Reducing Post-Operative Hospital Length of Stay following Uncomplicated Appendectomy in Pediatric Patients: A Prospective Clinical Study.

An uncomplicated appendectomy in children is common. Safely minimizing the post-operative length of stay is desirable from hospital, patient, and parent perspectives. In response to an overly long mean length of stay following uncomplicated appendectomies in children of 2.5 days, we developed clinical pathways with the goal of safely reducing this time to 2.0 or fewer days. The project was conducted in an urban, academic children's hospital. The pathways emphasized the use of oral, non-narcotic pain medications; the education of parents and caregivers about expectations regarding pain control, oral food intake, and mobility; and the avoidance of routine post-operative antibiotic use. A convenience sample of 46 patients aged 3-16 years old was included to evaluate the safety and efficacy of the intervention. The mean post-operative length of stay was successfully reduced by 80% to 0.5 days without appreciable complications associated with earlier discharge. The hospital length of stay following an uncomplicated appendectomy in children may be successfully and safely reduced through the use of carefully devised, well-defined, well-disseminated clinical pathways.

Colonoscopy following nonoperative management of uncomplicated diverticulitis may not be warranted.

BACKGROUND: Following the nonoperative management of acute diverticulitis, guidelines recommend routine follow-up colonoscopy; however, evidence to support this recommendation are lacking. OBJECTIVE: This study aims to determine the diagnostic yield of endoscopy for clinically significant neoplasia following the successful nonoperative management of acute diverticulitis. DESIGN: This study is a retrospective review. SETTING: This study was conducted in a large urban health region. PATIENTS: Adult patients who were admitted with a diagnosis of acute diverticulitis confirmed by CT and who were successfully managed nonoperatively to hospital discharge were included. Patients who underwent colonoscopy within 2 years of presentation were excluded. MAIN OUTCOME MEASURE: The primary outcome measured was the incidence of clinically significant neoplasia (invasive malignancy or advanced adenoma) on follow-up endoscopy within 1 year of admission. RESULTS: Four hundred fifty-eight patients were selected for analysis, of which 249 patients (54%) underwent endoscopy within 1 year of admission. Seventy-seven (30.9%) patients were found to have polyps, 19 (7.6%) patients had advanced adenomas, and 4 (1.6%) patients had an invasive malignancy; 23 patients (9.2%) were found to have clinically significant neoplasia. On subgroup analysis, patients presenting with complicated diverticulitis (n = 74) had a significantly higher incidence of advanced adenoma (18.9% vs 5%, p = 0.001) and invasive malignancy (5.4% vs 0%, p = 0.007) in comparison with patients who presented with uncomplicated diverticulitis (n = 175). On multivariate analysis, patient age (OR 1.04 (1.01-1.08), p = 0.02) and the presence of abscess (OR 4.15 (1.68-10.3), p = 0.002) were identified as significant risk factors for clinically significant neoplasia. LIMITATIONS: The use of retrospective data was a limitation of this study; 54% of selected patients underwent endoscopic follow-up. CONCLUSIONS: The incidence of clinically significant neoplasia on endoscopic follow-up after the nonoperative management of acute diverticulitis is 9.2%. Those with complicated diverticulitis are at higher risk, whereas the incidence of clinically significant neoplasia in those with uncomplicated diverticulitis is equal to the incidence in average-risk individuals. Routine diagnostic colonoscopy following the nonoperative management of acute uncomplicated diverticulitis may not be warranted.

Mucous fistula refeeding in neonates with enterostomies.

BACKGROUND/PURPOSE: Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications. METHODS: With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used. RESULTS: Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR. CONCLUSIONS: In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

Practice variation in gastroschisis: factors influencing closure technique.

BACKGROUND: Little is known about the factors influencing surgical practice variation in newborns with gastroschisis. The purpose of this study was to correlate prognostic variables with the intended and actual abdominal closure technique and assess related outcomes. METHODS: GS cases were abstracted from a national database. Variables evaluated included GA, BW, bowel injury severity (GPS), neonatal illness severity (SNAP-II), inborn status, center volume and training status, and admission time. Evaluated outcomes by closure method included duration of TPN, LOS, and complications. Descriptive, univariate and multivariable regression analyses were conducted. RESULTS: The cohort consisted of 679 patients. A total of 372 (55%) underwent attempted PR, of which 300 (81%) were successful, while 307 (45%) had a silo placed intentionally. Patients undergoing attempted PR were more likely to be inborn, have daytime admissions, and higher SNAP-II scores. Successful PR was predicted by low risk GPS and high volume center. With the exception of higher rates of SSI in the planned silo group, outcomes in the successful PR and planned silo groups were comparable. CONCLUSION: Practice variation related to type of closure is predicted by situational and institutional factors (outborn, nighttime admission, and center volume), while outcome variation is attributable to patient factors rather than practice variation.

Human milk fortifier: an occult cause of bowel obstruction in extremely premature neonates.

BACKGROUND: Human milk fortifier (HMF) is used in neonatal units throughout North America to facilitate growth of preterm infants. Little data is available on the gastrointestinal side effects and potential adverse events. The purpose of this paper was to present a series of infants presenting with bowel obstruction associated with HMF. METHODS: Cases of HMF obstruction were collected between January 2010 and December 2012. Charts were reviewed and relevant data was collected. RESULTS: During the study period, 7 premature infants presented with bowel obstruction secondary to intestinal concretions of HMF. All babies were premature with gestational ages from 25 to 27 weeks. Birth weight was less than 1000 grams in all patients. Patients presented with feeding intolerance, bilious aspirates, abdominal distension, and obstipation. Four of the patients presented with acute deterioration and required urgent surgical intervention. CONCLUSIONS: HMF is an important source of nutritional support in infants, which is felt to be safe. We present a series of infants where its use has resulted in significant complications. HMF should be used with caution in infants, especially those with a history of necrotizing enterocolitis. Further research should examine the calcium, protein, and fatty acid concentration tolerable in the gastrointestinal tract of infants.

Pediatric surgical camps as one model of global surgical partnership: a way forward.

BACKGROUND/PURPOSE: A uniquely Ugandan method of holding surgical "camps" has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership. METHODS: We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery. RESULTS: Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian-Ugandan pediatric surgery teaching alliance. CONCLUSION: Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.

The impact of multi-disciplinary intestinal rehabilitation programs on the outcome of pediatric patients with intestinal failure: a systematic review and meta-analysis.

BACKGROUND: Pediatric intestinal failure (IF) is a complex clinical problem requiring coordinated multi-disciplinary care. Our objective was to review the evidence for the benefit of intestinal rehabilitation programs (IRP) in pediatric IF patients. METHODS: A systematic review was performed on Medline (1950-2012), Pubmed (1966-2012), and Embase (1980-2012) conference proceedings and trial registries. The terms short bowel syndrome, intestinal rehabilitation, intestinal failure, patient care teams, and multi-disciplinary teams were used. Fifteen independent studies were included. Three studies that were cohort studies, including a comparison group, were included in a meta-analysis. RESULTS: Compared to historical controls (n=103), implementation of an IRP (n=130) resulted in a reduction in septic episodes (0.3 vs. 0.5 event/month; p=0.01) and an increase in overall patient survival (22% to 42%). Non-significant improvements were seen in weaning from PN (RR=1.05, 0.88-1.25, p=0.62), incidence of IFALD (RR=0.2, 0-17.25, p=0.48), and relative risk of liver transplantation (3.99, 0.75-21.3, p=0.11). Other outcomes reported included a reduction in calories from parenteral nutrition (100% to 32%-56%), earlier surgical/transplant evaluation, and improved coordination of patient care. CONCLUSION: For pediatric IF patients, IRPs are associated with reduced morbidity and mortality. Standardized clinical practice guidelines are necessary to provide uniform patient care and outcome assessment.

Predictors of surgery and consult with an oncologist for adjuvant chemotherapy in early stage NSCLC patients in Alberta, Canada.

INTRODUCTION: In the fall of 2004, adjuvant chemotherapy for early stage non-small cell lung cancer (NSCLC) patients was approved for coverage by the Alberta Cancer Board, the provincial agency responsible for systemic therapy in the province of Alberta. The purpose of this study was to measure the proportion of early stage NSCLC patients diagnosed between 2004 and 2006 that received surgery and subsequently had a consult with an oncologist at a cancer facility, and to identify factors related to receiving surgery and having a consult that could be addressed. METHODS: A retrospective observational study was conducted. All patients diagnosed with stage IB, IIA, or IIB NSCLC in Alberta from 2004 to 2006 were identified from the Alberta cancer registry. Date of definitive surgery, gender, age at diagnosis, and area of residence were also obtained from the cancer registry and evaluated as predictors for surgery and oncology consult. Date of consult with an oncologist was obtained from the electronic medical record of the Alberta Cancer Board. RESULTS: There were 561 patients diagnosed with stage IB-IIB NSCLC from 2004 to 2006, 352 of whom had surgery and 255 of whom subsequently had a consult with an oncologist. Age and residence at diagnosis were both strongly associated with the likelihood of receiving surgery and the likelihood of attending a consult with an oncologist. DISCUSSION: Several areas of further research have been identified by this study including age and rural residence on treatment/referral patterns.