94.12 Maturation of Effect Size During Enrollment of Prospective Randomized Trials

Posted on January 26, 2017

A. S. Poola1, T. Oyetunji2, G. W. Holcomb1, S. D. St. Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Surgery,Kansas City, MO, USA 2Lurie Children’s Hospital-Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
 Randomized trials with a definitive study design are powered by calculating the minimum sample required to achieve statistical significance given an estimated effect size (ES). The ES is the raw difference between two treatment arms. ES quantifies the magnitude of measurable differences between cohorts and is usually reflective of the true meaning of the trial regardless of statistical significance. Under a fixed protocol, we hypothesize that the effect size may mature near its final magnitude well before the completion of enrollment. To investigate patterns of ES during enrollment, we analyzed completed randomized trials with definitive study designs. 

Methods:
Primary outcomes of 11 prospective trials were reviewed at a single institution. ES was calculated at intervals throughout each trial to determine at which point a steady clinical difference was achieved between treatment cohorts. 

Results:
Table 1 summarizes our overall findings. Both the completed trial sample size and the number of enrolled patients at which the ES stabilized, are provided. ES stabilized at a median of 64% enrollment. All patients were needed to meet the precise ES in our smallest study, indicating the need for full enrollment in smaller studies. Otherwise, 50% of our trials required between 48% and 76% of patient enrollment to meet ES. In comparing clinical outcomes, 9 of 12 found a final difference that was nearly identical to the difference that could have been determined much earlier. Categorical outcomes met stabilized ES at 51% enrollment and continuous outcomes at 68%.

Conclusion:
ES and final clinical outcomes were achieved prior to the completion of enrollment for most of our studies. This suggests that clinical differences detected by randomization may not necessarily require the robust sample size often needed to establish statistical significance. This is particularly relevant in fixed-protocol interventional trials of homogenous populations where protocol compliance is high. 
 

84.15 Cleft Care in the Medically Complex Patient

Posted on January 26, 2017

F. Fallahian1, M. Tracy1, A. Kaye1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Department Of Plastic Surgery,Kansas City, MO, USA

Introduction:  Direct causality of congenital cleft conditions is often not known and is currently considered to represent a combination of complex environmental and genetic factors and interactions. There are numerous syndromes which can be associated with cleft lip and/or palate as well as unique patients with multiple medical problems without an over-arching diagnosis. This provides us with a number of patients for whom highly individualized treatment plans must be devised. Safety and appropriateness for surgery or the need to prioritize other necessary surgeries are factors that may preclude following typical cleft treatment protocols. This study aims to determine the prevalence of children in our Cleft Team population who also carry concomitant complex medical diagnoses in order to assess the challenges of this population and the alterations in their ultimate cleft-related care.

Methods:  This study is a retrospective review of patients presenting to the Cleft Team for cleft care with a history of multiple medical issues in addition to a diagnosis of cleft lip and/or palate.

Results: 133 patients were identified with a variety of cleft conditions: incomplete cleft lip (CL) = 7, cleft lip and palate (CL/P) = 51, isolated cleft palate (CP) = 53, and submucous cleft palate (SMCP) = 22. A numerous variety of concomitant diagnoses were seen including 37 named syndromes, 20 unique chromosomal abnormalities, and 17 unidentified constellations of anomalies. Diagnoses were made by a combination of clinical assessment (30.7%), specific gene studies (25.0%), high resolution chromosome (18.3%) or CGH microarray analysis (16.3%). 51.9% of patients have congenital heart disease, 40.6% of which required surgery to treat. 36.8% of patients have brain abnormalities. 23.3% have congenital hearing loss. 63.9% have developmental delays. 81.2% of patients are cared for by 3 or more subspecialty teams aside from the Cleft Team, most commonly: ENT, Cardiology, Ophthalmology and Orthopedic Surgery. 54.1% of these patients have surgical feeding tubes and 15.0% have tracheostomies. 6.7% of these patient have died prematurely related to their condition. Average age at cleft lip repair when performed in this group is 7.29 months (SD 2.65). Average age at primary palate repair in this group is 23.13 months (SD 20.56). One third of patients have delayed or missed cleft-related surgeries. 60.9% of these patients have global developmental delays. More than half have speech-language delays, 59.4% of which are severe or profound.

Conclusion: Patients with congenital cleft conditions and concomitant complex medical presentations present unique situations for coordinated cleft team care. These patient have frequent delays in the timing of their cleft-related surgeries resulting from poor health condition, need for other surgery, or significant speech/developmental delays.  
 

83.18 DNR Orders and High Risk Pediatric Surgery: Professional Nuisance or Medical Necessity?

Posted on January 26, 2017

L. M. Baumann1,2, K. Williams1,2, F. Abdullah1,2, R. J. Hendrickson3, T. A. Oyetunji1,2  3Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 1Feinberg School Of Medicine – Northwestern University,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA

Introduction:  There is a paucity of data in the literature regarding end-of-life care and do-not-resuscitate (DNR) status of the pediatric surgical patient, despite the fact that invasive procedures are frequently performed in very high risk and critically ill children.  There have been significant efforts in adult medicine to enhance discussions around end-of-life care, however, little is known about similar endeavors in the pediatric population.

Methods:  A retrospective review of the National Surgical Quality Improvement Program Pediatric (NSQIP Pediatric) was performed.   Patients <18 years old with ASA class 3 or greater who underwent elective operation in 2012-2013 were identified and included for analysis.  Demographic factors, principal diagnosis, associated conditions, DNR status and mortality were extracted.  Descriptive analysis was performed using Stata 11.

Results: A total of 114,395 records were initially identified, with 20,164 patients meeting the inclusion criteria.  91.6% of patients were ASA III, 8.3% ASA IV, and 0.1% ASA V. Less than 1% (0.18%) of all patients had a signed DNR order prior to operation.  Of severely ill patients defined by ASA IV, only 1 out of a hundred were DNR status.  There were no differences in gender, race, ethnicity or surgical department of patients with and without a DNR order. Of those children who died within 30 days of operation, 11.1% were DNR status.  Notably, 17.1% of children who died within this period had multiple operations performed prior to expiring.

Conclusion:  The rate of documented DNR status is extremely low in the high-risk pediatric surgical population undergoing elective surgery, even amongst severely ill children where systemic disease is a “constant threat to life”. It is unclear if this is due to physician hesitancy or parents’ unwillingness to make this difficult decision.  Regardless, well-informed end-of-life care and DNR status discussions in a patient focused approach are essential in the surgical care of children with complex medical conditions and critical illness. Better documentation of any DNR discussion will also allow better tracking and benchmarking.

83.14 Efficacy of Oral Antibiotics in Children with Post-Operative Abscess from Perforated Appendicitis

Posted on January 26, 2017

K. L. Weaver1, A. S. Poola1, K. W. Gonzalez1, S. D. St. Peter1  1Children’s Mercy Hospital,Department Of Pediatric General Surgery,Kansas City, MISSOURI, USA

Introduction:
Post-operative intra-abdominal abscess (PIAA) is the most common complication after appendectomy for perforated appendicitis (PA). This results in a protracted  medical course. Intravenous antibiotics by a peripherally inserted venous catheter are commonly employed to treat the abscess. We sought to evaluate the role of oral antibiotics in this population. 

Methods:
A retrospective review was conducted of children between January, 2005 to September, 2015 with a PIAA. Demographics, laboratory values, type and duration of antibiotics, interventions, imaging, length of stay, complications and hospital costs were all analyzed using descriptive statistics. Comparative analysis was performed on those who were treated with oral versus IV antibiotics after diagnosis of PIAA upon discharge utilizing a Pearson chi-square and Fisher’s exact test.  

Results:

103 children, of whom 66% where male with an average age at time of surgery of 11 + 3.6 years were included. Days of symptoms prior to admission was 3.2 + 2.3 days with a WBC of 17.9 + 6.4.  The median time to diagnosis of PIAA from appendectomy was 7 days (range 7-10) with 46% being treated with antibiotics only, 39% requiring drain placement and 15% aspiration. Mean total length of stay was 10 + 3.4 days. Comparing those who were discharged with oral antibiotics (42%) versus IV antibiotic therapy (58%), there was no significant difference in number of days of IV antibiotics prior to PIAA diagnosis, length of drain days if required, or total number of hospitalizations. However, there was a significant difference found in total length of hospital stay (9.1 vs. 10.7, p=0.02) and number of medical encounters required for treatment (3.4 vs. 4.4, p= <0.01). 

Conclusion:
PIAA treatment after appendectomy for PA can be treated with oral antibiotics with equivocal outcomes as IV antibiotic treatment, but with shorter length of hospitalizations and less medical encounters required. 
 

83.12 Are Foley Catheters Needed in the Postoperative Care of Children with Perforated Appendicitis?

Posted on January 26, 2017

S. Mohammed1, Y. R. Yu1,2, R. Sola3, J. T. Lackey1, S. John4, E. Rosenfeld1,2, W. Zhang2, S. D. St. Peter3, S. R. Shah1,2  1Baylor College Of Medicine,Division Of General Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Division Of Pediatric Surgery,Kansas City, MO, USA 4University Of Texas Health Science Center At Houston,Houston, TX, USA

Introduction: Patient-controlled analgesia (PCA) is often used for postoperative pain control in children with perforated appendicitis.  Additionally, some providers routinely use postoperative Foley catheters in this population to prevent urinary retention; however, this practice varies by surgeon and institution.  The objective of this study was to determine the rate of urinary retention in this patient population to guide future practice.

Methods: A retrospective review was performed of all pediatric patients (≤ 18 years old) who received PCA postoperatively for perforated appendicitis between July 2015 and June 2016 at two academic children’s hospitals.  Data collected included patient characteristics, intraoperative findings, postoperative narcotic use, and incidence of urinary retention and urinary tract infections.  Urinary retention was defined as the inability to spontaneously void during the postoperative period requiring straight catheterization or placement of a Foley catheter.  Statistical analysis was performed using the Wilcoxon rank test and Fisher’s exact test, as appropriate.  Additional univariate logistic regression analysis was performed to identify risk factors for urinary retention.

Results: A total of 313 patients (mean age 9.5 ± 3.9 years) underwent appendectomy for perforated appendicitis during the study period (175 at Hospital 1 and 138 at Hospital 2). An intraoperative Foley catheter was placed in 22 (13%) patients at Hospital 1, and 107 (78%) patients at Hospital 2 (p<0.0001).  For the combined study population there were 196 (63%) males and the overall postoperative length of stay was 5.6 ± 2.9 days.  The mean PCA morphine usage was 0.4 ± 0.3 mg/kg/day per patient.  Age, gender, and body mass index (BMI) was similar between those that had an intraoperative Foley catheter placed (n=129) and those that did not (n=184).  There were no urinary tract infections in either group.  The urinary retention rate was 4.3% (n=8) for patients without an intraoperative Foley catheter, and 0.8% (n=1) for those with an intraoperative Foley catheter after removal on the inpatient unit (p=0.06).  Univariate analysis of patient characteristics, intraoperative findings, PCA specifics (narcotic type, duration, average daily usage, and basal rate), postoperative length of stay, and postoperative abscess formation did not identify any significant risk factors for urinary retention.

Conclusion: Practice variations exist regarding placement of intraoperative Foley catheters in children with perforated appendicitis.  However, the risk of urinary retention in this population is low despite the use of patient-controlled analgesia.  Based on these results we conclude that children with perforated appendicitis do not require routine postoperative Foley catheter placement to prevent urinary retention.

 

79.12 Protective Role of Intestinal HSP70 in Barrier Maintenance and Milk Induction of HSP70.2

Posted on January 26, 2017

R. M. Rentea1, Y. Guo2, X. Zhu3, M. W. Musch3, D. M. Gourlay4, J. L. Liedel5  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 2University Of Chicago,Pediatrics, Section Of Neonatology,Chicago, IL, USA 3University Of Chicago,Medicine,Chicago, IL, USA 4Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 5Albert Einstein College Of Medicine,Pediatrics And Critical Care,Bronx, NY, USA

Introduction:  Necrotizing Enterocolitis (NEC) is a gastrointestinal disease of complex etiology that effects 1 in 10 premature infants. We previously demonstrated that formula feeding inhibits ileal expression of Heat Shock Protein -70 (Hsp70), a critical stress protein within the intestine and that may serve to lower the injury threshold for subsequent stressors. Barrier function for the premature intestine is critical. It is unknown whether decreased neonatal intestinal Hsp70 increases permeability. We sought to determine whether reduced Hsp70 protein expression increases neonatal intestinal permeability. 

Methods:  Young adult mouse colon cells (YAMC) were utilized to evaluate barrier function (translocation of fluorescent dextran) as well as intestine from Hsp70-/- pups (KO). Sections of intestine were analyzed by Western blot, immunohistochemistry, and real time PCR. Statistical data were analyzed by paired students t-test and expressed as a mean +/- SEM with p<0.05 considered significant.

Results: YAMC cells were sub-lethally heated or treated with expressed milk (EM) to induce Hsp70. Immunostaining demonstrates co-localized Hsp70 and tight junction protein Zona Occludens-1 (ZO-1), suggesting physical interaction to protect tight junction function. The permeability of YAMC monolayers increases following oxidant injury and is partially blocked by Hsp70 induction either by prior heat stress or EM (fluorescent dextran-70 flux oxidant injury 12 µg/mL vs. heat shock 1.5 µg/mL p<0.007 or EM 3.0 µg/mL p<0.01). Consistent with previous results in the rat, Hsp70 was detected in the ileum of all mother fed mouse pups on day 3.  RT-PCR analysis demonstrated that the Hsp70 isoforms, 70.1 and 70.3 predominate in WT pup, however, Hsp70.2 predominates in the KO pups via a 3 fold change (p<0.05).   While Hsp70 is present in WT milk, it is not present in KO EM (450 ng/mL vs. 0.10 p<0.001).

Conclusion: Hsp70 associates with ZO-1 to maintain epithelial barrier function. Both induction of Hsp70 and exposure to EM prevent stress-induced increased permeability. Hsp70.2 is present in both WT and KO neonatal intestine suggesting a crucial role in epithelial integrity.  Induction of the Hsp70.2 isoform appears to be mediated by mother’s milk.  These results suggest that mothers milk feeding modulates Hsp70.2 expression and could attenuate injury leading to NEC. 
 

47.20 Fertility Preservation in Female Patients with Pelvic Tumors Receiving Pelvic Radiation

Posted on January 26, 2017

R. M. Rentea1, A. S. Poola1, J. M. Fulbright3, S. D. St. Peter1, S. R. Shah4  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Hematology/Medical Oncology,Kansas City, MO, USA 4Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA

Introduction:  Pediatric patients with pelvic tumors often necessitate a multidisciplinary treatment approach involving pediatric surgeons, pediatric oncologists, and radiation oncologists.  Current guidelines recommend discussion of fertility preservation in pre- and post-pubertal patients with cancer.  The objective of this review is to assess the number of female patients with pelvic tumors receiving radiation therapy, and the proportion that undergo measures for fertility preservation.  

 

Methods: A retrospective review was conducted of all female patients treated with pelvic tumors at an academic children’s hospital from January 1, 2003 – December 31, 2012.  Data collected included tumor type, tumor location, treatment regimen, and discussion of fertility preservation. 

 

Results: A total of 47 female patients with pelvic tumors were identified.  Fifteen (31.9%) of these patients underwent pelvic radiation therapy.  The distribution of the types of pelvic tumors for patients that underwent pelvic radiation therapy is shown in Table 1.  Three of the patients received radiation therapy for palliative treatment.  Of the remaining 12 female patients receiving radiation therapy, three (25%) were pre-pubertal.  Two patients (16.7%) had documentation of a discussion of fertility preservation measures prior to radiation therapy.  Both of these patients were post-pubertal, and neither pursued fertility preservation measures.  Five patients (41.7%) were evaluated by endocrinology after radiation therapy, diagnosed with ovarian failure, and placed on hormone therapy.  

 

Conclusion: This 10-year review of female patients that underwent radiation therapy for pelvic tumors at an academic children’s hospital demonstrated < 17% of patients have documentation of a discussion of fertility preservation measures.  Based on these findings we have established a protocol for discussing and documenting the impact of pelvic radiation on fertility and available measures for fertility preservation. We anticipate this standardized protocol will improve compliance with current guidelines.

 

47.08 Elective Laparoscopic Gastrostomy in Children: Potential for an Enhanced Recovery Protocol

Posted on January 26, 2017

K. Williams1, L. M. Baumann1, F. Abdullah1,2, R. J. Hendrickson3, T. A. Oyetunji1,2  1Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:  Gastrostomy tube placement is one of the most common procedures performed in the pediatric population. The laparoscopic approach is associated with shorter postoperative length of stay and is increasing in popularity. Single-institution studies have corroborated both the safety and efficacy of early initiation of postoperative feeding using defined pathways, with discharge as early as the first postoperative day. We examined a national database to establish current practice and outcomes as it relates to elective laparoscopic gastrostomy tube placement in children primarily for feeding difficulties.

Methods:  We queried the 2012-2013 National Surgical Quality Improvement Program Pediatric (NSQIP-P) database, including all patients who underwent elective laparoscopic gastrostomy tube placement for failure to thrive or feeding difficulties. Only patients who had the procedure performed on the day of admission were selected. Patients who had other procedures on the same admission were excluded, as well as those with other indications for gastrostomy tube placement. Demographic data, admission status, disposition at discharge, surgical subspecialty data and hospital length of stay (LOS) were extracted. 

Results: A total of 114,395 patients had laparoscopic gastrostomy placement. After excluding patients who had any other procedures during the admission and keeping only the elective cases, 1486 patients were analyzed. Only 599 gastrostomy tubes were done for failure to thrive or feeding intolerance, the most common indications for gastrostomy tube placement (73%). The majority, 52%, was male and 69.28% were White. The median age was 2.2y (IQR 0.9-6.3).  Of the total, 28.7% were infants. Most patients were admitted from home, 96%, and also discharged to home, 95%. Pediatric surgeons performed 96% of gastrostomies and 3.8% were done by general surgeons. Notably, in this elective population, the median total hospital LOS was 2 days (IQR 1-2), with only 39% discharged in a day or less.

Conclusion: Pediatric patients undergoing rather straightforward elective laparoscopic gastrostomy tube placement have a median hospital length of stay of 2 days, despite evidence that early feeding and discharge within 24 hours is both feasible and safe. There is therefore potential for the implementation of an enhanced recovery protocol as a quality metric for this commonly performed procedure in this population. This will result in more efficient healthcare resource utilization without compromising the quality of care.
 

47.05 Small Bowel Obstruction in Children

Posted on January 26, 2017

K. L. Weaver1, H. Alemayehu1, B. David1, S. D. St. Peter1, P. Aguayo1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:
Small bowel obstruction (SBO) remains a significant source of morbidity and accounts for up to 16% of surgical admissions in the US. Despite this prevalence, literature relevant to the management of pediatric SBO is sparse. We reviewed our institutional experience to determine the etiologies, clinical course, management and outcomes of pediatric SBO.

Methods:
With IRB approval, we conducted a retrospective review of all patients <18yrs admitted for SBO from 2008 through 2013. Patients with a history of chronic obstruction, known intestinal dysmotility, colonic obstruction, neonatal SBO, or acute ileocolic intussusception were excluded. Patients with inflammatory bowel strictures were included only if they presented acutely. Both descriptive and comparative analysis was performed. All means reported ± standard deviation.

Results:
There were 156 patients with acute SBO during the study period; 73 male and 83 female. 42 children had 57 recurrent SBOs for a recurrence rate of 27% after a single episode of SBO.   Overall there were 213 episodes of SBO. The mean age at SBO was 8.1 ± 6.0 years. Overall 79% (n=169) underwent operative management. 69% (n=148) of the episodes of SBO had prior abdominal surgery, and 85% (n=126) were managed operatively; adhesions were the most common etiology (n=86). Mean time from previous operation to initial episode of SBO was 33.2 ± 46.1 months. Children without previous abdominal surgery had obstructions due to intestinal strictures (n=11), perforated appendicitis (n=8), Meckel’s Diverticulum (n=7), congenital adhesions (n=7), volvulus (n=1), and other causes (n=9).  Non-operative management with bowel rest and nasogastric tube decompression was attempted in 51% (n=108) of patients.  Non-operative management failed in 59% of these patients, 62% of which had adhesive bowel obstructions. Recurrent SBO after successful non-operative management was 39% which was higher than those who underwent operative management who had a recurrence rate of 19% (p=0.01). 

Conclusion:
Non-operative management of SBOs in children has a higher failure rate than reported in adults.  Further, those who succeed with conservative management have a higher rate of recurrence than those who undergo exploration.
 

46.10 Are Foley Catheters Needed Following Minimally Invasive Repair of Pectus Excavatum?

Posted on January 26, 2017

T. C. Friske1, R. Sola3, Y. R. Yu1,2, A. R. Jamal1, E. Rosenfeld1,2, H. Zhu2, S. D. St. Peter3, S. R. Shah1,2  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 3Children’s Mercy Hospital,Division Of Pediatric Surgery,Kansas City, MO, USA

Introduction: High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Intraoperative Foley catheters are often placed to minimize the risk of this complication; however, there is variation in this practice. The objective of this study is to determine the urinary retention rate in this population to guide future practice.

Methods: A retrospective review was performed of all patients that underwent MIRPE from 1/2012–7/2016 at two academic children’s hospitals. Data collected included patient demographics, body mass index (BMI), severity of pectus defect [Haller Index (HI)], postoperative pain management, and incidence of urinary retention and urinary tract infections (UTI). Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley. Statistical analysis was performed using the Wilcoxon rank test, Fisher’s exact test, and univariate and multivariable logistic regression analyses to identify risk factors for urinary retention.

Results:A total of 305 patients (mean age 15.9 ± 2.6 years) underwent MIRPE (205 at Hospital 1 and 100 at Hospital 2). An intraoperative Foley was placed in 84 (41%) patients at Hospital 1, and 80 (80%) patients at Hospital 2 (p<0.0001). Overall, mean HI was 4.4 ± 1.5 and there were 257 (84%) males. The mean IV morphine equivalents received was 1.4 ± 1.2 mg/kg/day per patient with a mean hospital length of stay of 4.7 ± 1.1 days. There were 195 (64%) patients who exclusively had patient-controlled analgesia (PCA), 95 (31%) exclusively had an epidural, and 15 (5%) had both for postoperative pain management. An intraoperative Foley was placed in 164 (54%) patients. Gender, BMI, and HI were not factors in determining Foley placement. However, patients with epidurals were more likely to have an intraoperative Foley (OR 2.1, 95% CI 1.3–3.5, p<0.01). There were no UTIs in the entire population. The urinary retention rate was 38% (n=53) for patients without an intraoperative Foley, and 1.8% (n=3) in patients after removal of intraoperatively placed Foley (p<0.0001). Adjusting for age, gender, BMI, HI, and pain control regimen, the only significant risk factor for urinary retention in patients without an intraoperatively placed Foley was having an epidural (OR 2.8, 95% CI 1.2–6.4, p=0.02); however, patients on a PCA without an intraoperatively placed Foley still had a urinary retention rate of 32%.

Conclusion:Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection following minimally invasive repair of pectus excavatum. Based on high rate of retention in those managed without an intraoperative Foley, we suggest surgeons discuss these findings with patients and families to determine the preference for Foley catheter placement during minimally invasive repair of pectus excavatum.

43.02 Diagnostic Imaging and Resource Utilization in Spontaneous Pneumomediastinum

Posted on January 25, 2017

K. Williams1, L. M. Baumann1, C. Stake2, R. J. Hendrickson3, F. Abdullah1,2, T. A. Oyetunji1,2  1Northwestern University,Feinberg School Of Medicine,Chicago, IL, USA 2Ann & Robert H Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction:  Primary spontaneous pneumomediastinum is a rare, often benign, self-limiting condition typically affecting the male adolescent population.  Several single-institution retrospective studies have shown that an extensive imaging workup is invariably negative and does not significantly affect clinical decision-making. It has also been shown that these children are often admitted to a critical care setting but are discharged from hospital within three days. Given the current trend toward increasing healthcare expenditure and the need for efficient resource utilization, our aim was to explore current practices in the management of spontaneous pneumomediastinum by analyzing a national database.

Methods:  The Pediatric Health Information System (PHIS) database from January 2011 to December 2015 was retrospectively analyzed.  All patients aged 10 to 21 years with a principal diagnosis of interstitial emphysema (ICD9 518.1) who were admitted for 3 days or less were included. Patient demographics, imaging studies and associated charges, as well as ICU admission, were extracted. Descriptive analysis was performed using Stata 11. 

Results: A total of 368 patients with a principal diagnosis of interstitial emphysema between the ages of 10 and 21 and a hospital LOS less than 3 days were identified. Of these, 77% were male and the mean age at admission was 12.5y(+/-4.8). 15 patients were admitted to the ICU. Among the 368 patients, 863 imaging studies were done. Chest X-ray was the imaging modality used most frequently in all patients; with 21 (5.7%) patients having 3 or more. Over a quarter of the patients (27.1%) had either esophageal or stomach and upper gastrointestinal fluoroscopy. Computed tomography scans were done in approximately 1 in 5 of the patients (18.5%). The associated cost of fluoroscopy in this population was approximately $72,222 while computed tomography added another $140,849.

Conclusion: Besides plain radiography, several other imaging modalities and some ICU care are currently being used in the management of spontaneous pneumomediastinum. This extensive resource utilization is not only expensive, but also associated with unnecessary radiation exposure, particularly for a condition that has been shown to be self-limiting in the vast majority of cases. There is therefore a need for better education and knowledge dissemination. 

 

32.02 Effectiveness of ATOMAC Guideline for Blunt Pediatric Injury: A 3-Year 10-Center Prospective Study

Posted on January 25, 2017

D. M. Notrica1,11,12, C. S. Langlais1, M. E. Linnaus1,11, K. A. Lawson2, J. W. Eubanks6, A. C. Alder3, N. M. Garcia2, R. W. Letton5, D. W. Tuggle2, T. Ponsky8, D. Ostlie1, A. Bhatia10, S. D. St. Peter9, C. Leys7, R. T. Maxson4, D. M. Notrica1,11,12  1Phoenix Children’s Hospital,Phoenix, AZ, USA 2Dell Children’s Medical Center,Austin, TX, USA 3Children’s Medical Center Dallas, Part Of Children’s Health,Dallas, TX, USA 4Arkansas Children’s Hospital,Little Rock, AR, USA 5The Children’s Hospital At OU Medical Center,Oklahoma City, OK, USA 6LeBonheur Children’s Hospital,Memphis, TN, USA 7American Family Children’s Hospital,Madison, WI, USA 8Akron Children’s Hospital,Akron, OH, USA 9Children’s Mercy Hospital,Kansas City, MO, USA 10Children’s Healthcare Of Atlanta,Atlanta, GA, USA 11Mayo Clinic,Phoenix, AZ, USA 12University Of Arizona College Of Medicine – Phoenix,Phoenix, AZ, USA

Introduction: Prior guidelines had required bedrest equal to the grade of injury +1 day. The ATOMAC guideline is an evidence-based published guideline for management of pediatric blunt liver and spleen injury (BLSI). The guideline allows for an abbreviated period of bedrest, and provides a detailed algorithm for management. The purpose of this study was to prospectively evaluate the effectiveness of the algorithm to safely guide care and confirm the safety of the abbreviated bedrest included in the algorithm.

Methods: After IRB approval, data was prospectively collected on patients ≤18 years of age admitted with a BLSI identified by Computed Tomography. Data collected included injury details, hospital details, and clinical outcomes. The algorithm was amended during the study to make early recurrent hypotension a failure point. Descriptive statistics are reported. Length of stay (LOS) was compared to a LOS equal to grade + 1 day.

Results: A total of 1008 children were included; 499 liver injuries (50%), 410 spleen injuries (41%), and 99 with both (10%).  Median age was 10.3 years [IQR 5.9, 14.2]. At initial presentation, 286 (28%) had recent or ongoing bleeding and were assigned to the bleeding pathway; 242 (24%) were tachycardic and 129 (13%) were hypotensive. Concomitant traumatic brain injury was present in 189 (19%).  There were 23 in-hospital deaths (2.5%), 2 due to bleeding. Of the 717 patients clinically assessed and started on the stable pathway, 10 (1.5%) crossed over to the algorithm’s unstable pathway. While minor deviations were common, only 1 patient (0.1%) was at risk of a negative outcome if they followed the original algorithm, resulting in the algorithm amendment. In patients with isolated injuries, median [IQR] lengths of stay by grade of injury (in days) were 0.94 [0.75, 2.17], 1.21 [0.83, 1.89], 1.65 [1.17, 2.08], 2.00 [1.46, 3.29], and 3.23 [2.35, 4.88] for isolated injuries grade 1-5, respectively, totaling 678 days, compared to an expected LOS of 1,211days.

Conclusion:The original ATOMAC guideline was safely applied to 99.9% of 1008 children with BLSI.  With the modification for recurrent hypotension in the guideline published last year, the guideline could have safely guided care for 100% of the children with BLSI. Ninety-one (9%) patients reached the algorithm endpoint where continued NOM could no longer be recommended; 22 (24%) of these were still managed nonoperatively at the surgeon’s discretion. Ten patients (1.5%) crossed over from the stable to the unstable pathway. The algorithm saved 533 hospital days over the prior guideline. In the largest prospective study ever conducted of pediatric BLSI, the ATOMAC guideline performed well in guiding non-operative management of patients with BLSI.