Efficacy of oral antibiotics in children with post-operative abscess from perforated appendicitis.

BACKGROUND: Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). Typically, intravenous antibiotics by a peripherally inserted venous catheter are utilized to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. METHODS: This is a retrospective review conducted of children between January 2005 and September 2015 with a PIAA. Demographics, clinical course, complications, and follow-up were analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral vs IV antibiotics after diagnosis of PIAA. RESULTS: 103 children were included. Days of symptoms prior to admission were 3.2 ± 2.3 days with a WBC of 17.9 ± 6.4. Median time to diagnosis of PIAA from appendectomy was 7 days (7, 10). Mean total length of stay was 10 ± 3.4 days. 42% were treated with oral antibiotics (n = 43) versus 58% IV antibiotics (n = 60) at the time of discharge. We found a significant increase in total length of hospital stay (9.1 vs 10.7, p = 0.02) and number of medical encounters required for treatment (3.4 vs 4.4, p ≤ 0.01) in the IV group. CONCLUSIONS: PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivalent outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required.

The impact of thromboelastography on resuscitation in pediatric liver transplantation.

Although TEG directs effective resuscitation in adult surgical patients, pediatric data are lacking. We performed a retrospective comparative review of the effect of TEG on blood product utilization and outcomes following pediatric liver transplantation in 38 patients between 2008 and 2014. Diagnoses, laboratory values, fluid and blood product use, and outcomes were examined. Nineteen patients underwent liver transplantation prior to the implementation of TEG, and 19 had perioperative TEG. The most common indications for transplant were BA (n = 14), HB (n = 7), and metabolic disorders (n = 7). Intraoperative blood loss, urine output, fluid and blood product use were similar between groups. However, the use of fresh frozen plasma decreased significantly in TEG patients within the first 24 hours (29 vs 0 mL/kg, P < .01), and between 24 and 48 hours (12 vs 0 mL/kg, P = .01) post-operatively. The total use of fresh frozen plasma during hospitalization was markedly reduced (111 vs 17 mL/kg, P < .01). Four patients in the TEG group had thromboembolic graft complications, including portal vein or hepatic artery thrombosis, and underwent retransplantation. The decreased use of fresh frozen plasma since implementation of TEG is an important finding for resource utilization and patient safety. However, the increased incidence of thromboembolic complications requires further investigation.

A safe and efficacious preventive strategy in the high-risk surgical neonate: cycled total parenteral nutrition.

INTRODUCTION: Hepatic dysfunction in patients reliant on total parenteral nutrition (TPN) may benefit from cycled TPN. A concern for neonatal hypoglycemia has limited the use of cycled TPN in neonates less than 1 week of age. We sought to determine both the safety and efficacy of cycled TPN in surgical neonates less than 1 week of age. METHODS: A retrospective chart review was conducted on surgical neonates placed on prophylactic and therapeutic cycled TPN from January 2013 to March 2016. Specific emphasis was placed on identifying incidence of direct hyperbilirubinemia and hypoglycemic episodes. RESULTS: Fourteen neonates were placed on cycled TPN; 8 were prophylactically cycled and 6 were therapeutically cycled. Median gestational age was 36 weeks (34, 37). Sixty-four percent (n = 9) had gastroschisis. There was no difference between the prophylactic and therapeutic groups in incidence of hyperbilirubinemia > 2 mg/dL (3 (37%) vs 5 (83%), p = 0.08) or the length of time to development of hyperbilirubinemia [24 days (4, 26) vs 27 days (25, 67), p = 0.17]. Time on cycling was similar though patients who were prophylactically cycled had a shorter overall time on TPN. Three (21%) infants had documented hypoglycemia, but only one infant became clinically symptomatic. CONCLUSION: Prophylactic TPN cycling is a safe and efficacious nutritional management strategy in surgical neonates less than 1 week of age with low rates of hypoglycemia and a shorter total course of TPN; however, hepatic dysfunction did not appear to be improved compared to therapeutic cycling.

The impact of developing a pectus center for chest wall deformities.

PURPOSE: In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS: A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS: 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.

Understanding parental refusal of permission for child participation in surgical prospective trials.

PURPOSE: The success of prospective randomized trials relies on voluntary participation, which has been perceived as a barrier for successful trials in children who rely on parental permission. We sought to identify the reasons parents decline child participation to understand potential limitations in the consent process. METHODS: A prospective observational study was conducted in 92 patients asked to participate in prospective randomized trials between 2012 and 2015. Parental reasons for refusal were documented. RESULTS: The 92 refusals were distributed between studies investigating the management of circumcision, gastroschisis, pectus excavatum, appendicitis, pyloric stenosis, undescended testicles, abdominal abscess and gastroesophageal reflux. Reasons for refusal included preference of treatment path (37 %), inability to follow up (21 %), unspecified resistance to participate in research (18 %), preference to maintain independent surgeon decision (16 %), and desire for historically standard treatment (8 %). Of the families who opted to pursue a specific treatment arm rather than randomization, 35 % had prior experience with that treatment, 32 % had researched the procedure, 18 % wished to pursue the minimal intervention and 15 % did not specify. CONCLUSIONS: Parental preference of therapy is the most common reason for refusal of study participation. This variable could be influenced with more effective explanation of study rationale and existing equipoise.

Effect of timing of cannulation on outcome for pediatric extracorporeal life support.

PURPOSE: Literature reports worse outcomes for operations performed during off-hours. As this has not been studied in pediatric extracorporeal life support (ECLS), we compared complications based on the timing of cannulation.. METHODS: This is a retrospective review of 176 pediatric ECLS patients between 2004 and 2015. Patients cannulated during daytime hours (7:00 A.M. to 7:00 P.M., M-F) were compared to off-hours (nighttime or weekend) using t-test and Chi-square. RESULTS: The most common indications for ECLS were congenital diaphragmatic hernia (33 %) and persistent pulmonary hypertension (23 %). When comparing regular hours (40 %) to off-hours cannulation (60 %), there were no significant differences in central nervous system complications, hemorrhage (extra-cranial), cannula repositioning, conversion from venovenous to venoarterial, mortality on ECLS, or survival-to-discharge. The overall complication rate was slightly lower in the off-hours group (45.7 % versus 61.9 %, P = 0.034). CONCLUSION: Outcomes were not significantly worse for patients undergoing ELCS cannulation during off-hours compared to normal weekday working hours.

Antibiotic utilization based on primary treatment of pediatric empyema.

BACKGROUND: Chemical fibrinolysis has been shown to be as effective as surgical debridement for the treatment of pediatric empyema. However, no studies effectively evaluate antibiotic treatment. We evaluated antibiotic utilization among different treatments of pediatric empyema. METHODS: This is a retrospective review of 169 empyema patients who underwent chemical and/or mechanical fibrinolysis at a dedicated children's hospital from 2005-2013. Data points included duration of therapy, cultures, presence of necrosis or abscess, and adverse drug reactions. Immunocompromised patients and those with additional foci of infection were excluded. RESULTS: Twenty-seven patients underwent video-assisted thoracoscopic surgery (VATS), 123 had chemical fibrinolysis via tube thoracostomy with tissue plasminogen activator (tPA), and 19 had tPA followed by VATS. The mean (± standard deviation) duration of total antibiotic therapy was 25.7 ± 6.5 d; following a 24 h afebrile period of 19.4 ± 6.3 d. Patients who had tPA had a significantly shorter duration of parenteral antibiotic therapy when compared with primary VATS (9.2 ± 3.6 d versus 11.6 ± 5.5 d, P = 0.04) and VATS following tPA (9.2 ± 3.6 d versus 14.3 ± 8.1 d, P < 0.01). Patients with necrosis or abscess (n = 26) had an increased total duration of antibiotics (29.3 ± 5.7 d versus 25.1 ± 6.4 d, P < 0.01). Seventy patients (41%) had an adverse reaction related to antibiotic use. CONCLUSIONS: Patients with empyema currently receive a protracted variable course of antibiotic therapy influenced by primary treatment and the presence of necrosis or abscess. With a high incidence of adverse reactions, a standardized protocol with truncated treatment duration should be considered.

Same day discharge after laparoscopic cholecystectomy in children.

BACKGROUND: Although the safety of same day discharge (SDD) after laparoscopic cholecystectomy (LC) for symptomatic cholelithiasis (SC) and biliary dyskinesia (BD) in adults has been well documented in the literature, the same data in the pediatric population are lacking. We have recently instituted a protocol for SDD after LC for SC and BD, and this study is an analysis of our initial experience. METHODS: A retrospective chart review of all patients who underwent LC for BD and SC in our institution from January 2011-July 2014 was performed. RESULTS: A total of 227 LC were performed for SC and BD during the study period. Approximately 25% (n = 57) of patients were in the SDD group. The remaining 75% (n = 170) of patients were admitted at least overnight stay (ONS) for the following reasons: medical 16.5% (n = 28), surgery ending too late 4.1% (n = 7), or clinical care habits 79.4% (n = 135). Comparing the SDD group with ONS group, no differences were found in the complication rate, readmissions, or follow up before scheduled appointment. Length of stay was significantly less for the SDD group than for the ONS. A trend for more SDDs was observed as time elapsed from initiation of the protocol. Also, earlier completion of surgery trended toward SDD. CONCLUSIONS: SDD appears safe for pediatric patients undergoing LC for BD or SC. The main obstacles to discharge were time of surgery completion and clinical care habits, both of which improved as comfort level with SDD grew among the staff.

Screening and Prophylaxis for Venous Thromboembolism in Pediatric Surgery: A Systematic Review.

OBJECTIVE: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY: Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE: Level 3-4.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee.

INTRODUCTION: Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. METHODS: Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. RESULTS: Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment. CONCLUSIONS: The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention. LEVEL OF EVIDENCE: Level 4. TYPE OF STUDY: Systematic Review of Level 1-4 studies.

Ruptured omphalocele: Diagnosis and management.

Omphalocele is an abdominal wall defect which can be classified as small, giant, or ruptured. Ruptured omphaloceles require prompt diagnosis and management to prevent associated morbidity and mortality and represent a challenging surgical condition. This review serves to define the etiology, diagnosis, initial resuscitation, and surgical therapy employed in the treatment of ruptured omphalocele. Resuscitation should focus on maintaining hydration and normothermia. Broad spectrum antibiotics should be initiated. Similar to giant omphaloceles, procedural intervention includes primary closure, silo, synthetic and biologic mesh, negative pressure wound therapy, and topical agents. Despite advances in neonatal care, the prognosis remains guarded and mortality is high.

Does Intravenous Acetaminophen Improve Postoperative Pain Control after Laparoscopic Appendectomy for Perforated Appendicitis? A Prospective Randomized Trial.

INTRODUCTION: The recent increased awareness of the dangers of opioids in the United States has highlighted the need to minimize narcotics and identify nonopioid options for pain control after surgery. With evidence suggesting that intravenous acetaminophen (IVA) can be an opioid sparing option, we conducted a prospective, randomized trial that evaluated the effect of IVA on the postoperative pain course of children with perforated appendicitis. MATERIALS AND METHODS: After IRB approval, children with perforated appendicitis were randomized to receive postoperative IVA with the standard patient/nurse-controlled analgesia (PCA) or to receive the PCA alone. All patients were treated according to an evidence-based treatment protocol. The primary outcome was duration of time on PCA. RESULTS: Eighty-two patients were analyzed from 7/14 to 11/15. There was no statistically significant difference in the time to transition from the PCA to oral pain medications for children given IVA compared with children not receiving IVA (76.4 ± 32.5 versus 86.7 ± 49.3 hours; p = 0.73). Children in the IVA group had no statistically significant difference in intravenous narcotics delivered and pain scores compared with the non-IVA group. There was no significant difference in the amount of oral narcotics between both groups (2.8 ± 2.4 versus 2.9 ± 2.5; p = 0.88). Patients who received IVA had higher medication charges ($3752.7 ± 1618.3 vs. $1198.19 ± 521.51; p < 0.01), but not total hospital charges ($53842.0 ± 19409.2 vs. $50501.03 ± 16223.32; p = 0.76). CONCLUSION: Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.

Primary Closure versus Bedside Silo and Delayed Closure for Gastroschisis: A Truncated Prospective Randomized Trial.

BACKGROUND: We report a prospective randomized trial comparing primary closure (PC) to bedside silo and delayed closure (DC) for babies with gastroschisis. MATERIALS AND METHODS: Patients were randomized to PC versus DC. We excluded those with atresia/necrosis, <34 weeks' gestation, or congenital anomalies. The primary outcome was length of stay (LOS). RESULTS: A total of 38 patients were included from August 2011 to August 2016; 18 patients underwent DC and 20 PC. There were no differences in gestational age or birth weight. Fifty percent of PC patients were successfully closed with the rest closed at a median of 4 days (interquartile range [IQR]: 2-4 days). DC patients were closed at a median of 4 days after silo placement (IQR: 2-5.8 days). None of the patients in this series developed abdominal compartment syndrome after closure. Median LOS, median time to enteral tolerance, and median time on ventilation were not statistically different. Two patients (one DC and one PC) had bowel ischemia and necrosis following silo placement requiring reoperation. Four patients (two DC and two PC) were noted to have small umbilical defects; none have yet required operative correction. CONCLUSION: There were no differences seen between PC and DC in LOS, time to enteral feeds, or ventilator times.

Re-Tubularization of Highly-Ischemic Anti-Mesenteric Border (ReHAB): A Novel Bowel Preservation Technique in Complex Gastroschisis.

Complex gastroschisis with bowel necrosis poses an operative challenge. Surgeons must weigh the decision between resection versus preservation of ischemic bowel. As one of the leading causes of short bowel syndrome, aggressive resection in complicated gastroschisis subjects children to prolonged dependence on parenteral nutrition and its attendant complications. Herein, we describe a novel technique aimed towards bowel preservation in complex gastroschisis patients with severe bowel ischemia with the ultimate goal for enteral autonomy.

Pelvic Angiography for Trauma in Children: A Rare but Useful Adjunct.

Introduction Pelvic angiography with embolization can successfully control hemorrhage in adults with pelvic fractures. However, evidence to support similar application in children is sparse. We describe our experience using angiography for pediatric pelvic fractures to further highlight the safety and efficacy of this treatment approach. Methods A retrospective review at a pediatric tertiary care center was performed from 2004 to 2014. Inpatients treated for a pelvic fracture were considered. Results A total of 216 patients were analyzed. Four patients (1.9%) underwent pelvic angiography. Three of these patients had active contrast extravasation on angiography and underwent successful embolization. All patients who underwent angiography showed computed tomography (CT) or clinical evidence of ongoing hemorrhage. No surgical intervention was needed after angiography. No complications of angiography occurred. Three patients who were found to have active extravasation on CT did not require angiography and were stabilized in the intensive care unit; two patients went on to have delayed operative repair. Mortality was 2.3%. All deaths were secondary to concomitant traumatic brain injury. No mortality occurred in patients undergoing pelvic angiography or those with pelvic contrast extravasation on CT. Conclusions Pelvic angiography is a useful treatment option in pediatric patients with pelvic fractures and clinical evidence of ongoing blood loss without other explanation. Contrast extravasation on CT scan alone may not require further intervention.

The financial impact of flipping the coin.

BACKGROUND: Esophageal foreign body retrieval is typically performed by rigid or flexible esophagoscopy. Despite evidence supporting the efficacy and safety of balloon extraction, it is rarely performed. We sought to establish the financial benefits of this minimally invasive approach. METHODS: A retrospective review of 241 children with esophageal coins between 2011 and 2013 was performed. Coins were removed via endoscopy or fluoroscopic-guided balloon retrieval. Timing, symptoms, facility cost, and patient charges were compared. RESULTS: Two hundred patients had attempted balloon retrieval with 80% success. Forty-one patients went directly for operative removal. Patients with respiratory difficulty (p=0.05), wheezing (p<0.01), or fever (p=0.03) were more often taken directly for endoscopic retrieval. The median cost and charges for attempted balloon extraction were $484 and $1647. The median cost and charges for primary endoscopy were $1834 and $6746. The median total cost and charges of attempted balloon extraction including ED, OR, transport, admission, and balloon retrieval were $1231 and $3539 versus $3615 and $12,204 in the primary endoscopy group (p<0.001, p<0.001). Seventeen percent of patients who underwent attempted balloon retrieval were admitted prior to removal compared to 76% who underwent primary endoscopy (p<0.001). CONCLUSIONS: Fluoroscopic guided balloon extraction of esophageal coins is a financially prudent choice which shortens hospital stay. LEVEL OF EVIDENCE: III. TYPE OF STUDY: Retrospective treatment and economic study.

Chest radiograph after fluoroscopic guided line placement: No longer necessary.

PURPOSE: Historically, a chest radiograph was obtained after central line placement in the operating room. Recent retrospective studies have questioned the need for this radiograph. The prevailing current practice at our center is to order chest radiograph only for symptomatic patients. This study examines the outcomes of selective chest radiography after fluoroscopic guided central line placement. METHODS: After obtaining institutional review board approval, a single institution retrospective chart review of patients undergoing central venous catheter placement by the pediatric surgery or interventional radiology service between January 2010 and July 2014 was performed. Outcome measures included CXR within 24h of catheter placement, reason for chest radiograph, complication, and complication requiring intervention. RESULTS: In the study population 622 catheters were placed under fluoroscopy. A chest radiograph was performed in 118 (19%) patients within 24h of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required chest tube placement. There were no re-operations because of mal-position of the catheter. In the 504 patients with no postoperative chest x-ray, there were no adverse outcomes. At our institution the current average charge of a chest radiograph is $283, thus we produced savings of $142,632 for the study period without adverse events. CONCLUSION: After placement of central venous catheter under fluoroscopic guidance, a chest radiograph is unlikely to be helpful in an asymptomatic patient.

Transition of Techniques to Treat Choledochal Cysts in Children.

INTRODUCTION: Traditionally open resection with hepaticojejunostomy (HJ) reconstruction has been the surgical treatment for cases of choledochal cyst. Our center has recently transitioned from open to laparoscopic and HJ to hepaticoduodenostomy (HD) as our preferred method of excision and biliary reconstruction. Our initial experience is presented here. MATERIALS AND METHODS: A single-center retrospective chart review was performed from 2005 to 2014. All patients undergoing surgical treatment for choledochal disease were considered. RESULTS: During the study period 18 patients had surgical treatment for choledochal cyst disease. The average age of all patients was 4.7 years (range, 2 months-15.5 years). Eleven of these patients had laparoscopic excision and reconstruction. Of these 11 patients, 7 had an HD anastomosis. Comparing the laparoscopic with the open group and the HD with the HJ group, there was no significant difference in operative time, estimated blood loss, time to regular diet, length of stay, or complication rate. Mean follow-up of 3.1 years revealed no documented cases of bile reflux or cholangitis. A recent adaptation in technique may improve ease of HD anastomosis. In this method, two strands of temporary monofilament suture cut to 8-10 cm each are tied extracorporeally. This knot is then placed on the outside of the medial corner. The anastomosis is then completed in a running fashion with the two strands and then secured intracorporeally at the lateral corner. CONCLUSIONS: Laparoscopic choledochal cyst resection with both HJ and HD reconstruction appears safe and has equivalent outcomes to open procedures in our series.

Epidural versus Patient-Controlled Analgesia after Pediatric Thoracotomy for Malignancy: A Preliminary Review.

Introduction The use of thoracic epidural is standard in adult thoracotomy patients facilitating earlier mobilization, deep breathing, and minimizing narcotic effects. However, a recent randomized trial in pediatric patients who undergo repair of pectus excavatum suggests patient-controlled analgesia (PCA) produces a less costly, minimally invasive postoperative course compared with epidural. Given that thoracotomy is typically less painful than pectus bar placement, we compared the outcomes of epidural to PCA for pain management after pediatric thoracotomy. Methods A retrospective review of 17 oncologic thoracotomies was performed at a children's hospital from 2004 to 2013. Data points included operative details, epidural or PCA use, urinary catheterization, days to regular diet, days to oral pain regimen, postoperative pain scores, length of stay, and anesthesia charges. Patients were excluded if they did not have epidural or PCA following thoracotomy. Results Six thoracotomies were managed with an epidural and 11 with a PCA. Three epidural patients were opiate naïve compared with two with a PCA. The most common indication for thoracotomy was metastatic osteosarcoma (n = 13). When comparing epidural to PCA, there was no significant difference in days to removal of Foley catheter, regular diet, oral pain control, length of stay, or total operating room time. Postoperative pain scores were also comparable. The mean anesthesia charges were significantly higher in patients with an epidural than with a PCA. Conclusion Epidural catheter and PCA provided comparable pain relief and objective recovery course in children who underwent thoracotomy for oncologic disease; however, epidural catheter placement was associated with increased anesthesia charges, suggesting that PCA is a noninvasive, cost-effective alternative.

Wound classification in pediatric surgical procedures: Measured and found wanting.

PURPOSE: Surgical wound classification has emerged as a measure of surgical quality of care, but scant data exist in the era of minimally invasive procedures, especially in children. The aim of this study is to examine the surgical site infection (SSI) rate by wound classification during common pediatric surgical procedures. METHODS: A retrospective analysis of the 2013 Pediatric-National Surgical Quality Improvement Program (Peds-NSQIP) dataset was conducted. Patients undergoing pyloromyotomy, cholecystectomy, ostomy reversal, and appendectomy were included. Wound classification, SSI rate, reoperation, and readmission were analyzed. RESULTS: A total of 10,424 records were included. Pyloromyotomy, a clean case, had a 0.7% SSI rate, while ostomy reversal, a clean contaminated case, had an SSI in 6.9% of cases. Appendectomy for nonperforated acute appendicitis and laparoscopic cholecystectomy for cholecystitis, both contaminated cases, had SSI rates of 2.1% and <1%, respectively. Appendectomy for perforated appendicitis, a dirty procedure, had a 9.1% SSI rate, below the expected >40% for dirty cases. Reoperations and readmission rates ranged from <1% to 9% and increased with case complexity. CONCLUSION: Current wound classifications systems do not reflect surgical risk in children and remain questionable tools for benchmarking surgical care in children. Role of readmissions and reoperations as quality of care indices needs further investigation.