13.15 Pediatric Surgical Risk Assessment Tools: A Systematic Review

Posted on January 18, 2018

D. Ji1, S. L. Goudy2, M. V. Raval3, N. P. Raol2  1Mercer University School Of Medicine,Savannah, GA, USA 2Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Otolaryngology, Department Of Otolaryngology – Head And Neck Surgery,Atlanta, GA, USA 3Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Surgery, Department Of Surgery,Atlanta, GA, USA

Introduction:  Currently used pediatric surgical risk assessment tools use patient and procedure-specific variables to predict postoperative complications following specific procedures. These tools assist clinicians in preoperative counseling and surgical decision-making. The objective of this systematic literature review was to compile and evaluate current pediatric surgical risk scores that are applicable across pediatric surgical specialties. 

Methods:  A systematic literature review was performed following PRISMA guidelines to identify relevant publications. Studies were independently screened by two reviewers by pre-defined eligibility criteria. Data was extracted from the selected manuscripts and the included articles were assessed for quality and risk of bias using the Newcastle-Ottawa Scale. Studies were included if they met the following criteria: designed to develop a preoperative risk model predicting postoperative complications or mortality, applicable across various surgical specialties, and pertinent to the pediatric population. Studies with specialty- or procedure-specific risk scores and validation studies were excluded.

Results: Of 19 studies identified on initial title and abstract review, 4 studies (21%) comprising of 2,352,481 patients met inclusion criteria. Each study reported assessment of a novel, generally applicable pediatric surgical risk score to risk stratify children preoperatively. Risk variables evaluated across the models reflected the degree of resilience or fragility of the patient prior to surgery. Risk factors common to all studies were the presence of cardiovascular or neurological diseases. Three of the four included studies defined most risk factors in binary terms, whereas one study used a scale of severity of organ system disease when defining preoperative risk. Generated risk scores positively correlated with inpatient mortality or postoperative complications, with c-statistic values ranging from 0.77-0.98. 

Conclusion: Though a variety of risk assessment tools are available to reliably inform adverse events for children undergoing surgery, many of the characteristic risk factors were addressed in binary terms, limiting capture of differences in risk across gradients of preoperative condition and fragility. More study is needed to assess generalizability in all populations and procedures.

13.13 Examination of Postoperative Length of Stay Following Common Procedures in ACS-NSQIP Pediatric

Posted on January 18, 2018

D. Papandria1, Y. V. Sebastião1, K. J. Deans1, K. A. Diefenbach1, P. C. Minneci1  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA

Introduction:

Though frequently reported in comparative studies, there are few reports describing typical postoperative length of stay (LOS) associated with commonly performed operations in the pediatric population. The objective of this study was to identify ranges of postoperative LOS for common pediatric procedures using a large multi-institutional database.

 

Methods:

A retrospective analysis of the ACS-NSQIP Pediatric Public Use File (2013-2015) was performed. General surgical procedures were grouped using Current Procedural Terminology codes (CPTs). The most frequently performed procedures were identified and analyzed. These included: laparoscopic appendectomy (LA), laparoscopic cholecystectomy (LC), laparoscopic gastrostomy (LG), laparoscopic esophagogastric fundoplication (LF), thoracoscopic repair of pectus excavatum (TPE), appendectomy (OA), enterostomy closure (OEC), gastrostomy closure (OGC), and bowel resection (OBR). Patients < 6 months or > 18 years of age and those receiving unrelated major concurrent surgical procedures were excluded, as were day-of-surgery discharges and inpatient deaths. Postoperative LOS was examined for each procedure, including multivariable analysis of patient preoperative risk factors for postoperative LOS > 75th percentile.

 

Results:

A total of 29, 557 cases were identified (median age: 7 years; 57% male; 73% white), and included procedure subgroups ranging from 505 (OBR) to 19,260 (LA) cases. Procedure-specific median postoperative LOS (75th percentile; 90th perecentile) were: LA 1d (2d; 5d); LC 1d (1d; 2d); LG 2d (2d, 4d); LF 3d (4d, 6d);  TPE 4d (5d, 6d);  OA 3d ( 6d, 9d);  OEC 4d (6d, 10d);  OGC 1d (1d, 2d); and OBR 6d (10d, 20d)(Fig. 1). Preoperative risk factors for high postoperative LOS varied by procedure and included patient demographics (age, race), admission factors (inpatient classification, admission from Emergency Dept.), case characteristics (emergent designation, ASA class III / IV), and comorbidities (sepsis, developmental delay, neurologic disease). No single risk factor reached statistical significance for more than six of the procedures.

 

Conclusion:

The range of postoperative LOS for commonly performed procedures varies considerably across procedures. Risk factors for high postoperative LOS also varied by procedure. These results may be a useful reference for benchmarking and resource utilization analyses at the institutional and health systems levels.

13.10 Approaches and Safety Profile of Surgical Treatment of Velopharyngeal Insufficiency Using NSQIP

Posted on January 18, 2018

A. D. Chen1, B. N. Tran1, Q. Z. Ruan1, B. T. Lee1, O. Ganor2  1Beth Israel Deaconess Medical Center,Plastic And Reconstructive Surgery,Boston, MA, USA 2Boston’s Children Hospital,Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction: Velopharyngeal insufficiency (VPI) often manifests after cleft repair or adenoidectomy as a result of an occult palatal problem, which can result in hypernasal speech and nasal air emission. This study aims to study the outcomes of different techniques for VPI correction using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).  

Methods: VPI cases from 2012-2015 were identified.  Patients were subdivided in 4 unique cohorts: (1) palatoplasty, (2) pharyngeal flap and sphincter pharyngoplasty, (3) lengthening, and (4) others including tissue excision and rearrangement, dermal grafts or fillers. Group characteristics and postoperative outcomes were compared using chi-square test for categorical variables and one-way ANOVA for continuous variables.

Results:  There were 591 VPI cases identified, 83 in group1, 359 in group 2, 40 in group 3, and 109 in group 4. The average age of repair was 7.9 with palatoplasty and pharyngeal flap done at a later time. More Asian patients received lengthening compared to other techniques. The longest operating time (108 minutes) was noted in lengthening group while the longest length of stay (2 days) was seen in the palatoplasty group.  Pediatric plastics performed the majority of the palatoplasty and lengthening cases whereas pediatric ENT performed most of the pharyngeal flap and local tissue rearrangement. Overall complication rate was 2%, with palatoplasty group had the lowest rate. Subgroup analysis comparing flap and sphincter techniques showed more complications in the pharyngeal flap group, however, these trends were not statistically significant.

Conclusion: Repairing a VPI can be done safely and effectively using different surgical approaches depending on the extent of the defect. A small gap causing a mild VPI will probably require a secondary palatoplasty, local tissue rearrangement or lengthening while a wide gap mandates bringing extra tissue to narrow it. Timely correction is crucial to facilitate proper phonation in children of developmental age. 

13.11 Typhoid Intestinal Perforation: Burden & Outcomes of a Neglected Pediatric Surgical Disease in Uganda

Posted on January 18, 2018

M. Cheung1, J. M. Healy1, N. Kakembo2, A. Muzira2, P. Kisa2, J. Sekabira2, D. Ozgediz1  1Yale University School Of Medicine,Surgery,New Haven, CT, USA 2Mulago Hospital, Makerere University,Surgery,Kampala, , Uganda

Introduction:  Typhoid ileal perforation comprises a substantial pediatric surgical burden in low-income countries, while in high-income countries it is rarely encountered and the mortality rate negligible. Mortality rates are 10-20-fold higher in low-income countries where surgical treatment ranges from repair of intestinal perforation to diverting enterostomy and interval ostomy reversal. There has been no prior analysis of pediatric typhoid perforation epidemiology and outcomes in Uganda despite the significant socioeconomic impact on these children and families.

Methods:  Review of a prospectively collected database of 3,289 pediatric surgical admissions to a tertiary referral hospital in Uganda from January 2012 to March 2016.

Results: 95 cases were identified: 79 new cases and 16 patients presenting for ostomy reversal   (excluded). The majority underwent operations (94.9%) with 56 (75%) requiring ostomy creation. Median age was 8 years with a range of 2-12 years.  Median distance traveled was 30 km with a range of 4-450 km, and duration of hospitalization ranged from 1–44 days, with a median of 9 days.  Geospatial mapping showed a majority of cases from the south central and west of the country (Figure 1). Post-operative courses ranged from 1–38 days with a median of 6 days.  Overall mortality was 19.0%.

Conclusion: Typhoid perforation preferentially affects vulnerable populations in low-income countries, and in Uganda a similar demographic is affected. Distance travelled approached the recommended 50 km set by the World Health Organization. While repair of perforation has been described, 75% of these children required diversion, suggesting more severe disease at presentation, and in Uganda ostomy creation has been associated with social isolation and impoverishment. The 19% case fatality rate is comparable to similar settings and underscores disease severity. More hospital and community-based data are needed for a more accurate national geospatial disease profile. This disease presents an opportunity for the global pediatric surgery community to promote disease prevention and access to emergency children’s surgical care in resource-poor areas.

 

13.12 Trends in Pediatric Electronic Burns

Posted on January 18, 2018

J. A. Cook1, S. E. Sasor1, S. P. Duquette1, M. P. Landman2, S. S. Tholpady1,3, M. W. Chu1,3  1Indiana University School Of Medicine,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 3R.L Roudebush VA Medical Center,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA

Introduction: The Consumer Product Safety Improvement Act (CPSIA) was passed in 2008 to improve testing and standardize the quality of manufactured products. Electronic toys and devices are common in today’s market and pose risks to the user. The purpose of this study is to characterize burn injuries caused by consumer devices in the pediatric population and to determine the impact of the CPSIA.

Methods: The National Electronic Injury Surveillance System (NEISS) database was used to collect data on pediatric burns between 2000 and 2015. Thermal and electric burns from cell phones, batteries, and electronic toys were included.  Age, gender, affected body part, mechanism of injury, and fire department involvement were recorded. Binary values were calculated using a Chi-square goodness-of-fit test.

Results: A total of 126 pediatric burns were identified. The majority of patients were male (60.3%) and mean age was 8.3 years. Thirty-eight pediatric burn cases were identified before 2008; 88 cases were identified after 2008. The proportion of contact burns before 2008 (0.18) was significantly less than the proportion of contact burns after 2008 (0.44), X2 = 7.68, p < 0.01. Before 2008, the leg was the most affected body part (0.39); after 2008, the proportion of leg burns significantly decreased (0.17), X2 = 7.359, p = 0.01. Hand injuries significantly increased after 2008 (0.50) as compared to before 2008 (0.26), X2 = 6.08, p = 0.01. The proportion of cell phone injuries before 2008 (0.16) was significantly less than the proportion of cell phone injuries after 2008 (0.39), X2 = 6.39, p = 0.01. A significantly smaller proportion of powered scooter burns occurred after 2008 (0.09) as compared to before (0.36), X2 = 14.18, p < 0.01. The proportion of cases admitted to the burn unit did not differ before (0.03) or after 2008 (0.08), X2 = 1.27, p = 0.26.

Conclusions: The overall incidence of pediatric burns caused by electronic devices was low, both before and after 2008. The enactment of the Consumer Product Safety Information Act has not affected the severity of burns based on the number of patients requiring hospital admissions. However, the mechanism of burn and affected area did change significantly. Providers should be aware of these patterns in pediatric patients and should educate guardians about these risks.

13.08 Put a Ring on it: Better Pediatric Pre-Induction Checklist Adherence Observed with Parent Engagement

Posted on January 18, 2018

D. N. Supak1,2, M. A. Bartz-Kurycki1,2, K. T. Anderson1,2, S. N. Wythe1,2, G. M. Garwood1,2, R. F. Martin1,2, R. Gutierrez1,2, A. L. Kawaguchi1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction:  Patient and parent engagement in healthcare has been shown to improve compliance and outcomes in many medical disciplines, but no literature exists regarding parent engagement in the perioperative process. The World Health Organization surgical safety checklist (SSC) recommends including the parents of pediatric patients in checklist completion. At our children’s hospital, the pre-induction SSC is conducted in pre-operative holding with anesthesia, nursing and often with parents. We hypothesized that better checklist compliance would be observed when parents were engaged in checklist performance.

Methods:  An observational study of pre-induction checklist adherence during non-emergent pediatric operations was performed from 2016 to 2017 during two separate 8-week periods. Adherence was defined as verbalization of each checkpoint with or without parent confirmation. Six of 13 checkpoints (patient identification, procedure, surgical site marked, weight, allergies and NPO status) containing information relevant to parental knowledge were evaluated for staff confirmation with parents. Trained observers assessed parent engagement based on: parents off their phones, not distracted, positive body language, eye contact and demonstrating an understanding of the checkpoint. Chi-square test and linear regression were used for analysis. P-value <0.05 was significant.

Results: Over the study period, 459 pre-induction checklists were observed with at least partial completion in 93.3% of cases with kappa >0.7. The mean proportion of checkpoints completed was 64.6% ± 31.1% and the proportion of fully completed pre-operative checklists was only 18.3%. Parents were present in 82% of cases and at least 1 checkpoint was confirmed with parents in 79% of checklists. Pre-induction checklist adherence was better when parents were present compared to when absent (p<0.001 for all checkpoints). Linear regression demonstrated a 1.2 (95%CI 1.0-1.3) increase in pre-induction adherence for every unit increase in parent engagement (Figure). Furthermore, meaningful completion of checkpoints by staff confirmation with parents differed significantly based on parent engagement with 93.9-100% of staff confirmation of checkpoints occurring with engaged parents compared to 0.3-6.1% in parents deemed not engaged (p<0.001).

Conclusion: Pre-induction SSC performance remains a challenge, as less than one-fifth of checklists were completed in full. However, dramatic improvement in compliance and staff confirmation of checkpoints was observed when parents were present for and engaged in the checklist process. Creating a process and training operative teams how to engage parents may increase checklist compliance and improve patient safety.

 

13.09 Surgical safety checklists in children’s surgery: Surgeon’s attitudes and a review of the literature

Posted on January 18, 2018

J. Roybal3, K. Tsao1,9, S. Rangel4,7, M. Ottosen2, D. Skarda6,8, L. Berman5  1UTHealth Medical School,Pediatric Surgery,Houston, TX, USA 2UT Houston-Memorial Hermann,Center For Healthcare Quality And Safety,Houston, TX, USA 3Ochsner Hospital For Children,Pediatric Surgery,New Orleans, LA, USA 4Boston Children’s Hospital,Pediatric Surgery,Boston, MA, USA 5Nemours/Alfred I. DuPont Hospital For Children,Pediatric Surgery,Wilmington, DE, USA 6Primary Children’s Hospital,Pediatric Surgery,Salt Lake City, UT, USA 7Harvard Medical School,Pediatric Surgery,Boston, MA, USA 8University Of Utah,Pediatric Surgery,Salt Lake City, UTAH, USA 9Children’s Memorial Hermann,Pediatric Surgery,Houston, TX, USA

Introduction:  Safety initiatives, such as peri-operative checklists, aim to create a safe environment for patients undergoing surgery.  Attitudes toward and adherence to the checklist among providers affect its ability to prevent harm.   The pediatric surgeon’s perception of the importance of the surgical checklist, and its perceived role in improving patient safety, is unknown.  We designed a survey to assess safety knowledge, attitudes and perceptions of North American pediatric surgeons, and to specifically gauge the “buy-in” of the American Pediatric Surgical Association (APSA) membership on checklists.

Methods:  An online survey of APSA members was conducted to evaluate utilization of and attitudes towards surgical safety checklists (SSCs). Surgeons’ perceptions of SSC’s, including the components that make them effective as well as barriers to participation, were measured.   Closed and open-ended questions were designed to quantify surgeon participation in the pre-induction, pre-incision, and post-operative debriefing checklists, and to describe surgeons’ attitudes about the effectiveness of checklists.  Standard frequency analyses were performed, and content analysis was used to evaluate open ended responses.  In addition to the survey, a literature search was carried out to identify systematic reviews of safety checklists in surgery and any studies focusing on the use of checklists in the pediatric surgical population.

Results:  The survey response rate was 38% (353/928). Use of the SSC was reported by 93.6% of respondents, but only 54.7% felt that checklists improve patient safety, and only 62.6% would want it used in their own child’s operation.  Being in a safety position was the only respondent characteristic that correlated with believing that checklists improve patient safety or wanting the checklist used in one’s own child’s operation.  Reasons most commonly cited for skepticism around checklist efficacy included length of the checklist process, distraction from thoughtful patient care, and lack of data to support use.   For the literature review, 10 manuscripts met inclusion criteria and were reviewed in detail.  Only one study addressed pediatric surgery patients.  

Conclusion:  Most pediatric surgeons participate in surgical safety checklists at their institutions, but many question their benefit.   While data is lacking on the morbidity and mortality benefit of surgical safety checklists in the pediatric population, checklists have been shown to improve communication, promote teamwork, and identify errors. Checklists should be regarded as key elements in improving peri-operative safety culture.  

 

13.05 Blunt Renal Injury in Children: Do National Trends in Management Follow Recent Literature?

Posted on January 18, 2018

R. Sola1, T. A. Oyetunji1, K. D. Graziano2, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 2University Of Arizona,College Of Medicine/ Department Of Surgery,Phoenix, AZ, USA

Introduction:  Published prospective observational data suggest children with blunt renal injury can be managed without bedrest, the use of catheters or antibiotics, and follow up imaging can be reserved to those with urinary extravasation. We wanted to investigate the current practice patterns of major children’s’ hospital to identify variation and areas for improvement with the use of evidence based protocols. 

Methods:  Data from 2006 to 2015 were requested from the Pediatric Health Information System. Patients were included based on the International Classification of Disease Ninth Revision (ICD-9) coding for blunt renal injury. Children were excluded if they had concomitant major thoracic or abdominal injury, diagnosis of renal injury without computerized tomography (CT) imaging confirmation, length of stay greater than seven days, underwent laparotomy and those that were intubated. Demographics, need for further imaging, and hospital outcomes were analyzed.

Results: During the study period, 1487 children were found to have a blunt renal injury. A total of 638 children were identified after excluding those that did not meet our inclusion criteria.  Median age was 12 years old (8,14). There were 474 (74%) males and 386 (61%) were white.  Median length of stay was 3 days (2,4).  Foley catheters were placed in 93 (15%) children and 157 (25%) were given antibiotics during their hospital course.  Two or more CT scans were performed in 376 (59%) children during their hospitalization.  

Conclusion: Children with blunt renal injury appear to be utilizing excess healthcare resources compared to published recommendations.  Further studies implementing an evidence based protocol would allow for the reduction of Foley catheters, antibiotics and CT scans. 

 

13.06 Hurry Up and Wait: Pre-Incision Time in the OR Associated with Pre-Induction Checklist Adherence

Posted on January 18, 2018

S. N. Wythe1, K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, D. N. Supak1, R. F. Martin1, G. M. Garwood1, R. Gutierrez1, A. L. Kawaguchi1,2, M. T. Austin1,2, K. P. Lally1,2, K. Tsao1,2  1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction: Delays in surgery impact patient care and resource utilization.  Operating room (OR) delay metrics are often defined when the patient enters the OR, but may not reflect in-room inefficiencies prior to incision. We hypothesized that low adherence to the pre-induction surgical safety checklist (SSC) may be associated with pre-OR delays or longer pre-incision times. 

Methods: An observational study of a convenience sample of scheduled, elective pediatric surgical cases in a tertiary care children’s hospital was performed over a 12-week period by trained observers. Specialties included general and thoracic, urology, neurosurgery, ophthalmology, orthopedics, otorhinolaryngology (ENT), and plastic & reconstructive surgery. Performance of the pre-induction checklist in the pre-operative area between nursing staff, anesthesia staff and patient/parents was observed. Degree of adherence to the pre-induction SSC was the proportion of checklist items completed. Pre-OR delays are institutionally defined as cases in which the patient enters the OR more than 5 minutes after scheduled case start. Pre-incision time was calculated as the difference between scheduled case start or room entry, whichever occurred first, and incision time. Cases were classified by scheduled order in the day (first start vs. later case). Descriptive statistics, chi2, t-tests, ANOVA and linear regression were performed. Inter-rater reliability was determined before the start of study using Cohen’s kappa.

Results:Interrater reliability for SSC performance was 0.70 (95%CI 0.68 – 0.72) for 5 observers. Of the 197 observed cases, 33% had pre-OR delay. Median total pre-incision time was 38 minutes (IQR 23-52). Median pre-induction adherence was 85% (IQR 69-100%) and did not vary by specialty (p=0.73). Pre-induction adherence to the SSC (p=0.91) and specialty (p=0.17) were not associated with pre-OR delays. First cases of the day were more likely to be on time (p<0.01). Longer total pre-incision times were associated with specialty (p<0.01) and worse pre-induction checklist adherence (p<0.01). After adjustment for specialty, case order, and adherence to SSC, first cases (p<0.01), ENT specialty (p<0.01), and higher pre-induction checklist adherence (p<0.01) remained associated with shorter pre-incision times (figure).

Conclusion:While pre-OR delays are tracked and audited, total pre-operative time, including time in the OR prior to surgery is not usually captured. Trying to achieve one metric of timeliness and efficiency may drive the necessary preparations to the OR, where costs may be higher. Pre-operative readiness may be reflected by meaningful pre-induction SSC performance and better measured by total pre-operative time. 
 

13.07 The Effect of Hospital Volume on Patient Outcomes for Pyloric Stenosis

Posted on January 18, 2018

C. Tom1, C. Niino2, A. D. Lee2, E. Saab2, S. Friedlander3, S. L. Lee1,2,3  1Harbor-University Of California Los Angeles Medical Center,Department Of Surgery,Torrance, CA, USA 2University Of California Los Angeles,Department Of Surgery,Los Angeles, CA, USA 3Los Angeles Biomedical Research Institute,Torrance, CA, USA

Introduction: For many surgical operations, there is a well-established relationship between surgical volume and outcome.  In the field of pediatric surgery, this has been shown to be true for conditions requiring complex operations, however, for common conditions this relationship is less clear. This study investigated the relationship between hospital volume and surgical outcomes for infants affected by hypertrophic pyloric stenosis. 

Methods:  Kid’s Inpatient Database (KID) was used to identify patients with congenital hypertrophic pyloric stenosis who underwent pyloromyotomy for years 2003, 2006, 2009, and 2012. Surgical outcomes were measured by length of stay (LOS), complication rates, mortality, and cost. Hospitals were stratified based on case volume. Low-volume hospitals had the lowest quartile of patients treated per year, medium-volume hospitals had the middle two quartiles, and high-volume hospitals had the highest quartile of patients. 

Results: A total of 2,234 hospitals treated 51,792 patients with pyloric stenosis. The majority of hospitals were low-volume (n=1,834), while only 51 were high-volume. The overall mortality rate was 0.1% and the median length of stay was 2 days. Females were associated with higher complication rates. Results of multivariate analysis are summarized in table. High-volume hospitals were associated with lower complication rate and increased cost compared to medium- or low-volume hospitals. There were no differences in mortality or LOS. 

Conclusion: Using national data, we found that patients with hypertrophic pyloric stenosis treated at high-volume hospitals have improved outcomes despite higher costs. This indicates a benefit to receiving treatment for pyloric stenosis at a high-volume hospital. 

 

13.04 Pediatric Trauma Outcomes in the Obese.

Posted on January 18, 2018

R. Duran1, R. Barry1, M. Modarresi1, E. Thimpson1, J. Sanabria1  1Marshall University Schoool Of Medicine,Department Of Surgery,Huntington, WV, USA

Introduction:
 

Obesity affects one in four adults in the West, and this epidemic has extended to the young patient. The aim of this study is to assess the effects of obesity in the pediatric population affected by blunt trauma at a Global, Country, State and local medical center level. 

Methods:

The incidence, prevalence and mortality rates of blunt trauma by age, sex, cause, BMI, year, and geography were found using datasets from i) the Global Burden of Disease (GBD) group, where the epidemiological data obtained were modelled in DisMod-MR 2.1, a Bayesian meta-regression tool which pools data-points from different sources and adjusts for known sources of variability and iii) the local level II trauma registry at where data was modelled by JMP methods. GBD data was extracted from 284 country-year and 976 subnational-year combinations from 27 countries in North America, Latin America, Europe, and New Zealand from 1990 to 2015. Outpatient encounter data was also available from the USA, Norway, Sweden, and Canada for 48 country-years. There were 1026 pediatric patients admitted to the local trauma service who were evaluated (2014 to 2016). 

Results:

The Global, USA and State (WV) mortality on pediatric patients from transport related injuries has decreased (from 55, 64 and 49% to 46, 58 and 41%, respectively) as well as from falls (from 43, 55 and 41% to 30, 52 and 25 %, respectively) from 1990 to 2015.  The local cohort of pediatric patients included 880 non-obese (85.8%) and 146 obese (14.2%) patients. There was no significant difference in mortality rate, length of stay, ventilator support days, Glasgow Coma Scale score, presence of comorbidities or injury Severity score. The obese cohort, however, had a significantly longer ICU LOS. The average ICU LOS in our non-obese population was 2.46 vs 4.97 days in the obese group (p<0.05).

Conclusion: In the pediatric population, obesity is not a risk factor for fatality but for an increased ICU length of stay. Protocols engaging patients and parents aimed to pediatric weight control are being implemented.

 

13.03 The Role of LFTs in the Evaluation of Blunt Trauma in Pediatric Trauma Patients: Are They Necessary?

Posted on January 18, 2018

S. F. Rosati1, B. A. Borg1, P. Kato1, A. Husseini1, L. Donoghue1, C. Shanti1  1Children’s Hospital Of Michigan,Pediatric Surgery,Detroit, MI, USA

Introduction:  Injury is the leading cause of morbidity and mortality in children over one year; over 90% are the result of blunt trauma. Diagnostic aids to detect intra-abdominal injuries (IAIs) of the liver and spleen include abdomen/pelvis CT scans (AP CT) and liver function tests (LFTs). Historically, elevated LFTs have been used as a marker for when to obtain AP CTs. Our objectives were to evaluate the number of clinically significant injuries (defined as Grade IV or V) found using AP CT, and if there was a correlation to elevated LFTs.

Methods:  This is a retrospective review of pediatric patients (<18 years) evaluated at our Pediatric Level I trauma center from 1/1/15-12/31/16, who suffered blunt trauma. Variables included age, gender, injury severity score (ISS), LFTs, AP CTs and IAI with grades. 

Results: 1138 children were evaluated: 63% male, 37% female, with ages from 6 wks – 18 yrs (mean 5.25 yrs) and ISS from 0-45 (mean 5.4).  38% of patients (pts) had LFTs, 5% had an AP CT, 37% had IAI (1.8% overall). In the 62% of pts without LFTs, there were 16 AP CTs, 4 IAI, 0 significant; in pts with LFTs 0-100 (33%), there were 27 AP CTs, 7 IAI, 1 significant; in pts with LFTs 101-200 (2.8%), there were 7 AP CTs, 1 IAI, not significant; in pts with LFTs 201-300 (0.8%), there were 6 AP CTs, 5 IAI, 0 significant; in pts with LFTs 301-400 (0.4%), there were 2 AP CTs, 1 IAI, significant; in pts with LFTs 401-500 (0.01%), there was 1 AP CT, 1 IAI, not significant; in pts with LFTs > 500 (0.7%), there were 8 AP CTs, 2 IAI, 0 significant. 

Conclusion: In this limited review, a fraction of pts required an AP CT. While 33% of them were found to have IAI on CT, only 1% was clinically significant. Elevated LFTs do not correlate with the severity of IAI. LFTs alone may be a poor screening lab to determine need for an AP CT. We propose developing a different screening approach to our pts besides LFTs to determine need for AP CT.

 

13.02 The Management of Blunt Traumatic Retroperitoneal Hematomas in Children.

Posted on January 18, 2018

P. Dasari1, G. P. Wools2, L. S. Burkhalter2, F. G. Qureshi1,2  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA

Introduction:
Management of blunt traumatic Retroperitoneal Hematomas (RPH) in adults is dependent on anatomical classification.  Zone 1 is central, contains the aorta, inferior vena cava, renal vessel origins, partial duodenum/pancreas and requires mandatory exploration. Zone 2 includes the paranephric areas, renal vessels, kidneys, ureters, adrenals/colon and is explored for expanding hematoma.  Zone 3 includes iliac vessels, distal ureters, sigmoid/ rectum and may need surgical or radiologic interventional. This strategy has been used in children but has not been studied.  The aim of this study is to evaluate the management and outcome of children with retroperitoneal hematomas after blunt trauma. 

Methods:
With IRB approval, 10 year (2007-2016) retrospective review of all children with RPH from blunt trauma was performed.  RPH zone was determined by imaging and/or operative findings. Mechanism of injury, laparotomy, RPH explorations, and outcomes were collected.  Descriptive statistics provided mean, standard deviation, median and range. Comparative statistics identified univariate correlations using Fischer’s exact test. 

Results:
We identified 32 patients (84% male, mean age 10±4) with 43 RPH injuries, 14 zone 1, 25 zone 2 and 4 zone 3 injuries (table 1). Mechanisms included motor vehicle collision (75%), struck by object (19%), and pedestrian struck (6%). Nine (28%) patients were unstable on arrival and two expired in the emergency room. Laparotomy was performed in 17 patients, 10 immediately for instability, shock or peritonitis. 13 (30%) RPH zone injuries were explored; two zone 1, nine zone 2 and two zone 3. Four zone explorations required intervention: none in zone 1, four zone 2 (three nephrectomies, one packing) and none in zone 3.  RPH exploration had no post-operative surgical complications. Overall mortality was five (16%): two zone 1 before laparotomy (traumatic brain injury, TBI); two zone 1 after laparotomy (TBI and uncontrolled liver hemorrhage); and one zone 2 after laparotomy from chest injury.  Mortality was higher in unstable patients (p=0.0006). No mortality occurred from RPH exsanguination and RPH exploration did not impact mortality.

Conclusion:
Only a third of pediatric RPH injuries were explored which identified injuries requiring intervention in zone 2 but not zone 1 or 3.  RPH injury in children may require a different treatment paradigm compared to adults. Zone 1 injuries in an otherwise stable pediatric patient without peritonitis may benefit from non-operative management. Further larger scale studies will be required to understand the role of surgical intervention in RPH injury in children.
 

13.01 Underutilization of the Organ Injury Scaling System in a Pediatric Trauma Center

Posted on January 18, 2018

K. B. Savoie1, N. Jain2, R. F. Williams1  1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA

Introduction:
The value of the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS) system has been beneficial in managing solid organ injuries in adults. However, OIS may not correlate with pediatric solid organ injuries and thus may be inconsistently used at pediatric institutions. We hypothesized that radiologists inconsistently assign OIS grades for pediatric blunt solid organ injuries.

Methods:
All patients with blunt liver, spleen, and kidney organ injuries from a January 2009 to December 2014 at an urban tertiary pediatric hospital were identified from an institutional trauma database. Demographic information, imaging, radiologic grade of injury, and surgical grade of injury were collected.  Spearman’s correlation and weighted Kappa was used to evaluate radiologist and surgeon’s grading agreement of the injuries. 

Results:
A total of 352 patients were identified; OIS grading was assigned to 73% of patients; 37% had grading by a radiologist and 66% by a surgeon. Liver: 128/179 injuries were graded. 56 patients had grading by both radiologists and surgeons with a Spearman correlation of 0.70 and a weighted kappa of 0.59 (figure). OIS was associated with overall need for intervention (p <0.01) and specifically for need for transfusion (p <0.01) and operative intervention (p = 0.02); it was not associated with need for angiography. Spleen: 97/126 injuries were graded. 41 patients had grading by both radiologist and surgeons with a Spearman correlation of 0.93 and a weighted kappa of 0.86. Kidney: 30/47 injuries were graded. 9 patients had grading by both radiologist and surgeons with a Spearman correlation of 0.82 and a weighted kappa of 0.67. For spleen and renal injuries there was no correlation between OIS grade and need for overall intervention (spleen p=0.12, renal p=0.23) or specific types of intervention. There was no correlation between grade and complications for any type of injury.

Conclusion:
Pediatric surgeons utilized OIS more frequently than pediatric radiologists; there was higher correlation for spleen and renal injuries. Although OIS was associated with need for intervention in liver injuries, it was not associated with interventions for spleen and renal or for complications for any type of injury. Efforts to increase utilization or the development of a pediatric specific grading system may help standardize care for pediatric trauma patients.
 

12.19 Outcomes of Intercostal Nerve Cryoablation with the Nuss Procedure compared to a Thoracic Epidural

Posted on January 18, 2018

C. Harbaugh1, K. N. Johnson1, M. D. Jarboe1, R. B. Hirschl1, J. D. Geiger1, S. K. Gadepalli1  1University Of Michigan,C.S. Mott Children’s Hospital, Section Of Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Video-assisted intercostal nerve cryoablation (INC) during minimally invasive repair of pectus excavatum (Nuss procedure) in adolescents may decrease postoperative pain, opioid use, and length of stay. We sought to evaluate intraoperative and postoperative outcomes in comparison to thoracic epidural (TE) at our center.

Methods: We retrospectively reviewed the hospital course of adolescent patients who underwent Nuss procedure with INC (n=19) or TE (n=13) from January 1, 2015 – August 15, 2017. We compared both groups with respect to patient demographics, postoperative complications, opioid (including oral and intravenous opioids, excluding intrathecal), and non-opioid pain medications (nonsteroidal anti-inflammatories, acetaminophen, and muscle relaxants). The primary outcome was length of stay and secondary outcomes were opioid use and complication rate. All opioid doses were converted to oral morphine equivalents (OME) in milligrams. Mann-Whitney U was used to compare medians, and chi-squared for postoperative complications.

Results: The mean age was 16.7 ± 2.0 years old and 86% of the patients were male. Haller Index was significantly higher in INC compared to TE (4.3±1.3 vs. 3.4±0.9, p=0.03), with no other significant differences in demographics. Length of stay was significantly shorter for INC as compared to TE (median (IQR): 4 (3-4) days vs 6 (4-6) days; p<0.001). Intraoperative opioids (75(48–87) OME vs 30(15–30) OME; p=0.003) and immediate postoperative intravenous opioids (77.4 (63.2–171.1) OME vs 0 (0–36) OME; p<0.001) were significantly higher in INC as compared to TE; however, opioid use at discharge were decreased (200 (200 – 266.7) OME; 266.7 (266.7–400) OME; p=0.024). There was no difference in postoperative complications (21.1% vs. 38.5%, p=0.28).

Conclusion: INC during Nuss procedure reduced length of stay and discharge opioid pain medications, but increased intraoperative and postoperative IV opioid requirements. This opioid trend may reflect the need for improved pain control until INC takes effect, when long-term pain control improves. Prospective evaluation of INC including neuropathy and costs will be necessary prior to recommending routine use with all Nuss procedures.

12.20 Hemorrhage After On-ECMO Repair of CDH is Equivalent for Muscle Flap and Prosthetic Patch

Posted on January 18, 2018

H. Nolan1, E. Aydin1, J. Frischer1, J. L. Peiro1, B. Rymeski1, F. Lim1  1Cincinnati Children’s Hospital Medical Center,Cincinnati, OH, USA

Introduction: The defect in severe congenital diaphragmatic hernia (CDH) often requires a prosthetic patch (patch) or muscle flap (flap) repair. The patch is easy to use but is synthetic, while the flap’s autologous tissue dissection has potential for increased bleeding. Hemorrhage can be further exaggerated when maintained on therapeutic anticoagulation for extracorporeal membrane oxygenation (ECMO), especially if clinical status demands on-ECMO repair. The purpose of this study was to assess bleeding complications for on-ECMO patch compared to flap repair of CDH.

Methods: We retrospectively reviewed on-ECMO CDH repairs from 2010-2016 at a single academic children’s hospital (IRB2017-2322). Exclusions included incomplete records or concomitant procedures that could result in additional blood loss. Patients were grouped by repair type and bleeding complications were captured with intra-operative blood loss, 48-hour re-operation rates for bleeding, and 48-hour post-operative blood product use.

Results: Twenty-nine patients met criteria for analysis. Thirteen (44.8%) had patch repair and 16 (55.2%) had flap repair. Eight (62.5%) of the patch and 13 (81.2%) of the flap group were left-sided defects (p=0.223). All had Type C or D defects with comparable distribution (Type C: patch 56%, flap 54%, p=0.596). There was no difference in mean gestational age at delivery (patch 37.5±0.9 weeks, flap 37.2±1.3 weeks, p=0.390) or mean age at time of repair (patch 7.46±6.6 days, flap 6.00±4.3 days, p=0.476). Both had similar total ECMO duration (patch 361.4±167.1 hours, flap 277.1±149.4 hours, p=0.170) and time from repair to decannulation (patch 7.77±6.0 days, flap 7.00±6.0 days, p=0.734). Only one patient in each group was decannulated within 48 hours of repair for bleeding. Seven patch patients (53.8%) and 9 flap patients (56.2%) survived to discharge (p=0.596).

 

Estimated intra-operative blood loss was equivalent (patch 35.3±53.9 mL, flap 24.2±18.4 mL, p=0.443). One patient (7.6%) in the patch group and two patients (12.5%) in the flap group required re-operation for bleeding (p=0.580). Transfusion requirements in the re-operative group were no different for the patch compared to the flap repair (282.0 mL/kg vs 208.5±21.9 mL/kg, p=0.054). Transfusion requirements for those who did not require a reoperation were also similar (patch 120.7±111.7 mL/kg, flap 118.4±89.9 mL/kg, p=0.561).

Conclusions: Our study demonstrates the feasibility of CDH repair while on ECMO for both flap and patch techniques. Bleeding risks were no different between the two groups with regard to estimated blood loss, reoperation rates, and post-operative transfusions.

12.18 Same Day Discharge vs Observation For Uncomplicated Laparoscopic Appendectomy: A Prospective Cohort

Posted on January 18, 2018

K. Gee1, S. Ngo1, A. Beres1  1University Of Texas Southwestern Medical Center,Department Of Surgery, Division Of Pediatric Surgery,Dallas, TX, USA

Introduction:  Appendicitis remains the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain and hospital stay after laparoscopic procedures have been significantly reduced. Through 2015 our institution routinely admitted uncomplicated appendicitis patients for overnight observation after laparoscopic appendectomy. Given the increasing body of evidence suggesting the safety and feasibility of same day discharge after uncomplicated appendectomies we elected to perform a prospective study evaluating the complication rates of same day discharge appendectomies compared to overnight observation.

Methods:  After IRB approval, all pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were observed. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times and outcomes of complications, readmissions, return to the ED and non-scheduled clinic visits were collected and analyzing using chi-square and multivariate regression.

Results: A total of 1321 appendectomies were performed during the study period; 849 were uncomplicated, of which 382 were discharged same day and 467 were admitted for overnight observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs observation (2 vs 6 patients, p=0.21) or in emergency department visits (22 vs 27 patients, p=0.98). There was also no difference between the number of surgical site infections or the number of patients who required an extra clinic visit. On multivariate logistic regression, controlling for age, gender and discharge from PACU vs floor, there was a significant difference only for calls related to pain favoring those who went home same day (OR=0.88, p value 0.008).

Conclusion: Same day discharge for laparoscopic non-complicated appendectomy is a safe and feasible alternative to post-operative admission and observation. In our prospective study of 849 patients there were no differences in outcomes between the two groups. This has the potential to yield significant healthcare cost savings.

12.16 Utility of Liver Biopsy in the Evaluation of TPN Cholestasis

Posted on January 18, 2018

C. Buonpane1,2, G. Ares1, G. Englert3, I. Helenowski3, F. Hebal1, C. Hunter1,3  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Geisinger Medical Center,General Surgery,Danville, PA, USA 3Northwestern University,Chicago, IL, USA

Introduction:
Cholestasis is a common and serious complication of total parenteral nutrition (TPN) in neonates, however the pathogenesis is poorly understood.  Approximately 50% of infants requiring long-term TPN develop hepatic dysfunction.  The diagnosis is made when there is development of cholestasis and an absence of other causes such as biliary obstruction, viral hepatitis, drug toxicity, and other metabolic disorders.  Liver biopsies may be requested to assess the severity of cholestasis and fibrosis; however, the impact on treatment strategies and patient outcomes has not been defined.  We hypothesize that liver biopsies in the evaluation of TPN cholestasis do not lead to changes in management or improved patient outcomes.

Methods:
This study is a single institution retrospective review of infants diagnosed with TPN cholestasis from January 2008 to January 2016.  Primary outcomes were length of stay (LOS), 30-day readmission, complication after biopsy, change in management after biopsy (Omegavan and Ursodiol) and mortality.  Univariate analysis was performed using Fisher’s exact test.

Results:

Ninety-five patients with TPN cholestasis were identified, of which 27 (28%) underwent a liver biopsy.  Nineteen (73%) patients had concurrent abdominal surgery for other indications at the time of liver biopsy. Sixty percent of patients with TPN cholestasis had short bowel syndrome and 78% of patients that had a liver biopsy had short bowel syndrome (P=0.036).  There was a significant difference in race (P=0.047) between neonates that had liver biopsies versus those that did not.  Forty eight percent of patients who underwent liver biopsy were African American.

Liver biopsy was associated with a significant change in medical management, including the initiation of Omegavan or Ursodiol.  Eleven (41%) patients were started on medical therapy as a result of liver biopsy, thirteen (48%) patients were on medical therapy prior to biopsy and three patients (11%) were unchanged. 

Patient total bilirubin levels normalized within 6 months of stopping TPN in 92% of cases, with or without liver biopsy.  There was no difference in LOS or mortality in patients with liver biopsy versus without; however, patients with liver biopsy had a higher rate of 30-day re-admission (40% vs 19%, P=0.04).  Five (19%) patients had complications after liver biopsy including bleeding requiring transfusion, need for additional procedures and apnea after anesthesia.

Conclusion:
Liver biopsy in patients with TPN cholestasis was associated with an increase in utilization of medical therapy but did not result in improved patient outcomes.   

12.17 A Pediatric Surgical Team Improves Surgeon Volume and Exposure to Index Pediatric Surgery Cases

Posted on January 18, 2018

W. G. Lee1, D. P. Puapong1,2, R. K. Woo1,2, S. M. Johnson1,2  1University Of Hawaii,John A. Burns School Of Medicine,Honolulu, HI, USA 2Kapi’olani Medical Center For Children,Honolulu, HI, USA

Introduction: High surgical volume for both surgeons and hospital systems has been linked with improved outcomes for complex pediatric surgical problems, yet the current number of accredited pediatric surgeons (PS) necessarily means case volumes per surgeon are diminishing nationally in complex pediatric surgery. Referral of complex patients to centralized high volume referral centers is one solution, but has high costs to families, hospital systems, and insurers especially in areas of geographic isolation. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve surgeon volume as well as team/system experience.

Methods: As a surgical group we incorporated a surgical team approach to complex pediatric surgical cases six years ago. We obtained IRB approval to review our PS index case volume experience to date. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases.

Results: A surgical team approach (2/3 BC surgeons working as co-surgeons or assistant) was used in the majority of cases for TEF/EA (77%), CPAM (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung’s disease (51.9%), CDH (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoplastoma surgery) (85-100%). Surgeon case exposure for all surgeons/all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations. Over the 5-year period, all surgeons were exposed to a high volume of studied index pediatric surgery cases when contrasted to published experience.

Conclusion: A surgical team approach to complex pediatric surgery exposes pediatric surgeons to higher complex case volumes and varieties. This model has implications for geographically isolated and smaller hospitals that specialize in pediatric surgical care and impacts resource allocation, systems development, and workforce allocation in pediatric surgery.

 

12.14 Predicting Outcomes in Necrotizing Enterocolitis: What is the Role of Surgery?

Posted on January 18, 2018

C. Chabuz1, S. D. Larson1, J. A. Taylor1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Objective: Necrotizing enterocolitis (NEC) is the most common condition in neonates that requires surgery. While the mortality in NEC is very high, it is unclear which factors are most responsible for poor outcomes. The purpose of this study was to understand the factors influencing mortality in a large cohort of neonates with NEC.  

Methods: Neonates diagnosed with NEC over an 8-year period (2008-2016) at UF Health were selected using ICD 9 and 10 codes. All patients’ charts were reviewed and only those with a definitive diagnosis of NEC that was in the initial NICU stay were included. Data regarding demographics, maternal and gestational history, presentation, lab and radiologic studies, interventions required, surgical management, and outcomes were collected and compiled. The primary outcome variable was mortality, with secondary outcomes of NICU LOS and neurodevelopmental status in survivors. The cohort was divided into those requiring surgical management (drain or laparotomy) vs. those treated medically. Uni- and Multi-variate analysis was carried out and p values of less than 0.05 were considered significant. 

Results:

A total of 245 cases of NEC were identified during the study period. Overall, the mean gestational age was 28.6 weeks, average birth weight was 1.21 kg, and mortality rate 16.3%. There were 75 patients who required surgical management, while 170 were treated medically. There was no difference between these two groups for race, gender, APGAR score, hematocrit, or length of stay (see table please). Surgical patients were significantly smaller and lower gestational age, had a lower platelet count and presented more often with distention. Univariate analysis noted a significant 5-fold higher mortality rate. Linear, multivariate regression analysis with mortality as the outcome variable noted that surgical management was not a significant predictor, while gestational age, APGAR score, weight at diagnosis of NEC, vasopressor requirement, and intubation were responsible for mortality.

Conclusions: The higher mortality rate in neonates with NEC that require surgery is in part due to the lower gestational age, lower APGAR, higher need for ventilator support at birth, and requirement for vasoactive drugs for circulatory support. Patients presenting with abdominal distention rather than hematochezia are at higher risk for requiring surgery. These data will be used to help predict outcome, plan therapy, and advise parents.

 

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