51.20 Radiographic and Clinical Factors in Pediatric Patients with Surgical Small Bowel Intussusception

Posted on January 18, 2018

R. J. Vandewalle1, A. K. Bagwell1, J. R. Shields2, R. C. Burns1, B. P. Brown2, M. P. Landman1  2Indiana University School Of Medicine,Department Of Radiology Division Of Pediatric Radiology,Indianapolis, IN, USA 1Indiana University School Of Medicine,Department Of General Surgery, Division Of Pediatric Surgery,Indianapolis, IN, USA

Introduction:

Pediatric patients with small bowel-to-small bowel intussusception (SBI) found on radiographic work up for abdominal pain or other indications can create a diagnostic dilemma.  While the majority of SBI found on imaging have no clinical significance, a small proportion may require surgical intervention.  Radiographic and clinical factors predicting the need for operative management of these patients remain poorly defined.

Methods:

A comprehensive database from a tertiary pediatric hospital was reviewed from 1/1/2011 to 12/31/2016 for any radiographic study mentioning intussusception.  Patients were included if  they had only SBI (i.e. not ileo-colic intussusception) and SBI due to enteral feeding tubes were excluded.  The electronic medical records for these patients were reviewed for clinical presentation variables, radiographic data (ultrasound or computed tomography), need for operative intervention, and identification of SBI at the time of surgery.  

Results:

142 patients were included in the study and 133 had radiographic data available for review.  Of these patients, 18 underwent surgical exploration (18/142: 12.7%) and 11 were found to have an intussusception at the time of surgery (11/142: 7.7%).  All patients that had operative intervention had radiographic data available for review.  Univariate analyses found a significant positive correlation between longer duration of pain at the time of presentation (3.5 vs. 1 days [IQR: 1-4 vs. 1.5-6]; p=0.047) and the presence of localized abdominal pain (OR: 12.1 [CI: 1.463-99.8]; p=0.004) for having an SBI found at the time of surgery.  The positive and negative predictive values for presence of localized pain for intussusception at the time of surgery were 14.5% and 98.6%, respectively.  SBI identified at the time of surgery were longer (7.1 vs. 2.2cm; p=0.03), greater in overall diameter (3.0 vs. 1.7cm) and greater in bowel wall thickness (6.5 vs. 4mm; p=0.02) versus those SBI treated non-operatively or found to be spontaneously reduced at the time of surgery.  Reciever operating characteristic curves cut-offs for these variables maximized Youden's index at 5.8cm, 2.4cm, and 5.5mm, respectively.  Additional significant secondary radiographic findings included the presence of fat-stranding, bowel dilation proximal to the SBI, and the presence of lymphadenopathy.

Conclusion:

SBI is generally a self-limited phenomenon that does not require operative intervention.  The absence of localized abdominal pain suggests surgical intervention is not necessary, whereas prolonged duration of pain suggests surgical intervention may be required.  Additionally, several radiographic features exist which predict the need for operative intervention.

 

51.16 Impact of access to freestanding ambulatory surgery centers on rates of myringotomy

Posted on January 18, 2018

J. N. Cooper1, B. Iten1, C. A. Elmaraghy2  1The Research Institute At Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Department Of Otolaryngology-Head And Neck Surgery,Columbus, OH, USA

Introduction: Myringotomy with pressure equalization tube (PET) placement is the most common ambulatory surgical procedure performed in children. However, rates of this procedure vary widely across geographic regions and sociodemographic groups in the US. It is unclear to what extent this variation is explained by patient and family characteristics versus health system characteristics. One health system factor that may influence PET utilization is the availability of freestanding ambulatory surgery centers (ASCs). Previous studies have suggested that freestanding, physician-owned ASCs can drive the overutilization of elective surgical procedures in adults. We aimed to determine whether access to freestanding, non-hospital affiliated ASCs is associated with higher PET placement rates in Florida and New York, two states with similar population sizes but very different numbers of ASCs.

Methods: We studied children under age 5 who underwent outpatient PET placement in New York or Florida in 2010-2014. Data came from the Healthcare Cost and Utilization Project State Ambulatory Surgery Databases, which contain all outpatient surgeries at hospital-affiliated and non-hospital-affiliated facilities. Population size estimates and other population characteristics at the zip code level came from the American Community Survey. Rates of PET placement were calculated at the state and zip code level. Weighted linear regression models were used to assess the association between the proportion of PET procedures performed in non-hospital-affiliated ASCs and the rate of PET placement in a zip code.

Results: A total of 106 non-hospital affiliated ASCs in Florida and 29 in New York performed PET placement in young children in 2010-2014. The rate of PET placement was 9.1 procedures per 100 children in Florida and 4.7 procedures per 100 children in New York. The correlation between the zip code level proportion of PET procedures performed in a non-hospital-affiliated ASC and the rate of PET placement was stronger in Florida (r=0.44, p<0.001) than New York (r=0.05, p=0.06). However, after adjustment for zip code level urban/rural status, an index of socioeconomic status, and the proportion of residents of non-Hispanic White race, greater utilization of non-hospital affiliated ASCs was associated with higher rates of PET placement in both states. In Florida, children residing in zip codes in the top tertile of non-hospital affiliated ASC utilization had 68.4% higher PET utilization than children from zip codes in the bottom tertile. In New York, residing in a zip code with any utilization of non-hospital affiliated ASCs was associated with 10.2% higher PET utilization.

Conclusion: Rates of PET placement are higher in communities that utilize non-hospital affiliated ASCs. Future research should evaluate whether recently released guidelines for the use of PET decrease variability in its utilization. However, policies that promote more appropriate utilization may be also needed.

 

51.17 The Use of Three Dimensional Printed Templates in the Repair of Large Fetal Myelomeningoceles

Posted on January 18, 2018

S. A. Hilton2, M. M. Hodges2, L. C. Dewberry2, D. M. Mirsky1,3, M. Handler1,4, C. C. Wilkinson1,4, H. L. Galan1,5, M. V. Zaretsky1,5, N. Behrendt1,5, A. I. Marwan1,2, L. Pyle6, J. L. Wagner7, J. G. Jacot7, C. Zgheib2, T. M. Crombleholme1,2, K. W. Liechty1,2  1Children’s Hospital Colorado,Colorado Institute For Fetal & Maternal Health,Aurora, CO, USA 2University Of Colorado Denver,Laboratory For Fetal And Regenerative Biology,Aurora, CO, USA 3University Of Colorado Denver,Department Of Radiology,Aurora, CO, USA 4University Of Colorado Denver,Department Of Neurosurgery,Aurora, CO, USA 5University Of Colorado Denver,Division Of Maternal Fetal Medicine,Aurora, CO, USA 6Children’s Hospital Colorado,Department Of Pediatrics,Aurora, CO, USA 7University Of Colorado Denver,Department Of Bioengineering,Aurora, CO, USA

Introduction: In utero repair of myelomeningcele (MMC) has become the gold standard to decrease rates of ventriculoperitoneal (VP) shunting in selected cases.  It is thought that repair of the MMC in utero restores normal cerebrospinal fluid circulation by decreasing leakage from the MMC defect.  In large MMC or myeloschisis defects, primary skin closure is not possible and an acellular human dermal matrix is used. The use of a patch requires additional time and is only determined at the time of the procedure. In addition, there has been no assessment of whether patch closure is as effective in reversing the hindbrain herniation (HBH) or decreasing the rate of VP shunts.  We hypothesized that 3-Dimensional (3D) printing could be used to standardize the use of a patch as well as be predictive of the need for a patch prior to surgery.  In addition, we hypothesized that the use of a patch closure would be associated with decreased rates of improvement in HBH and increased rates of shunt placement at 1 year compared to primary closure.

Methods: Retrospective review of patients who underwent fetal closure of MMC at a quaternary referral center for fetal surgery between 2013 and 2016. 3D models of the spinal defect were created and the size of the template correlated with the need for a patch. The degree of HBH was assessed on MRI preop and two weeks post-repair. The need for ventricular shunt placement at 1 year was assessed by phone survey. Univariate analyses were performed using Fisher’s exact test and multivariate analyses were performed using logistic regression.

Results: Of 41 patients, 24 (59%) were diagnosed preoperatively with MMC and 17 (41%) with myeloschisis.  58% of MMC and 53% of patients with myeloschisis required patch closure.  3D printed templates with total defect area >6cm2 accurately predicted over 90% of the cases that required a patch (ROC curve with area under the curve 0.8). In univariate analysis, primary closure was associated with higher rates of HBH improvement than patch closure (100% vs 48%, p<0.001), however, there was no significant difference in rate of shunt placement by closure type (38% vs 42%, p=NS).  Consistent with the literature, only maximum ventricle size was associated with need for shunt placement on multivariate analysis (p=0.04).

Conclusion: This is the first direct comparison of outcomes following primary versus patch closure of MMC. Our findings indicate that primary closure of MMC and myeloschisis is associated with significantly higher rates of HBH reversal. The decreased rates of HBH improvement following patch closure suggests the need for either an improved surgical technique or an improved, impermeable biomaterial patch to better protect the exposed neural elements. We found that custom, 3D printed models of fetal MMC defects aid in the preoperative planning of fetal intervention and have the potential to reduce operative times, preserve tissue and function, and improve patient outcomes.

51.14 Clinical Outcomes of Pediatric Patients after Ileal Pouch-Anal Anastomosis

Posted on January 18, 2018

C. C. Huang1, F. J. Rescorla1, M. P. Landman1  1Indiana University School Of Medicine,Department Of Pediatric Surgery,Indianapolis, IN, USA

Introduction:
Ileal pouch-anal anastomosis (IPAA) is the standard surgical reconstruction for patients with familial adenomatous polyposis (FAP) and ulcerative colitis (UC) who undergo total proctocolectomy (TPC). Although FAP and UC patients receive the same reconstruction, their postoperative complications can differ in type and severity. We hypothesize that indication for total proctocolectomy and other preoperative clinical factors are associated with differences in postoperative outcomes following IPAA.

Methods:
A retrospective cohort of pediatric patients who underwent proctocolectomy with IPAA at Riley Hospital for Children from 1996-2016 was identified. Relevant preoperative, operative, and postoperative clinical variables were collected. Univariate analyses were performed to evaluate for relevant clinical differences in outcome. The sample size limited the ability to perform multivariate analyses.

Results:
A total of 79 patients, 17 with FAP and 62 with UC, were identified. Preoperatively, as expected, UC patients had more frequent abdominal pain (p<0.001), more hospitalizations (p=0.004), and lower albumin (p<0.001) than FAP patients.  FAP patients spent an average of 1125±1011 days between initial diagnosis and first surgery compared to 585±706 days by UC patients (p=0.038). FAP patients took an average of 57±38 days to complete TPC with IPAA compared to UC patients at 177±121 days (p=<0.001). At their first postoperative visit, FAP and UC patients did not differ in average number of bowel movements [4.3±2.3 vs. 6.1±3.9, respectively (p=0.083)]. In addition, FAP and UC patients also did not differ in average number of bowel movements at their 6 month postoperative visit [4.7±2.1 vs. 5.6±1.9, respectively (p=0.134)]. Postoperatively, FAP patients are significantly less likely to experience pouchitis (p=0.013), pouch failure (p=<0.001), psychiatric symptoms (p=0.017), and daily antimotility agent use (p=0.003) but more likely to experience bowel obstruction (p=0.001). Within the UC group, preoperative steroid use was associated with superficial surgical infection (p=0.049) but not associated with pouchitis (p=0.872). 

Conclusion:
IPAA is a safe, restorative treatment for FAP and UC patients after TPC. Based on diagnosis and preoperative clinical course, there are differences in morbidity in IPAA patients. This data is limited by sample size and inability to perform multivariable analyses. Clinical data such as these will allow surgeons to help families anticipate their child’s pre- and post-operative course and to maximize successful clinical outcomes.
 

51.15 Intensive Pediatric Weight Loss Program Associated with Decrease in Obesity-Related Biomarkers

Posted on January 18, 2018

C. B. Cummins1, B. Hughes1, O. Nunez-Lopez1, J. Prochaska2, E. Lyons3, D. Jupiter2, K. Perino3, A. Glaser4, R. Radhakrishnan1,4, K. Bowen-Jallow1  1University Of Texas Medical Branch,Department Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Department Of Preventive Medicine And Community Health,Galveston, TX, USA 3University Of Texas Medical Branch,Department Of Nutrition And Metabolism,Galveston, TX, USA 4University Of Texas Medical Branch,Department Of Pediatrics,Galveston, TX, USA

Introduction:
The prevalence of childhood obesity has nearly tripled in the past 50 years, with current estimates of ~ 20% in school-aged children. Multiple biomarkers associated with obesity have been identified and studied recently, including gamma-glutamyltransferase (GGT) and C-reactive protein (CRP). GGT has been shown to be associated with central obesity, increased risk of cardiovascular disease, and metabolic syndrome in adults and adolescents. CRP has been linked to the low-grade systemic inflammatory response in obese adults and children. In this study we examined the short-term outcomes of our intensive multidisciplinary pediatric weight loss program exploring the anthropometric and clinical factors as well as obesity-related biomarkers.

Methods:
Patients were seen in the multidisciplinary clinic every 4-6 weeks by a pediatric surgeon, a pediatric gastroenterologist, a dietician, and a fitness instructor. Referrals were made to a pediatric psychiatrist as needed. Anthropometric and clinical data were obtained at each visit. Obesity-related biomarkers were collected at the initial visit and at selected subsequent visits when clinically indicated.  Biomarkers collected included HcbA1C, total cholesterol, triglycerides, HDL, LDL, GGT, CRP, and insulin levels.

Results:
A total of 70 patients have been evaluated for an initial visit with a total of 25 patients available for 3 month short-term outcome follow-up. Mean baseline weight was 108.5 kg with a mean baseline BMI of 39.5.  Mean weight loss and mean BMI change at 3 months were -0.99 kg (p<0.000005) and -0.84 (p<0.00001), respectively, confirming short term success of the weight loss program. 6 patients had GGT follow up at 3 months with a mean loss of -1.67 U/L (p<0.00001). 4 patients had CRP follow up at 3 months with a mean loss of -0.12 mg/dL (p<0.00001). Additionally, trends in decreased waist circumference, decreased insulin levels, and decreased triglyceride levels were seen but the study is currently under-powered to provide statistical significance.

Conclusion:
An intensive multidisciplinary approach to weight loss in the pediatric population led to both a short-term decrease in weight and BMI and a decrease in obesity-related biomarkers CRP and GGT. Further studies will be necessary to report long-term outcomes as well as confirm trends currently observed in the data.
 

51.12 Antibiotic Therapy is Inconsistent in the Treatment of Necrotizing Enterocolitis

Posted on January 18, 2018

T. A. Boyle1, R. A. Starker1, E. A. Perez1, A. Hogan1, A. Brady1, J. Sola1, H. Neville1  1University Of Miami,Pediatric Surgery,Miami, FL, USA

Introduction:  Necrotizing enterocolitis (NEC) is a common, persistent cause of morbidity and mortality in neonatal intensive care units (ICU). Even infants who recover from acute illness face the prospect of impaired neurodevelopment, cholestasis, or short bowel syndrome. Despite the relative ubiquity of NEC in the setting of neonatal ICU patients, a successful algorithm has not been found and thus treatment strategies, such as time to resume feedings, antibiotic choice and duration, vary dramatically within and between neonatal intensive care units. The aim of this study is to demonstrate the variability of antibiotic therapy regimens in NEC despite similar patient outcomes, and prepare for future study evaluating the appropriate length of antibiotic therapy and time to resume feeds for each stage of NEC.

Methods:  A retrospective chart review was conducted on all NEC patients presenting at a high-volume tertiary care center from January to December 2015. Cases were identified using a query of the following ICD9 and ICD10 codes:  ICD9 777.50, 777.51, 777.52, 777.53; ICD10 P77.9, P77.1, P77.2, P77.3. Each case was reviewed for patient and maternal demographics, antenatal history, symptom presentation, feeding management, antibiotic use, surgical intervention, and patient outcome. Patients included those managed both surgically and medically. The primary outcomes were time to feeds and in-hospital mortality.  

Results: A total of 32 infants were diagnosed with NEC during the study period. The cohort was 63% males and 50% African American. The median gestational age was 26 weeks (IQR: 25, 31) and the median birthweight was 927 grams (696, 1566). In this cohort, 47% of the cases were classified as stage I, 22% as stage II and 31% as stage III. Every patient was treated with at least 3 days of antibiotics, and the most common regimen was 10 days of broad spectrum coverage, including anaerobic coverage. Overall, the regimens were inconsistent and correlated poorly with disease stage and outcome. The median (IQR) duration of antibiotics in each stage was 10 days (7,10) in stage 1, 10 days (7,14) in stage 2, and 14 days (10,17) in stage 3 (Figure 1). The median time to feeds was 21 days (8, 33) in stage 1, 11 days (10, 14) in stage 2, and 27 days (13, 50) in stage 3. Two patients died, one stage 1A patient, who was treated with 7 days of antibiotics, and one stage 2B patient, who was treated with 10 days of antibiotics. Neither death was directly attributable to NEC.

Conclusion: This retrospective chart review revealed broad variability in medical management of necrotizing enterocolitis with neither successful, nor poor outcomes being related to length of antibiotic treatment. Clearly, research is needed to improve and standardize clinical management of infants presenting with NEC. This is required to eliminate excess antibiotic usage, and modernizing care for this common ailment in the premature infant. 

 

51.13 Comparison of Pediatric and Adult Solid Pseudopapillary Neoplasms of the Pancreas

Posted on January 18, 2018

R. T. Russell1, I. I. Maizlin1, M. B. Dellinger2, K. W. Gow2, A. B. Goldin2, M. Goldfarb3, J. J. Doski4, A. Gosain8, M. Langer7,8, M. V. Raval6, J. G. Nuchtern5, S. A. Vasudevan5, E. A. Beierle1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2Seattle Children’s Hospital,Pediatric Surgery,Seattle, WA, USA 3John Wayne Cancer Institute At Providence St. John’s Health Center,Surgery,Santa Monica, CA, USA 4Methodist Children’s Hospital Of South Texas, University Of Texas Health Science Center-San Antonio,Surgery,San Antonio, TX, USA 5Baylor College Of Medicine, Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 6Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Pediatric Surgery,Atlanta, GA, USA 7Maine Children’s Hospital, Tufts University,Surgery,Portland, ME, USA 8University Of Tennessee Heath Science Center,Pediatric Surgery,Memphis, TN, USA

Introduction: Solid pseudopapillary neoplasms (SPPN) are rare pancreatic neoplasms. While constituting only 1-3 % of pancreatic tumors, they comprise the majority (71%) of pediatric pancreatic neoplasms. To our knowledge, there have been no large scale comparative studies between pediatric and adult SPPN. Therefore, we, queried the National Cancer Data Base (NCDB) to compare pediatric and adult patients with SSPN diagnosis, to examine differences in demographics, tumor characteristics, treatment modalities and overall survival. We aimed to determine if survival differences existed between adult and pediatric patients with SPPN.

Methods: The NCDB (2004-2014) was reviewed for cases of pancreatic SPPN. Patients were stratified by age at diagnosis: pediatric (≤21 years) and adult (≥22 years). Once cases lacking survival data were excluded from analysis, demographics, comorbidities, tumor characteristics, diagnostic periods, treatments, and survival rates were compared using pooled variance t-tests and χ2, followed by multivariate Cox proportional hazard model (α=0.05). Log-rank test was used to compare survival.

Results: 468 patients with SPPN were analyzed and categorized according to age-group (pediatric: N=80; adult: N=388). 414 patients (pediatric=61; adult=334) were included in the survival analysis as 54 patients had incomplete survival data, with all 414 utilized in the multivariate analysis. The pediatric patients were primarily female (91%), non-Hispanic White (55%), had no comorbidities (89%), and presented with Stage I disease (59%). Race/ethnicity (p=0.130), gender (p=0.064), socioeconomic status (income: p=0.827; education: p=0.891; insurance status: p=0.933), comorbidities (p=0.136), and disease stage at presentation (p=0.359) were similar between the groups. Following diagnosis, there was no difference in time to initiation of therapy (p=0.083) or time to surgical intervention (p=0.058). No significant difference was found between the groups in type of surgical resection, chemotherapy (p=0.059), or radiotherapy (p=0.082) utilization. Despite the similarities between the age groups, comparison of overall survival (Figure 1) demonstrated improved survival of pediatric SPPN as compared to adult SPPN in every pathologic stage (Stage I: p< 0.001, Stage II: p= 0.045, Stage III: p= 0.018, Stage IV: p=0.009 ).

Conclusions: The results of the current study suggest that pediatric SPPNs are similar to those in adults with regards to demographics, tumor characteristics, and treatment modalities. However, survival was better in children with SPPNs, which may be due to differences in tumor biology and may serve for evidence-based risk stratification of prognosis. 

 

51.10 Parental Presence During Induction of Anesthesia for Elective Surgery May Delay Surgery Start Time

Posted on January 18, 2018

B. Wong1, A. Melucci1, V. Dombrovskiy3, Y. Lee2,4  1Rutgers Robert Wood Johnson Medical School,New Brunswick, NJ, USA 2Rutgers Robert Wood Johnson Medical School,Pediatric Surgery,New Brunswick, NJ, USA 3Rutgers Robert Wood Johnson Medical School,Vascular Surgery,New Brunswick, NJ, USA 4Bristol Myers Squibb Children’s Hospital,New Brunswick, NJ, USA

Introduction:
Parental presence during induction of anesthesia (PPIA) has been used to reduce anxiety and increase patient satisfaction for pediatric surgical patients and their families. There remains variability in its implementation with anecdotal resistance from anesthesiologists and pediatric surgeons due to their concern about OR efficiency. However to date, there has been no formal study on the effect of PPIA on OR delay.

Methods:
A retrospective chart review of 1,590 children aged 1-12 years in a large academic children’s hospital who underwent same day elective ENT (ear/nose/throat) surgery (n=904), esophago/gastro/duodenoscopies (GI; n=200), or general surgical/urologic procedures (GS/UR; n=486) was performed. Those with the ASA (American Society of Anesthesiologists) physical status classification system grade > 3 or emergent were excluded from analysis. After approval from the surgeon and anesthesiologist, parents were offered PPIA and chose to be present (n=765) or not (n=825) during induction of general inhaled anesthesia. Surgical start time (SST, procedure start time minus wheels-in time) with and without parental presence was compared by Wilcoxon rank sum test and generalized linear gamma model with log link and adjustment for patient demographic characteristics and type of procedure.

Results:
Parental presence varied across procedures, comprising of 58% of ENT, 75% of GI, and 18% of GS/UR cases. Children with PPIA were younger with a median age of 4.5 years compared to 5.3 years without PPIA (p=0.003). Median parental presence ranged from 3-4 minutes and median SST ranged from 8-13 minutes depending on the procedure category. SST for GS/UR and GI cases were significantly longer than in ENT cases (p<0.0001) when controlling for age, gender and PPIA. Across all cases, each additional age year increased SST by 1.7% (p<0.001). There was no effect of gender on SST in ENT and GI cases; GS/UR patients were not analyzed as they were primarily male. When controlling for age, gender, and procedures, PPIA increased SST overall by 7.7% (p=0.0043), which is approximately 1 minute. Specifically, PPIA increased SST by 7.3% in ENT (p=0.042), 14.7% (p=0.046) in GI and made no difference in GS/UR patients (p=0.14). SST was significantly longer with PPIA for GS/UR patients aged 2-<6 years (p=0.043) and ENT and GI patients ≥6 years (p=0.009, p=0.003).

Conclusion:
PPIA increases SST for some surgical procedures and age groups, however the median overall delay of 1 minute is a small fraction of total OR time. Further research is needed to identify patients who may benefit from PPIA without negative impact on operating room efficiency.
 

51.11 Can ultrasound reliably identify complicated appendicitis in children?

Posted on January 18, 2018

D. O. Gonzalez1, A. Lawrence1, J. Cooper1, R. Sola2, E. Garvey3, B. C. Weber4, S. D. St. Peter2, D. J. Ostlie3, J. E. Kohler4, C. M. Leys4, K. J. Deans1, P. C. Minneci1  1Nationwide Children’s Hospital,Columbus, OH, USA 2Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA 3Phoenix Children’s Hospital,Phoenix, AZ, USA 4American Family Children’s Hospital,Madison, WI, USA

Introduction:  Although ultrasound is commonly used to diagnose pediatric appendicitis, its ability to identify specific features relevant to non-operative management, such as the presence of complicated appendicitis (CA) or an appendicolith, are unknown. The objective of this study was to determine the reliability of ultrasound in identifying these features.

Methods:  We performed a multi-institutional retrospective study of patients aged 2-18 years who underwent appendectomy after an abdominal ultrasound during 2015 at four children’s hospitals. Interval and incidental appendectomies were excluded.  Charts were reviewed for patient characteristics and imaging, operative, and pathology reports. All cases were classified as either CA or simple appendicitis (SA) based on pathology and operative findings. CA was defined as appendicitis with a perforation of the appendix or extraluminal appendicoliths/enteric contents; SA was defined as a hyperemic or inflamed/gangrenous appendix without perforation.  Two separate analyses of the diagnostic parameters of ultrasound were performed. First, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound for identifying CA were calculated. In these analyses, equivocal ultrasounds were considered as not indicating CA. Second, the sensitivity, specificity, PPV, and NPV of ultrasound for identifying the presence of an appendicolith (ether intra- or extraluminal) were calculated.

Results: 1027 patients were included. Based on pathology, 77.5% had SA, 16.2% had CA, 5.4% had no evidence of appendicitis, and 15.6% had an appendicolith. The sensitivity and specificity of ultrasound for detecting CA based on pathology were 42.2% and 90.4%; the PPV and NPV were 45.8% and 89.0%. The sensitivity and specificity of ultrasound for detecting CA based on intra-operative findings were 37.3% and 92.7%; the PPV and NPV were 63.4% and 81.4%. The sensitivity and specificity of ultrasound for detecting an appendicolith based on pathology were 58.1% and 78.3%; the PPV and NPV were 33.1% and 91.0%. Results were similar when equivocal ultrasounds and negative appendectomies were excluded.

Conclusion: Despite the low sensitivity of ultrasound for diagnosing CA or an appendicolith, the high specificity and NPV suggest that ultrasound is a reliable test to exclude CA and an appendicolith in patients being considered for non-operative management of SA.

 

51.08 Outcomes Following Laparoscopic Gastrostomy Suture Techniques in Children

Posted on January 18, 2018

C. A. Mason1, D. E. Skarda1, B. T. Bucher1  1University Of Utah School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Salt Lake City, UT, USA

Introduction:  Historically, gastrostomy placement involved securing the stomach to the anterior abdominal wall in a Stamm-like fashion.  With the advent of laparoscopic gastrostomy (LAG), several methods have been described to mimic the Stamm technique which include the use of temporary or subcutaneous transfascial abdominal wall sutures.  Our goal is to determine if a particular suture technique results in an increased risk for the development of postoperative complications or resource utilization.

Methods:  A retrospective cohort analysis was performed for patients less than 18 years of age who underwent LAG placement surgery at a tertiary Children’s Hospital between 2012 and 2016.  Children were identified based on Current Procedural Terminology Code for Laparoscopic Gastrostomy.  The medical records were reviewed and children were grouped according to suture techniques for LAG placement:  subcutaneous absorbable or temporary (externally-fixed or none) sutures.  Postoperative outcomes at 30 days were defined as major complications (tube dislodgement, unplanned reoperation, readmission) and minor complications (stitch abscess, surgical site infection, emergency department visit).  The Chi Square Test was used to determine if an association existed between the suture techniques and 30-day postoperative complications.

Results:  We identified 682 pediatric patients (52% female) who underwent LAG placement during the study period. The mean age of our cohort was 3 years, the most common comorbidity that necessitated the use of a feeding tube was failure to thrive (44%), and 10% of our patient population had previously undergone GI surgery.  Of the patients in our cohort, 301 (44%) had subcutaneous sutures placed and 381 (56%) had temporary sutures placed. The overall rate of major and minor complications was 8.3% and 22%, respectively.  We observed a significant difference in the occurrence of major postoperative complications between the subcutaneous and temporary suture techniques (11% vs 6.3%, p=0.04).  However, there was no statistical significance among the individual major complications including tube dislodgment, reoperation, and readmission. (Table)  Likewise, there was no significant difference in the development of minor complications between subcutaneous and temporary suture techniques.

Conclusion:  Children undergoing subcutaneous absorbable suture placement during laparoscopic gastrostomy (LAG) are at an increased risk for developing a major complication (accidental tube dislodgment, unplanned reoperation, or hospital readmission) within 30 days of the procedure.  The rate of 30-day postoperative minor complications was similar in children undergoing either subcutaneous or temporary suture placement during LAG.

 

51.09 Utility of Serial Prenatal MRI assessment in Congenital Diaphragmatic Hernia

Posted on January 18, 2018

C. C. Style1,5, T. C. Lee1,5, A. R. Mehollin-Ray4, P. E. Lau1, M. A. Verla1,5, S. M. Cruz1, J. Espinoza2, C. J. Fernandes3, S. G. Keswani1,5, D. L. Cass5, O. O. Olutoye1,2,5  1Baylor College Of Medicine,Micheal E. DeBakey Department Of Surgery,Houston, TEXAS, USA 2Texas Children’s Hospital,Department Of Obstetrics And Gynecology,Houston, TEXAS, USA 3Texas Children’s Hospital,Department Of Pediatrics,Houston, TEXAS, USA 4Texas Children’s Hospital,Department Of Radiology,Houston, TEXAS, USA 5Texas Children’s Fetal Center,Division Of Pediatric Surgery,Houston, TEXAS, USA 6Baylor College Of Medicine,Micheal E. DeBakey Department Of Surgery,Houston, TEXAS, USA

Introduction: Congenital diaphragmatic hernia (CDH) is a congenital anomaly that causes significant morbidity and mortality. Fetal MRI has been used to characterize and stratify the severity of CDH after diagnosis. The purpose of this study was to determine the utility of serial MRI in predicting severity of outcomes in CDH. 

Methods:  A single institution retrospective review was performed of fetuses referred to our institution from April 2004 to March 2017 with a diagnosis of CDH.  Prenatal MRI indices including total fetal lung volume (TFLV), observed to expected total lung volume (O/E TLV), and presence of intrathoracic liver herniation were evaluated to predict outcomes. Primary outcomes included survival, need for extracorporeal membrane oxygenation (ECMO) and pulmonary hypertension (PH). Patients were included if they underwent fetal MRI at least twice prior to delivery.  Fetuses that underwent endotracheal balloon occlusion were excluded. Data were analyzed using student’s t-test and logistic regression, a p value <0.05 was considered significant.  

Results:Of 250 fetuses evaluated for CDH, 193 were further characterized by MRI; a total of 73 had serial MRIs, with 53 having at least one occurring between 20 – 28 weeks (2nd trimester) and one occurring at >28 weeks gestation (3rd trimester). Mean gestational age at the 2nd trimester and 3rd trimester MRI were 23.5 ± 2.1 and 33.1 ± 1.70 weeks, respectively.  Of the 53 patients, 67% (n=36) were male and 85% (n=45) had a left-sided CDH. There was an average of 10.1 weeks (± 4.4) between the 1st and 2nd MRI.  Of these patients, 98% (n=52) had an increase of TFLV with a mean growth of 1.45 ± 0.85 mm/week between the 2nd and 3rd trimester. There was a significant correlation of interval TFLV growth and PH postnatally (p=0.009). O/E TLV either increased or decreased by >10% in 74% with no statistical correlation to postnatal outcome.  When comparing all three MRI parameters in the overall cohort (n=193), O/E TLV, TFLV, and liver herniation were predictive of infant survival (p<0.05).  TFLV in the 3rd trimester was an independent predictor of PH, however O/E TLV at initial presentation was a strong predictor for need for ECMO and survival when comparing serial MRIs (Table 1).  Overall cohort survival was 79%.

Conclusion: TFLV in the 3rd trimester is a strong predictor of pulmonary hypertension, but MRI assessment of lung volumes in the second trimester is more predictive of survival than 3rd trimester studies. Our results suggest that the timing of MRI assessment of lung volumes in CDH patients who have not undergone fetal intervention is important in predicting outcomes, and that serial MRI assessments may be of value in selected cases.       
 

51.05 "Impact of Insurance Status on Surgical Transfer for Appendicitis in Pediatric Patients"

Posted on January 18, 2018

K. Gee1, R. E. Jones1, A. Beres1  1University Of Texas At Southwestern,Department Of Surgery, Division Of Pediatric Surgery,Dallas, Tx, USA

Introduction:  Tertiary referral centers exist to provide specialty and critical care for patients presenting to surrounding hospitals which lack these resources. However, there is a notion among tertiary centers that transferring hospitals are more likely to refer patients with unfavorable insurance coverage, and there is evidence to support this belief in adults and pediatric literature. Children’s Health in Dallas, Texas, is a large freestanding children’s hospital which frequently receives transfer requests for surgical patients. We examined funding status in patients transferred to our hospital for surgical management of acute appendicitis, hypothesizing that transferred patients were more likely to have Medicaid or no funding.

Methods:  With IRB approval, the electronic medical record was queried retrospectively for all patients who underwent a laparoscopic appendectomy for acute appendicitis at our hospital between January 2011 and December 2015. Data retrieved included transfer status, funding source, and demographic variables such as age, sex, race, and ethnicity. Funding source was grouped in to three categories: commercial, Medicaid/ Children’s Health Insurance Plan (CHIP), or none.  Transferred patients were compared to patients who presented directly. Descriptive analysis included determination of frequencies, means and standard deviations, and comparative statistics included with Chi squared test and t test.

Results: A total of 5,758 patients underwent laparoscopic appendectomy during the study period, of which 1,683 (29.2%) were transferred from other hospitals. Transfer patient were more likely to be older with a median age of 10.5 years versus 9.8 years in non-transferred patients (p=<0.0001). Additionally, transfer patients were more likely to identify as non-Hispanic than patients directly admitted (63.5% vs 50.0%, p=<0.0001). Transfer patients and directly admitted patients had similar rates of being uninsured, at 6.5% in direct patients and 6.1% in transferred patients (p = 0.5761). There was no difference in rate of Medicaid/CHIP coverage at 59.5% in directly admitted patients and 58.7% in transferred patients. 

Conclusion: The rate of uninsured children in our study was 6.4%, which is slightly higher than the 5% national level.  Our results show that patients transferred for laparoscopic appendectomy were just as likely to be uninsured as directly admitted patients, which contradicts evidence from other studies in which uninsured patients were more likely to be transferred. The underlying cause for this finding deserves further investigation, but could be attributed to regional phenomena or the diagnosis of acute appendicitis. This study highlights ongoing concerns that nonclinical factors affect interfacility transfer practices for pediatric patients.

 

51.06 Same Day Discharge for Non-Perforated Appendicitis in Children: An Updated Institutional Protocol

Posted on January 18, 2018

L. O. Benedict1, J. Sujka1, J. Sobrino1, P. Aguayo1, S. St. Peter1, T. Oyetunji1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA

Introduction:  The evolving demands of our current health care system for enhanced efficiency and safety while decreasing hospital length of stay has led to our institutional protocol for same day discharge (SDD) after laparoscopic appendectomy.  We have previously demonstrated a 28% rate of same day discharge in children with non-perforated appendicitis.  The purpose of our study is to assess effectiveness of a mature protocol for SDD by evaluating discharge success, duration of hospital stay and readmissions.

Methods:  A retrospective review of prospectively collected data was conducted.  All children undergoing a laparoscopic appendectomy at our freestanding Children's Hospital between December 2015 and July 2017 were included.  Patients with non-perforated appendicitis were classified according to whether they were discharged home the same day as their operation or had an overnight stay.  Demographic data, time of day the procedure was completed, post-operative length of stay and readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA using chi square or fisher exact test for categorical variables and t-test for continuous variables.

Results: A total of 569 children were included, with 87% (n=495) discharged home the same day as their appendectomy.  Of the patients discharged home the same day of surgery, their median length of post-operative stay was 4 hours (IQR: 3, 5) compared to 19 hours for the patients who stayed overnight (IQR: 15,25, p<.0001).  Approximately two-thirds of patients who had their appendectomies after 6pm stayed overnight.  In addition, patients discharged home the same day had significantly lower readmission rates than patients who stayed overnight (1% vs. 4%, p=.038).  

Conclusion: After laparoscopic appendectomy in children with non-perforated appendicitis, SDD not only reduces post-operative length of stay but is not associated with higher readmission rates. 

 

51.07 What is a Normal Appendix? Impact of Pathological Criteria on Pediatric Negative Appendectomy Rate

Posted on January 18, 2018

C. Maloney1, M. C. Edelman2, A. C. Bolognese1, L. Collins3, A. M. Lipskar1, B. S. Rich1  1Hoftstra Northwell School Of Medicine,Surgery,New Hyde Park, NY, USA 2Hofstra Northwell School Of Medicine,Pathology And Laboratory Medicine,New Hyde Park, NY, USA 3Hoftstra Northwell School Of Medicine,Pediatric Radiology,New Hyde Park, NY, USA

Introduction: Negative appendectomy rate (NAR) is a quality metric used in the surgical management of appendicitis. An acceptable NAR minimizes the morbidity of missed appendicitis, which is typically higher than that of non-therapeutic appendectomy. The rates of negative appendectomy (NA) in children range from 5-40% in the literature. Many reports do not provide a clear pathological definition of acute appendicitis or NA. In order to interpret these data, a generalizable definition of a normal appendix must be accepted. We reviewed our experience with pediatric appendectomy and the pathological spectrum encompassed within our definition of a NA and examined how the definition impacts our hospital’s NAR.

Methods: A retrospective review from 2012-2016 identified 1,676 children that underwent appendectomy. Average age was 11.4 (4-18 yo). Interval and incidental appendectomies were excluded. Patient demographics, perioperative data and pathological findings were collected. Appendicitis was defined as the presence of transmural aucte inflammation in the appendix while NA was defined as the absence of transmural inflammation.

Results: 1,437 patients underwent appendectomy for presumed appendicitis. The rate of pathologically diagnosed appendicitis was 91%(1,318/1437). Using the proposed definition of NA, NAR was 8.4% (120/1437). 60% of patients with true appendicitis presented with vomiting vs 38.5% of NA patients (p<0.01). The average white blood cell count was 11.3 ± 4.8 in the NA group vs 15.5 ± 5.3 in the patients with true appendicitis (p<0.001). 88.3% of NA patients were diagnosed with ultrasound alone and 27.5% with CT scan. 11.6% of NA patients had mesenteric lymphadenopathy on US vs 3% of patients with true appendicitis (p<0.05). Review of the pathology of the NA cohort identified 61/120(50.8%) patients with completely normal pathology. The remaining 59 (50.4%) patients displayed some sort of pathological abnormality including fecaliths (n=9), pinworms (n= 3), cryptitis (n=10), granuloma (n=2), fibrous obliteration of the appendiceal tip (n=4), lymphadenopathy (n=1), and non-specific inflammation (n=30). Exclusion of these patients decreased the NAR to 4.2%. Subgroup analysis could not identify pre-operative factors that differentiated the patients with normal pathology from those with pathological abnormalities.  Of the NA patients, 5(4.2%) were readmitted for recurrent abdominal pain (2 with normal pathology and 3 with abnormal pathology).

Conclusion: Pediatric NAR is dependent upon the pathological definitions of a normal appendix and variations in definition may explain discrepancies in the literature. Changing our definition of a NA to “the absence of inflammation or other appendiceal pathology” decreased the negative appendectomy rate by 50%. Further follow-up of patients with pathological abnormalities other than transmural inflammation is warranted to determine the necessity for surgery in this group.  

51.03 Early Operative Versus Observational Management in Children with Adhesive Small Bowel Obstruction

Posted on January 18, 2018

J. M. Hyak1, G. A. Campagna1, Z. T. Stone1, B. Johnson1,3, Y. Yu2,3, A. D. Schwartz4, E. H. Rosenfeld2, B. Naik-Mathuria2,3  4Baylor College Of Medicine,Department Of Pediatrics,Houston, TX, USA 1Baylor College Of Medicine,Houston, TX, USA 2Baylor College Of Medicine,Michael E. Debakey Department Of Surgery,Houston, TX, USA 3Texas Children’s Hospital,Department Of Surgery,Houston, TX, USA

Introduction:  

Adhesive small bowel obstruction (ASBO) occurs in 1.1-8.3% of pediatric abdominal surgery patients. Our study compared surgical outcomes of non-operative and operative management of adhesive small bowel obstruction in children and assessed the impact of age on surgical management.

 

Methods:

We retrospectively studied children (age ≤18 years) admitted for ASBO to a tertiary academic children’s hospital from 2011-2015. Children with no prior abdominal surgery, surgery ≤4 weeks prior to admission, and complex medical conditions such as genetic or metabolic diseases were excluded. Patients were stratified by management: early operative (EO; time to surgery ≤12 hours), delayed operative (DO; time to surgery >12 hours) or non-operative (NO; discharged without operation). Rates of perforation and small bowel resection were compared using χ2 test. A receiver operating characteristic (ROC) curve was used to evaluate age as a diagnostic indicator for non-operative management. A p-value <0.05 was considered significant.

Results:

We identified 212 unique patients, comprising 269 total hospitalization, who were admitted for ASBO. Early operation was required in 58/269 (22%), failed non-operative management requiring delayed operation in 83/269 (31%), and successful non-operative management in 128/269 (48%). Mean age at admission (EO 7.7 vs DO 7.8 vs NO 8.7 years, p=0.42) and age at index abdominal surgery (EO 3.0 vs DO 3.3 vs NO 4.2 years, p=0.35) were similar.

 

Incidence of leukocytosis (EO 47.9% vs DO 62.9% vs NO 51.7%, p=0.206) and fever (EO 16% vs DO 8.9% vs NO 6.7%, p=0.298) did not differ between groups. There was no difference in length of stay between DO and EO (21.7±27.5 vs 18.2±22.2 days, p=0.43). Rate of bowel resection was greater in DO versus EO (27.7% vs 12.1%, p=0.026). However, bowel perforation incidence (DO 15.7% vs EO 10.3%, p=0.36) and length of bowel resected (DO 4.6±11.8 cm vs EO 6.2±25.1 cm, p=0.61) were similar. ROC analysis for age at admission yielded AUC 0.56 (p=0.07, 95% CI 0.495-0.633) for discriminating the need for surgery. Optimal criterion value for age was 1.88 years, representing the greatest accuracy in predicting non-operative management of ASBO, with sensitivity and specificity of 86.5% and 32.1%, respectively. Children ≤2 years of age had a higher operative rate than older children (61% vs. 49%, p=0.06).

 

Conclusion:

Though most children with ASBO are initially managed non-operatively, over one third fail conservative management, requiring delayed surgery. This results in significantly higher rates of bowel resection. Age alone did not distinguish children requiring operation from those managed non-operatively. However, we found a trend towards higher operative rate in children ≤2 years. Further studies are needed to evaluate risk factors for failing non-operative management as these children may benefit from early surgical intervention to prevent bowel loss.

51.04 Role of Surgery in Management of Children with Crohn’s Disease

Posted on January 18, 2018

S. Lo1, G. Beasley1, C. Jolley1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction:

The role for surgery in management of Crohn’s disease has diminished over the past few decades, with improved medical treatment. However, there remains a subset of patients who require an operation due to complications and frequently this intervention is delayed. The purpose of this study was to understand and identify which children would benefit from surgery and their outcomes.

 

 

Methods:

Retrospective review of 107 children who were seen at our institution over a 10-year period (6/2006 to 6/2016) for Crohn’s disease was performed. Data regarding demographics, presentation, disease course, phenotype and location, management, and complications. The cohort was divided into medically managed (medicine) vs. surgical therapy (surgery), and were compared using the students t-test for continuous, Fisher’s exact test for categorical, and the Mann – Whitney test for non-parametric data. P values of less than 0.05 were considered significant.

 

Results:

107 children and adolescents with Crohn’s disease were identified that met inclusion criteria. We noted no significant difference in gender, race, family history, insurance status, age at diagnosis, symptoms at diagnosis, initial management, and numbers of flares per year between the surgery group (n=29) and the medicine group (n=78). The surgery group had significantly more small bowel (90% vs. 72%, p=0.019) and stricturing variant of Crohn’s (52% vs. 6%, p<0.0001) than the medicine group. The surgery group had a trend to reduction in the average number of flares per year pre- and post-surgery (3.1 vs. 1.9, p=0.08). Patients with fistulizing disease were mostly managed medically.

 

Conclusions:

The number of patients undergoing surgery was low, and in our experience, those children did not have a more severe presentation. Patients with ileal (small bowel) location and the stricturing variant of the disease are the ones who required surgery, and they benefited from bowel resection. These data will be used to counsel patients and offer early surgery where indicated. 

51.02 Parent Reported Quality of Life Outcomes in Children with Congenital Diaphragmatic Hernia

Posted on January 18, 2018

J. L. Morsberger1, H. L. Short1, K. J. Baxter1, C. Travers2, M. S. Clifton1, M. M. Durham1, M. V. Raval1  1Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  With improved survival of patients with congenital anomalies, long-term outcomes including quality of life (QoL) assessment are needed. The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including QoL measures, gastrointestinal symptom burden, surgical reoperation rates, and current health status.

Methods: We performed a retrospective review of surviving patients who underwent CDH repair between 2007 and 2014 at a quaternary children’s hospital. Phone surveys of parents were conducted using two validated measures (Pediatric Quality of Life Inventory (PedsQL) and PedsQL Gastrointestinal Symptoms Module). Additional outcomes of interest were collected including subsequent operations and current health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients, when appropriate.

 

Results: Of 102 CDH patients identified, 56 families (54.9%) were reached with 46 (82.1%) agreeing to participate. The mean age at follow up was 5.8 years. 28 patients (60.9%) had thoracoscopic repair, 10 (21.7%) required ECMO, and 11 (23.9%) had a recurrence. For the overall cohort, median PedsQL score was 91.8 (scale 0-100) with a physical health summary score of 93.8 and a psychosocial health summary score of 91.7. Median PedsQL gastrointestinal score was 95.8. Statistically significant differences were found in PedsQL scores when stratified by surgical approach and defects where the stomach was found in the thoracic cavity (stomach up). No difference was found when stratified by defect side (left vs right), patch vs primary repair, prenatal diagnosis, ECMO, or recurrence (Figure). Older patient age correlated with worse school functioning and heartburn symptoms (Pearson Coefficient -0.31 (p=0.03) for both).

 

Conclusion: Children with CDH have reassuring overall and gastrointestinal QoL scores. Our study shows higher QoL scores in patients who undergo thoracoscopic repair and no difference in outcomes based on recurrence. Given the correlation between older age and poor school function, even longer follow up of patients with CDH is warranted.  

50.20 Failure to Rescue in Liver and Pancreas Surgery: Is the "July Effect" Real?

Posted on January 18, 2018

D. S. Lee1, L. W. Chiu1, C. Chai1, K. I. Makris1, N. Becker1, L. Gillory1, S. S. Awad1  1Baylor College Of Medicine,Surgery,Houston, TX, USA

Introduction: Every July, new medical school graduates begin training and there is significant turnover of residents and other trainees.  There is a question as to whether this affects patient outcomes.  Previous studies have produced mixed results and the effect of resident turnover on failure to rescue (FTR) after liver and pancreatic surgery has not been studied.

Methods:  A retrospective analysis was carried out using the National Inpatient Sample (NIS) from years 2012-2013.  Patients who underwent liver or pancreatic resection were identified using ICD-9 procedure codes.  Major in-hospital complications were identified using ICD-9 codes and included myocardial infarction, pneumonia, cerebrovascular accident, acute renal failure, urinary tract infection, wound complications, sepsis, and pulmonary embolism.  FTR was defined as an in-hospital mortality among patients who had one of these major complications.  Hospital factors (location and teaching status) and month of admission were analyzed using logistic regression to determine if they were associated with increased rates of FTR. 

Results: 13,246 patients were identified.  Of these 3,056 had a complication of which 289 died (FTR = 9.5%). 10,190 patients did not have a complication and of these, 99 died (0.97%, p<0.0001).  When analyzed by month of admission, the rate of FTR ranged from 7.1% (November) to 12.5% (October).  Using logistic regression models, we found that in the entire patient sample, the presence of one or more complications was associated with higher in-hospital mortality (OR 2.36, 99%CI 2.12-2.59, p<0.0001).  In the group that had a major complication, neither hospital teaching status (OR -0.20, 95%CI -0.459-0.060, p=0.132) or month of admission (OR 0.001, 95%CI -0.034-0.036, p=0.962) was associated with higher rates of FTR.

Conclusion: Based on this data, neither the teaching status of the hospital or the month of the year is associated with increased FTR.  Administrative data does have limitations and further prospective studies using control groups of non-teaching hospitals will be necessary to determine whether or not resident turnover is associated with increased FTR.

 

51.01 Pancreatic Islet Cell Tumors in Adolescents and Young Adults

Posted on January 18, 2018

I. I. Maizlin1, R. T. Russell1, M. B. Dellinger2, A. B. Goldin2, M. Goldfarb3, J. J. Doski4, A. Gosain5, M. Langer6, M. V. Raval7, J. G. Nuchtern8, S. A. Vasudevan8, K. W. Gow2, E. A. Beierle1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA 2Seattle Children’s Hospital,Pediatric Surgery,Seattle, WA, USA 3John Wayne Cancer Institute At Providence St. John’s Health Center,Surgery,Santa Monica, CA, USA 4Methodist Children’s Hospital Of South Texas, University Of Texas Health Science Center-San Antonio,Surgery,San Antonio, TX, USA 5University Of Tennessee Health Science Center,Pediatric Surgery,Memphis, TN, USA 6Maine Children’s Cancer Program, Tufts University,Portland, ME, USA 7Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Pediatric Surgery,Atlanta, GA, USA 8Baylor College Of Medicine, Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA

Introduction: While pancreatic islet cell tumors (ICTs) are rare pancreatic neoplasms in any age group, less than 10% of them occur in adolescents. While recent studies investigated the most appropriate treatment of pancreatic ICTs, as well as the effect of age on consequent survival, none of the patients examined were in the adolescent and young adult (AYA) category, with most patients in their 6th or 7th decade of life. The question arises, therefore, whether AYA patients would demonstrate a similar improvement in overall survival following ICT diagnosis. Therefore, we utilized a national database to describe the histological and clinical pattern of ICTs in AYA patients, comparing them to their older adult counterparts. Based on the limited studies on older populations, we hypothesized that AYA patients would have better overall survival following ICTs diagnosis.

Methods: A search of all AYA patients (15-39 yo) in the National Cancer Data Base (1998-2012) with ICT diagnosis was performed. Demographics, tumor characteristics, treatment modalities, and outcomes were abstracted and compared to adults (≥40 yo).

Results: After 11 patients were excluded for lack of survival data, 383 patients (56% female) were identified, with a median age of 27 (IQR 16-34) years at diagnosis. Non-Hispanic Caucasians comprised 65% of patients, 14% were Hispanic Caucasians, 14% African Americans, and 7% other ethnicities/races. Islet cell carcinoma was the most common histology (74%, n=285), followed by insulinomas (9%, n=36), gastrinomas (7%, n=28), mixed-cell tumors (6%, n=22), and VIPomas (3%, n=12). 24% of patients presented with early stage disease (Stage I:16%, Stage II:8%); 25% had advanced disease (Stage III:5%, Stage IV:20%). 267 patients underwent surgical resection, consisting of local excision 44%, Whipple procedure 37.5%, and total pancreatectomy 19%. Chemotherapy was utilized in 29% of cases and radiotherapy in 8%. With mean follow-up of 4.7 years, mortality was 36%. Cox regression analysis (n=361) demonstrated no difference in survival between different histologies (p=0.779). Comparison of AYAs to older adults demonstrated similar stage distribution (p=0.054), rates of comorbidities (p=0.727), and utilization of adjuvant therapies (chemotherapy p=0.153, radiation therapy p=0.666), with more extensive resections (p=0.001) in AYA patients as well as lower mortality rates (p<0.001).

Conclusions: This study found that AYA patients with ICTs had similar histologic distributions and comparable utilization of adjuvant therapies to older adult counterparts, but underwent more extensive resections and demonstrated a higher overall survival rate. While requiring further investigation, these results demonstrate a differentiation that may serve for evidence-based risk stratification of prognosis in ICT patients.

 

50.17 Impact of Active Opioid Use on Healthcare Costs for Patients with Intestinal Obstruction

Posted on January 18, 2018

V. K. Dhar1, Y. Kim1, D. E. Go1, K. Wima1, A. D. Jung1, A. R. Cortez1, R. S. Hoehn1, S. A. Shah1  1University Of Cincinnati,Department Of Surgery,Cincinnati, OH, USA

Introduction:  The overuse of prescription opioid medications is a growing epidemic in the United States. Recent studies have shown that preoperative narcotic use impacts hospital cost and outcomes in surgical patients, but the underlying reasons are unclear.

Methods:  A single-center retrospective analysis was performed on surgical patients admitted with a diagnosis of intestinal obstruction between 2010 and 2014. Patients were grouped into active opioid and non-opioid user cohorts. Active opioid use was defined as having an opioid prescription interval overlapping the date of admission. Chronic opioid use was defined by duration of opioid use for 90 days or longer. Admission or intervention due to opioid-related illness was determined through consensus decision of two independent, blinded clinicians. Primary endpoint was to analyze the effect of active opioid use on hospital resource utilization.

Results: During the study period, 296 patients were admitted with a primary diagnosis of intestinal obstruction. Active opioid users accounted for 18.6% of patients, with a median length of opioid use of 164 days (IQR 54-344 days). Of these, 18.2% were on multiple narcotics at time of admission and 76.4% met criteria for chronic opioid use. Compared to non-opioid users, active users were found to have increased median length of stay (8 days vs 6 days, p<0.05) and higher hospital costs ($12,241 vs $8,489, p<0.05) during index admission. Subgroup analysis of active opioid users demonstrated that opioid-related conditions were responsible for ten admissions (18.2%) and two readmissions (3.6%). Among active users requiring surgical intervention, three patients (21.4%) underwent exploratory laparotomy with negative findings. 

Conclusion: Active opioid users, comprising 19% of this cohort of emergency acute care surgery patients, are predisposed to avoidable admissions and interventions for opioid-related illnesses. Efforts to address opioid use in the surgical population may improve patient outcomes and overall healthcare spending.

 

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