsequently discontinued because of emesis. CONCLUSION: Bedside abdominal ultrasound provides real-time evidence regarding intestinal motility and is a feasible tool to detect return of bowel function in neonates with gastroschisis. Future studies are needed to determine if abdominal ultrasound can shorten time to start of enteral feeds. LEVEL OF EVIDENCE: III (diagnosis: nonconsecutive study).

A stitch in time saves nine: suture technique does not affect intestinal growth in a young, growing animal model.

BACKGROUND: Although this issue remains unexamined, pediatric surgeons commonly use simple interrupted suture for bowel anastomosis, as it is thought to improve intestinal growth postoperatively compared to continuous running suture. However, effects on intestinal growth are unclear. We compared intestinal growth using different anastomotic techniques during the postoperative period in young rats. METHODS: Young, growing rats underwent small bowel transection and anastomosis using either simple interrupted or continuous running technique. At 7-weeks postoperatively after a four-fold growth, the anastomotic site was resected. Diameters and burst pressures were measured. RESULTS: Thirteen rats underwent anastomosis with simple interrupted technique and sixteen with continuous running method. No differences were found in body weight at first (102.46 vs 109.75g) or second operations (413.85 vs 430.63g). Neither the diameters (0.69 vs 0.79cm) nor burst pressures were statistically different, although the calculated circumference was smaller in the simple interrupted group (2.18 vs 2.59cm; p=0.03). No ruptures occurred at the anastomotic line. CONCLUSIONS: This pilot study is the first to compare continuous running to simple interrupted intestinal anastomosis in a pediatric model and showed no difference in growth. Adopting continuous running techniques for bowel anastomosis in young children may lead to faster operative time without affecting intestinal growth.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough?

BACKGROUND/PURPOSE: Surgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. METHODS: A before-and-after study from 2011-2014 at eleven children's hospitals was conducted. The SWC recorded in the hospital's intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen's weighted kappa and chi square. RESULTS: Surgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42-0.48) to 0.73 (95% CI 0.70-0.75). Median (range) improvement per institution was 23% (7-35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. CONCLUSIONS: Intraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

Implementation of the World Health Organization checklist and debriefing improves accuracy of surgical wound class documentation.

BACKGROUND: Surgical wound classification (SWC) is a component of surgical site infection risk stratification. Studies have demonstrated that SWC is often incorrectly documented. This study examines the accuracy of SWC after implementation of a multifaceted plan targeted at accurate documentation. METHODS: A reviewer examined operative notes of 8 pediatric operations and determined SWC for each case. This SWC was compared with nurse-documented SWC. Percent agreement pre- and postintervention was compared. Analysis was performed using chi-square and a P value less than .05 was significant. RESULTS: Preintervention concordance was 58% (112/191) and postintervention was 83% (163/199, P = .001). Appendectomy accuracy was 28% and increased to 80% (P = .0005). Fundoplication accuracy increased from 44% to 84% (P = .016) and gastrostomy tube from 56% to 100% (P = .0002). The most accurate operation preintervention was pyloromyotomy and postintervention was gastrostomy tube and inguinal hernia. The least accurate pre- and postintervention was cholecystectomy. CONCLUSION: Implementation of a multifaceted approach improved accuracy of documented SWC.

Surgeon as educator: bedside ultrasound in hypertrophic pyloric stenosis.

OBJECTIVE: Our institution has demonstrated the diagnostic accuracy of surgeon-performed ultrasound (US) in the diagnosis of hypertrophic pyloric stenosis (HPS). Moreover, we have also shown this modality to be accurate and reproducible through surgeon-to-surgeon instruction. The purpose of this study was to determine whether a surgical resident with experience in diagnosing HPS can teach pediatric emergency medicine (PEM) fellows, with little experience in sonography, to accurately measure the pyloric channel with bedside US. METHODS: A surgical resident with experience in diagnosing HPS with US-proctored 4 emergency medicine fellows for 5 bedside US examinations each. A PEM fellow, who was blinded to the results from the radiology department US, then performed bedside US and measured the pyloric channel in patients presenting to the emergency department with HPS. Results between the radiology department and the fellows were compared using the Student t test. RESULTS: In total, 18 USs were performed on 17 patients. There were no false-negative or false-positive results. There was no statistical difference between the radiology department and fellow measurement when evaluating muscle width (p = 0.21, mean deviation = 0.2 mm) or channel length (p = 0.47, mean deviation = 0.6 mm). CONCLUSION: Bedside-performed US technique for measuring the pylorus length and width in patients with HPS is reproducible and accurate when taught to PEM providers. The learning curve for this technique is short.

Hemodynamic variables predict outcome of emergency thoracotomy in the pediatric trauma population.

BACKGROUND: Limited data exist regarding indications for resuscitative emergency thoracotomy (ETR) in the pediatric population. We attempt to define the presenting hemodynamic parameters that predict survival for pediatric patients undergoing ETR. METHODS: We reviewed all pediatric patients (age <18years), entered into the National Trauma Data Bank from 2007 to 2010, who underwent ETR within one hour of ED arrival. Mechanism of injury and hemodynamics were analyzed using Chi squared and Wilcoxon tests. RESULTS: 316 children (70 blunt, 240 penetrating) underwent ETR, 31% (98/316) survived to discharge. Less than 5% of patients survived when presenting SBP was ≤50mmHg or heart rate was ≤70bpm. For blunt injuries there were no survivors with a pulse ≤80bpm or SBP ≤60mmHg. When survivors were compared to nonsurvivors, blood pressure, pulse, and injury type were statistically significant when treated as independent variables and in a logistic regression model. CONCLUSIONS: When ETR was performed for SBP ≤50mmHg or for heart rate ≤70bpm less than 5% of patients survived. There were no survivors of blunt trauma when SBP was ≤60mmHg or pulse was ≤80bpm. This review suggests that ETR may have limited benefit in these patients.

Improving gastroschisis outcomes: does birth place matter?

PURPOSE: Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. METHODS: Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120kcal/kg/day). RESULTS: 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. CONCLUSIONS: Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis.

Persistent gastrocutaneous fistula: factors affecting the need for closure.

PURPOSE: The occurrence of gastrocutaneous fistula (GCF) is a well-known complication after gastrostomy tube placement. We explore multiple factors to ascertain their impact on the rate of persistent GCF formation. METHODS: We retrospectively reviewed patient records for all gastrostomies (GT) constructed at our institution from 2007 to 2011. Association of GCF with method of placement, concomitant fundoplication, neurologic findings, duration of therapy, and demographics was evaluated using logistic regression. RESULTS: Nine hundred fifty patients had GTs placed, of which 148 patients had GTs removed and 47 (32%) of 148 required surgical closure secondary to persistent GCF. Laparoscopic and open procedures comprised 79 (53%) of 148 and 69 (47%) of 148, respectively. Seventeen (22%) patients in the laparoscopic group developed persistent GCF, compared to 30 (43%) in the open group (P=0.035, OR=2.52). Seventy-one patients had concomitant Nissen fundoplication. Thirty-one (44%) developed GCF, compared to 16 (21%) without a Nissen (P=0.002, OR=4.94). Patients with button in place for 303 days had persistent GCF incidence of 23%, compared to 45% at 540 days (P<0.001, OR=3.51) and 50% at 850 days (P=0.011, OR=4.51). Patients with device placed at 1.8 months of age were more likely to develop GCF compared to those with device placed at 8.9 months of age (P=0.017, OR=2.35). CONCLUSION: Open operations, concurrent Nissen and younger age at placement were all statistically significant factors causing persistent GCF.