15.05 Circumferential and Complete Wound VAC Application to the Grafted Hand Does Not Compromise Dermal Perfusion

Posted on January 31, 2019

C. N. Thompson2,3, R. Smith4, B. Carney4,5,7, K. Monger4, L. Moffatt2,4,5,8, J. W. Shupp2,4,5,6, L. S. Johnson2,4,6  4Firefighters’ Burn and Surgical Research Laboratory,MedStar Health Research Institute,Washington, DC, USA 5Georgetown University School of Medicine,Department Of Biochemisty,Washington, DC, USA 6Georgetown University School of Medicine,Department Of Surgery,Washington, DC, USA 7Georgetown University School of Medicine,Biochemistry, Graduate Student,Washington, DC, USA 8Georgetown University School of Medicine,Biochemistry, Faculty Appointment,Washington, DC, USA 2MedStar Washington Hospital Center,The Burn Center,Washington, DC, USA 3Georgetown University Medical Center,General Surgery,Washington, DC, USA

Introduction: Negative pressure wound therapy (NPWT) is used to accelerate healing of various wounds.  Studies have demonstrated that NPWT optimizes blood flow, decreases local tissue edema, and removes excess fluid from the wound bed. Use of circumferential NPWT on distal extremities is controversial; while isolated case reports suggest positive outcomes, macrodeformation of the tissue in the wound bed has been shown to increase extracellular pressure.  This data has been extrapolated to suggest a risk for decreased blood flow in the setting of circumferential placement. In the present experiment, the impact of circumferential NPWT on perfusion was examined in hands. 

Methods: Part 1: Healthy volunteers (n=16)  had NPWT sponge placed circumferentially around a hand and secured into position in the standard fashion. Windows for imaging the tissue during the therapy application were created over the thenar eminence (palmar area) and over the central dorsal hand (dorsal area) and 125mmHg suction was applied for 15min.  Laser doppler imaging (LDI) was utilized to measure the perfusion of the hands before (baseline), during, and after NPWT. Regions of interest were selected for analysis in each area and averaged to obtain mean perfusion units.  Data were analyzed using a one-way ANOVA to determine the significance of the differences in perfusion between pre-and post-application of NPWT and between regions of the hand imaged. Part 2: A retrospective case review was performed on patients who underwent split thickness skin grafting and NPWT to identify graft loss, need for repeat operation, and pain associated with therapy. 

Results: 

Part 1:There was no difference in perfusion during and after NPWT placement compared to baseline in the palmar position (Figure 1, p=.86). A statistically significant increase in perfusion at the end of NPWT compared to baseline was identified in the dorsal position (p=0.01). 

Part 2:Over a twelve-month time period, 63 patients underwent burn eschar excision, split thickness skin grafting and the placement of circumferential NPWT. Only 1 patient required a repeat operation for graft loss; two additional patients had documented graft loss requiring local wound therapy. No patients deviated from protocolized unit pain algorithms for reasons related to their NPWT. 

Conclusion: The use of circumferential NPWT on the hand does not decrease cutaneous blood flow during the therapy period. Split thickness skin grafts stabilized with NPWD rarely need second operations for graft failure and are tolerated by patients for the 72-hour period of treatment. Maintenance of blood flow coupled with other therapeutic properties of NPWT may explain upper extremity skin grafting results after use of NPWT for stabilization.  

15.04 Prepectoral Breast Reconstruction Lowers Capsular Contracture Rates after Post-mastectomy Radiation

Posted on January 31, 2019

R. E. Weitzman1, N. Sobti1, K. P. Nealon1, A. S. Colwell1, W. G. Austen1, E. C. Liao1  1Massachusetts General Hospital,Division Of Plastic And Reconstructive Surgery,Boston, MA, USA

Introduction:  Breast cancer is one of the most common cancers to affect women, and implant-based breast reconstruction accounts for more than 80% of reconstruction cases, with over 100,000 procedures performed in the US per year. One of the most common problems after implant-based breast reconstruction occurs after post-mastectomy radiation therapy (PMRT).  Breast implants are usually placed in the subpectoral plane, but we and others have innovated muscle-sparing prepectoral implant placement. This study tests the hypothesize that prepectoral breast reconstruction is associated with lower incidence of capsular contracture when compared to subpectoral placement in an irradiated patient population.

Methods:  Retrospective chart review was conducted to identify consecutive procedures performed at a tertiary academic medical institution over 4 years. Patients who had either pre-operative or post-operative radiation therapy were included. Univariate and penalized logistic regression analyses were conducted to compare clinical endpoints across the implant positioning groups.

Results: Rate of capsular contracture was significantly greater in the subpectoral group compared to the prepectoral group [n = 14 (9.5%) v. n = 0 (0.0%), respectively, p = 0.04]. Penalized logistic regression revealed that subpectoral implant placement was nearly 3 times as likely to result in capsular contracture when compared to prepectoral breast reconstruction within an irradiated population, although the result did not achieve statistical significance. Rates of revision, explantation, infection, tissue necrosis, and hematoma were comparable between groups.

Conclusion: This study compares capsular contracture rates between prepectoral and subpectoral breast reconstruction groups in an irradiated patient population. The results suggest that prepectoral implant breast reconstruction is associated with lower rate of capsular contracture after breast irradiation when compared to subpectoral reconstruction. This data supports the hypothesis that implant coverage by skeletal muscle tissue in subpectoral breast reconstruction could predispose the breast to prosthesis deformity and contracture after radiation as the muscle undergoes fibrosis. Prepectoral breast reconstruction technique excludes the pectoralis muscle from the reconstruction soft tissue, mitigating post-radiation deformity and reducing capsular contracture.

 

15.03 Ankylosis of the Temporomandibular Joint in Pediatric Patients: A Meta-Analysis of 227 Joints

Posted on January 31, 2019

C. Rozanski1, K. Wood1, P. Sanati1, H. Xu1, P. J. Taub2  1Icahn School of Medicine at Mount Sinai,New York, NY, USA 2Kravis Children’s Hospital at Mount Sinai,Division Of Pediatric Plastic Surgery,New York, NY, USA

Introduction:
Temporomandibular joint (TMJ) ankylosis involves the fusion of the mandibular condyle to the skull base. Surgical interventions include: gap arthroplasty, interpositional arthroplasty, and joint reconstruction. Managing TMJ ankylosis in the pediatric population presents particular challenges due to the need to anticipate unpredictable mandibular growth and high rate of recurrence. While surgical management of TMJ ankylosis is well documented in the literature, there is a lack of consensus regarding which approach is best, especially in pediatrics. 

Methods:
A systematic review of PubMed (Jan 1, 1990-Jan 1, 2017) and Scopus (Jan 1, 1990-Jan 1, 2017) was performed by searching an appropriate combination of key words and MeSH terms including “temporomandibular joint ankylosis” and “TMJ ankylosis” with “pediatric” or “pediatrics”. Case reports and case series in the English language including at least one patient under the age of 18 that had a diagnosis of TMJ ankylosis who underwent surgical correction were included for review. Only pediatric cases were included. Main outcomes included preoperative maximum interincisal opening (MIO), postoperative MIO, change in MIO, and complications.

Results:
24 case series and case reports were identified that met inclusion criteria. From these studies, 176 patients and 227 joints were included. There was a significant difference in ΔMIO between intervention groups as determined by one-way ANOVA (p<0.001). Independent sample t-tests comparing MIO variables for each of the intervention groups were performed. MIOpostop (mm) was greater for gap arthroplasty (30.18) compared to reconstruction (27.47) (t=4.9, p=0.043), interpositional arthroplasty (32.87) compared to reconstruction (t=3.25, p=0.002), but not for gap arthroplasty compared to interpositional arthroplasty (t=-1.9, p=0.054). ΔMIO (mm) was not significantly different for gap arthroplasty (28.67) compared to reconstruction (22.24) (t=4.2, p=0.001) or interpositional arthroplasty (28.33) compared to gap arthroplasty (t=0.29, p=0.33). There was no significant difference in incidence of re-ankylosis between treatment modalities.

Conclusion:
Previous studies in adult patients with TMJ ankylosis have suggested interpositional arthroplasty to be superior to gap arthroplasty; however, this distinction has not been explored in pediatrics. The present study found no significant difference in ΔMIO, postoperative MIO, or recurrence of ankylosis between gap arthroplasty and interpositional arthroplasty. Given these nonsignificant differences and the relative technical ease and shorter operation time of gap arthroplasty compared to interpositional arthroplasty, the authors suggest serious consideration of gap arthroplasty for primary ankylosis repair in pediatric patients. 

15.02 Virtual Reality Improves Patient Experience during Wide Awake Local Anesthesia No Tourniquet Surgery

Posted on January 31, 2019

I. J. Behr1, E. Hoxhallari1, J. Clarkson1  1Michigan State University,Surgery,Lansing, MI, USA

Introduction: While technology has the power to change medical practice, it can sometimes take decades for advances to become adopted. At Michigan State University (MSU) we offer Wide Awake Local Anesthetic Surgery No Tourniquet (WALANT) to our hand surgery patients using virtual reality (VR) technology during procedures. We hypothesized the patient experience might be improved by the introduction of VR.

Methods: All patients undergoing routine WALANT hand surgeries in an office procedure room at MSU Department of Surgery were invited to participate. Data collection took place over a 6-month period.

Unlabelled Envelopes containing either VR or Non-VR were given to patients so that single blinded randomization was achieved; Those who received VR during injection and surgery (VR) and those who did not (Non-VR).  A Galaxy S7 phone and a Samsung Gear VR headset with headphones was used.

Phase 1: Tumescent local anesthesia
All patients received an injection of local anesthetic. For the VR patients, this was performed while watching a specifically selected video in which the injection was timed to coincide with a moment of catharsis in the VR experience. 

Phase 2: Surgical procedure
During the procedure, VR patients were provided with freely available 360 YouTube materials.

Prospective data collection:
Data was collected prospectively at multiple time points during the injection and procedure phases.  In addition, there was a postoperative questionnaire completed by all patients.

Prospective physical observations, including pulse and blood pressure, were recorded. Anxiety, fun, and pain were assessed with a Likert type scale rating each 0-10 points. Follow up questions were administered after the procedure to the VR group. All patients were asked to rate how much they enjoyed their surgical experience on a 10-point Likert type scale.

Results:

There were no significant differences between the VR and Non-VR group for either heart rate or blood pressure (p= 0.0072).

Analysis revealed a highly significant difference between the anxiety scores of VR versus Non-VR patients, with anxiety reduced for the VR group (p=0.0003).

Using a 10-point Likert type scale all patients were asked how much they enjoyed their experience with the VR group reporting significantly higher enjoyment (P= 0.0001).

Conclusion:This study demonstrates readily available VR hardware and software can be utilized to provide a passive and immersive experience that reduces patient anxiety during both the injection phase of tumescent local anesthetic and during the surgical procedure. Patients that utilized VR also reported higher levels of joy during the injection and procedure than those who did not. A post procedural questionnaire also revealed the VR group reported a significantly more enjoyable surgical experience than the Non-VR group. 

15.01 Surgical Approach as a Risk Factor for Trigger Digit Development Following Carpal Tunnel Release

Posted on January 31, 2019

J. Nosewicz1, C. Cavallin1, C. Cheng2, A. Zacharek3  1Central Michigan University College Of Medicine,Mount Pleasant, MI, USA 2Central Michigan University,Department Of Mathematics,Mt. Pleasant, MI, USA 3Covenant Healthcare,Saginaw, MI, USA

Introduction: Carpal tunnel release (CTR) is associated with trigger digit development. Surgical approach to CTR has been inconsistently reported as an independent risk factor for postoperative trigger digit. This study aims to identify whether endoscopic (ECTR) or open carpal tunnel release (OCTR) will increase the risk of postoperative trigger digit. Furthermore, shared comorbidities of trigger digit and CTS will be evaluated as potential risk factors for trigger digit development following CTR.

Methods:  967 CTR procedures were evaluated for the development of trigger digit. Multivariate regression analysis was conducted to evaluate independent patient risk factors for trigger digit development. Patients were then stratified into an ECTR group and an OCTR group. Two logit models were conducted to test the association between patient risk factors and postoperative trigger digit within each surgical group.

Results: A total of 47 hands developed trigger digit following 967 carpal tunnel release procedures (4.9%). Regression analysis revealed no independent risk factors for postoperative trigger digit development, including surgical approach. Both the OCTR and ECTR groups were similar in baseline characteristics. There was no significant difference between ECTR and OCTR groups to develop trigger digit following CTR. Furthermore, the majority of risk factors were found to not be associated with postoperative trigger digit when evaluated within the ECTR or OCTR groups. Females were significantly more likely than males to develop trigger digit following OCTR, but were significantly less likely to develop trigger digit following ECTR.

Conclusion: OCTR may predispose females to develop trigger digit following surgery while ECTR may predispose males. Further studies evaluating gender differences in structural changes of the postoperative carpal tunnel are needed to support our findings.

 

14.20 Evaluation of Growth Outcomes in Pediatric Cerebral Palsy Patients with Gastrostomy Tubes

Posted on January 31, 2019

J. Jadi1,2, N. Rodriguez-Ormaza3, R. Maine1, A. Charles1, E. Hoke1, T. Reid1  1University Of North Carolina At Chapel Hill,General And Acute Care Surgery,Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill,School Of Medicine,Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill,School Of Public Health,Chapel Hill, NC, USA

Introduction:  Malnutrition as a result of feeding difficulties is a common complication in children with cerebral palsy. There are currently few studies looking at interventions for malnutrition and which ones have the best growth outcomes for pediatric cerebral palsy patients. The goal of this study was to examine characteristics of cerebral palsy patients undergoing gastrostomy tube placement and assess the growth outcomes after 3 months, 6 months, and 1 year.

Methods:  This study was a retrospective study of all pediatric patients with cerebral palsy under the age of 18 who received a gastrostomy tube placement between April 2014-December 2017 at UNC Hospital.  Baseline information was collected, including age, sex, degree of malnutrition, comorbidities, change in weight and z scores over time, nasogastric (NG) tube placement, and prior gastrostomy tube placement. The primary outcome was weight gain at 3 months, 6 months, and 1 year. Secondary outcomes included mortality and complications. Bivariate analysis and a proportional odds model were used to examine the association between increase in weight (based on quantiles) and patient characteristics at 3 months, 6 months, and 1 year. 

Results: Out of the 63 patients who received a gastrostomy tube, 30 (47.6%) were female, with a mean age of 4.3 months +/- 4.9. Almost all patients (98.8%) had at least one comorbidity. At the time of placement, 11.8% of patients had mild malnutrition, 29.4% had moderate malnutrition, and 58.8% had severe malnutrition. A majority of 53 (94.6%) patients had their tube placed laparoscopically, while the rest were placed open. Greater increases in weight at all time intervals were significantly associated with younger age, adjunct NG tube, and longer length of hospital stay after adjusting for confounders. Patients weight changes tracked at 3 months, 6 months, and 1-year post gastrostomy placement showed an overall weight increase for 98% of patients. Forty-six percent of patients had at least one gastrostomy tube related complication, 23.8% had two complications, and 4.76% had 3 or more with the most common complications being minor tube functional issues (43.6%), such as clogging, leakage, or tube dislodgment. 

Conclusion: The use of gastrostomy tubes for malnutrition in cerebral palsy patients resulted in an increase in weight for the majority of patients over the course of a year. Although the majority of complications were minor, patients had a high complication rate.  Given the high complication rate and the significantly increased weight gain in younger patients who were hospitalized longer and who had NG tubes, further studies should be conducted to evaluate if certain patients might benefit from longer trials of NG tube nutrition.

14.19 Practice Patterns and Outcomes of Pediatric Thyroid Surgery: A NSQIP Analysis

Posted on January 31, 2019

A. F. Utria1, J. Liao1, M. Belding-Schmitt1, J. Shilyansky2, G. Lal1  1University Of Iowa,General Surgery,Iowa City, IA, USA 2University Of Iowa,Pediatric Surgery,Iowa City, IA, USA

Introduction:  

Pediatric thyroid cancer represents approximately 3% of all pediatric malignancies and incidence rates are rising.  The first American Thyroid Association guidelines for the management of pediatric thyroid nodules and cancer (2015) recommended that pediatric thyroid surgery be performed by high-volume surgeons (at least 30 cervical endocrine procedures annually).  However, other data demonstrate that low-volume surgeons working with multidisciplinary teams also have good outcomes. The aim of this study was to determine the state of current practice and outcomes for pediatric thyroidectomy.

Methods:

The National Surgical Quality Improvement Pediatric database (NSQIP-P) was used to identify all cases of pediatric thyroidectomies and neck dissections at participating hospitals from 2015 and 2016.  The CPT codes 60252, 60240, 60220, and 38724 were used to extract cases. Patient, disease and treatment-related factors affecting 30-day outcomes were analyzed using univariate and multivariate analysis. P-values < 0.05 were considered significant.

Results: 

There were 771 cases of pediatric thyroidectomy included in our study. The mean age at time of surgery was 13.2 (SD 4.4) years and the majority of patients were female (77%) and Caucasian (73%).  Pediatric general surgeons performed the largest proportion of cases (40%), followed by pediatric otolaryngologists (35%), adult general surgeons (19%), and adult otolaryngologists (7%). Malignant diagnoses were present in 30% of cases. The overall rate of complications was 2.9%, with the most frequent 30-day complication being readmission (1.4%). Median length of stay across all specialties was 1 day. On multivariate analysis, adult surgeons were less likely to operate on patients with ASA > 2 (OR: 0.55, 95%CI: 0.37-0.84).  In terms of procedures, modified radical neck dissections were more likely to be performed by adult surgeons (OR: 2.46, 95%CI: 1.28-4.72), whereas unilateral thyroidectomies were less likely to be performed by them (OR: 0.64, 95%CI: 0.21-0.98).  In addition, adult surgeons were associated with shorter operative times (OR: 0.64, 95%CI: 0.41-0.99). There was no significant difference between pediatric and adult surgeons in terms of patient age, diagnoses, and overall complication rate.

Conclusion: 

This multi-institutional study shows that Pediatric surgeons continue to perform the majority of thyroid surgeries in children. Our data, while lacking information on surgeon volume show that thyroid surgery is being safely performed at NSQIP- affiliated hospitals by both adult and pediatric surgeons.  Further studies are needed to determine if there are differences in specific procedure related-complications and long-term outcomes between pediatric and adult surgeons.

 

14.18 The effect of gross total resection and surgical margins on patients with pleuropulmonary blastoma

Posted on January 31, 2019

A. K. Zamora1, M. J. Zobel1, N. M. Shillingford2, S. Zhou2, E. S. Kim1,3  1Children’s Hospital Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 2Children’s Hospital Los Angeles,Pathology,Los Angeles, CA, USA 3University Of Southern California,Surgery,Los Angeles, CA, USA

Introduction:  Pleuropulmonary blastoma (PPB) is the most common primary lung cancer in children. While rare, these tumors are highly aggressive and often present as massive intrapleural tumors. Tumor recurrence and overall survival is dependent on extent of surgical resection, and neoadjuvant chemotherapy may help facilitate a complete resection. We sought to examine our institutional experience with PPB and determine the effect of incomplete versus complete tumor resection on patient outcomes and recurrence.

Methods:  After IRB approval, a retrospective chart review of all patients diagnosed with PPB was performed at Children’s Hospital Los Angeles from 1/1998 to 8/2018. Cases were identified by histologic confirmation and Dehner graded from I to III: grade I being purely cystic and the more advanced grade III purely solid. Data collection included age, gender, location of tumor, use of chemotherapy and radiation, extent of resection, recurrence and overall survival.

Results: Eight cases of PPB were identified in 7 patients (4 females: 3 males) that underwent surgical resection. The median age at diagnosis was 2.3 years (1 day to 4 years).  Neoadjuvant chemotherapy was utilized in 3 of 8 cases (38%) prior to attempted surgical resection, while 5 cases (62%) proceeded straight to surgery.  The operative goal was to achieve gross total resection (>95%), and to this end, 3 partial lobectomies/wedge resections, 4 lobectomies, and 1 pneumonectomy were performed. Histologically, 3 cases were Type I, 1 was Type II, and 4 were poor prognosis Type III PPB. The average length of follow up was 4.4 years with an overall survival of 71%.  Six of 8 cases (75%) underwent complete resection with negative gross and microscopic margins (R0).  One of these six (17%), who had Type III disease, recurred locally and eventually died, while all of the other patients survived. Two of the 8 cases had incomplete resections; one patient underwent re-excision on post-operative day 4 to achieve negative margins, and the other patient, who received neoadjuvant chemotherapy, had a positive hilar microscopic margin (R1) which was not amenable to further excision. This R1 resection patient, who had Type III disease, subsequently developed a brain metastasis, which was surgically removed.  Both patients are alive, and currently disease-free.  None of the patients experienced any other post-operative complications.

Conclusion: Our data shows that PPB patients who achieve gross total resection with or without neoadjuvant chemotherapy have good overall survival with minimal morbidity. Further large-scale studies are needed to determine the benefit of surgical resection margins on tumor recurrence and survival to guide future surgical protocols.

14.17 Not All Bilateral Congenital Diaphragmatic Hernias are the Same

Posted on January 31, 2019

H. Sriraman1, M. Verla1, C. Style1, A. Mehollin-Ray2, C. Fernandes3, A. Vogel1, T. Lee1, S. Keswani1, O. Oluyinka1  1Baylor College Of Medicine, Michael E. DeBakey Department of Surgery,Texas Children’s Fetal Center,Houston, TX, USA 2Texas Children’s Hospital – Fetal Center,Department Of Radiology,Houston, TX, USA 3Texas Children’s Hospital,Departments Of Pediatrics – Newborn Section,Houston, TX, USA

Introduction:  Bilateral congenital diaphragmatic hernia (CDH) is a rare variant of CDH with a mortality rate as high as 74%. However, we hypothesize that not all variants of bilateral CDH have a poor prognosis. The aim of our study was to evaluate our institution’s postnatal outcomes of neonates with bilateral congenital diaphragmatic hernia to determine which elements may portend a better prognosis.

Methods:  Following IRB approval, a single center, retrospective review of all patients with bilateral CDH evaluated from January 2004 to December 2017 was performed. Demographics, associated congenital abnormalities, type of CDH defect, operative repair and approach, ECMO use and survival were collected. Descriptive statistics were used to analyze the data.

Results: Over the 14-year study period, 282 patients with CDH were identified and 7 had a bilateral intrapleural defect. Six of the seven neonates with bilateral CDH were diagnosed prenatally. Four neonates had posterior-lateral defects, while the other three neonates had anterior CDH defects. Three neonates had at least one concomitant major congenital anomaly, but none had a genetic anomaly (Table 1). The median gestational age at birth was 38 weeks (IQR: 37, 39) and birthweight was 3020 grams (IQR: 2288, 3525). The median Apgar scores at 1 and 5 minutes were 6 (IQR: 3, 7) and 8 (IQR: 7, 8), respectively. None of the seven patients required ECMO and the overall cohort survival was 57% (Table 1). Median age at follow-up was 2 years (IQR: 0.4, 7). All the patients with anterior defects received a primary repair, while two of the four neonates with posterior-lateral defects had some form of patch repair.

Conclusion: Prognosis from bilateral intrapleural CDH may not be as grim as initially reported. Compared to posterior-lateral defects, patients with large bilateral anterior defects have a relatively benign course. This case series indicates good outcomes for patients with bilateral anterior CDH defects which suggests that not all patients with bilateral CDH will have a dismal outcome. Better prenatal determination of anterior versus posterior bilateral CDH may be helpful when counseling about clinical outcomes.

14.16 Twenty Year Experience Treating Pediatric Pelvic Fractures

Posted on January 31, 2019

P. M. Elias1, M. B. Mulder1, W. J. Yang1, S. Rodriguez1, D. Wietecha1, A. Cohen1, E. A. Perez1, J. E. Sola1, N. Namias1, K. G. Proctor1, C. M. Thorson1  1University Of Miami,Dewitt Daughtry Department of Surgery: Division Of Pediatric Surgery,Miami, FL, USA

Introduction:
 

Pediatric pelvic fractures are generally rare and most previous studies have been limited by sample size. As a result, risk factors for mortality are poorly defined. To address this issue, we present one of the largest reviews of pediatric pelvic fractures in the past decade.

 

Methods:
All patients age 0-17 admitted with pelvic fractures at a single level I trauma center from January 1, 1998 to December 31, 2017 were retrospectively reviewed. Univariate and multivariate analysis identified predictors of mortality.

Results:
 

There were 8,758 admissions and 163 pelvic fractures, for an overall incidence of 1.86%. Age was 12.9 ± 4.8y with 61% male (n=99), 44.2% African American (n=72), and 27.6% White Hispanic (n=45). Males more commonly sustained gunshot wounds (15.2% vs. 0%) and associated gastrointestinal injuries (17.2% vs. 4.7%) vs. females, both p < 0.01. Mortality was 11.8% (n=19) and was higher in males vs. females (16.5% vs. 4.7%, p=0.023); in fact, 84% of all deaths were in male patients. Those that died were more likely to have additional organs injured including the brain (28.9% vs. 6.5%), liver (22.6% vs. 9.2%) spleen (26.7% vs. 8.4%), major vascular (33.3% vs. 9.1%), chest (21.1% vs. 3.5%), heart (66.7% vs. 8.6%), and spine (23.8% vs. 7.6%), all p < 0.05. The majority of deaths were in males (84%) and those with brain injuries (58%), whereas there were no deaths in patients with isolated pelvic fractures (n=19). Other factors associated with mortality were requiring an operation for chest injuries (50% vs. 9.8%) or arriving in shock (44.5% vs. 7.7%), both p <0.05. On multivariate regression, male gender (OR 6.03 [1.23-29.6], p=0.027), brain injury (OR 6.18 [1.81-21.1], p=0.004), spine injury (OR 5.06 [1.41-18.1], p=0.01), and cardiac injury (OR 35.0 [4.29-286], p=0.001) were independently associated with mortality. 

Conclusion:

Pelvic fractures are rare in pediatric patients, even at a high-volume center. Male gender and additional injuries, especially brain, spine, and/or cardiac, are associated with an increased risk of death in these patients. On the other hand, isolated pelvic fractures have an extremely low mortality.

 

14.15 Clinical Management and Outcomes of Pelvic Neuroblastoma

Posted on January 31, 2019

M. J. Zobel1, A. K. Zamora1, L. Wang1,2, J. E. Stein1,2, A. Marachelian1,2, E. S. Kim1,2  1Children’s Hospital Los Angeles,Los Angeles, CA, USA 2Keck School of Medicine, University Of Southern California,Los Angeles, CA, USA

Introduction:

Pelvic neuroblastomas are rare and often present in children as massive tumors whose surgical resection following chemotherapy can be associated with significant morbidity given involvement of sacral nerve roots and close proximity to pelvic vascular structures. We sought to examine the characteristics of pelvic neuroblastoma at our institution and the effect of extent of surgical resection on survival and surgical outcomes.

Methods:

After IRB approval, a retrospective chart review of 554 neuroblastoma patients was performed at Children’s Hospital Los Angeles over an 18-year period (2000-2018). Collected data included tumor location, size, histology, stage and risk classification, MYCN oncogene amplification, use of pre-operative chemotherapy and/or radiation, and extent of surgical resection. Outcome variables included postoperative complications and survival.

Results:

Ten patients (7 females: 3 males) with primary pelvic neuroblastoma tumors were identified. The median age at diagnosis was 4.2 years (5 months to 11 years).  Five patients presented with a localized pelvic tumor; four with stage 1 and one with stage 2.  Five patients presented with advanced disease; two patients with stage 3 and three patients with metastatic stage 4 disease.  The mean post-operative follow-up was 3.9 years with overall survival of 90%.  One patient died from extensive metastatic disease for which no resection was attempted.  Of the remaining 9 patients, surgical resection was attempted. Five patients with localized tumors (stage 1 or 2) underwent gross total resection, with one complication of a small bowel obstruction seven years post-operatively. The other 4 patients with advanced disease (stage 3 or stage 4) received neoadjuvant chemotherapy, followed by partial resection (30-90% debulked).  Of these, one patient, whose tumor encased the left internal iliac vein, which resulted in ligation, subsequently experienced lower extremity hypotonia following a gross total resection attempt. 

Conclusion:

Our data shows that patients with pelvic neuroblastoma have an excellent overall survival following surgery.  Patients with localized pelvic neuroblastomas who undergo gross total resection and those with advanced disease who undergo neoadjuvant therapy followed by partial resection have good outcomes with minimal morbidity.  Based on these findings, we recommend that small localized pelvic neuroblastoma undergo gross total resection or even be observed, while large unresectable tumors undergo neoadjuvant chemotherapy followed by a partial debulking resection to avoid neurovascular morbidity.

14.14 Conversion from Venovenous to Venoarterial Cannulation is Associated with Increased ECMO Mortality

Posted on January 31, 2019

M. L. Kovler1, A. V. Garcia1, J. H. Salazar2, J. Weller1, J. Vacek3, B. T. Many3, Y. Rizeq3, F. Abdullah3, S. D. Goldstein3  1Johns Hopkins University School Of Medicine,Baltimore, MD, USA 2Children’s Hospital Of Wisconsin,Milwaukee, WI, USA 3Lurie Children’s Hospital,Chicago, IL, USA

Introduction:

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) does not provide circulatory augmentation, unlike venoarterial (VA) cannulation. There is an increasing national trend towards initial VV support for noncardiac disease; however, some proportion of children initiated on VV ECMO will ultimately require conversion to VA for persistent hemodynamic instability. The purpose of this work is to perform a descriptive analysis of patients who were converted from VV to VA ECMO.

Methods:

Data on neonates and children who underwent VV-VA ECMO conversion were extracted from the Extracorporeal Life Support Organization (ELSO) registry. Comparisons to VV and VA cannulations without conversion were made from contemporary ELSO International Summary reports.

Results:

This study cohort consisted of 1,382 ECMO patients, comprising 2.5% of pediatric registry entries. The hospital survival rate for neonates denoted as primary respiratory support requiring conversion was 62%, compared to 83% for unconverted VV ECMO and 71% for unconverted VA ECMO. Similarly, the survival of older children requiring conversion was 47% compared to 62% and 52%, respectively. 

Conclusion:

VV to VA conversion does occur and is associated with increased mortality. The need for conversion from VV to VA ECMO may represent an early failure to recognize physiologic parameters or disease severity that would be better managed with initial VA support. The delay in circulatory support could be a factor contributing to this cohort’s decreased survival compared to both VV and VA cannulations not requiring conversion. Further research is needed to determine predictors of VV failure so initial ECMO mode selection can be improved.

14.13 Predictors and Outcomes of Tracheostomy Patients with Congenital Diaphragmatic Hernia

Posted on January 31, 2019

C. C. Style1, M. A. Verla1, T. C. Lee1, S. C. Fallon1, H. Srirani1, C. J. Fernandes2, S. G. Keswani1, A. M. Vogel1, O. O. Olutoye1  1Baylor College Of Medicine, Texas Childrens Hospital,Department Of Surgery, Divison Of Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine, Texas Children’s Hospital,Department Of Pediatrics, Newborn Secton,Houston, TX, USA

Introduction: Numerous advances in pre- and postnatal management of critically-ill CDH patients have improved long term survival and outcomes, but a small percentage of patients continue to require tracheostomy.  The purpose of this study was to define the characteristics and associated risk factors for tracheostomy in the CDH population. 

Methods: An IRB approved retrospective review of all infants evaluated for CDH at a single institution from March 2004 to April 2018 was performed. Data analyzed included maternal and fetal demographics, prenatal imaging data, and postnatal clinical outcomes.  Primary outcomes assessed were indication for and duration of tracheostomy, requirement for ECMO and survival.  Statistical analysis included chi-square analysis, student’s t test, and stepwise logistic regression.  A p-value of <0.05 was considered significant. 

Results:Of 273 CDH patients treated, 10% (26) underwent a tracheostomy prior to 2 years of life (median age of 4 [3 – 8] months). Of these 26 patients, 65% (17) had a left-sided CDH and 76% (19) were male.  Indications for tracheostomy were persistent pulmonary hypertension in the setting of severe pulmonary hypoplasia (31%, 8), tracheomalacia (27%, 7), bronchopulmonary dysplasia (27%, 7), upper airway obstruction/structural defect (11%, 3), and vocal cord paralysis (4%, n=1).  Only two patients underwent tracheostomy after their initial inpatient hospitalization; both were eventual recipients of lung transplants.  Prenatally, although lungs volumes were similar to the non-tracheostomy cohort, percent liver herniation was significantly higher in the tracheostomy group (27% ± 18, p<0.01).  Additionally, 79%(p=0.009) had an associated structural, genetic, and/or cardiac anomaly, which was a strong predictor of tracheostomy (OR 4.991,CI:1.25 – 20.3) in this cohort.  At birth, prematurity and low birthweight also significantly correlated to need for tracheostomy (p<0.05, table 1). Incidence of ECMO was similar to the non-tracheostomy cohort (39% vs 31%, p=0.44) as was the overall survival (62% vs 74%, p=0.171). Non-survivors with a tracheostomy were, however, significantly older at time of death. Of the surviving tracheostomy patients (n=16), median length of hospital stay was prolonged 259 [187, 299] days (p<0.05) with a median time from tracheostomy to discharge of 98 [78, 172] days.  Length of outpatient follow-up was 3 [0.5 – 9] years during which time 38% of survivors were decannulated (a range of 28 days to 3.5 years after tracheostomy).

Conclusion:CDH patients born prematurely and/or those with associated anomalies are at increased risk for tracheostomy.  This is associated with prolonged hospitalization and median tracheostomy time of 1.5 years.  

 

14.12 The Role of Dilation in Children with Eosinophilic Esophagitis

Posted on January 31, 2019

C. Rodhouse1, J. A. Taylor1, C. E. Jolley1, M. M. Mustafa1, G. Beasley1, S. D. Larson1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction:

Eosinophilic esophagitis (EoE) is an increasingly common diagnosis in children. Medical therapy involves the use of topical steroids, dietary changes, and treatment of reflux; however, a number of patients have persistent dysphagia and require esophageal dilation. The purpose of this report is to better understand management of EoE in children and current use of esophageal dilation.

 

Methods:

A single center retrospective study looking at children and adolescents (0-24 years to capture dilations) diagnosed with EoE was performed. Patients selected had to have records available for treatment and response. Data regarding demographics, diagnosis, treatment, and dilation use was collected. Descriptive and comparative statistics were performed, and a p value of <0.05 was considered significant.

 

Results:

A total of 175 cases of EoE were found with a mean age of 16.05 years. 71% were male, 81% Caucasian, and 51% had commercial insurance. Dysphagia (58%) was the most common presenting symptom, followed by abdominal pain (39%). Topical swallowed steroids were used in all patients initially and 91% were also started on PPI. Fifteen cases (8.6%) required esophageal dilation due to persistent dysphagia (77%), or esophageal stricture (46%). Majority underwent bougie dilation, and over half required repeated dilation over 3-24-month intervals. All cases reported resolution of dysphagia after each dilation and there were no complications noted. The table shows differences between dilation and non-dilation groups. 

 

Conclusions:

EoE is a common diagnosis in children and adolescents with a majority responding to medical management. Dilation was a safe and effective therapy in patients with continued and persistent symptoms, particularly dysphagia. Patients who have continued dysphagia should be considered for dilation early. Further, larger studies may help to better define the patients who would benefit from dilation. 

14.11 UNINTENTIONAL FIREARM INJURIES IN PEDIATRIC PATIENTS

Posted on January 31, 2019

R. J. McLoughlin1, C. Murray1, S. Rice2, M. P. Hirsh1, M. Cleary1, J. T. Aidlen1  1University Of Massachusetts Medical School,Surgery,Worcester, MA, USA 2University Of Massachusetts Medical School,Worcester, MA, USA

Introduction:
Unintentional firearm injuries in the pediatric population are common and carry a significant risk of mortality. We aim to describe the most common injuries associated with unintentional firearm discharges.

Methods:
A cross-sectional analysis was performed by combining the Kids’ Inpatient Database for study years of 2006, 2009, and 2012. We identified cases (age <21 years) of accidental firearm-related injury (AFI) using external cause of injury codes. Patient characteristics and injuries were analyzed using ICD-9 codes, and national estimates were obtained using case weighting. Multiple multivariable logistic regressions were performed adjusting for gender, race, age, payer, income quartile, setting, and region.

Results:
There were 4,696 admissions for AFI. The defining patient characteristics were high-school age or older (85.2%), male (87.8%), black (48.4%), urban setting (59.5%) and occurred in the South (46.8%). There were approximately 30 AFI weekly and mortality was 5%. The most common injuries overall were any fracture (48.8%), open wound of the extremities (34.5%) and open wound of the head, neck, or trunk (24.0%). Other notable injuries were any thoracic injury (13.3%), any abdominal injury (18.8%), any blood vessel injury (11.0%) and intracranial injury (8.22%). When analyzed by age group, there was an increase of the proportion of patients having any type of fracture from elementary to post-high school (42.0% to 52.2%, p-value 0.01) whereas the elementary school age group had the highest proportion of intracranial injuries (18.5%). Adjusted logistic regression showed that compared to post-high school, elementary school age were at significantly higher risk of an intracranial injury (aOR 3.28, 95% CI 2.14-5.05) but lower risk of any fracture (aOR 0.67, 95%CI 0.49-0.92).

Conclusion:
Unintentional firearm injuries cause a wide variety of injury patterns likely related to the varying nature of the accidents themselves. Younger children are at higher risk of intracranial injuries whereas older children have higher risks of fractures. To improve injury prevention and public safety, gun safety and education programs should focus on all children and their caregivers and be tailored to injury patterns most likely to occur based on age.
 

14.10 Self-Reported Outcomes Following Cholecystectomy for Hyperkinetic Biliary Dyskinesia

Posted on January 31, 2019

C. Dekonenko1, J. Sujka1, R. M. Dorman1, S. St. Peter1, T. Oyetunji1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA

Introduction:   Biliary dyskinesia (BD) is a common indication for cholecystectomy in children.  Diagnosis is made by the presence of right upper quadrant abdominal pain, lack of gallstones on ultrasound, and a gallbladder ejection fraction (EF) that is abnormal.  We previously reported resolution of symptoms at longterm post-operative follow-up in 61% of pediatric patients undergoing laparoscopic cholecystectomy for hypokinetic BD with EF of <35%; however, data supporting the efficacy of cholecystectomy for hyperkinetic BD (EF >75%) is sparse.  We sought to determine whether children with hyperkinetic BD had similar resolution of their symptoms after laparoscopic cholecystectomy at our institution.

Methods:   We conducted a retrospective chart review of children who had undergone laparoscopic cholecystectomy for hyperkinetic BD at our free-standing children’s hospital between September 2010 and July 2015.  Patients were contacted via telephone and answered a short questionnaire regarding symptom resolution, whether they were happy to have undergone cholecystectomy, satisfaction with cholecystectomy on a 1-10 scale, and a narrative of additional workup or treatment for those with ongoing abdominal pain.  Analysis of outcomes was performed only for patients who could be contacted. An unpaired t test was used to compare ejection fractions of patients with and without symptom resolution.

Results:  Of the 13 patients identified on chart review, 8 participated in the phone survey.  Median ejection fraction was 93% (range 81%- 99%) with a median follow-up of 3.75 (range 2.50-6.75) years.  Five patients (one with ongoing pain and four with symptom resolution), were happy their gallbladder had been removed.  Four patients (50%) reported symptom resolution. The median EF of the four patients with resolution of symptoms was 93.5% and the median EF of the four patients with ongoing pain was 91% (p = 0.24).  Frequency of pain varied among the symptomatic patients, ranging  from <1 time per week to a few times per day. Three of the patients rated their overall satisfaction with the results of surgery as 5.2 on a scale of 1-10.  Two of the four symptomatic patients previously endorsed resolution of abdominal pain at their initial post-operative visit. Two patients reported seeing a physician other than their surgeon for their persistent symptoms and have undergone further diagnostic testing and procedures.

Conclusion:  Some children with hyperkinetic biliary dyskinesia may benefit from cholecystectomy. However, a high ejection fraction does not correlate with symptom resolution.

 

14.09 A Synopsis of Pediatric Patients with Hepatoblastoma and Wilms’ Tumor: NSQIP-P 2012-2016

Posted on January 31, 2019

A. M. Waters1, M. Mathis1, E. A. Beierle1, R. T. Russell1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA

Introduction:  Hepatoblastoma and Wilms’ tumor is the most common primary liver and kidney tumor in children, respectively.  Multiple prospective cohort studies have been performed to describe the long-term outcomes of children with solid tumors.  However, little is documented about outcomes in the perioperative period. The aim of this study is to analyze the short-term outcomes of pediatric patients after surgical resection for hepatoblastoma or Wilms’ tumor. 

Methods:  We queried the 2012 to 2016 ACS National Surgical Quality Improvement Program-Pediatric (NSQIP-P) Participant Use File for patients with hepatoblastoma who underwent liver resection and patients with Wilms’ tumor who underwent a partial or total nephrectomy.  Patient demographics, preoperative, intraoperative, and postoperative characteristics were analyzed.  Multivariate logistic regression was used to determine independent risk factors for unplanned reoperations and readmissions.  

Results: A total of 189 patients with hepatoblastoma and 586 patients with Wilms’ tumor met inclusion criteria. Demographics were as expected with mean age of 4.2 years of patients with hepatoblastoma and 3.1 years in the Wilms’ group.  79.9% of liver resections were performed open and 9% (n=17) of patients underwent an unplanned reoperation. Furthermore, 78.7% of nephrectomies were completed open and 4.1% (n=24) of patients experienced an unplanned reoperation. Over half of patients with hepatoblastoma (59.8%, n=113) and 29.7% (n=174) patients with Wilms’ tumor received a blood transfusion intraoperatively or in the perioperative period.  The mean volume of blood transfused after liver resection was 40.8 ml/kg (SD=37.9) and 24.5 ml/kg (SD=28.8) after nephrectomy.  Patients in both groups demonstrated low rates of surgical site infections but 6.3% (n=12) of hepatoblastoma patients showed evidence of sepsis (Table 1). Multivariate analysis demonstrated no significant risk factors for readmission or reoperation. 

Conclusion: This study will allow providers to more effectively counsel families of the common morbidities in the associated perioperative period following surgical resection of either solid tumor type including the high risk of blood transfusion

 

14.08 The Role of Mechanical Bowel Prep and Perioperative Antibiotics in Pediatric Pull-through Procedures

Posted on January 31, 2019

K. L. Carpenter1, F. Breckler2, B. W. Gray1,3  1Indiana University School Of Medicine,Department Of Surgery,Indianapolis, IN, USA 2Riley Hospital for Children,Department Of Pharmacy,Indianapolis, IN, USA 3Riley Hospital for Children,Section Of Pediatric Surgery,Indianapolis, IN, USA

Introduction:

There are no clear guidelines for the use of mechanical bowel prep and postoperative antibiotics in children undergoing elective colorectal pull-through surgery. Mechanical bowel prep in this patient population has not been demonstrated to provide benefit. The objective of this study was to determine whether preoperative mechanical bowel prep administration or duration of postoperative antibiotics impacted the rate of complications following elective pediatric pull-through surgery.

Methods:
Patients under 18 years who underwent a pull-through procedure between 2011 and 2017 at a single institution were retrospectively identified based on CPT code. Patient data included diagnosis, procedure, administration of mechanical bowel prep, and duration of perioperative IV antibiotics. Outcomes of interest included surgical site infections and anastomotic complications.

Results:
181 patients met inclusion criteria, of which 47.5% received mechanical bowel prep. Only one patient received oral antibiotics as part of the bowel prep regimen. There were three anastomotic complications overall, two leaks and one stricture. Neither administration of bowel prep (p=0.4983) nor duration of IV antibiotics (p=1.000) was associated with anastomotic complications. Table 1 shows the rates of infectious complications for each subgroup. The overall rate of complications was 13.3%. There was no significant difference in complication rate among those receiving mechanical bowel prep compared to those who did not (15.1% vs. 11.6%, p=0.48). When stratified by procedure type, administration of mechanical bowel prep in the anoplasty subgroup was associated with higher rates of wound infection (33.3% vs 3.3%, p=0.03).  111 patients (60%) received perioperative IV antibiotics for 24 hours or less. This group had similar rates of complications (14.4%) compared to those receiving IV antibiotics for longer than 24 hours (11.4%, p=0.56).

Conclusion:
Although mechanical bowel prep did not affect the overall complication rate for pull-through procedures, it was associated with more wound infections in those undergoing anoplasty. Duration of postoperative IV antibiotics was not significantly associated with the rate of wound and anastomotic complications. Further work should lead to a prospective study of bowel prep and perioperative antibiotics in this patient group.

14.06 Predictors of Bowel Resection During Non-Elective Ladd for Pediatric Malrotation

Posted on January 31, 2019

W. S. Do1, C. W. Marenco1, J. D. Horton1, M. A. Escobar1  1Mary Bridge Children’s Health Center,Pediatric Surgery,Tacoma, WA, USA

Introduction:
Historically, small cohort studies have shown a bowel resection rate of 22% at the time of Ladd procedure for malrotation. Patients who undergo bowel resection at the time of Ladd procedure present with more advanced disease. The objective of this study was to identify risk factors for bowel resection (a surrogate marker for disease severity) in a larger, modern cohort of patients undergoing non-elective Ladd procedures.

Methods:
This was a retrospective descriptive analysis of patients who had a Ladd procedure (CPT 44055) in the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012-2015. Exclusion criteria were: elective case, atresias or other known congenital anomaly (except cardiac, structural CNS, or airway anomaly), and open wounds from prior procedures. Descriptive statistics were performed on all pre-operative variables collected by NSQIP-P (listed in results). The primary outcome variable was bowel resection as a concurrent procedure. Univariate analysis was performed using Pearson Chi-square or ANOVA for categorical variables and t-testing for continuous variables. Multivariate analysis was performed by incorporating all variables into a stepwise forward logistic regression model to identify independent risk factors for bowel resection.

Results:
Of the 267,289 patients captured in NSQIP-P, a total of 1284 had a Ladd procedure. Of these, 292 were performed urgently/emergently in children with no known atresias, aforementioned congenital anomalies, or open wounds from prior procedures. Descriptive statistics in this cohort were: 46% age 0-30 days, 33% age >1 year, 68% weight ≤10 kg, 68% male, 21% history of prematurity, 8% ventilator dependence, 2% asthma, 2% chronic lung disease, 8% oxygen support, 1% tracheostomy, 2% structural airway abnormality, 73% esophageal/gastric/intestinal disease, 1% biliary/liver/pancreatic disease, 11% cardiac risk factors, 9% developmental delay, 3% cerebral palsy, 3% structural CNS abnormality, 2% neuromuscular disorder, 1% intraventricular hemorrhage, 1% steroid use, 14% nutritional support, 2% hematologic disorder, 0.3% malignancy, 8% SIRS, 1% septic shock, 3% inotropic support, 1% CPR, and 18% WBC >15k. Overall bowel resection rate was 10%. Higher rates of bowel resection were observed in patients with cardiac risk factors, WBC >15k, oxygen support, and developmental delay (Table 1, left; all other variables were not significant on univariate analysis). Of these, only cardiac risk factors and WBC >15k were significant on multivariate analysis (Table 1, right).

Conclusion:
Bowel resections (performed in 10% of this cohort of non-elective Ladd procedures) were independently associated with cardiac risk factors and WBC >15k. 
 

14.05 Abscess on Admission is a Predictor of Outcomes for Childrens with Complicated Appendicitis

Posted on January 31, 2019

A. Munoz Abraham1,2, H. Osei1,2, P. Sutthatarn1,2, S. Kazmi1,2, M. Winkelmann1,2, M. Gibbons1,2, K. Chatoorgoon1,2, J. Greenspon1,2, C. M. Fitzpatrick1,2, G. A. Villalona1,2  1Saint Louis University,Pediatric Surgery,St. Louis, MO, USA 2Cardinal Glennon Children’s Hospital,Pediatric Surgery,St. Louis, MO, USA

Introduction:

A complicated appendicitis clinical practice guideline was established in July 2016. Early appendectomy (EA) was offered to patients presenting with no abscess or abscess ≤ 3 cm, whereas, interval appendectomy (IA) was offered to patients with presenting with an abscess > 3 cm. We hypothesized that patients presenting with abscess ≤ 3 cm would least likely benefit from interval appendectomy. We tracked the overall and subgroup effectiveness of the new appendicitis management protocol for outcomes and complications.

Methods:

An appendicitis protocol establishing criteria for management of complicated appendicitis patients was instituted in July 2016 (Figure 1). Pre-protocol (G1, 2014-2016) records were compared to post-protocol (G2, 2016-2018) records. Differences in early (EA) versus interval appendectomy (IA), demographics, baseline clinical characteristics, short-term outcomes, antibiotic and imaging utilization were assessed with chi-squared test and analysis of variance.  Subgroup analysis was performed to compare patients with abscess ≤3 cm treated with IA pre-protocol versus same patients treated by EA post-protocol.

Results:

A total of 246 patients were reviewed (G1=152, G2=94). Half of patients pre-protocol were treated with early appendectomy (51%). Whereas, 82% of post-protocol patients were treated with EA. There were no differences in demographics. Post-protocol patients had less total CT scans performed (40% vs 28%, p 0.03), lower number of admissions (2 days  vs 1 day, p=0.000, median) and decreased total (LOS) length of stay (7.7 days vs 6.5 days, p=0.049).

On subgroup analysis, we matched pre-protocol IA patients to post-protocol EA patients presenting with no abscess or abscess ≤3 cm. For this cohort, post-protocol EA patients had lower total number of admissions (EA 1 vs IA 2, p=0.000, median), decreased total LOS (EA 5 days vs IA 7 days, p= 0.000), less total CT scans performed (EA 23% vs IA 58%, p=0.000) and less complications (EA 22% vs IA 42%, p 0.022).

Conclusion:

Establishment of a new management protocol for complicated appendicitis improves resource utilization and decreased complications. Patients presenting with no abscess or ≤3 cm abscess have higher complications and longer hospital stay if treated with interval appendectomy.

 

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