73.09 Do All Intestinal Malrotations Require a Ladd Procedure? Prophylactic vs Post-Symptomatic Outcomes

Posted on January 18, 2016

S. E. Covey1, L. R. Putnam1,2, K. T. Anderson1,2, K. P. Lally1,2, K. Tsao1,2 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA

Introduction: Intestinal malrotation can lead to midgut volvulus resulting in sepsis, short bowel syndrome, and death. Treatment includes the Ladd procedure to correct intestinal malrotation for symptomatic patients. However, debate remains regarding the timing of the procedure for asymptomatic infants with known malrotation. We hypothesized that the benefits of prophylactic Ladd procedure outweigh the risks of post-symptomatic repair.

Methods: A retrospective chart review of pediatric patients undergoing the Ladd procedure was performed. Prophylactic Ladd procedures were identified as those that occurred prior to any malrotation-related symptoms (i.e. abdominal pain, distention, nausea, emesis, constipation, or feeding intolerance). Results were analyzed with Mann-Whitney U and chi-squared tests.

Results: From 2011-2014, 42 patients (prophylactic=19, post-symptomatic=23) underwent the Ladd procedure for intestinal malrotation. The median (interquartile range) age of patients was 9.6 (3.9-18) months and 18 (2.4-52) months for prophylactic and post-symptomatic patients, respectively (p=0.38). In patients who underwent post-symptomatic Ladd procedures, 9 (39%) were found to have volvulus and 1 (4.3%) had bowel necrosis at time of surgery. No prophylactic Ladd procedure patients required reoperation while 6 (26%) post-symptomatic patients required reoperation for gastrointestinal-related complications (p=0.02). Prophylactic versus post-symptomatic Ladd procedure patients required a median (interquartile range) of 5.0 (3.3-6.8) days vs 7.4 (5.0-11) days to tolerate full enteral feeds (p=0.11) and 8.0 (6.1-11) days vs 11 (7.5-32) days until discharge (p=0.09). There was one respiratory-related death in each group.

Conclusion: Although the post-symptomatic group represents sicker children, the postoperative complications appear to be higher. For infants with known malrotation, prophylactic operations may be beneficial and should be considered. A larger, prospective study comparing prophylactic Ladd procedures to observation is needed to demonstrate its comparative effectiveness and generalizability.

73.10 Temporal Distribution of Pediatric Extracorporeal Life Support

Posted on January 18, 2016

K. W. Gonzalez1, B. G. Dalton1, K. L. Weaver1, A. K. Sherman1, S. D. St. Peter1, C. L. Snyder1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: Extracorporeal life support (ECLS) has proven to be a lifesaving measure for patients with cardiovascular collapse. Although several studies address the uses and outcomes of ECLS, no studies have specifically evaluated the impact the time of cannulation has on clinical outcomes. We sought to compare the incidence of complications based on timing of cannulation during the work day.

Methods: A retrospective review was conducted in patients less than 18 years of age who were placed on ECLS at a pediatric tertiary care center between May 2004 and May 2015 by the pediatric general surgery service. Data analyzed included gender, age at cannulation, timing of cannulation and decannulation, total duration of ECLS, diagnosis, complication and survival to discharge. Patients placed on ECLS during the work day were compared to those placed on ECLS after hours using 2-tailed Student t-tests and Pearson chi-square.

Results: There were a total of 176 patients placed on ECLS. The most common indications for cannulation were congenital diaphragmatic hernia (n=58), primary pulmonary hypertension (n=41), meconium aspiration (n=19), and respiratory failure (n=18). There was a male predominance (61%), and the median age of cannulation was 2 days (0, 5526 days). One hundred sixty two patients underwent preoperative echocardiogram; 83% of these had cardiac dysfunction, most often pulmonary hypertension. Forty one (23%) patients were placed on ECLS between the hours of 12 AM to 7:59 AM, 56 (32%) patients between 8AM and 3:59 PM, and 79 (49%) patients between 4 PM and 11:59PM (p < 0.01). When comparing scheduled operative hours (8 AM-3:59 PM) versus off hours (4PM-7:59AM), there was no statistically significant difference in total complications, central nervous system derangement, mortality on ECLS, hemorrhage (non intracranial source), or cannula repositioning (Table). Conversion from venovenous to venoarterial bypass (1.8% versus 3.4%, p=0.35) and survival to discharge (62.5% versus 60.0%, p=0.75) were also similar. The timing to decannulation was comparable (240 ± 172 hours versus 207 ± 120 hours, p=0.21).

Conclusion: More patients were placed on ECLS in the evening compared to other time frames. Despite the natural concern for the initiation of ECLS during off hours, we found no significant difference in patient outcomes.

73.05 No Difference in Reliability and Efficacy of Caudal versus Penile Block in Circumcision

Posted on January 18, 2016

K. Malik3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple local analgesia techniques including caudal block (CB) and penile block (PB) have been utilized and championed as offering optimal pain control during circumcision in toddlers and older children with no clear consensus. This meta-analysis investigates the efficacy of CB and PB during circumcision and their impact on postoperative analgesic requirements in the pediatric population age 16 months to 18 years.

Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled Trials (1966-2015) was completed for all published randomized control trials (RCTs). Keywords searched included ‘circumcision’, ‘caudal block’, and ‘penile block’. Inclusion criteria were limited to the comparison of PB versus CB in children 16 months to 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed.

Results: 9 RCTs involving 574 children, 287 undergoing PB and 287 undergoing CB, were included. There was no difference between the efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia (standardized difference in mean (SDM) = 0.510, CI = -0.07 to 1.09; p = 0.066). Time to first micturition (SDM = 0.767, CI = 0.51 to 1.02; p < 0.001) and duration of motor blockade (SDM = 0.788, CI = 0.08 to 1.50, and p = 0.03) was significantly greater for CB. No differences were observed between CB and PB for the incidence of vomiting (RR = 1.56, CI = 0.91 to 2.67, and p = 0.11) and length of stay (SDM = 0.741, CI = -0.05 to 1.53 and p = 0.066). No differences between levobupivacaine and bupivacaine are observed in regards to the efficacy of the blocks (p = 0.570), time to first micturition (p = 0.196), duration of prolonged motor blockade (p = 0.098), and risk of vomiting (p = 0.825).

Conclusion: CB and PB offer equivalent anesthetic outcomes in pediatric patients’ age 16 months to 18 years undergoing circumcision. CB is associated with a longer time to urination and ambulation. Additional adequately powered studies are needed to further investigate optimal medication dose and anesthetic choice.

73.06 Ultrasound Guided Central Venous Catheter Placement Increases Success Rates in Pediatric Patients

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Real-time ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase cannulation success rates and reduce complications in adults. Literature regarding ultrasound guided CVC placement in children remains limited and conflicting. This meta-analysis examines the impact of ultrasound guided CVC placement among pediatric patients in regards to success rate, number of attempts required, incidence of accidental carotid artery puncture, and time to cannulation.

Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of real-time ultrasound guided CVC insertion in pediatric patients <18 years of age was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘ultrasound guided’ and ‘central venous catheter’. Studies comparing the use of real-time ultrasound CVC insertion with anatomic landmark CVC placement in pediatric patients <18 years of age were included. Primary outcomes analyzed were cannulation success rate, number of attempts required, incidence of carotid artery puncture, and time to cannulation.

Results: 8 RCTs involving 760 patients (367 via ultrasound guidance and 393 via anatomic landmark placement) were analyzed. Ultrasound guided CVC insertion significantly increased success rates by 31.8% (Relative Risk (RR) = 1.318; 95% CI, 1.101 – 1.576; p=0.003) and decreased the mean number of attempts required (Mean Difference (MD) = -1.261; 95% CI, -1.711 to -0.812; p<0.001). A trend towards a decrease in the risk of accidental carotid artery puncture with the use of ultrasound guided CVC insertion was also observed (RR = 0.359; 95% CI, 0.118 – 1.093; p=0.071). Ultrasound guided CVC insertion was not associated with a significantly longer time to CVC placement (MD = 1.175 = -0.287 to 2.636; p=0.115).

Conclusion: Ultrasound guided CVC placement is associated with significantly higher success rates and decreased mean number of attempts required for cannulation. There is also a trend towards a decrease in accidental carotid artery puncture, which was not statistically significant likely due to inadequate sample size. Ultrasound guided CVC insertion improves success rates, efficacy, and safety among pediatric patients. Additional studies are required to determine the efficacy and safety of ultrasound guided CVC insertion in specific age populations of neonates compared to older children, and in the various healthcare settings.

73.07 Impact of Body Mass Index on Outcomes of Single-Incision Laparoscopic Appendectomy

Posted on January 18, 2016

C. N. Litz1, S. M. Farach1, P. D. Danielson1, N. M. Chandler1 1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FL, USA

Introduction:
Single-incision laparoscopic appendectomy (SILA) has emerged as a less invasive alternative to conventional laparoscopy and has been reported to be safe in appendicitis. However, little is known about the clinical implications of obesity on outcomes following SILA. The purpose of this study was to assess the impact of body habitus on outcomes following SILA.

Methods:
A retrospective review of 413 patients who underwent SILA from July 2012 through April 2015 was performed. Body mass index (BMI) was calculated and the BMI percentile was obtained according to CDC guidelines for gender and age. Standard definitions for overweight (BMI 85-94%) and obese (BMI>95%) were used. General admission, demographic, and outcome data were collected and analyzed. Statistical significance was set at p<0.05.

Results:
SILA was performed in 413 patients during the study period, of which 66.3% were normal weight, 16% were overweight, and 17.7% were obese. There were no significant differences in age at presentation (11.58 ± 3.75 vs 11.87 ± 3.23 vs 10.83 ± 3.53 years, p=0.196), WBC (14.74 ± 5.15 vs 15.41 ± 5.0 vs 15.74 ± 5.51, p=0.3) or time to diagnosis (128 ± 176 vs 120 ± 94 vs 118 ± 92 min, p=0.868) among the groups. Severity of appendicitis was determined intraoperatively as follows: acute (55.5% vs 51.5% vs 50.7%), suppurative (13.5% vs 12.1% vs 23.3%), gangrenous (11.3% vs 18.2% vs 8.2%), perforated (10.2% vs 15.2% vs 12.3%), normal (1.1% vs 0.0% vs 2.7%) and interval appendectomy (8.4% vs 3.0% vs 2.7%). There were no significant differences in intraoperative findings among normal, obese, and overweight patients (p=0.122). Furthermore, there were no significant differences in operative time (26.99 ± 9.11 vs 27 ± 9.80 vs 28.37 ± 9.41 minutes, p=0.514), postoperative length of stay (0.97 ± 1.65 vs 1.53 ± 4.15 vs 1.14 ± 2.27 days, p=0.214), 30 day complications (6.9% vs 8.2% vs 12.1%, p=0.377), ED visits (8.4% vs 11% vs 10.6%, p=0.726) or readmissions (4.7% vs 4.1% vs 4.5%, p=0.972).

Conclusion:
Our results indicate that obesity does not significantly impact outcomes following single-incision laparoscopic appendectomy. SILA can be performed in overweight and obese children without increased rates of perforation, longer operative times, longer length of stay or an increased complication rate. SILA should continue to be offered to overweight and obese children.

73.03 Optimizing Fluid Resuscitation in Hypertrophic Pyloric Stenosis

Posted on January 18, 2016

B. G. Dalton1, K. W. Gonzalez1, S. R. Boda1, P. G. Thomas1, A. K. Sherman1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction: Hypertrophic pyloric stenosis (HPS) is the most common diagnosis requiring surgery in infants. Electrolytes are used as a marker of resuscitation of prior to general anesthesia induction. Often multiple fluid boluses and electrolyte panels are needed, delaying operative intervention. We have attempted to predict the amount of IV fluid boluses needed for electrolyte correction based on initial values.

Methods: A single center retrospective review of all patients diagnosed with HPS from 2008 through 2014 was performed. Abnormal electrolytes were defined as Chloride < 100 mmol/L, bicarbonate ≥ 30 mmol/L or potassium > 5.2 or < 3.1 mmol/L.

Results: During the study period 542 patients were identified with HPS. Of the 505 that were analyzed 202 patients had electrolyte abnormalities requiring IV fluid resuscitation above maintenance, and 303 patients had normal electrolytes at time of diagnosis. Weight on presentation was significantly lower in the patients with abnormal electrolytes (3.8 vs 4.1kg, p<0.01). Length of stay was significantly longer in the patients with electrolyte abnormalities, 2.6 vs 1.9 days (p<0.01). Fluid given was higher over the entire hospital stay for patients with abnormal electrolytes (106 vs 91 ml/kg/d, p<0.01). The number of electrolyte panels drawn was significantly higher in patients with initial electrolyte abnormalities, 2.8 vs 1.3 (p<0.01).

Chloride was the most sensitive and specific indicator of the need for multiple saline boluses. Using an ROC curve, parameters of initial Cl– < 80 mmol/L and the need for 3 or more boluses AUC was 0.71. Modifying the parameters to initial Cl– ≤ 97mml/L and 2 boluses AUC was 0.65. Sensitivity and specificity values are shown for various initial Cl– levels are shown in table 1. These findings show that a patient with an initial Cl- < 85 will need three 20ml/kg boluses 73% (95% CI 52% to 88%) of the time. A patient with an initial Cl- ≤ 97 will need two 20ml/kg boluses at a rate of 73% (95% CI 64% to 80%).

Conclusion: Children with electrolyte abnormalities at time of diagnosis of HPS have a longer length of stay; require more fluid resuscitation and more lab draws. This study reveals high sensitivity and specificity of presenting chloride in determining the need for multiple boluses. We recommend the administration of two 20ml/kg saline boluses separated by an hour prior to re-checking labs in patients with initial Cl– value ≤97 mmol/L. If the presenting Cl– < 85 three boluses of 20ml/kg of saline separated by an hour are recommended. If implemented these modifications have potential to save time by not delaying care for extraneous lab results and money in the form of fewer lab draws.

73.04 ‘Masqueradors of Appendicitis: Incidence of Atypical Diagnoses in 6816 Pathologic Specimens’

Posted on January 18, 2016

Z. Farzal1, Z. Farzal1, N. Khan2, S. Cope-Yokoyama3, A. C. Fischer4 1UT Southwestern Medical Center,Dallas, TX, USA 2Honor Health,Phoenix, AZ, USA 3Cooks Children’s,Pathology,Fort Worth, TX, USA 4Beaumont Health System,Pediatric Surgery,Royal Oak, MI, USA

~~Introduction: Given the newly evolving paradigm of non-operative management of appendicitis, our goal was to identify the incidence of atypical diagnoses including tumors, detected among appendectomy specimens to better elucidate those potentially missed in non-operative management. The possibility of missing an alternative or co-incidental diagnosis such as carcinoid tumor in the non-operative management of appendicitis merits knowing the actual risks of nonoperative management.

Methods: An IRB-approved (062012-049) retrospective review of pediatric patients (n=6816) who underwent appendectomies at an independent children’s hospital over an 11 year period from January 2000 to December 2010 was performed. Demographics analyzed and the various multiple classifications of appendicitis was captured. Inclusion criteria required age <17 and surgery for presumed appendicitis thus excluding incidental appendectomies (n=269) from this sample with a final review of 6547 specimens.

Results: 5998 (91.6%) subjects showed true appendicitis including acute non-perforated, perforated, chronic, suppurative, gangrenous, and catarrhal appendicitis. In 224 subjects (3.4%), diagnoses other than appendicitis were identified: non-inflammatory obstruction (n=71), other infectious etiologies (n=58), non-specific inflammatory changes (n=58), extra-appendiceal pathology (n=31), tumors (n=4), and foreign body (n=2). Additionally, 6 patients with true appendicitis had co-existing carcinoid tumors. 325 specimens (5.0%) were documented as negative appendicitis.

Conclusion: This is the largest analysis of the incidence of pathologies that masquerade as appendicitis in the pediatric population conveying a broad overlap of diagnoses that present similarly or coincidently. Given the common diagnosis of appendicitis, follow-up for routine appendectomies has been streamlined and expedited in such a way that review of pathology may be overlooked; the number of infectious etiologies and tumors detected reinforces the increasing importance of pathology review in post-operative follow-up to appropriately diagnose uncommon conditions that may necessitate further work-up and treatment. Incidence of carcinoids and infections was low but will need to be considered in nonoperative management with persistence of symptoms or in follow up.

73.02 Patients Presenting as Transfers for Intussusception have an Increased Risk for Surgical Management

Posted on January 18, 2016

B. P. Blackwood1,2, F. Hebal1, C. J. Hunter1,3 1Ann And Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Rush University Medical Center,General Surgery,Chicago, IL, USA 3Northwestern University Feinberg School Of Medicine,Pediatrics,Chicago, IL, USA

Introduction: Intussusception is a potentially life-threatening condition and is the most frequent cause of bowel obstruction in the first two years of life. Multiple attempts at reduction are sometimes required, however intussusceptions are successfully treated with therapeutic enemas in 75-90% of cases. We hypothesized that patients who transferred from outside community hospitals (OSH) to a large academic children’s hospital with intussusception were more likely to require operative management for their intussusception than those who were directly admitted.

Methods: After IRB approval the electronic medical record was queried for patients presenting to Ann and Robert H. Lurie Children's Hospital of Chicago with a diagnosis of intussusception (July 1st, 2009 – July 1st, 2014). Age, sex, symptom duration, radiologic management, and surgical care were recorded. Additionally, OSH and transfer reports were analyzed for those patients that presented as a transfer. Statistical analysis was performed with Student’s T-test and ANOVA using Graph Pad Prism 6 Software.

Results:We identified 270 patients with intussusception confirmed radiographically with ultrasound or CT. Of these patients, 212 (78.5%) were successfully treated non-surgically, and 58 (21.5%) required surgical management. Of the patients requiring surgery, there were 38 reductions (24 laparoscopic, 14 open) and 20 bowel resections (1 laparoscopic, 19 open).There were 120 (47.2%) transfers from OSH. Of those patients requiring surgery, 37 (63.8%) had presented as a transfer from an OSH. We found that transferred patients, requiring surgery, spent a mean 7.77 hours at the OSH compared to 4.03 hours for the transferred patients that did not require surgery (p=0.0188). There was no significant difference in transport time (p=0.44).

Conclusion:In conclusion, intussusception can be managed non-operatively 78.5% of the time based on our experience. We have identified the amount of time patients spend at hospitals without pediatric surgical capabilities as an independent risk factor necessitating surgical management of intussusception. These data suggest that patients with the diagnosis of intussusception who present to hospitals without pediatric radiology or pediatric surgery, should be transferred in an expedited fashion. Furthermore, in the event of a failed enema reduction at an OSH the transport of the patient should not be delayed as this may result in a higher likelihood of surgical management.

72.19 A Systematic Review of Thymectomy for Juvenile Myasthenia Gravis (JMG)

Posted on January 18, 2016

A. L. Madenci1, G. Z. Li1, C. B. Weldon2 1Brigham And Women’s Hospital,Boston, MA, USA 2Children’s Hospital Boston,Boston, MA, USA

Introduction: Treatment of JMG stems from experience with pharmacologic agents, immunoglobulins, and surgery among adults. Thymectomy may eliminate the production of auto-antibodies, but its role among pediatric patients has never been defined by a prospective, randomized trial. We performed a systematic review to evaluate the complications and outcomes of thymectomy for JMG.

Methods: We performed a computerized search of MEDLINE from January 2000 to March 2015, supplemented with manual searches. Using a priori criteria, we evaluated 118 studies. Case series with fewer than 10 thymectomies were excluded. Data extraction was performed by independent reviewers and included demographic characteristics, timing of thymectomy, serology data, severity of JMG, peri-operative complications, surgical pathology, study design, and potential confounders.

Results: Twelve retrospective studies met inclusion criteria. Of 653 total participants with JMG, 400 (61%) underwent thymectomy. The majority of thymectomies were performed via transsternal approach (n=295, 69%). Median (or mean) time to thymectomy was less than one year in 4 (44%) of 9 studies that specified time to thymectomy. Pre-operatively, patients were primarily Osserman stage I (n=135, 45%), followed by stages II (n=99, 33%), III (n=47, 16%), and IV (n=21, 7%). Elevated anti-acetylcholine receptor (AChR) antibodies were found in 87% (n=65/75) of thymectomized patients tested. Surgical pathology most often showed thymic hyperplasia (n=283, 87%), followed by normal thymus (n=35, 11%), and thymoma (n=8, 2%). Mean post-operative follow-up ranged from 2 to 5 years. Post-operative complications were not well documented. Post-operative improvement in JMG severity was recorded in 89% (n=281/316), including 28% (n=90/316) patients with complete sustained remission. Twenty-four (8%) patients had unchanged symptom severity post-operatively and nine (3%) patients had worsening of symptoms post-operatively. Two patients died post-operatively. Comparisons of thymectomy to non-operative management were mixed. One study reported a trend toward higher remission rate with thymectomy (55% vs. 38%, p=0.06). A second reported similar incidences of complete remission with and without thymectomy. One study found no effect of anti-AChR antibody status on response to thymectomy. Outcomes specific to surgical pathology findings were limited. No study stratified outcome of thymectomy by severity of JMG or timing of thymectomy for JMG.

Conclusion: Existing data studying thymectomy for JMG is entirely retrospective and does not support a clear benefit toward decreasing severity of disease. Reported complications were rare. Overall, the included studies were limited by power and heterogeneity with respect to timing of surgery, serology, patient age, and severity of JMG. Prospective, randomized study of thymectomy for JMG is warranted.

72.20 Extent of Peritoneal Contamination on Resource Utilization in Children with Perforated Appendicitis

Posted on January 18, 2016

C. Feng1, S. Anandalwar1, F. Sidhwa1, C. Glass1, M. Karki1, D. Zurakowski1, S. Rangel1 1Children’s Hospital Boston,Surgery,Boston, MA, USA

Introduction: The degree of peritoneal contamination can be widely variable in children with perforated appendicitis and its effects on disease severity has not been characterized. The purpose of the study was to explore this relationship in the post-operative setting using measures of resource utilization as surrogate markers for disease severity.

Methods: Intraoperative findings were collected prospectively from attending surgeons using a standardized survey at a single children’s hospital from 2011 to 2014. Peritoneal contamination (defined as the presence of purulent fluid or fibrinous exudate) was categorized as ‘localized’ (confined to the right lower quadrant and pelvis) or ‘extensive’ (extending to the liver as a marker for uncontained perforation) in patients with perforated disease. Imaging utilization, postoperative length of stay (PLOS), hospital cost, and readmission rates were compared using chi-square statistics for proportions and the Mann-Whitney U-test for continuous data.

Results: Eighty-eight patients were identified with perforated disease, of which 38% (34/88) were found to have extensive peritoneal contamination. Groups were similar on the basis of age, weight, gender, race, insurance status, preoperative WBC count and maximum temperature. Patients with extensive peritoneal contamination had significantly higher rates of postoperative abdominal imaging (58.8% vs 27.7%, p<0.01) and a 30% higher median hospital cost ($17,663[IQR $12,564-$23,697] vs $13,516[IQR $10,546-$16,686], p<0.01, figure) compared to patients with localized contamination. Median PLOS was 50% longer for patients with extensive contamination (6 days [IQR 4-9] vs 4 days [IQR 2-5], p<0.01, figure), and the readmission rate was nearly four-fold higher compared to children with localized contamination (20.6% vs 5.6%, p=0.04).

Conclusion: In children with complicated appendicitis, extensive peritoneal contamination is associated with greater postoperative imaging, length of stay, cost, and readmission rates. These findings may have important severity-adjustment implications for reimbursement and comparative performance reporting for hospitals that serve populations where late presentation and more severe disease are common.

73.01 30-day Outcomes for Children and Adolescents undergoing Sleeve Gastrectomy at a Children’s Hospital

Posted on January 18, 2016

A. L. Speer1, J. Parekh1, F. G. Qureshi2, E. P. Nadler1 1Children’s National Medical Center,Pediatric Surgery,Washington, DC, USA 2University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA

Introduction:
Morbid obesity affects millions of children and adolescents and its prevalence continues to rise. The incidence of obesity-related comorbidities in the pediatric population has also increased with a concomitant decrease in age of onset. Nonsurgical options do not result in significant or sustained weight loss in these children and thus bariatric surgery has become an increasingly utilized option. Bariatric surgery is known to be a safe and effective weight loss solution in morbidly obese adults, however, limited data exists regarding safety and efficacy for pediatric bariatric surgery outside of NIH-funded centers. We sought to assess the perioperative outcomes and safety of children and adolescents undergoing laparoscopic sleeve gastrectomy for morbid obesity at a free-standing children’s hospital which is not part of the NIH consortium.

Methods:
We retrospectively reviewed demographics, comorbidities, and 30-day complications for all patients who underwent laparoscopic sleeve gastrectomy during a 5 year period from 2010-2015 at a single free-standing children’s hospital that is not a member of the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study.

Results:
A total of 105 patients underwent 107 laparoscopic sleeve gastrectomy procedures (2 revisions). The mean age was 17.3 years (4.5-24.8). The male to female ratio was 1:3.6. The majority of the patients were Black (56.2%), followed by White (22.9%), and Hispanic (17.1%). The mean Body Mass Index was 51.0 m2/kg (37.4-86.8). The most common comorbidities included obstructive sleep apnea (61.3%), hypertension (14.2%), diabetes (11.3%), nonalcoholic fatty liver disease (9.4%), and dyslipidemia (6.6%). Average length of stay (LOS) was 1.8 days (1-7). One patient was excluded from LOS as she was awaiting heart transplant and her LOS exceeded the 30-day outcome period. There were no deaths. Major complications occurred in 3 patients (2.9%) during their initial postoperative hospitalization requiring reoperation and in 1 patient (1.0%) after discharge before the 30th postoperative day. The reoperations were for gastric leak, epigastric bleed, and splenic parenchymal laceration. The fourth patient did not require reoperation but did require anticoagulation for pulmonary embolus and deep venous thrombosis. Minor complications were observed in 4 patients (3.8%). These included one submucosal hematoma requiring 2 weeks of TPN and three patients with decreased oral intake secondary to edema which required readmission for intravenous fluid hydration and steroids.

Conclusions:
Laparoscopic sleeve gastrectomy is a safe treatment option for morbidly obese children and adolescents and can be successfully performed at a non-NIH funded center. Future studies and more longitudinal data are necessary to confirm the long-term safety profile as well as the efficacy of bariatric surgery in the pediatric population.

72.18 Morbidity and Healthcare Costs of Vascular Anomalies: a National Study of 7,485 Pediatric Inpatients

Posted on January 18, 2016

J. Kim1, Z. Sun1, B. C. Gulack1, E. Benrashid1, M. J. Miller2, A. C. Allori1, H. E. Rice1, C. K. Shortell1,2, E. T. Tracy1 1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke University Medical Center,Radiology,Durham, NC, USA

Introduction:
With novel medical therapies, interventional procedures, and surgical techniques increasingly used to manage vascular anomalies, the quality of life for children with vascular anomalies has improved. This study aimed to define morbidities and costs related to modern-day care for children with vascular anomalies.

Methods:
We reviewed the 2003-2009 Kids’ Inpatient Database (KID) for pediatric patients (age < 21 years) hospitalized with hemangiomas, arteriovenous malformations (AVM), or lymphatic malformations (LM) as a primary diagnosis. Patients were grouped by type of vascular anomaly. Patient characteristics, comorbidities, complications, and hospital charges were compared.

Results:
In total, 7,485 pediatric patients with vascular anomalies were identified. Within this cohort, frequently associated comorbidities included chronic anemia (4.0%), hypertension (2.4%), and coagulopathy (1.8%). They also had nontrivial rates of sepsis (4.6%) and cellulitis (1.4%) associated with hospital care. Notably, children with AVM had the highest rate of in-hospital mortality (1.0%, p < 0.001). AVM also were associated with the highest median hospital charge ($38,574, p < 0.001), more than twice the cost for hemangiomas or LM. AVM care also had the greatest increase in median hospital charge (38.8%) from 2003 to 2009 (Figure).

Conclusion:
We found a significant rate of morbidity in children with vascular anomalies, most often from blood loss and infection. The greater cost of AVM care may be related to the higher mortality rate as well as the complexity of procedures required to treat them. Cost-effective management of vascular anomalies should target prevention and early recognition of both chronic comorbidities and acute complications.

09.10 Pediatric Appendicitis: Time to Give Antibiotics

Posted on January 18, 2016

A. G. Antunez1, S. K. Gadepalli1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Perforated appendicitis is a cause of major morbidity and reduction of rates can improve patient outcomes. Since appendicitis management is time-dependent, we hypothesized that distance and time traveled to initial evaluation and time to antibiotics impact perforation rates.

Methods: After IRB approval (HUM00095746), we retrospectively reviewed medical records, including from outside institutions (OI), of pediatric appendectomy patients from 2012-2013 at University of Michigan (UM). We collected demographics, zip codes to determine travel distances, insurance, labs, radiology, path reports, times of presentation to various institutions, to antibiotics, and to admission. We excluded patients with atypical findings not consistent with appendicitis and if over 18 years old. Primary outcome was perforated (transmural defect on path) appendicitis. Logistic regression was used to determine effect of distance and travel time and time from evaluation to antibiotics, adjusting for demographics, insurance, and site of primary evaluation with p-value <0.05 deemed significant.

Results: Of 245 appendectomies, 14 were excluded by atypical path and age criteria. Patients were 11.4±3.8yr, male (60.8%), Caucasian (83.6%), and privately insured (70.1%), with 63.2% complicated and 30.7% perforated. Interval appendectomies constituted 13.4% and diagnosis was missed previously in 8.7%. Median time traveled to initial evaluation was 18min(IQR14-25) with median distance of 11.5mi(6.8-17.4). Time for antibiotics from initial evaluation was a median of 5hr(IQR3.4-8.9). Approximately 43% were seen at UM first; there was no difference in gender and race but they were older and privately insured. Patients traveled a longer distance and took more time to be seen, but travel did not affect the rate of complicated or perforated appendicitis. Patients seen at OI first had higher rates of complicated, missed, or perforated appendicitis but received antibiotics later (p=0.003), regardless of age, race, or insurance status. On logistic regression, longer time from evaluation to antibiotics increased likelihood of perforation (OR1.03, p=0.03), when adjusted for age, race, insurance, and location of initial evaluation.

Conclusion: Distance and time traveled to initial evaluation did not increase the risk of perforation; however, the risk significantly increased with delayed antibiotic times. This study suggests that decreasing time to antibiotics during evaluation improves outcomes in pediatric appendicitis. Further prospective studies are needed to confirm our findings and determine what led to delays in antibiotic administration.

72.15 Pediatric Near-Drowning Accidents: Do They Warrant Trauma Team Activation?

Posted on January 18, 2016

P. N. Chotai1, B. Eithun2, L. Manning1, J. Ross3, J. W. Eubanks1, A. Gosain1 1Univeristy Of Tennessee Health Science Center,Pediatric Surgery, Le Bonheur Children’s Hospital,Memphis, TN, USA 2University Of Wisconsin,Pediatric Trauma Program, American Family Children’s Hospital,Madison, WI, USA 3University Of Wisconsin,Division Of Pediatric Emergency Medicine, Department Of Emergency Medicine, American Family Children’s Hospital,Madison, WI, USA

Introduction:
Drowning and near-drowning events remain a leading cause of accidental deaths in children. Currently, many American College of Surgeons (ACS) designated pediatric trauma centers activate the trauma team on receipt of drowning or near-drowning patients. The purpose of this study is to determine the incidence of traumatic injuries, factors associated with mortality and need for Pediatric Trauma Surgery involvement for children involved in drowning and near-drowning events.

Methods:
Following IRB approval, retrospective chart review was performed for patients presenting with drowning and near-drowning events at either of the two ACS Level I Pediatric Trauma Centers between 1/1/2011-12/31/2014. Patients with ICD-9 codes for fatal/nonfatal drowning or E-codes for fall into water, accidental drowning, or submersion were included. Patient demographics, drowning characteristics, level of trauma activation, transfer, Glasgow coma scale (GCS) and body temperature at arrival, cervical spine and head imaging, admission and discharge details, mortality, need for surgical intervention in first 24 hours, and other associated injuries were recorded. Univariate analysis using chi-square or Fisher exact test for nominal variables and student t-test for continuous variables was performed.

Results:
104 patients, with a median age of 4.0 years (range, 18 days to 17 years), met the inclusion criteria. 27 (26%) were female and 77 (74%) were male. The most frequent site of drowning was the pool (78.1%), followed by bathtub (14.4%), and natural water (6.7%). A witnessed fall or dive was reported in 35.6% patients, 39.4% patients did not fall or dive and 25% had an unwitnessed near-drowning event. Most (72.1%) patients did not undergo any cervical spine imaging. Brain/Head imaging was obtained in 33.7% patients. Notably, none of the patients, at either site, required any form of surgical intervention in the first 24 hours after presentation, other than placement of monitoring lines. Only 6.7% patients were admitted to the Pediatric Trauma Surgery service. The majority of patients (59.6%) were admitted to the pediatric intensive care unit, or to general pediatric floor (34.6%). A small proportion of patients (5.8%) were discharged home from the emergency department. Overall mortality was 17.3%. Factors associated with mortality included transfer from outside hospital (p=0.016), presence of hypothermia on arrival (p<0.0001), GCS of 3 on arrival (p<0.0001), or drowning in a pool compared to bathtub or freshwater (p=0.013).

Conclusion:
The incidence of associated traumatic injury in drowning and near drowning patients is low. In this series, we did not find any traumatic injures requiring immediate surgical attention. Additionally, the majority of patients are admitted to non-surgical services for their inpatient management. These data suggest that routine Pediatric Trauma Surgery service involvement in patients with near-drowning accidents may be unnecessary.

72.16 10 Year Analysis of Benign Teratomas: Outcomes and Follow-up

Posted on January 18, 2016

B. P. Blackwood1,2, C. J. Hunter1, H. Sparks1, M. Browne3 1Ann And Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Rush University Medical Center,General Surgery,Chicago, ILLINOIS, USA 3Children’s Hospital, Lehigh Valley Health Network,Pediatric Surgery And Urology,Allentown, PA, USA

Introduction: Benign teratomas account for 80% of all teratomas. Surgical resection remains the standard of care. However, evidence-based recommendations for post-operative follow up are lacking. In some centers, patients may receive no long term follow up; whereas at others institutions, long-term care for several years may be provided. Our aim was to review outcomes of patients that have undergone therapy for benign teratomas in an effort to generate a decision tree for the follow up of these patients.

Methods: After IRB approval, the electronic medical records of patients at the Lurie Children's Hospital of Chicago (January 1st, 2005 to January 1st, 2015) were queried. Patient age, sex, classification of teratoma, surgical procedure, alpha fetoprotein levels (AFP), pathology, follow up plan, follow up time, and recurrences were recorded. Patients with the pathological diagnosis of sacrococcygeal teratoma were excluded. Statistical analysis was completed with Student’s T-test and ANOVA using Graph Pad Prism 6 software.

Results:We identified 73 patients with a pathologic diagnosis of a teratoma. Of these, there were 65 ovarian teratomas (4 immature, 61 mature), 5 mediastinal teratomas (all mature), and 3 retroperitoneal (1 immature, 2 mature). Ages ranged from 2 days to 21 years. There was a significant difference in the initial AFP level between the groups. The immature teratomas had an average AFP of 2239.2 and the mature teratomas had an average AFP of 3.15 (p<0.0004). There were no significant differences in follow-up time (p=0.895). There was one recurrence in the immature group and no recurrences in the mature group (p=0.0001). Overall, there was a 1.3% recurrence rate. The only recurrence was that of an immature ovarian teratoma with an initially elevated AFP of 1978. Post-operative AFP levels were not elevated, even during episodes of recurrence. We identified high variability in the recommended follow up (10 different strategies). Most commonly, an ultrasound and AFP every 3 months for 1 year, every 6 months for the next 2 years, and then yearly till 5 years postoperatively.

Conclusion:Our data indicates that patients with a diagnosis of ovarian, mediastinal, or retroperitoneal teratoma are at a low risk of recurrence after complete surgical resection. Our findings correlate with current literature in that immature teratomas may have an increased risk of recurrence as compared to the mature teratomas. Based on our review, patients with mature teratomas do not need to be followed past the initial post-operative period. However, surgeons may consider following patients with benign teratomas with immature elements, especially patients with elevated preoperative AFP, for at least one year post-operatively.

72.17 To Wrap or Not? Antireflux Procedures after Gastrostomy in Infants

Posted on January 18, 2016

K. A. Nestor1, S. Larson1, J. A. Taylor1, D. W. Kays1, S. Islam1 1University Of Florida College Of Medicine,Pediatric Surgery,Gainesville, FL, USA

Introduction: There is controversy regarding the need for an antireflux procedure in infants who require feeding access. A Cochrane review on this topic noted a lack of evidence and recommended further studies. The purpose of this report was to assess outcomes in infants who underwent a gastrostomy alone vs. gastrostomy plus fundoplication.

Methods: A retrospective review of all neonates and infants who had a gastrostomy placed at a single institution from 2009-2014 was conducted. Demographics, comorbidities, hospital course, procedure, and outcomes were recorded. The cohort was then divided into gastrostomy and gastrostomy plus fundoplication. Main outcome variable was need for further antireflux procedures.

Results: There were 226 cases – 104 gastrostomy and 122 with fundoplication. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion neurologically impaired. Preoperative diagnosis of reflux was significantly higher in the fundoplication cohort (22 vs. 87%). There was a trend to increased overall complications in the gastrostomy group (31 vs. 20%), including minor issues. Postoperative need for antireflux medications was significantly increased for gastrostomy patients compared to preoperative use (p=0.01). Readmission for respiratory issues or aspiration events was equivalent (Table). Post-op reflux requiring a fundoplication or GJ tube was noted in 21/104 gastrostomy cases (25%), and compared to the remaining gastrostomy patients (n=83), the incidence of neurologic impairment, type of feeds, and age at surgery, were similar.

Conclusion: There was a high rate of reflux in patients who had a gastrostomy alone with a significant number requiring a secondary antireflux procedure, despite the ‘high-risk’ patients undergoing a fundoplication already. These results suggest that a more liberal use of concomitant fundoplication may be justified in these patients.

72.13 Sub-specialty Surgical Care and Outcomes for Pediatric EGS Patients in a Low-Middle Income Country

Posted on January 18, 2016

A. Shakoor4, A. Shah2, C. K. Zogg1, A. H. Haider1, R. Riviello3, A. Latif6, F. G. Qureshi7, T. Oyetunji8, A. Mateen5, H. Zafar5 8Children’s Mercy Hospital And Clinics,Department Of Surgery,Kansas City, MO, USA 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,BOSTON, MA, USA 2Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burns And Surgical Critical Care,Boston, MA, USA 4West Virginia University School Of Medicine,Department Of Pediatrics, Charleston Area Medical Center (CAMC),Charlston, WV, USA 5Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 6Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA 7Children’s National Medical Center,Department Of Surgery,Washington, DC, USA

Introduction:
Whether adult general surgeons, in addition to pediatric specialists, should handle pediatric emergency general surgery (EGS) remains controversial. Unlike surgical centers in higher income countries, resource-limited settings in low-middle income countries often lack staff, resources, and training needed to maintain ready access to specialist care, making treatment by general surgeons an imperative. The objective of this study was to examine differences in surgical outcomes among children/adolescents managed by pediatric versus adult surgical teams for EGS conditions presenting to a regional tertiary hospital in South Asia with split patient coverage between pediatric and adult surgical teams.

Methods:
Pediatric patients (<18y) admitted to the Aga Khan University Hospital in Karachi, Pakistan, with an EGS diagnosis (defined by the AAST) between March 2009 and April 2014 were included. Patients were dichotomized into those managed by adult versus pediatric teams. Differences in length of stay (LOS), mortality, and major complications were compared between the two groups using descriptive statistics and multivariable linear (family gamma; link log)/logistic regression. Propensity scores accounted for potential confounding associated with demographic/clinical factors.. Quasi-experimental counterfactual models examined hypothetical differences in outcomes, assuming that all patients were managed by pediatric teams.

Results:
A total of 2,323 patients were included. Average age was 7.1y (±5.5 SD); most were male (77.7%). The majority, n=1,958, was managed by pediatric specialty teams; however, 365 patients received treatment from adult general surgery teams. 42 patients (1.8%) developed complications; 21 (0.9%) died (all adult general surgery). Relative to patients managed by pediatric surgery, patients managed by adult surgery had 5.42 times higher risk-adjusted odds of developing complications (OR[95%CI]: 5.42[2.10-14.00]) and longer average LOS (predicted mean difference: 1.87[1.45-2.31] days). Counterfactual models suggest that patients at Aga Khan would have experienced 39.8% fewer complications and a 36.7% relative reduction in average LOS if all patients had been managed by pediatric surgery.

Conclusion:
In light of recent work by the Lancet Commission and DCP3, it becomes important now, more than ever, to address questions related to relevant development efforts in both burgeoning and established global surgical fields. Beyond efforts to establish surgical capacity, the results of this study speak to a need for health systems strengthening, suggesting that, where possible in resource-constrained settings, efforts should be allocated to promote development/staffing of diverse surgical teams.

72.14 Institutional and Patient Factors Affecting Pediatric Patient Transfer in Testicular Torsion

Posted on January 18, 2016

D. L. Lodwick1, J. N. Cooper1, K. J. Deans1, P. C. Minneci1, D. McLeod1,2 1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Urology,Columbus, OH, USA

Introduction: Acute testicular torsion is a surgical emergency that requires prompt diagnosis and treatment to maximize testicular salvage. Delays in care increase the chance that a patient will undergo orchiectomy rather than orchidopexy. Interhospital transfers represent a potential delay in care, and the patient and hospital level factors influencing the decision to transfer remain unclear. This population-based study aimed to determine patient and institutional factors associated with transfer for pediatric testicular torsion.

Methods: This retrospective cross-sectional study utilized the National Emergency Department Sample (NEDS) from 2006 to 2012. Encounters by males aged 1 to 21 years with one of the diagnosis codes for testicular torsion (608.2, 608.20, 608.21, or 608.22) were included. Visits at freestanding children’s hospitals were excluded. All analyses were weighted to produce nationally representative estimates. Associations of interhospital transfer with patient and institutional characteristics were evaluated using Rao-Scott chi square tests then multivariable logistic regression.

Results: During 2006 to 2012, there were 11,435 ED visits for testicular torsion by males aged 1-21 years who were either admitted or transferred to another hospital. In multivariable logistic regression, we found that the probability of transfer decreased significantly with increasing age (Figure) and was lower for patients living in zip codes in the highest income quartile (OR=0.69, p=0.003), or who had any listed comorbidity (OR=0.55, p<0.001). Patients were less likely to be transferred at hospitals in the Northeast region of the United States (OR=0.28 compared to the Midwest, p<0.001), at urban hospitals (OR=0.31, p<0.001), at teaching institutions (OR=0.55, p<0.001), and at level 1 or 2 trauma centers (OR=0.31, p<0.001). There was also a decreasing probability of transfer with increasing annual pediatric ED volume (OR=0.95 per 1000 patients seen, p<0.001). The probability of interhospital transfer increased significantly over the study period from 23.6% to 38.8% (p<0.001).

Conclusion: Older adolescents with testicular torsion are significantly more likely to be transferred than young adults. Interhospital transfers in these patients may represent a potential target for improving outcomes in testicular torsion. Future work should focus on evaluating the effect of transfer on the risk for undergoing orchiectomy.

72.11 Premature Babies with Inguinal Hernias: When Should we Repair?

Posted on January 18, 2016

N. Zeidan1, S. D. Larson1, J. A. Taylor1, D. W. Kays1, D. Solomon1, S. Islam1 1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: The survival of increasingly premature neonates continues to improve with excellent neonatal intensive care (NICU). About 10-13% of premature babies will have an inguinal hernia diagnosed, and the timing of repair of these is controversial, as the data balancing risks of general anesthesia vs. incarceration are not clear. The purpose of this study was to understand outcomes from inguinal hernia repair in premature babies performed before or after discharge from the NICU.

Methods: A retrospective analysis was performed on all babies who had inguinal hernia repair performed at a single institution over a 5 year period. Babies with a gestational age at birth less than 35 weeks were included in this analysis and data regarding clinical course, surgery, and postoperative course were collected and analyzed. Primary outcomes of incarceration and anesthesia related complications were chosen.

Results: Overall, 226 premature babies had inguinal hernia repair, with a 3.3:1 male preponderance, mean birth weight of 1.24 kg, and mean gestational age of 29.3 weeks. The cohort was stratified by timing of repair into before or after NICU discharge. Those repaired before discharge were significantly smaller, had more comorbidities, repaired earlier, longer postoperative hospital stay, and higher rates of delayed extubation. Complication rates, use of laparoscopy, gender, and race were similar, but operative times tended to be longer in the group before discharge (table). More babies were on oxygen at the time of surgery in the NICU group. Incarceration rates were similar, and none required a bowel resection.

Conclusion: While there was no difference in recurrence, complications or incarceration rates whether surgery was performed before or after discharge, the operations tended to take longer and there were more respiratory issues in those repaired in the NICU. Despite the retrospective nature of these data, it suggests that delayed repair in selected neonates may be warranted. A prospective, multicenter study would help understand this better.

72.12 Long Term Central Venous Access in a Pediatric Leukemia Population

Posted on January 18, 2016

A. Fu1, E. Hodgman2, L. Burkhalter1, R. Renkes1, T. Slone3, A. C. Alder1,4 1Children’s Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of General Surgery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Pediatrics,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Department Of Pediatric Surgery,Dallas, TX, USA

Introduction: Central venous access devices (CVADs) play an important role in the management of pediatric oncology patients; unfortunately, they are also associated with potentially serious peri-operative and long-term complication rates. Our aim was to evaluate the rates of peri-operative and long-term complications as well as risk factors for premature catheter removal among patients with acute leukemia at a single pediatric tertiary referral center.

Methods: We retrospectively studied clinical characteristics and procedure records for all patients admitted with a leukemia diagnosis at our institution from May 2009 – July 2014. Patient data, including demographics, CVAD type (subcutaneous port or tunneled catheter), complications, and patient outcomes were collected. Peri-operative complications (≤24 hours of surgery) include pneumothorax, hematoma, hemothorax, arterial puncture, and catheter malposition. Long-term complications (>24 hours after surgery) include deep venous thrombosis (DVT), line-associated infection (blood stream and/or port site infection), and line malfunction (kinks, leaks, breaks). Chi square, t-tests, and multivariable logistic regression were performed (significance p<0.05).

Results: A total of 292 CVADs were placed in 198 patients during the study period; these CVADs remained in place for an average of 488 ± 399.8 days and a total of 142,607 catheter-days are included in this study. Our observed peri-operative complication rate was 6%, including 3 hematomas, 1 hemothorax, and 10 catheter malpositions. Over 70% of lines had at least one long-term complication (thrombosis, catheter-related blood stream infection, or unexplained line malfunction). Seventy-five lines were removed prematurely: 31 due to infection, 36 due to malfunction, and 8 due to malposition. Obesity (OR 6.9, 95% CI 1.62-29.43), pre-operative dosage of packed red blood cells (OR 3.13 , 1.07-9.21), blood stream infection (OR 5.75, 1.69-19.56) were associated with increased risk of premature catheter removal; unexplained malfunction was associated with a lower risk (OR 0.28, 0.09-0.93).

Conclusion: While the rate of peri-operative complications is low, our observed long-term complication rate was higher than expected. Obesity, the preoperative dosage of packed red blood cells, presence of a blood stream infection, and unexplained line malfunction are significant predictors of premature CVAD removal in a pediatric leukemia population. Patients with these characteristics may represent a subset population that warrant closer CVAD surveillance and may benefit from additional prophylatic thrombolytic therapy. This study represents the largest recent evaluation on CVAD complications within a single institution and is also the largest report on a Hispanic pediatric leukemia population to date.

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