L. Selesner1, R. Bigej1, C. Gause2, M. Butler1,3, S. Krishnaswami1, E. Fialkowski1 2Providence Portland Cancer Center, Department Of Pediatric General Surgery, Portland, OR, USA 1Oregon Health And Science University, Division Of Pediatric Surgery, Portland, OR, USA 3Legacy Emmanual Children’s Hospital, Division Of Pediatric Surgery, Portland, Oregon, USA
Introduction: To minimize variance in care and improve outcomes following anorectal malformation surgery, we implemented a postoperative protocol across two pediatric surgery centers and nine pediatric surgeons. The protocol specified antibiotic duration, feeding advancement, VACTERL association workup, and wound management. Our goal was to standardize postoperative care with the primary endpoints of wound complications and length of stay.
Methods: The anorectal malformation postoperative protocol (Figure 1) was implemented in June 2019 at our two children’s hospitals. Data was collected on all associated patients over 12 months, after an initial 6-month transition period for protocol implementation and acceptance. Patients who underwent surgery for an anorectal malformation were analyzed. Patient demographics, VACTERL workup completion, age at repair, type of malformation, bowel prep, presence of colostomy, surgeon compliance, complications, length of stay (LOS), return to the emergency department, readmission, and reoperation were compared with a 12-month control period preceding protocol initiation.
Results: A total of 18 patients were included (7=control, 11=protocol). Demographics were similar among groups. The majority of the study group had a diagnosis of rectoperineal fistula (57% control vs. 54% protocol). Nine patients underwent posterior sagittal anorectoplasty (PSARP), and 2 underwent cutback anoplasty. Postoperative LOS was not significantly different between groups (control mean 4.5/median 2.5 days; protocol mean 2.9/median 2 days; t-test p = 0.50). One complication was identified in the control population, which included wound dehiscence requiring an unplanned return to the operating room. There were no isolated wound infections in either cohort. Surgeon compliance with the protocol in patients who underwent PSARP was 78%. Noncompliance in all patients was due to diet advancement on postoperative day 1, instead of maintaining “nothing by mouth” for 48 hours. In addition, one patient did not undergo a complete VACTERL workup.
Conclusion: Implementation of a standard pediatric postoperative protocol following anorectal malformation surgery is achievable across hospital systems and surgeons. Standardizing management in our patient population maintained excellent outcomes with a trend toward decreased postoperative length of stay, while a small sample size limited our analysis. Further study with a larger population size is needed to analyze our protocol’s impact on wound complications, length of stay, and other outcomes, including hospital cost.
