64.06 The Use and Quality of Cost-Utility Analysis in Surgical Research from 1990-2013

Posted on January 18, 2016

A. Benedict1, M. Chenoweth1, H. Jen1 1Tufts Medical Center,Boston, MA, USA

Introduction: Cost-utility analysis (CUA) assesses healthcare interventions by measuring value in terms of incremental cost per quality-adjusted-life-year (QALY) gained. CUA can comprehensively assess a wide range issues in the care of surgical patients. To date, comprehensive assessment of the CUA literature in surgery has not been conducted. The purpose of our study was to investigate the use and quality of CUA in surgical research.

Methods: A comprehensive Cost-Effectiveness Analysis (CEA) Registry, which catalogs more than 4297 peer-reviewed English-language CUAs through 2013, was used. This registry performs yearly systematic review of the CUA literature since 1976 and collects publication information, methodological characteristics, cost effectiveness ratios as well as utility weights from each article. Study characteristics were analyzed over three time periods: 1990-1999, 2000-2009, and 2010-2013. The quality of CUAs in the registry was rated on a 7-point scale. General surgery disciplines (GS) include general, bariatric, cardiothoracic, colorectal, oncologic, pediatric, transplant, trauma, and vascular surgeries. Trends were compared using the Cochran-Armitage trend test and designated significant if p<0.05.

Results: Out of the 4297 CUA articles in the CEA Registry, 647 (15.06%) focused on surgical interventions. The number of surgical CUA publications per year increased from 7.6 articles per year in 1990-1999 to 62.3 articles per year in 2010-2013 (p<0.03 for trend; see figure). This rate of increase was dwarfed by the increase in non-surgical CUA publications (26.3 articles per year in 1990-1999 to 395.8 articles per year in 2010-2013; p<0.005). The proportion of CUAs evaluating GS disciplines compared to other surgical subspecialties decreased significantly over time (from 55.2% in 1990-1999 to 41.6% in 2010-2013; p<0.001). The quality of CUAs was similar when comparing GS discipline to non-surgical CUAs (4.47 vs. 4.54, p=0.18). However the quality of GS discipline CUAs was superior compared other surgical subspecialties (4.47 vs. 4.19, p<0.005). There was also a significant increase in the proportion of surgical CUA publications from low- and middle-income countries (0% in 1990-1999 to 5.2% in 2010-2013; p<0.01).

Conclusion: There has been a significant growth in use of cost-utility analysis in surgical research, but the rate of increase still lags behind non-surgical subspecialties. Although the proportion of general surgery CUAs compared to other surgical subspecialties have decreased overtime, the quality of general surgical CUAs was superior. Furthermore, our data also suggest a growing interest in surgical CUAs by low- and middle-income countries.

64.07 Surgeon-Patient Communication during Awake Procedures

Posted on January 18, 2016

K. Guyton1, C. Smith2, A. Langerman1, N. Schindler1,3 1University Of Chicago,Surgery,Chicago, IL, USA 2University Of Chicago,Pritzker School Of Medicine,Chicago, IL, USA 3Northshore University Health System,Surgery,Evanston, IL, USA

Introduction:
Awake surgery offers patients an efficient and cost-effective alternative to procedures under general anesthesia. Surgeon-patient communication during awake procedures is an important component of the overall patient experience and has been inadequately described in the literature.

Methods:
Surgeons who perform a high volume of procedures on awake (no sedation or conscious sedation) patients were identified at two medical centers. Surgeons were contacted via email to participate in audio-recorded semi-structured interviews. Interviews were continued until saturation was reached. Review of transcripts allowed for iterative development of themes by two researchers; discrepancies were resolved by consensus.

Results:
Fifty two percent of surgeons agreed to participate, consisting of 23 faculty from 8 surgical specialties. Surgeons describe the primary drivers to perform awake procedures as decreased physiologic and monetary patient impact and increased procedure efficiency, while anticipated emotional, sensory and physical responses are deterrents. Surgeons emphasize that pre-procedure expectation management and a calm environment are integral contributors to the patient experience. Intra-procedure surgeon-patient communication is focused on providing instructions, verifying patient comfort, alerting the patient to changes in stimulation, diverting patient attention, and using words that do not cause patient alarm. Surgeon communication with staff and trainees is modified with an awake patient: verbal exchanges are minimized and quiet or nonverbal communication is utilized. With less explicit communication, surgeons value working with consistent teams. Trainee presence decreases focus on the patient. All surgeons report an absence of formal training in awake communication skills and report development of their techniques through observation of mentors and trial and error. Numerous surgeons report feeling insecure in their techniques and cite interest in learning other awake communication methods.

Conclusion:
Awake surgical procedures are unique circumstances for doctor-patient communication. Surgeons cite varied techniques to prepare and reassure patients before and during the procedure. Inconsistent education in communication skills results in surgeon insecurity. Challenges with trainee involvement warrant further evaluation of teaching practices, surgeon-trainee communication and the effect on patients during awake procedures. Development of best practices and a formalized curriculum in awake procedure communication would offer surgeons useful guidance for optimizing patient experience.

64.08 A Pilot Surgical Ethics Curriculum for General Surgery Residents

Posted on January 18, 2016

P. Singh1, M. D. Sur1, B. A. Shakhsheer1, P. Angelos1 1University Of Chicago,Surgery,Chicago, IL, USA

Introduction:
Education in clinical medical ethics has been increasingly recognized as a valuable component of surgical education. The Accreditation Council for Graduate Medical Education (ACGME) includes professionalism, defined as adherence to ethical principles, as one of its six core principles. Although most general surgery residency programs currently include some consideration of ethics in their curricula, the content and format for ethics education varies widely. The objective of this study was to develop and evaluate a surgical ethics curriculum specifically for surgical residents that was integrated into the clinical conference schedule.

Methods:
A year-long, IRB-approved curriculum was developed focusing on eight major topics within surgical ethics: informed consent, transplantation, withdrawing and withholding care, surgical training, error disclosure, surgical innovation, surgical research and global surgery. Each topic was presented as a case-based discussion drawing from selected readings with faculty-led moderation and presentation of pertinent clinical issues. Residents participated in pre- and post-test closed-form surveys assessing their attitudes toward ethics education, confidence in their skills in management of challenging ethical situations, and factual knowledge of key concepts in surgical ethics.

Results:
Forty categorical general surgery residents participated in at least one component of the curriculum. Of these, 31 completed the pre-test and 21 completed the post-test; 16 completed both. Although 75% of residents had received formal ethics training previously, 94% believed ethics education to be ‘important’ or ‘very important.’ Prior to participating in the course, residents felt most comfortable with informed consent and least comfortable with advanced directives and do-not-resuscitate (DNR) orders. Residents scored an average of 68.6% (range 52.6–89.5%, n=31) on 19 multiple choice knowledge-based questions on the pre-test and did not significantly improve with the course. Pre-test scores did not correlate with level of residency as compared between junior (PGY 1-2) and senior (PGY 3-5) residents (P=0.42). There was a trend toward improved confidence in all areas at the completion of the curriculum and a significant improvement in confidence managing advanced directives and DNR orders (P<0.001, n=16). Most participating residents responded with ‘somewhat agree’ or ‘strongly agree’ to statements that the course was useful, made an important contribution to their surgical training and was valuable for future residents.

Conclusion:
A surgical ethics curriculum can be successfully implemented as part of general surgery residency and residents value a curriculum that presents relevant issues to their training. Although residents may have received ethics education in the past, an ethics curriculum can help improve their confidence in dealing with a variety of ethical issues.

64.02 Pediatric Appendicitis: Is Referral to a Regional Pediatric Center Necessary?

Posted on January 18, 2016

M. M. Hodges1, S. N. Acker2, E. E. Moore3, A. Schubert4, L. R. Hill2, D. A. Partrick2, D. Bensard2,3 1University Of Colorado Denver,Laboratory For Fetal And Reproductive Biology, Division Of Pediatric Surgery, Department Of General Surgery,Aurora, CO, USA 2Children’s Hospital Colorado,Department Of Pediatric Surgery, University Of Colorado School Of Medicine,Aurora, CO, USA 3Denver Health Medical Center,Department Of General Surgery,Aurora, CO, USA 4University Of Colorado Denver,Anschutz Medical Campus,Aurora, CO, USA

Introduction: Acute appendicitis is the most common emergent surgical procedure performed among children in the US, with an incidence exceeding 70,000 cases per year. In large urban centers, appendectomies are often performed by both pediatric surgeons and adult trauma and acute care surgeons (TACS surgeons). We hypothesized that children undergoing appendectomy for acute appendicitis have equivalent outcomes whether a pediatric surgeon or a TACS surgeon performs the operation. To evaluate our hypothesis we analyzed the outcomes of pediatric appendectomy performed by three populations of surgeons; pediatric surgeons operating in a pediatric, tertiary referral center; pediatric surgeons operating in an urban safety-net hospital; and adult TACS surgeons operating in an urban safety-net hospital.

Methods: A retrospective chart review was performed for all patients under 18 years of age, who underwent appendectomy at either a tertiary care children’s hospital (group A, n=100) or an urban safety net hospital between July 2010 and June 2015. The population of patients operated upon at the safety net hospital was further subdivided into those operated upon by pediatric surgeons (group B, n=60) and those operated upon by adult TACS surgeons (group C, n=60). Baseline characteristics and operative outcomes were compared between these three patient populations utilizing one-way analysis of variance (ANOVA) and Chi-squared test for independence.

Results: When comparing the three populations, we found no difference in either the proportion of patients with complicated appendicitis (p=0.05), operative time (p=0.18), postoperative length of stay (p=0.14), rate of infectious complications (p=0.41), or rate of readmission (p=0.50). The three study populations did differ with regard to the mean age of the patients operated upon (group A 9.4±3.6 years [mean± SD], group B 8.3±3.6 years, and group C 12.4±3.6 years; p <0.0005); however, this can be attributed to protocol at the urban safety net hospital requiring patients less than 5 years old be treated by pediatric surgeons. Time from assessment in emergency department to operating room was also longer for patients in group B (13.1±11.0 hours versus 9.8±8.6 hours in group A and 8.3±3.3 hours in group C, p=0.006), and there was a higher rate of open appendectomy among children operated on by both pediatric surgeons and TACS surgeons at the urban safety net hospital versus the children’s hospital (30% in group B and 23.3% in group C versus 3.1% in group A, p <0.0005).

Conclusion: Our data demonstrate that among children undergoing appendectomy, length of stay, risk of infectious complications, and risk of readmission do not differ regardless of whether they are operated upon by pediatric surgeons or adult TACS surgeons, suggesting resources currently consumed by transferring children to hospitals with access to pediatric surgeons could be allocated elsewhere.

64.03 Evidence Based Medicine: The Low Hanging Fruit of Lean Healthcare Implementation

Posted on January 18, 2016

J. T. Langell1, J. T. Langell1 1University Of Utah,Department Of Surgery,Salt Lake City, UT, USA

Introduction: The financial healthcare crisis has significantly reduced operating revenues for healthcare organizations. Hospitals are now seeking better operational efficiency models within their organizations. The successful application of Lean operation principles in manufacturing and other service sectors has resulted in its adoption by several healthcare organizations. Lean focuses on a culture change that promotes creation of a continuous learning organization and empowers all employees to make changes that will ultimately lead to improved customer value. One of the critical aspects of Lean is removing waste from a system to optimize the value equation.

The practice of evidence-based medicine improves the value to patients through the application of proven patient management principles that improve outcomes and may reduce the costs. Historical data shows that even the strongest leels of evidence-based medicine do not have uniform adoption by practitioners, even when mandated and tracked by federal payers and quality organizations. We believe that the uniform application of evidence-based medicine provides a simple and data-driven approach to Lean implementation.

Methods: We performed a literature search of the Cochrane database for evidence-based perioperative surgical care. This identified several publications that conducted a systematic review and meta-analysis of the use of incentive spirometers (IS) to prevent pulmonary complications after abdominal and thoracic operations. The data show that IS provides no efficacy in preventing these complications. We then studied the use of IS in our hospital system including total IS used and annual cost of purchase.

Results: We found broad use of IS and IS-teaching by surgeons across all disciplines in our hospital. A review of IS purchasing noted that our 526 bed tertiary care hospital used a total of 11,051 incentive spirometers in 2013 at a purchase cost of $2.27 each, totaling $25,086. The cost data does not include the additional cost of nursing teaching time, product stocking space or procurement resources. There are 5,686 hospitals registered with the American Hospital Association and 914,513-staffed beds in the US and according to the CDC over 100 million surgical procedures performed in the United States annually. If our medical center’s IS ordering practices and IS costs are relatively representative of US hospitals as a whole, the elimination of IS could save the healthcare system as much as $227,000,000 per year for a product that has evidence it provides no benefit to the general postoperative patient population.

Conclusion: The application of evidence-based medicine has greatly improved clinical outcomes, but has been shown to have variable adoption curves by healthcare practitioners. Here we demonstrate that the application of evidence based medicine can also be use a tool to eliminate financial waste and improve hospital operations.

64.04 How Much Does it Cost? Monetary Implications of Blunt Splenic Injury Management

Posted on January 18, 2016

O. A. Olufajo1,2, Y. Wang2, W. Jiang2, J. Leow2, Z. Cooper1,2, J. M. Havens1,2, R. Askari1,2, A. H. Haider1,2, J. D. Gates1, A. Salim1,2, E. Kelly1 1Brigham And Women’s Hospital,Division Of Trauma, Burn And Surgical Critical Care, Department Of Surgery,Boston, MA, USA 2Brigham And Women’s Hospital,Center For Surgery And Public Health,Boston, MA, USA

Introduction: Splenic artery embolization (SAE) is a well-known adjunct to the non-operative management of blunt splenic injuries (BSI). Although numerous studies have examined clinical outcomes of patients treated with and without SAE, there is a paucity of data that examines the economic impact of these treatment decisions. Our objective was to determine the cost implications of various strategies for non-operative management of BSI.

Methods: Patients with BSI were identified in the TRICARE database (2006 – 2010), a healthcare data repository of active and retired U.S. military personnel and their dependents. Patients who were managed non-operatively were classified as either having splenic artery embolization (SAE) or non-invasive management (NIM). Patients were categorized based on their Injury Severity Scores (ISS). Length of hospital stay, readmission rates, and 30 day complication rate (pneumonia, urinary tract infections, ileus/small bowel obstruction, wound infection, sepsis, acute renal failure) were determined. The 30-day costs of patient care (admission, readmission and complications) were calculated. A decision tree was used to determine the cost-effective strategy for various patient groups. Effectiveness was measured using quality-adjusted life years (QALYs).

Results: There were 529 patients who were managed non-operatively: 41 had SAE and 488 had NIM. The majority of patients were male (78%), < 45 years old (79%), with ISS > 15 (54%). Comparing the SAE to the NIM groups showed similar in-hospital complications (9.80% vs. 10.50%, P > 0.99), lower 30-day readmission rates (2.41% vs. 7.99%, P = 0.350), and similar rates of operation on readmission (0.00% vs. 1.40%, P > 0.99). The costs measured in both groups increased as ISS increased. While the costs in the NIM and SAE groups were $5,882 and $18,766, respectively, for ISS <9, the costs were $19,442 and $35,678, respectively, for ISS >25. Incremental cost-effectiveness ratios of SAE vs. NIM were all above the commonly used willingness-to-pay threshold of $50,000/QALY regardless of the ISS (Table), indicating that NIM was cost-effective compared to SAE.

Conclusion: Our study suggests that the cost of SAE, as a strategy for non-operative BSI management, outweighs its benefits. As emphases on cost implications of patient management increase, these findings can prove useful in cost management in BSI patients.

63.21 Time to CT scan for major trauma activation in pediatric population

Posted on January 18, 2016

A. Desai1, H. Alemayehu1, K. Savoie3, R. Barker3, R. F. Williams3, S. Turner2, B. Tjaden2, J. Howard2, P. Aguayo1 1Children’s Mercy Hospital,Surgery,Kansas City, MO, USA 2University Of Kansas Medical Center,Surgery,Kansas City, KS, USA 3University Of Tennessee Health Science Center,Memphis, TN, USA

Introduction: There is a growing body of evidence demonstrating improved outcomes associated with early radiographic evaluation of trauma patients. While there are a number of imaging modality options, the accuracy of CT scan during the diagnostic phase of acute trauma care has been well established. The objective of this study was to compare the time to CT scan as well as time spent obtaining CT scans between pediatric and adult trauma patients.

Methods: We performed a multi-center retrospective review of all trauma activations at two pediatric and two adult level 1 trauma centers from January 2012 to December 2013.

Results: A total of 1,323 (645 adult, 678 pediatric) patients were eligible for review during the study period. There was no significant difference in hemodynamic instability in the trauma bay (42 adult, 56 pediatric, p=0.3). There were, however, a significantly higher number of level 1 activations (227 adult, 118 pediatric, p <0.01), and higher ISS score (13.7±11.8 adult, 12.4±10.8 pediatric, p=0.04) in the adult population. Time to CT scan was significantly shorter in the pediatric population (35±34min pediatric, 46±68 adult, p<0.01). Time spent in CT was also significantly shorter in the pediatric population (22±11 min pediatric, 35±17min, p<0.01).

Conclusion: Although time to CT scan as well as time spent in CT scan was significantly shorter in the pediatric population, the difference was less than 15 minutes. Small difference in time may not be clinically relevant, and may be secondary to higher level of acuity seen in the adult population.

64.01 The Medicare Value-Based Purchasing Program Ranks Hospitals by Total Performance Score

Posted on January 18, 2016

A. Ramirez1, G. Stukenborg1, B. Turrentine1, R. Jones1 1University Of Virginia,Charlottesville, VA, USA

Introduction:

To address Medicare’s escalating costs, decreasing quality, and transparency the US Congress enacted the Patient Protection and Affordable Care Act of 2010 (ACA). Section 3001 of ACA established the Hospital Value-Based Purchasing Program (VBP) to measure the value of healthcare provided by participating hospitals. The VPB established quality indicators for processes, outcomes, patient satisfaction and cost per Medicare beneficiary to estimate value (value=quality/cost) of care provided. The domains above were used to calculate the Total Performance Score (TPS) allowing CMS to rank hospitals. For 2015, the Center for Medicare and Medicaid Services (CMS) withheld 1.5% of each Medicare hospitals’ anticipated annual payment to establish a financial framework for redistribution based upon TPS rank. High quality hospitals are rewarded and lower quality hospitals are punished. Review of the top 100 TPS included 27 physician-owned specialty hospitals (POSH) suggesting possible stratification by hospital type/business model.

Methods:

We reviewed the February 2015 VBP database including hospital name, address, unadjusted and adjusted process, outcome, patient satisfaction, cost, and total performance scores. We chose to compare POSH with all hospitals and POSH with another hospital type, University Hospital Consortium (UHC) members. We used the general linear model to estimate the TPS reported for each hospital as a function of hospital category and categorized by POSH and UHC membership. The statistical significance of the association between TPS and hospital category was assessed using the F test statistic at the threshold of p < 0.05.

Results:

The dataset included 3,089 hospitals with TPS ranging from 92.86 to 6.6 and a mean of 41.7. Of these 92 were identified as POSH and 111 were UHC hospitals. The mean TPS for POSH (64.43) was significantly higher than all other hospitals. Results from the general linear model indicate the estimated mean differences in TPS was 23.45 points higher for POSH (p < 0.0001) compared to all other hospitals. The mean TPS for UHC hospitals (36.89) was significantly lower than all other hospitals. The mean difference in TPS was -4.95 points lower for UHC hospitals (p < 0.0001) compared to all other hospitals.

Conclusions:

The Medicare VBP scoring method can effectively sort participating hospitals. Over time this methodology should improve, particularly with the development of progressively better quality indicators. Application of VBP should incentivize quality improvement and decrease healthcare cost. The observation that POSH had higher than average TPS and UHC hospitals had lower than average TPS requires further study. POSH include predominantly surgical centers while UHC hospitals represent a more heterogeneous patient population with large numbers of chronic disease. The observed differences comment on the need to further explore the impact of healthcare business models on outcomes.

63.18 Predictors of Central Venous Line Infection Salvage in Patients with Intestinal Failure

Posted on January 18, 2016

K. D. Nadendla1, M. Shroyer1, L. Wilkinson1, R. Dimmitt2, D. Galloway2, C. A. Martin1 1University Of Alabama at Birmingham,Pediatric Surgery/Surgery,Birmingham, Alabama, USA 2University Of Alabama at Birmingham,Gastroenterology/Pediatrics,Birmingham, Alabama, USA

Introduction: Life threatening central venous line (CVL) sepsis is a primary cause of mortality in patients with intestinal failure (IF). Current Infectious Diseases Society of America (IDSA) guidelines recommend CVL removal for bacteremia. However, many IF patients have limited venous access prompting initial attempts to salvage the line (non-removal of the CVL and antibiotic treatment). Here we describe predictors of line salvage at our institution, a topic which has been poorly understood historically.

Methods: The database for the Georgeson Center for Advanced Intestinal Rehabilitation (GCAIR) at the University of Alabama at Birmingham was queried from 2010-2015 to identify all patients with IF that were admitted for a CVL infection. Demographics and clinical parameters were compared among patients who underwent line removal to patients where the line was salvaged. Results were compared by a student’s unpaired T test.

Results:Forty patients were identified with 125 admissions for CVL infections. Line removal occurred in 71(56.8%) and 54(43.8%) successfully had their lines salvaged. The average age (months) for the removed group was 29.38 and 28.39 for the salvage group. Episodes of life threating sepsis were less frequent among the salvaged group as well as fungemia (p<0.0001). There was no significant difference in the non-fungal organisms cultured, location of the CVL, and number of previous admissions.

Conclusion:With the exception of cases of fungemia, line salvage of infected CVLs should be attempted in patients with IF when clinically possible. General pediatric CVL infection guidelines should be modified for patients with IF with limited venous access to address line salvaging methods.

63.19 The Epidemiology of Supracondylar Elbow Fractures in Children.

Posted on January 18, 2016

J. M. Rinaldi1, M. D. Hatch2, W. L. Hennrikus2 1Penn State Hershey Medical Center,College Of Medicine,Hershey, PA, USA 2Penn State Hershey Medical Center,Department Of Orthopaedics,Hershey, PA, USA

Introduction: Previous authors have reported that skull, rib, and corner fractures, and fractures in young children who have not started walking are highly associated with abuse. The purpose of this study is to determine the epidemiology, etiology, and relationship of supracondylar elbow fractures with child abuse.

Methods: 75 consecutive displaced supracondylar elbow fractures were reviewed to determine specific information about the manner in which the injury occurred. Medical records and radiographs were analyzed for demographic and injury data.

Results: 42 males (56%) and 33 females (44%) were studied. The average age was 6 years (range: 1 year 4 months to 12 years 4 months). 2 patients were 1-2 years of age, 3 were 2-3 years of age, and 70 were older than 3. The left elbow was fractured in 45 cases (60%). 87% were right hand dominant, 9% were left hand dominant, and 4% were too young to determine handedness. 58% injured the non-dominant arm. 24 (31%) were Gartland Type 2 and 52 (69%) were Gartland Type 3 fractures. 1 fracture was open. 8 (11%) fractures had a pucker sign. 11% presented with a nerve palsy. 5% presented without a pulse. 7 patients (9%) presented with an additional ipsilateral distal radius fracture. 64 fractures (85%) were transferred from 27 different outside hospitals in 17 counties, while 11 fractures (15%) presented directly to the ED. 35 fractures (47%) occurred at home, 30 (40%) on the school grounds, 4 (5%) in a gymnasium, 4 (5%) in a park, 1 at a farm show, and 1 in a parking lot. 24 fractures were treated between midnight and 8am, 15 were treated between 8am and 5pm, and 33 were treated between 5pm and midnight. All fractures stemmed from a fall, including: playground equipment 29 (39%), furniture 10 (13%), sports 6 (8%), stairs 3 (4%), bikes 3 (4%), and miscellaneous– running and tripping, falling from a toy ball, sled, tree, wagon, fence, bounce house, van, deck, power-wheels car, ATV, and go-cart. The average time from injury to the call for a transfer was 3 hours 5 minutes; transfer acceptance to arrival at ED– 2 hours 1 min; arrival in ED to OR– 5 hours 14 min; injury to OR– 10 hours 20 min; and time to discharge– 16 hours 39 min. Multiple medical professionals including outside ED physicians and orthopaedic surgeons, local ED physicians, local orthopaedic surgeons, residents, and nurses evaluated each patient. Only 1 patient, the youngest patient in the cohort at 1 year 4 months, injured from a fall at home, was reported for possible abuse and the evaluation was negative.

Conclusion: Pediatric elbow supracondylar fractures occur from accidental falls while children are at play. The mechanism involves a fall on the outstretched hand, hyperextension of the elbow, and fracture of the humeral cortex at the supracondylar location. In this population, child abuse was rarely associated with supracondylar elbow fractures.

63.20 Straddle Injury Management in Female Pediatric Patients: a One Year Retrospective Review

Posted on January 18, 2016

S. Dadjoo1, J. C. Hakim2, M. L. Peterson1, P. I. Abbas1, M. E. Lopez1, M. L. Brandt1, J. E. Dietrich2 1Texas Children’s Hospital,The Michael E. DeBakey Department Of Surgery, Baylor College Of Medicine,Houston, TX, USA 2Texas Children’s Hospital,Department Of Obstetrics And Gynecology, Baylor College Of Medicine,Houston, TX, USA

Introduction:
Straddle injuries in females consist of blunt and/or penetrating trauma to the urogenital area. Treatment of Grade 1 and 2 straddle injuries most often consists of sitz baths, estrogen cream or antibiotic ointment. Surgical repair may be indicated for significant bleeding or deep lacerations. The purpose of this study is to report treatment and outcome of girls <18 years of age with Grade 1 or 2 straddle injuries who were treated as outpatients (< 24 hr observation) in a large, tertiary pediatric hospital.

Methods:
An IRB approved retrospective review of all patients with Grade 1 and 2 straddle injury seen at Texas Children’s Hospital in 2014 was performed. Exclusion criteria included male gender, admission >24 hours or concern for sexual abuse. Data collected included age, time of year, mechanism of injury, management, and outcomes.

Results:
There were 69 girls who met inclusion criteria. The mean age was 6 years (range 2-17). Injuries were most common in May and June (n=18, 26%). The main cause of injury was a fall at home (n=31), fall at school playgrounds (n=24), or a bicycle or scooter injury (n=10). There were no penetrating injuries in this series. 18 pts were transferred from an outside facility. 68% (n=47) of pts were managed solely by an emergency department (ED) physician, and 32% (n=21) were managed by the gynecologic or, less commonly, the surgical service. A consult from the ED was most often requested when pain prevented adequate examination and/or significant bleeding or deep lacerations were present. 15 patients (22%) required surgical repair of lacerations of the perineum, labia, or vaginal introitus− 9/15 were treated in the operating room, 6/15 were treated in the ED under conscious sedation. There were no urethral or rectal injuries. Two patients required post-operative Foley catheters to relieve urinary retention. There were no other complications. The gynecology service prescribed at least 1 medicated cream (bacitracin, estrogen, lidocaine) in all patients, with 2 or more creams used in 71% of patients. Patients treated solely by ED physicians were less likely to receive topical medical therapy than patients treated by the gynecology or surgical service (13/47, 28% vs. 22/22, 100% p<0.0001). No patients were readmitted for further management.

Conclusion:
Grade 1 and 2 straddle injuries are common and most often occur following a fall at home. Significant pain and/or bleeding requires specialty intervention for a careful exam under anesthesia or conscious sedation. The minority of patients (22% in this series) require surgical repair. Clear indications for surgery as well as indications and effectiveness of topical treatments will be most effectively answered in future, prospective trials.

63.16 Adverse Events and Quality Control Measures in the Intra-Hospital Transfer of Pediatric Patients

Posted on January 18, 2016

I. Khurana1, A. G. Antunez1, K. M. Zalewski1, K. Marchetti1, G. C. Ives1, S. K. Gadepalli1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Patient transfer to various areas within a hospital is a common yet high-risk activity that can result in morbidity. Mitigating risks involved by using various quality control measures can help reduce injuries; however, studies have predominantly focused on adult and inter-hospital transfers, with relatively little attention given to the more common intra-hospital transfer of pediatric patients. A systematic literature review was conducted to characterize adverse events (AE) encountered during intra-hospital transfers (IHT) of pediatric patients and to examine current quality control measures (QCM).

Methods: Studies investigating IHT of pediatric patients were found in the English-language literature of three databases (PubMed, Embase, and Web of Science), using the help of a medical librarian. We collected relevant outcome measures such as AE and QCM, along with study design and interventions used. Studies meeting inclusion criteria, based on two independent reviewers, were further categorized into the primary outcomes: AE identified and type of QCM. A Cohen’s unweighted kappa was used to determine inter-rater agreement.

Results: Of the initial 43 articles, 12 satisfied inclusion criteria, with a moderate inter-rater agreement on title/abstract review (k=0.54[0.34-0.74]). These studies focused on AE (5), QCM (1), or both (6) [see Table 1]. Only 6 of the 11 investigating AE and 2 of the 7 studies reporting QCM were prospective. A total of 1591 IHT were evaluated prospectively, with physiological deterioration accounting for 71% of reported AE, equipment failure 20%, and interventions required in 9%. These events mostly occurred during transfer between an intensive care unit and other parts of the hospital, and were related to extended duration of transport and sicker pre-transfer status of the patient (ventilation status, PRISM score). AE from human error can be remedied by teamwork and checklists to standardize QCM; while AE from disease processes can be improved by standardization of transfer protocols.

Conclusion: This review highlights the most common AE of pediatric IHT and suggests QCM to improve patient safety. Additional prospective studies to set threshold values for AE and to determine effectiveness of QCM should be conducted. This article impacts hospital policies and QCM used to benchmark and standardize pediatric IHT to reduce AE.

09.12 Surgeons as Agents of Change: Community Outreach and Provider Engagement

Posted on January 18, 2016

R. L. Hoffman1, K. O’Neill2, J. Olsen1, S. R. Allen1, M. K. Lee1, C. B. Aarons1, R. R. Kelz1 2Yale University School Of Medicine,New Haven, CT, USA 1Hospital Of The University Of Pennsylvania,Philadelphia, PA, USA

Introduction: Community outreach is a powerful tool for improving public knowledge of issues related to cancer care and decreasing disparities. Surgery is the only curative treatment of many types of cancer, therefore we developed a community outreach program to increase surgeon presence within the community.

Methods: In partnership with a large urban university cancer center, the Agnew society surgical interest group organized two community health outreach events focused on cancer prevention, screening and treatment in the surrounding community. Volunteers included medical students, surgical residents and faculty. The event consisted of free time for networking and engagement with participants. A survey instrument was used to gauge participant beliefs about cancer topics prior to the educational portion. The main event consisted of a presentation on colon cancer, followed by survivor and caregiver testimony and a question and answer session. Descriptive statistics were used to analyze survey results and to compare the demographics of the university to the community participants.

Results: Faculty are 69% male, 77% White, 3.5% African American and 14% Asian. Twenty-two surgical volunteers participated in the events and 2 of 6 faculty member panelists were African American. A total of 265 community members attended. Participants were 20% male and 96% African American. The survey response rate was 71% (188/256). Thirty-two percent endorsed mistrust in what doctors told them, 22% found it difficult to talk to doctors, and 25% felt that surgical treatment caused cancer to spread. After the first event, all medical professionals voluntarily continued participation in the second event and committed to future participation.

Conclusion: There was a clear difference between the demographic profiles of the university staff and the community that they served. Negative perceptions of physicians and the role of surgery in cancer treatment were prevalent within the community. Surgeon interest in community outreach is largely underappreciated. Surgeon engagement in community outreach can be easily expanded to other urban centers and may provide an opportunity to reduce surgical disparities.

63.14 Rethink Pediatric Nuclear Scans: Cost and Radiation Exposure of DMSA Scans in Children

Posted on January 18, 2016

M. Wang1, J. Michaud1, N. Gupta1, T. Bosemani1, M. Wang1 1Johns Hopkins,Urology,Baltimore, MD, USA

Introduction: Recent initiative set forth by the American Board of Internal Medicine, Choosing Wisely, asks physicians to carefully consider the risk and benefits of medical interventions. We examine our current protocol regarding pediatric patients who present with febrile urinary tract infection, who underwent DMSA scans. Specifically, calculating the added cost when compared to a dedicated pediatric renal ultrasound and the radiation dose associated with each scan.

Methods: DMSA renal scans are often utilized in the evaluation of pediatric patient present with febrile UTI. Given the prevalence of these exams in pediatric urology practice; we sought to quantify the cost, radiation exposure, and relative clinical utility when compared to dedicated pediatric renal ultrasound (RUS) in our patient population.
We conducted an IRB approved retrospective study of children referred to our institution for history of febrile UTIs between the years 2004-2013. Inclusion criteria: 1) children diagnosed with vesico-ureteral reflux (VUR) via voiding cystourethrogram (VCUG), 2) fever > 380 C, 2) urine culture with single organism of >50,000 cfu, and 3) patients who underwent both DMSA and RUS. Cost of each scan including professional and facility fee at our institution, radiation dosage, and radiographic results were analyzed.
Outcome measurements and statistical analysis: Chart review, and radiation dose equivalents were estimate from the Radiation Internal Dose Information Center (Oak Ridge Institute for Science and Education, Oak Ridge, TN).

Results:126 children (102 girls and 24 boys) met the inclusion criteria. The median age at presentation with febrile UTI was 8.1 months. The median age at first DMSA was 10.1 months. A total of 145 RUS and 171 DMSA were performed during the study period. Cost analysis revealed $865/RUS. DMSA $1,062/scan, and $2,115/scan for those children who need anesthetic sedation. The mean cumulative effective dose per patient/ DMSA was 3.75 mSv. This increased to 6.95 mSv for patients who underwent 3 scans. Limitations include retrospective design, tertiary referral center.

Conclusion:Both cost and radiation exposure from DMSA were significant when compared to RUS. Radiation exposure approached that of a pediatric chest CT (2-5 mSv) for a single DMSA.
Radiation exposure in early childhood can have significant impact on future cancer risk. Given the improved sensitivity of newer ultrasounds and comparable cost, efforts should be made to determine which children with urinary tract infection would benefit most from nuclear tests.

63.15 Chest radiograph after fluoroscopic guided line placement: no longer necessary

Posted on January 18, 2016

B. G. Dalton1, K. W. Gonzalez1, M. C. Keirsey1, D. C. Rivard1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction: Obtaining a chest radiograph after central line placement in the operating room is a historical standard. Retrospective studies at our institution and others have found these to be low yield. After our retrospective investigation, we changed our practice to avoid obtaining a routine post-operative film. In this study, we examine the impact of our clinical change on chest radiograph utilization, adverse events, and cost benefit.

Methods: After obtaining institutional review board approval, we reviewed the charts 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 24 hours 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 24 hours of the line placement with 25 (4%) of these patients being symptomatic in the recovery room. One patient required a chest tube for shortness of breath and pleural effusion. Four symptomatic patients (0.6%) were found to have a pneumothorax, none of which required intervention. There were no re-operations due 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 over 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.

63.11 The Management and Outcomes of Cervical Neuroblastic Tumors

Posted on January 18, 2016

J. R. Jackson1, H. Tran2, J. Stein1, H. Shimada4, A. M. Patel3, A. Marachelian2, E. S. Kim1 3Children’s Hospital Los Angeles,Otolaryngology,Los Angeles, CA, USA 4Children’s Hospital Los Angeles,Pathology,Los Angeles, CA, USA 1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2Children’s Hospital Los Angeles,Hematology/Oncology,Los Angeles, CA, USA

Introduction:

Neuroblastoma is a neural crest malignancy of childhood that arises from the sympathetic nerve chain from the neck to the pelvis. While studies have shown that extra-abdominal neuroblastoma (pelvic and thoracic) is associated with favorable biological and clinical characteristics, little has been published with regard to the management and outcomes of cervical neuroblastic tumors. Cervical neuroblastoma represents 2-4% of all neuroblastomas, and current practice is to resect as much tumor as possible without incurring injury to nearby vital structures. In this study we sought to determine the characteristics of these tumors and the effect that the extent of resection has on the overall survival and rate of complications in these patients.

Methods:

We performed a retrospective review of 325 children who were identified to have a neuroblastic tumor at Children’s Hospital Los Angeles over a 15-year period (1/1990–2/2015). Data collected from the medical record included location of tumor, age at diagnosis, age at resection, extent of resection, chemotherapy course, INSS stage, INPC histological classification, and MYCN amplification. Outcome variables included postoperative complications and overall survival.

Results:

Thirteen patients (13/325 – 4%) were identified to have cervical neuroblastic tumors (Table 1); 10 patients (77%) with neuroblastoma (NB), 1 patient with ganglioneuroblastoma (GNB)(7.7%), 2 patients with ganglioneuroma (GN)(15.4%). Median age at diagnosis was 5 months (range 1 mo-15 yrs). One 15 year old had high-risk stage 4 NB with unfavorable histology while the other 9 NB patients were infants <12 months of age. The remaining 3 patients (18-66 mos of age) had differentiating pathology (GN, GNB). All but one had favorable histology and none had MYCN amplification. Six of 10 NB patients underwent resection (5 gross total resection (GTR) and 1 partial resection) while the other 4 underwent biopsy followed by chemotherapy or observation. After GTR, 1 NB patient required prolonged intubation necessitating tracheostomy and another developed eyelid ptosis. The GNB patient, also post-GTR, developed Horner syndrome. The 2 GN patients underwent GTR as well, which resulted in permanent injury to 5 cranial nerves and eyelid ptosis. At latest follow-up, there has been 1 death secondary to relapsed disease.

Conclusion:

Cervical neuroblastic tumors represent favorable lesions with good outcomes similar to other extra-abdominal neuroblastic tumors. In our study, survival was excellent regardless of extent of tumor resection. Based on our data, with the high incidence of complications following GTR, we recommend a minimally agressive surgical approach in managing children with cervical neuroblastic tumors.

63.12 Pediatric Surgical Specialists Are Unaware if Out-of-pocket Cost Influenced Preoperative Decisions

Posted on January 18, 2016

H. Jen1, C. Calkins2, R. Dasgupta3, S. Shah4, S. Safford5, I. Bernstein6, M. Langham7, L. Chen8 1Tufts Medical Center,Boston, MA, USA 2Medical College Of Wisconsin,Milwaukee, WI, USA 3Cincinnati Children’s Hospital Medical Center,Cincinnati, OH, USA 4Children’s Mercy Hospital – University Of Missouri Kansas City,Kansas City, MO, USA 5Virginia Tech Carilion Clinic Children’s Hospital,Roanoke, VA, USA 6University Of Texas Southwestern Medical Center,Dallas, TX, USA 7University Of Tennessee Health Science Center,Memphis, TN, USA 8Baylor University Medical Center,Dallas, TX, USA 9American Academy Of Pediatrics Section On Surgery Committee On Delivery Of Surgical Care,N/A, N/A, USA

Introduction: The Affordable Care Act has increased insurance coverage for children in the United States, but variation in out-of-pocket expenses for families with health insurance seeking pediatric surgical care for their children has also increased. Little is known about pediatric surgical specialists’ experience and attitude toward patients' insurance deductibles or whether pediatric surgical specialists take their patients’ out-of-pocket expenses into account when planning care. A national survey of pediatric surgical specialists was conducted to define the their experience with patient insurance concerns.

Methods: Members from the American Academy of Pediatrics Sections on Plastic Surgery, Surgery and Urology were asked to participate in an anonymous online survey to assess the relationship between surgeon experience with patients’ insurance plans and resource utilization. A 6-item Likert-type scale was used to assess surgeon experience with patients’ insurance concerns. A higher score on the scale associates with increased empathy and concern towards patients’ insurance status. Analysis of variance (ANOVA) was used to investigate practice pattern differences.

Results: Two hundred and eighteen out of 973 (21%) surgeons representing 38 states completed the survey. Almost half of the surveyed surgeons did not know if cost was a determinant for their patients’ choice in surgical facility (43%), or if parents compared provider costs prior to the visit (50%). If the family brought up cost or insurance coverage as an issue, the majority of surgeons would consider cheaper diagnostic modalities (84%) and adjust surgery schedules to decrease patient deductibles (94%). The minority (34%) of surgeons never considered cost as a determinant when scheduling multistage operations. The 6-item Likert-type patient insurance experience scale score did not differ significantly among surgical subspecialties, practice sizes, practice types or states of practice. Surgeons who scored lower on this scale tended to recommend laboratory and radiologic testing at their own facility, citing test reliability and accessibility to results as the top reasons for this practice (p<0.05). The majority of the surgeons surveyed (84%) would consider patient cost in their recommendation of a test or therapy if medically appropriate.

Conclusion: Pediatric surgical specialists are currently unaware if out-of-pocket cost influences patients’ preoperative decisions, but are sympathetic to the issue of out-of-pocket costs if families raised cost as an issue during their visit. As the financial burden of health care shifts to patients and families, the influence of this burden on health care choices by consumers and providers may affect both access to care and surgical outcomes.

63.13 An Evaluation of eHealth Utilization in Pediatric Surgery – What is the Parent’s Perspective?

Posted on January 18, 2016

A. Eguia2, B. Freemyer2, D. Pham2, E. Hamilton2, K. Tsao2, M. Austin1,2 1University Of Texas MD Anderson Cancer Center,Houston, TX, USA 2University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: eHealth is the use of digital information and online communication to improve a person’s health or health care. Previous studies have shown that patients face many barriers when attempting to utilize e-Health including factors related to socioeconomic status, language, age, and education. We hypothesized that barriers exist that significantly impact a parent’s ability to access and feel comfortable with using eHealth.

Methods: We performed a cross-sectional study which included 24 non-randomly selected parents of 21 pediatric surgical patients. After obtaining informed consent, semi-structured interviews were conducted in an outpatient clinic by one of two co-authors (AE and BF). The interviews were conducted in each participant’s primary language (11 English and 10 Spanish) and participants were asked about access to eHealth, mechanism(s) of use and challenges faced in accessing and using eHealth. The interviews were recorded and transcribed, and the qualitative data were analyzed using thematic analysis. English-speaking participants (ESP) and Spanish-speaking participants (SSP) were compared.

Results: All participants, except one SSP, had access to the Internet at home. Compared to SSP, ESP were more likely to use the Internet to learn about their own (73% vs 38%) or their child’s health (80% vs 50%). In both groups, parents who used eHealth were more likely to look up information regarding their child’s health versus their own health. ESP tended to use computers and cell phones, whereas SSP were more likely to use only tablets or cell phones. Challenges to using eHealth for ESP included the vast amount of knowledge available, uncertainty of resource credibility and poor Internet connections. Among SSP, non-Spanish websites, inadequate access and lack of knowledge on how to use the Internet presented challenges to utilizing eHealth. In both groups, most participants viewed the potential for email communication with their child’s physician as positive (85%).

Conclusion: While most parents report access to the Internet, both English-speaking and Spanish-speaking parents face challenges in utilizing eHealth. In this pilot project, we identified several key differences between ESP and SSP. We will use our results to inform content in developing a survey to identify and characterize comfort level and barriers that might hinder a parent’s ability to navigate eHealth. This will lay the foundation for the development of a program that can facilitate patient and parent access to and comfort engaging in eHealth.

63.08 Pancreaticoduodenectomy Outcomes in the Pediatric, Adolescent, and Young Adult Population

Posted on January 18, 2016

S. A. Mansfield1, J. P. Walker2, J. H. Aldrink3 1Ohio State University,Department Of General Surgery,Columbus, OH, USA 2Ohio State University,Division Of Gastroenterology, Hepatology And Nutrition,Columbus, OH, USA 3Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA

Introduction:
Pancreatic malignancy and chronic pancreatitis are rare in the pediatric, adolescent, and young adult (AYA) population, making pancreas resections an infrequent procedure in this demographic. Only case reports and small case series exist in the literature describing surgical outcomes and complications in this population. The aim of this study is to review the surgical complications and outcomes of pediatric and AYA patients undergoing pancreaticoduodenectomy at our institution.

Methods:
All pediatric, adolescent, and young adult patients (≤30 years) undergoing pacreaticoduodenectomy over a 15-year period (1998-2013) were identified for inclusion in this single-center, observational cohort study. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data, including indications for procedure, duration of hospital stay, pathologic data, 30-day mortality, complications, and re-operation data. Overall survival and disease-free survival was calculated using Kaplan-Meier curves.

Results:
Twenty-one patients with a median age of 25 years (range 11-30 years) underwent pancreaticoduodenectomy during the study period and comprised the cohort. Indications for surgery included chronic pancreatitis in 3 and mass/malignancy in 18. The most common post-operative histologic diagnoses were chronic pancreatitis (5, 23.8%), solid pseudopapillary neoplasm (5, 23.8%), and adenocarcinoma (4, 19.0%). For tumor resections, all surgical margins were negative. Six patients required reoperation, with a median time to reoperation of 26 months (range 4.4-136.1). Three reoperations were required in patients with chronic pancreatitis, all due to recurrent or continued pain. Other indications for re-operation included stricture of hepaticojejunostomy (n=1), primary choledocholithiasis (n=1) and upper gastrointestinal bleeding (n=1). The most common postoperative complication was intraabdominal abscess (3, 14.3%). Pancreatic leak occurred in only one patient. Thirty-day mortality was 0% for all patients. There were no recurrences or disease-related deaths in patients with solid pseudopapillary neoplasm. Patients with adenocarcinoma had a median survival of 15.6 (range 9-142) months.

Conclusion:
This is the largest series of pancreaticoduodenectomy procedures reported in the pediatric and AYA population. As in adults, surgical resection remains the mainstay of treatment for neoplasms of the pancreas and complicated chronic pancreatitis for the pediatric and AYA groups. Given how rare these pancreatic conditions are in this age group, cohort studies such as this may help improve therapies for this unique patient population.

63.09 Successful Non-operative Management of Esophageal Perforations in the Newborn

Posted on January 18, 2016

E. A. Onwuka1, P. Saadai1, L. A. Boomer2, B. C. Nwomeh1 1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 2LeBonheur Children’s Hospital,Pediatric Surgery,Memphis, TENNESSEE, USA

Introduction:

Esophageal perforation in neonates occurs most often in cases of extreme prematurity. Common etiologies include orogastric (OG) tube placement, endotracheal intubation, and endoscopy. Mortality as high as 29% has been reported. Treatment over the last decade has leaned towards non-operative management with nil per os (NPO), total parenteral nutrition (TPN), antibiotics, and radiographic examination prior to the re-institution of oral feeds. To date, treatment duration for non-operative management has not been well studied, therefore neonates may experience unnecessarily prolonged periods of enteral feed disruption and antibiotic exposure. The purpose of this study was to review cases of esophageal perforation in neonates to assess the outcomes of non-operative management.

Methods:

A retrospective chart review was performed of patients under one year of age with ICD-9 code 530.4 for esophageal perforation treated at our institution between the years of 2009 and 2015. Data collected included demographic information, etiology of perforation, treatment course, time to resumption of enteral feeds, length of antibiotic use, time to subsequent radiographic resolution, and mortality.

Results:

Twenty-nine patients met study criteria. The etiologies of perforation were orogastric tube placement (n=26) and esophageal dilation for stricture (n=1). Three patients with a primary surgical diagnosis (diaphragmatic hernia, esophageal atresia, non-accidental trauma) were analyzed separately. Of the 26 patients with a non-surgical etiology for esophageal perforation, the average post-conceptual age at time of diagnosis was 27 ± 3.3 weeks. All 26 patients were managed non-operatively for the esophageal perforation. All were kept NPO with TPN and were placed on broad-spectrum antibiotics. Enteral feeds were resumed after a median of 8 days [Interquartile Range (IQR): 7-11]. Median antibiotic duration was 7 days (IQR: 7-9.8), and the median time to follow-up esophagram was 7 days (IQR: 7-9.8). Twenty-five of 26 patients (96%) demonstrated radiological resolution of perforation on initial follow-up esophagram, with only one requiring a second study. Five patients expired during the study period, but no deaths were related to the diagnosis of esophageal perforation.

Conclusion:

In this largest reported sample of neonates treated for esophageal perforation, non-operative treatment with NPO, TPN, antibiotics, and follow-up esophagram was successful. In addition, all but one neonate demonstrated radiographic resolution of perforation by the time of initial esophagram. This data suggests that further investigation of a shorter duration for non-operative management and time to contrast study may be warranted, thus reducing the morbidities associated with enteral feed interruption and antibiotic administration.

« Previous Page
Next Page »