11.04 Early Thromboprophylaxis With Low Molecular Weight Heparin In Patients With Pelvic Fractures Is Safe

Posted on January 25, 2017

F. Jehan1, K. Ibraheem1, A. Azim1, A. Tang1, T. O’Keeffe1, N. Kulvatunyou1, L. Gries1, G. Vercruysse1, R. Friese1, B. Joseph1  1University Of Arizona,Trauma,critical Care, Burn And Emergency Surgery/Department Of Surgery,Tucson, AZ, USA

Introduction:
Early initiation of thromboprophylaxis is highly desired in patients with pelvic fractures but it is often delayed due to fears of re-bleeding and hemorrhage. The aim of our study was to assess the safety profile of early initiation of venous thromboprophylaxis in patients with pelvic trauma.

Methods:
Three year (2010-2012) retrospective study of trauma patients with pelvic fractures presenting at single level-I trauma center was performed. Patients who received thromboprophylaxis with low molecular weight heparin (LMWH) during their hospital stay were included. Patients were stratified in two groups based on timing of initiation of prophylaxis; early (initiation within first 24 hours) and late (initiation after 24 hours) initiation. Signs of bleeding or hemorrhage were defined as presence of pelvic hematoma, free fluid, or blush on CT scan. Decrease in hemoglobin (Hb) was defined as difference between admission Hb level and lowest post-prophylaxis Hb level. Our primary outcome measures were decrease in Hb levels, pRBC units transfused, and need for hemorrhage control (operative or angioembolization) after initiation of prophylaxis. Secondary outcome measures were hospital and ICU length of stay. Multivariate regression analysis was performed.

Results:
 

255 patients were included (158 in early and 97 in late group). Mean±SD age was 48.2±23.3 years, 50.6% were male, and mean±SD number of pRBC units was 0.62±1.59. After adjusting for confounders, there was no difference in the decrease in Hb levels (b= 0.087, 95% [CI]=[-0.253 – 1.025], p=0.23) or pRBC units transfused (b= -0.005, 95% [CI]= [-0.366 – 0.364]; p=0.75) between the two groups. Only one patient required hemorrhage control after initiation of thromboprophylaxis and belonged to the late group. There was no difference in the hospital LOS (b=0.120, 95% [CI]= -0.165 – 4.929; p=0.67). ICU length of stay was significantly shorter in early prophylaxis group (b= 0.206, 95% [CI]= 0.206 – 4.762; p=0.03).

On sub-analysis of patients with signs of bleeding or hemorrhage (n=52), there was no difference in decrease in Hb levels (b= 0.131, 95% [CI]= -1.411 – 2.586; p=0.55) or pRBC units transfused (b= -0.007, 95% [CI]= -1.588 – 1.518; p=0.96) between the two groups

Conclusion:
Our study shows no difference in pRBC transfusion requirements, drop in hemoglobin levels, or need for hemorrhage control between early and late initiation of thromboprophylaxis. We conclude that fear of hemorrhage with early thromboprophylaxis is not substantiated in patients with pelvic fractures

11.03 Early Versus Delayed Prophylactic Anticoagulation In Adult Trauma Patients With Pulmonary Contusions

Posted on January 25, 2017

M. B. Linskey1, A. B. Podany1, A. S. Kulaylat1, A. L. Lauria1, S. R. Allen1,2, J. D. Chandler1,2, R. M. Staszak1,2, S. B. Armen1,2  1Penn State University College Of Medicine,Department Of Surgery,Hershey, PA, USA 2Penn State University College Of Medicine,Division Of Trauma, Acute Care & Critical Care Surgery,Hershey, PA, USA

Introduction: Pulmonary contusions (PC) lead to morbidity and mortality in trauma patients, placing them at increased risk for mechanical ventilation, acute respiratory distress syndrome, and pneumonia. Tissue injury and hemorrhage in PC result in inflammation, edema, atelectasis, and intrapulmonary shunting even in the uninjured lung. We hypothesized that early prophylactic anticoagulation (pAC) would be associated with worsened respiratory outcomes in patients with PC.

Methods: A retrospective cohort study identified patients with PC from a rural Level I trauma center’s institutional registry. Patients with severe traumatic brain injury, prior use of therapeutic anticoagulation or antiplatelet therapy, and those who did not receive pAC were excluded. The cohort was stratified into those receiving early or delayed pAC, within or after 48 hours of admission, respectively. Outcomes including 30-day mortality, 30-day venous thromboembolism (VTE) rate, retained hemothorax, and pneumonia were modeled using multivariable logistic regression to control for patient and injury characteristics. Propensity score matching was then used to isolate two groups with similar comorbidities and injuries. Univariate statistics were performed to compare nadir oxygen saturation levels and supplemental oxygen requirements between the two groups before and after administration of pAC.

Results: 356 patients met inclusion criteria; 195 in the early and 161 in the delayed groups. The groups did not differ with respect to age, sex, race, mechanism, pulmonary comorbidities, number of rib fractures, or proportion with flail chest. The group receiving delayed pAC had lower admission GCS scores (12.0 vs 14.1, p<0.001) and higher injury severity scores (27.7 vs 20.0, p<0.001), and was significantly more likely to have bilateral PC (41.3% vs 28.4%, p<0.05), concomitant solid organ injury (42.2% vs 12.8%, p<0.001), intracranial or spinal hematoma (35.4% vs 5.64%, p<0.001), or other organ space hematoma (28.0% vs 14.9%, p<0.01). After controlling for differences between the groups, initiation of pAC within 48 hours of injury in patients with PC did not significantly increase the odds of 30-day mortality. Similarly, early pAC was not significantly associated with retained hemothorax or pneumonia. Delayed pAC was also not associated with VTE. Of the propensity score-matched groups, those with early pAC had a decrease between their pre- and post-pAC nadir oxygen saturation levels while those with delayed pAC had a slight increase (93.2% to 90.1% among early vs 90.9 to 92.1% among delayed, p<0.001). Changes in oxygen requirements before and after pAC, however, did not differ between the two groups (37% to 28% among early vs 36% to 25% among delayed, p=0.401).

Conclusion: In this study, early vs delayed pAC did not significantly impact outcomes in patients with PC, suggesting that other clinical factors should guide timing of pAC in adult trauma patients.

11.02 Putting the Pieces Together: A Principal Component Analysis of Acute Traumatic Coagulopathy in Kids

Posted on January 25, 2017

C. M. Leeper1,2, M. D. Neal2, C. McKenna1, T. Billiar2, B. A. Gaines1  1Children’s Hospital Of Pittsburgh Of UPMC,Pediatric Surgery,Pittsburgh, PA, USA 2University Of Pittsburgh Medical Center,General Surgery,Pittsburgh, PA, USA

Introduction:
Injured children commonly present with acute traumatic coagulopathy (ATC) defined by elevated international normalized ratio (INR). ATC is associated with poor outcome, though these patients usually are not clinically coagulopathic. INR, therefore, is not always a therapeutic target but rather a marker of complex systemic dysregulation. Our goal is to evaluate multiple coagulation parameters that encompass the broader hemostatic system and identify patterns after injury that may be associated with clinical outcomes.

Methods:
We performed principal components analysis (PCA) on prospectively collected data from children with highest trauma activation in our pediatric center from June 2015-June 2016. Admission labs included INR, platelet count and thromboelastography (TEG) parameters (clotting factors (ACT), fibrinogen (K), platelet function (MA) and fibrinolysis (LY30)). Variables were reduced to principal components (PC) and PC scores were generated for each subject for use in logistic regression. Outcomes included mortality, disability (based on functional independence measure score or discharge to rehabilitation facility), venous thromboembolism (VTE; screening ultrasound for high-risk or symptomatic patients), and blood transfusion in the first 24 hours.

Results:
133 subjects were included with median(IQR) age =10(5-13), median(IQR) ISS =17(9-25), 73.5% male, 70.8% blunt trauma. The rate of mortality was 5.6% (n=7), disability was 23.9% (n=28), early blood transfusion was 26.3%(n=35) and VTE was 10.3%(n=11). PCA identified 3 significant PCs accounting for 75.0% of overall variance. PC1 identified clot strength (platelets and fibrinogen); PC2 identified abnormal fibrinolysis, both hyperfibrinolysis and fibrinolysis shutdown (LY30 and INR); and PC3 identified global clotting factor depletion (INR and K). PC1 score was associated with increased mortality (odds ratio [OR] =1.63; p<0.001) and early transfusion (OR 1.36; p=0.002). PC2 score was correlated with ISS (rho 0.4; p<0.001) and associated with VTE (OR 1.84; p=0.034), functional disability (OR 1.66; p=0.017), increased mortality (OR 2.07; p=0.003) and early blood transfusion (OR 2.79; p<0.001). PC3 score was associated with increased mortality (OR 1.92; p=0.007) and early transfusion (OR 1.25; p=0.075).

Conclusion:
PCA detects three distinct patterns of coagulation dysregulation using widely available laboratory parameters: 1) abnormalities in clot strength; 2) abnormalities in fibrinolysis, and 3) clotting factor depletion. All were associated with poor outcomes; however, fibrinolytic dysregulation is associated with more severely injured patients and portends particularly poor outcome including increased mortality, DVT, disability and need for transfusion.
 

11.01 Massive Transfusion Protocol is Associated with Higher Rate of Venous Thromboembolism

Posted on January 25, 2017

N. K. Dhillon1, E. J. Smith1, A. Ko1, M. Y. Harada1, K. Patel1, M. Scheipe1, G. Barmparas1, E. J. Ley1  1Cedars-Sinai Medical Center,Los Angeles, CA, USA

Introduction:  Massive Transfusion Protocol (MTP) is often initiated in patients who are unstable secondary to hemorrhagic shock. Thrombotic events have been associated with MTP, however the risk factors for the development of venous thromboembolism (VTE) within this patient population is unknown.

Methods:  A retrospective review was conducted by examining the electronic medical records of all trauma patients admitted to a Level I trauma center who had MTP initiated from 2011 to 2015. Data was collected on patient demographics, mechanism of injury, injury severity scores, quantity of packed red blood cells (PRBC) transfused during MTP activation, incidence of VTE, ICU length of stay (LOS), hospital LOS, and ventilator days.

Results: Of the 63 patients identified who had MTP activated, 11 (17.5%) developed a VTE during their hospital admission. One patient was diagnosed with a pulmonary embolus. Patients who developed VTE were compared to those who did not. Age (40 (22-62) vs. 42.5 (25.5-54) years, p=0.94), sex (46% vs. 73% male, p=0.09), and mechanism of injury (59% vs. 64% blunt, p=1.0) were similar. ICU LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE (Table 1). Multivariable analysis revealed an increase in the odds for developing a VTE with each unit of PRBC transfused (AOR=1.17, p=0.011).

Conclusion: Patients who received PRBC after MTP activation were at higher risk for developing VTE. Clinicians may need a higher suspicion for the presence of VTE within this patient population.

 

08.20 The Surgical Treatment Of Graves' Disease in the Pediatric Population

Posted on January 25, 2017

B. C. James1, M. Landman3, R. Danforth2, W. Bennett4  1Indiana University,Endocrine Surgery/Surgery/School Of Medicine,Indianapolis, IN, USA 2Indiana University,Plastic Surgery/Surgery/School Of Medicine,Indianapolis, IN, USA 3Indiana University,Pediatric Surgery/Surgery/School Of Medicine,Indianapolis, IN, USA 4Indiana University,Pediaric Gastroenterology/Pediatrics/School Of Medicine,Indianapolis, IN, USA

Introduction:

Graves’ disease is the leading cause of hyperthyroidism in pediatric patients and can be a significant source of educational, social, and physiologic disturbances. Children with Graves’ disease unfortunately face lower rates of remission and higher rates of recurrence than their adult counterparts with medical treatment. Whether thyroidectomy or radioiodine therapy is the treatment of choice in children remains controversial, and there is a lack of multi-center data regarding the demographics, outcomes, and complications of total thyroidectomy in children. We aim to evaluate outcomes in the surgical treatment of Graves’ disease in the pediatric population.

Methods:
A retrospective analysis was performed using the Pediatric Health Information System (PHIS), an administrative database of from over 46 children’s hospitals with encounters from 2004 to present. All pediatric patients in the database with the diagnosis of Graves’ disease (ICD-9 242.XX) who underwent total thyroidectomy (ICD-9-CM 06.4) were included. The primary outcomes examined included: length of stay, hypocalcemia or hypoparathyroidism, and vocal cord paralysis. Logistic regression was performed to determine which hospital and patient factors contributed to these outcomes.

Results:
The study cohort included 883 pediatric patients who underwent total thyroidectomy for the treatment of Graves’ Disease.  The mean age was 13.5 years, 80.3% were female, and the majority were white (62.2%). Eleven patients (1.2%) developed vocal cord paralysis postoperatively and 231 (26%) patients were diagnosed with hypocalcemia. Infants had an increased risk of hypoparathyroidism (OR 2.1, p=0.004). Additionally, infants (OR 2.1, p=0.002) and children ages 2-7 years (OR 1.1, p=0.009) had longer hospitalizations than preadolescents and adolescents. Hospital volume below the highest quartile was also associated with length of stay greater than 48 hours (OR 1.15, p=0.002).

Conclusions:
Our study supports the surgical treatment of Graves’ Disease in the pediatric population, since we report similar rates of hypocalcemia and nerve injury to the adult population.  Further research should be conducted to compare thyroidectomy to radioiodine therapy.

08.19 Age at Diagnosis Correlates with Outcomes of Patients with Ovarian Yolk Sac Tumors

Posted on January 25, 2017

A. Waters1, I. Maizlin1, K. Gow2, M. Langer5, M. Goldfarb3, J. Nuchtern4, S. Vasudevan4, A. Goldin2, M. Ravul7, J. Doski6, E. Beierle1  1University Of Alabama At Birmingham,Pediatric Surgery,Birmingham, AL, USA 2University Of Washington,Surgery,Seattle, WA, USA 3Providence Saint John’s Health Center,Surgery,Santa Monica, CA, USA 4Baylor College Of Medicine,Surgery,Houston, TX, USA 5Maine Medical Center,Surgery,Portland, ME, USA 6University Of Texas Health Science Center At San Antonio,Surgery,San Antonio, TX, USA 7Emory University School Of Medicine,Surgery,Atlanta, GA, USA

Introduction: Yolk sac tumors (YST) of the ovary are malignant tumors frequently diagnosed in teenagers and young adults. Publications have demonstrated an association between stage of disease and mortality. However, it is not clear what effect age at diagnosis has on ovarian YST prognosis. We queried the National Cancer Data Base to determine if age at diagnosis is a prognostic factor for overall survival (OS) in ovarian YST patients.

Methods: The NCDB (1998-2012) was reviewed for cases. Patients were stratified by age at diagnosis into ≤15, 16-25, 26-40, and ≥41 years. Log-rank test was used to compare survival. Demographics, presence of comorbidities, tumor characteristics, diagnostic periods, treatments, and survival rates were compared using pooled variance t-tests and x ², followed by multivariate Cox proportional hazard model (α=0.05).

Results:Of 229,194 patients in the ovarian NCDB, there were 721 patients with ovarian YST. Patients were grouped according to age at diagnosis (≤15 years: N=156; 16-25: N=267; 26-40: N=175; ≥41: N=123). Race, socioeconomic status, and comorbidities were similar across groups. The time between diagnosis and staging (p=0.511), initiation of treatment (p=0.616), and definitive surgical procedure (p=0.068) were similar. Incidents of local tumor extension increased with age, with children ≤15 years more likely to be diagnosed with tumor confined to the ovary (T1 disease) compared to women >41 (60.4% vs 40.7%, p=0.002). Similar results were found comparing metastases: 9.7% of patients ≤15 had metastatic disease, as opposed to 30.2% of those ≥41 (p<0.001). Consequently, increase in age appeared to be associated with higher overall neoplasm stage at presentation, with patients ≤15 having 51.3% stage I and 12.2% stage IV while patients ≥41 had 32.9% and 25.7% respectively (p<0.001). In multivariate analysis, accounting for demographics, socioeconomic factors, presence of comorbidities, treatment modalities and stage of disease, only age and stage affected survival. Cox regression demonstrated increase in stage to be correlated with decrease in OS (p=0.002, HR=1.398, 1.928, 2.308 for each successive stage beyond the first). Controlling for effect of stage, OS was significantly higher in the younger age group and decreased chronologically with age (p<0.001; HR=1.083, 2.202 and 8.030 for each successive age group compared to the youngest age group). 

Conclusion:The results confirmed that increase in stage of disease negatively affects survival in ovarian YST. They also suggest that an earlier age at diagnosis of ovarian YST correlates with decreased rates of mortality. Therefore, age at diagnosis may be used as evidence-based risk stratification for prognosis.

 

08.18 Pediatric Gastrostomy Tubes and Techniques: Making Safer and Cleaner Choices

Posted on January 25, 2017

B. Carr1, C. Sutherland1, K. Biddle1, M. Jarboe1, S. Gadepalli1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Gastrostomy tube placement is a common procedure which can involve various techniques and types of tubes, and risks a number of common complications.  In an effort to standardize practice at our institution, we retrospectively evaluated complications including early dislodgement requiring operative repair, leaks, and granulation tissue to determine the ideal technique and tube type.

Methods:
A retrospective cohort study (June, 2008 – June, 2014) evaluating children(<18) receiving gastrostomy tubes was completed. We recorded demographic data, tube type, placement technique, and postoperative complications within 120 days, comparing the groups before and after 2012. Tube types included long tubes, low-profile tubes (buttons) and standard PEG tubes. Techniques were categorized as standard pull-type technique for PEGs, “push” technique using transabdominal sutures or fasteners for anterior apposition of the stomach, and those with fascial sutures securing the stomach wall to the edges of the abdominal fascial defect. Descriptive statistics were analyzed using t-test, chi-square, Kruskal-Wallis and age-adjusted outcomes with p<0.05 considered significant.

Results:
Of the 450 patients, 52% had long tubes, 26.7% buttons, and 21.3% PEGs, placed with fascial (54.4%), push (24.9%,) or pull (20.7%) techniques. Complications were lowest for the push technique and for button placement. As the number of buttons placed using push technique increased (6% to 68%), we saw a concomitant drop in dislodgements (6.8%v1.8%,p=0.03) and leaks (32.3%v20.8%,p=0.02), without any increase in granulation (51.3%v52%,p=0.9).

Conclusion:
Push technique to place button tubes was associated with the lowest complication rate and we recommend standardization to this approach and tube type.
 

08.17 Perioperative Blood Transfusion and Complication Risk in Children Undergoing Resection of Solid Tumors

Posted on January 25, 2017

D. O. Gonzalez1, J. N. Cooper1, E. Kelly2, P. C. Minneci1, K. J. Deans1, J. H. Aldrink1  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 2Ohio State University,College Of Medicine,Columbus, OH, USA

Introduction:  While transfusions are thought to be associated with a higher risk of complications, there is a paucity of data on outcomes related to perioperative blood transfusion (PBT) in the pediatric population. The objective of this study was to assess whether PBT is associated with a higher risk of postoperative complications in pediatric patients undergoing resection of solid tumors.

Methods:  Using the 2012-2014 NSQIP-Pediatric datasets, we identified patients aged 0 to 18 years who underwent resection of solid tumors of the liver, retroperitoneum, mediastinum, skeleton, soft tissue, ovary, kidney, or adrenal gland. We compared demographic, clinical and 30-day outcome characteristics between children who did and did not receive a PBT within 72 hours after the start of surgery using Wilcoxon rank-sum tests, Pearson chi-square tests, or Fisher exact tests. Propensity score matched analyses were used to estimate the effect of a PBT on the risk of a postoperative complication. All analyses were repeated in the subgroup of patients with liver tumors, as they were most likely to receive a PBT and develop postoperative complications.

Results: Of 961 patients who underwent resection of solid tumors, 267 (27.8%) required a PBT. Patients requiring a PBT were more likely to have preoperative risk factors, including ventilator dependence, hematologic disorders, chemotherapy, sepsis, blood transfusion within 48 hours prior to surgery, and an ASA class of 3 or greater (all p≤0.01). Postoperatively, patients requiring a PBT were more likely to have pneumonia and sepsis, and require the following: postoperative mechanical ventilation, unplanned intubation/reintubation, unplanned reoperation, and nutritional support or oxygen supplementation at discharge or at 30 days (all p<0.05). In propensity score matched analyses of 215 patient pairs, PBT was not significantly associated with overall complication risk (OR: 1.50, 95% CI: 0.97-2.32, p=0.07) but was significantly associated with an increased risk of postoperative mechanical ventilation (OR: 3.78, 95% CI: 1.81-7.88, p<0.001) and a longer length of stay (LOS) (median 7 vs. 5 days, p<0.001). Of 163 patients with liver tumors, 86 (52.8%) required a PBT, and those receiving a PBT were more likely to have any complication (51.2% vs. 32.5%, p=0.02).After propensity matching, PBT was no longer associated with a higher risk for postoperative complications (OR: 2.00, 95% CI: 0.90-4.45, p=0.09), but was still associated with a longer LOS (8 vs. 5 days, p=0.004).

Conclusion: Over 25% of children undergoing resection of solid tumors require a PBT. After accounting for demographic and clinical differences, PBT was associated with only a higher risk for postoperative mechanical ventilation and a longer LOS. Similar results were found in the subgroup of patients who underwent resection of liver tumors.

 

08.16 Outcomes for Thoracoscopic Versus Open Repair of Small-Moderate Congenital Diaphragmatic Hernias

Posted on January 25, 2017

C. N. Criss1, M. A. Coughlin2, N. Matsuko3, S. K. Gadepalli1  1C.S. Mott Children’s Hospital,Pediatric Surgery,Ann Arbor, MI, USA 2Henry Ford Health System,General Surgery,Detroid, MI, USA 3University Of Michigan Health System,General Surgery,Ann Arbor, MI, USA

Introduction:  Despite its popularity, the thoracoscopic approach to congenital diaphragmatic hernia (CDH) repairs continues to be heavily debated and criticized.  The variability in defect size, disease severity and patient characteristics pose a challenge when determining the ideal technique. Few studies use a patient and disease-matched comparison of techniques. We aimed to compare the clinical outcomes of open versus thoracoscopic repairs of small to moderate sized hernia defects in a low risk population.

Methods:  All neonates receiving CDH repair of small (type A) and moderate (type B) size defects (as defined by the CDH study group) at an academic children’s hospital between 2006 and 2015 were retrospectively reviewed and analyzed. Patients less than 36 weeks EGA, weighing less than 1500 kg at birth, and requiring ECMO were excluded.  Demographics, including CDH severity index, and hernia characteristics were recorded. Primary outcome parameter was recurrence. Secondary outcomes included length of hospital stay, length of mechanical ventilation, time to goal feeds, time to recurrence and mortality.  

Results: The 49 patients receiving thoracoscopic (34) and open (15) repairs were similar in patient and hernia characteristics, with median 27 month follow-up (range 1-102) for both groups. A patch was utilized in 2 (13.3%) open repairs and 9 (26.5%) thoracoscopic repairs (p=0.3).Patients with thoracoscopic repair had shorter hospital stay (16 vs. 23 days, p=0.03), days on ventilator (5 vs. 12, p=0.02), days to start of enteral feeds (5 vs 10, p<0.001), and days to goal feeds (11 vs. 20, p=0.006). Higher recurrence rates in the thoracoscopic groups (14.7% vs. 6.7%) were not statistically significant (p=0.45).  Average time to recurrence was 88 days for the open repair and 648 days (range 104-1837) for the thoracoscopic group. A single mortality was noted in the thoracoscopic group (3%). 

Conclusion: In low risk patients presenting with small to moderate size defects, a thoracoscopic approach demonstrated decreased hospital length of stay, shorter mechanical ventilation days, and a shorter time to feeding. Despite these favorable outcomes, the long-term effectiveness of a thoracoscopic repair versus open repair remains debatable.

 

08.15 Analysis of Water Sports Injuries Admitted to a Pediatric Trauma Center: A 13-year Experience

Posted on January 25, 2017

D. B. Horkan2, M. L. Bandeian1, J. E. Sola1, C. A. Karcutskie2, C. J. Allen2, E. A. Perez1, E. B. Lineen1, A. R. Hogan1, H. L. Neville1  1University Of Miami,Division Of Pediatric Surgery,Miami, FLORIDA, USA 2Ryder Trauma Center, Holtz Children’s Hospital,Division Of Pediatric Surgery,Miami, FLORIDA, USA

Introduction: The literature related to pediatric injury during recreational water sports is sparse. Herein, we compare pediatric water sports-related injury (WSI) factors to those occurring in the better documented mechanism of motor vehicle collision-related injuries (MVC).

Methods:   Retrospective review of 1935 patients aged <18 years admitted to a level 1 pediatric trauma center from 1/2000-8/2013 was performed. Demographics, injury descriptors, and outcomes were reviewed for each patient. Categorical variables were compared by Chi square or Fisher’s exact test, and continuous by t-test or Mann Whitney U test. Parametric data are reported as mean ± standard deviation and nonparametric as median (interquartile range). Significance was set at alpha level 0.05.

Results:  Eighteen patients were admitted for WSI excluding drownings. Age was 12±4 years, 72% male, 89% white, 44% tourists, 67% blunt injury, Injury Severity Score (ISS) 11±10, and Revised Trauma Score (RTS) 7.841(6.055-7.841). Penetrating/propeller injury accounted for all non-blunt injuries. 44% occurred by personal water craft, 39% by boat, and 17% by other means (diving/tubing/kite surfing). The most common WSI included skin/soft-tissue lacerations (59%), head injury/concussion (33%), tendon/ligament lacerations (28%), and extremity fractures (28%). Compared to 615 patients admitted for MVC, age, sex, race, Glasgow Coma Scale, ISS, RTS, spleen and liver laceration rates, neurosurgical consultation, ICU admission, ICU and total lengths of stay (LOS), and mortality were similar. WSI compared to MVC occurred more often in non-Hispanics (83% vs. 65%, p=0.43) and tourists (44% vs. 5%, p<0.000), were more often transferred from an outside hospital (39% vs. 8%, p=0.003), and more often occurred by penetrating mechanism (33% vs. 0.2%, p<0.000). WSI showed a significantly higher requirement for any surgical intervention (61% vs. 15%, p=0.001). The rate of open fracture (28% vs. 6%, p=0.006) and, subsequently, orthopedic procedures (39% vs. 17%, p=0.027) were also higher. 

Conclusion: WSI more often occur by a penetrating mechanism and show higher operative rates than MVC injuries of similar severity occurring in a pediatric population. Higher rate of transfer for WSI reflects this greater requirement for surgical care. Primary prevention strategies, particularly targeting tourists and tourist venues, should be implemented to reduce water sport-related injuries.  

 

08.14 Pre-operative concerns before elective pediatric surgery: The parental perspective

Posted on January 25, 2017

R. Wright1, C. Mueller1  1Stanford University,Surgery,Palo Alto, CA, USA

Introduction:

To understand what thoughts about healthcare lie in the minds of patients would be of tremendous benefit to treating physicians.  For surgeons, a knowledge of patient concerns in the pre-operative period can be of especial relevance, as that would facilitate communication specifically designed to address these individual interests.  In our study, we aimed to examine parental understanding of pediatric surgical procedures as well as parents’ questions and concerns before surgery.

Methods:
100 parents were approached during a pre-operative visit to Pediatric Surgery clinic.  After being seen by an attending surgeon, participants were given a paper-and-pencil survey aimed at assessing their preoperative questions and concerns.

Results:
Parents were generally very accurate in their description of the upcoming procedure (97%) and the benefits to be gained (93%).  However, 89% of parents reported have residual questions at the end of their clinic visit.  The majority of these questions focused on issues of safety and post-operative recovery.  In terms of additional fears/concerns, parents focused on pain (14%), anesthesia (12%), post-operative activities (11%), and patient anxiety (10%).  Interestingly, most parents seemed relatively uninterested in issues of cosmesis, with only 8% of questions aimed at this aspect of care.  Further, parents were  neutral in their ratings of all aspects of surgical scars: potential appearance (mean = 3.02, SD 1.81), length (mean = 3.00, SD 1.88), width (mean = 3.01, SD 1.81), location (mean 3.00, SD = 1.80).  No significant differences were found based on gender or age of children or parents.

Conclusion:

In spite of thorough conversations conducted by attending pediatric surgeons, the majority of parents whose children face elective surgery have a variety of unresolved concerns when they leave their initial clinic visit.  We have been able to identify several categories into which these questions fall, notably safety and post-operative logistics.  Rather surprisingly, questions about cosmesis or scar appearance were infrequent and seemed to carry less weight than might be assumed by many surgeons.  We suggest that surgeons take into account these findings in order to better target patient conversations in the clinic setting and thereby potentially decrease pre-operative anxieties.

08.13 Weekend vs. Weekday Appendectomy, Effects on Outcomes: A Propensity Score Matched Outcomes Study

Posted on January 25, 2017

J. Tashiro1, E. A. Perez1, J. E. Sola1  1University Of Miami,Surgery,Miami, FL, USA

Introduction:  We hypothesized that laparoscopic (LA) or open appendectomy (OA) outcomes are associated with weekend vs. weekday procedure date.

Methods:  We queried the Kids’ Inpatient Database (1997-2012) for simple (540.9) and complicated (540.0, 540.1) appendicitis treated with LA or OA. Propensity score (PS)-matched analysis compared outcomes associated with weekend vs. weekday LA and OA.

Results: Overall, 644,488 cases of simple and 147,952 cases of complicated appendicitis were identified.

On 1:1 propensity score (PS)-matched analyses of simple appendicitis, weekday OA had higher incision and drainage of wound (odds ratio: 2.2) and sepsis (odds ratio: 1.8) rates vs. weekend OA, p<0.04. Weekend OA had higher intraoperative perforation (1.9) and wound infection (1.5) rates and cost vs. weekday OA, p<0.02. Weekday LA had higher rates of wound infection (1.3) and pneumonia (1.4), but lower total charges (TC) vs. weekend LA, p<0.05.

For complicated appendicitis, weekday OA had increased wound infection rates (1.3) vs. weekend OA, p=0.003. Weekend OA had higher pneumonia rates (1.4) and longer LOS, but lower home healthcare requirement following discharge vs. weekday OA, p<0.05. Weekend LA had higher TC vs. weekday LA, p<0.001.

Conclusion: On a PS-matched comparison of appendectomies performed for simple and complicated appendicitis on weekends and weekdays, procedure day is associated with different complication rates and resource utilization for OA and LA. 

08.12 Mortality After Emergency Abdominal Operations in Premature Infants

Posted on January 25, 2017

S. B. Cairo2, B. Tabak1,2, L. Berman4, S. K. Berkelhamer3, D. H. Rothstein1,2  1State University Of New York At Buffalo,Pediatric Surgery,Buffalo, NY, USA 2Women And Children’s Hospital Of Buffalo,Pediatric Surgery,Buffalo, NY, USA 3Women And Children’s Hospital Of Buffalo,Neonatology,Buffalo, NY, USA 4Nemours Alfred I. DuPont Hospital For Children,Pediatric Surgery,Wilmington, DE, USA

Introduction:
Premature infants undergoing abdominal operations early in life are thought to have high perioperative mortality. Risk factors for mortality beyond simple prematurity are poorly understood. This study seeks to quantify 30-day mortality in premature infants undergoing emergency abdominal operations during the first two months of life to better inform interdisciplinary and family discussions surrounding operative risks.

Methods:
Retrospective descriptive analysis of premature infants undergoing emergency abdominal operations during the first two months of life using the National Surgical Quality Improvement Project, Pediatric. Crude mortality rates were calculated and stratified by gestational age (GA) and presence of risk factors for death. Birth weight for gestational age, gender, weight at time of operation, race/ethnicity, American Society of Anesthesia (ASA) class, cardiac risk factors, ventilator support and inotrope support at time of operation, and intraventricular hemorrhage (IVH) grade were incorporated into a logistic regression model using stepwise adjustment to calculate adjusted odds ratios for mortality. 

Results:
During the 2012-2014 study period, 1,004 premature infants were identified who underwent emergency abdominal operations in the first two months of life. Unadjusted 30-day mortality rates ranged from 27% for infants ≤ 24 weeks’ gestational age, to 4% for 35-36 week gestational age infants (Figure). Decreasing mortality correlated closely with increasing gestational age (R2 = 0.98 for logistic regression). In a multivariate regression model, female gender (aOR 1.58, 95% C.I. 1.09-2.30), race/ethnicity other than “White, non-Hispanic” (aOR 1.97, 95% C.I. 1.33-2.89), ventilator support at time of operation (aOR 5.19, 95% C.I. 2.16-12.48), highest ASA class (3.28, 95% C.I. 2.06-5.24) and inotropic support at time of operation (aOR 3.58, 95% C.I. 2.43-5.28) were significantly associated with increased 30-day mortality. None of the following appeared to correlate with increased mortality: birth weight for gestational age, weight at time of surgery, cardiac risk factors, pre-operative steroid use, or presence of IVH. 

Conclusion:
Premature infants undergoing emergency abdominal operations in the first two months of life have expectedly high 30-day mortality rates. Female gender, race/ethnicity other than White/non-Hispanic, highest ASA class, inotropic support and ventilator support are independently associated with increased mortality. These data may be helpful in guiding counseling and the informed consent process for families of high-risk neonates.
 

08.11 Controversies in the Management of Neonatal Testicular Torsion: A Meta-analysis

Posted on January 25, 2017

C. Monteilh2, R. Calixte2, S. Burjonrappa1,2  1Montefiore Medical Center,Surgery/Pediatric Surgery,Bronx, NY, USA 2Winthrop University Hospitals,Surgery/Pediatric Surgery,Mineola, NY, USA

Introduction: Management of neonatal testicular torsion (NTT) is controversial.  Since NTT is detected late many surgeons adopt a wait and watch approach as testicular salvage is unlikely in this setting. There are others who however strongly believe in immediate exploration and perform an orchiopexy on the opposite side simultaneously or after a few months. We performed a meta-analysis to evaluate the optimal management strategy.  

Methods: We reviewed all English language articles published between 2005-2015 in Medline, Pubmed and SCOPUS that had a defined diagnosis of NTT within the first thirty days of life, and discussed surgical and non-surgical management. Exclusion criteria were non-English literature, case reports, case studies, and failure to clearly describe management of NNT. The main characteristics of the studies evaluated were mode of delivery, laterality, and management of ipsilateral and contralateral testes.  Data from selected studies were analyzed using a random effect model with a random intercept to estimate the pooled proportions of interest.  Results are presented with 95% confidence interval.  All analyses were done in SAS 9.4®.  Each study was evaluated separately as well as pooled together to form combined data. All studies included in the meta-analysis were used to estimate pooled confidence intervals (CI).

Results:
 9 studies with 196 patients were included in the analysis. The pooled proportion of neonates with right testicular torsion was 0.43 ( 95% CI= 0.34 to 0.53).  The pooled proportion for left testicular torsion was 0.49 (95% CI= 0.39- 0.59). 7% of patients in the included studies had bilateral testicular torsion (95%CI=3%-15%). Synchronous testicular torsion occurred in 1% of those patients ( 95% CI= 0% -5%).  Asynchronous testicular torsion occurred in 4% of those patients (95% CI=1% to 11%). The pooled vaginal delivery rate was 54% (95% CI= 17% -87%) vs. a rate of 12% (95% CI= 6% -23%) for c-section delivery. Diagnosis at birth was made in 56% (CI 0.13-0.92)  and post natal diagnosis was made in 10% (CI 0.03-0.31). NTT was seen in full term infants in 70% of studied patients (CI 0.07-0.99) and in 2% of premature infants (CI 0.01-0.10).  In patients who had both testicles explored soon after diagnosis 75% underwent ipsilateral orchiectomy (CI 0.49-0.90) and testicle was salvaged in 6% (CI 0.02-0.14). There were no reports of contralateral torsion in this group. In patients who had ipsilateral exploration only, salvage was possible in 1% (CI 0-0.06) and no contralateral torsion on follow up was reported in this group. Only one study reported contralateral exploration only with no reported contralateral torsion in follow up. Two studies reported observation only with no reported contralateral torsion.

Conclusions: Testicular salvage after NTT is rare.  Unless the event is clearly diagnosed post-nataly, observation alone would be a judicious choice for management of the ipsilateral (affected side)  NTT.

08.10 Predictors and Outcome for Fetuses with Neck Masses

Posted on January 25, 2017

C. C. Style3, S. M. Cruz3, O. O. Olutoye2,3,5, P. Lau3, D. A. Lazar3,5, T. C. Lee3,5, R. Ruano2,6, S. E. Welty4,6, S. Keswani3,5, D. L. Cass3,5  1Texas Children’s Hospital,Micheal E. DeBakey Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Obstetrics And Gynecology,Houston, TX, USA 3Baylor College Of Medicine,Micheal E. DeBakey Department Of Surgery,Houston, TX, USA 4Texas Children’s Hospital,Pediatrics – Newborn Section,Houston, TX, USA 5Texas Children’s Hospital,Fetal Center,Houston, TX, USA 6Baylor College Of Medicine,Houston, TX, USA

Introduction:  

Fetal neck masses encompass an array of rare congenital malformations that can have potentially devastating consequences in the perinatal period.  Prenatal MRI and calculation of the tracheoesophageal displacement index (TEDI) helps to risk-stratify fetuses at risk for airway obstruction and those who may most benefit from an ex-utero intrapartum treatment (EXIT) at delivery.  Other postnatal complications experienced by these infants include respiratory failure, feeding problems, cosmetic disfigurement, and persistent disease.  The purpose of this study is to evaluate the association between prenatal features and postnatal outcomes, and indications for an EXIT procedure in this population.

Methods:

A single center retrospective review was performed on all fetuses referred to our institution from July 2001 to January 2016 with a prenatal ultrasound diagnosis of neck mass.  Imaging features, fetal diagnosis, treatment modality, and fetal and postnatal outcomes were evaluated.  At birth, each infant’s airway was classified as uncomplicated or complicated.  Fetal diagnosis was compared to postnatal diagnosis as confirmed by surgical and pathological findings

Results:

Of 47 fetuses identified, 3 had pregnancy termination; 5 had fetal demise.  Fetal diagnostic accuracy was 97%; 1 case of thymic cyst was not accurately diagnosed antenatally.  Prenatal findings of a teratoma diagnosis (9/10), polyhydramnios (61% vs 33%), small stomach bubble (52% vs 0%), mass size (10 [4-15] vs 7 [2-20]), and TEDI >12 all correlated with a difficult airway at birth.  EXIT procedures, performed for 20 fetuses with teratoma or large lymphatic malformation (see table), were associated with similar outcomes with regard to survival (77% vs 81% respectively, p=0.54) and long term pulmonary morbidity compared to those not requiring EXIT.  With multivariate regression analysis, location of the mass (anterior or posterior), presence of polyhydramnios, and mass size as per fetal MRI were independent prenatal predictors of survival at 6 months (p=0.001). 

 

Conclusion:
Fetuses diagnosed prenatally with neck mass that are at a high risk for difficult airway can be safely delivered via an EXIT. They have a similar rate of survival and morbidity as those fetuses of lower risk who did not require an EXIT. These findings can help aid in the prenatal counseling of these patients.

08.09 The Effect of Level-of-Care on Gastroschisis Outcomes, Independent of Surgical Volume

Posted on January 25, 2017

J. C. Apfeld1, Z. J. Kastenberg1,5, K. G. Sylvester1,2,3,4, H. C. Lee3,4  1Stanford University School Of Medicine,Department Of Surgery,Palo Alto, CA, USA 2Stanford University School Of Medicine,Center For Maternal And Fetal Health, Lucile Packard Children’s Hospital,Palo Alto, CA, USA 3Stanford University School Of Medicine,Department Of Pediatrics,Palo Alto, CA, USA 4Stanford University,California Perinatal Quality Care Collaborative (CPQCC),Palo Alto, CA, USA 5Stanford University School Of Medicine,Center For Health Policy/Center For Primary Care And Outcomes Research,Stanford, CA, USA

Introduction:

There has been significant expansion in low-level (AAP 2007 designation IIA,IIB) and midlevel (IIIA,B) neonatal intensive care units (NICUs) in recent decades. Previous literature has established the relationship between case-specific surgical volume and outcomes. It is also widely recognized that very-low-birthweight (VLBW) infants experience better outcomes at higher-volume/level-of-care NICU’s. The relationship between expertise of the center and neonatal surgical volumes for specific anomalies is less well established. We sought to determine the relationship between outcomes for infants born with gastroschisis and volume/level-of-expertise of the treating center. 

Methods:

A retrospective cohort study was conducted of NICUs in California. We used data from the California Perinatal Quality Care Collaborative from 2008-2014 to assess outcomes among a population-based sample of 1588 gastroschisis infants, according to levels of NICU care. Birth at each respective AAP Level was examined, alongside different birth-hospital volume measurements. SAS 9.3 was used for univariate and multivariate analysis to examine mortality, total days on ventilation, and total length of stay.

Results:

1588 total infants were born with gastroschisis between 2008-2014, 146 at NICUS with AAP Level IIA or B, 133 at Level IIIA, 633 at IIIB NICUs, and 666 at IIIC NICUs.  Infants born at Level IIIA NICUs had higher adjusted odds of acute transfer to a higher NICU level at 14.4 (95% CI, 8.8-23.5) and adjusted odds of death at 2.2 (CI, 0.8-6.2), while ORs for mortality at level IIIB were 1.5 (CI, 0.7-3.0) and at level IIIC were 0.5 (CI, 0.2-1.1). In multivariate linear regression, infants born at Level IIIB NICUs had longer time on a ventilator by 1 days (p=0.04) and longer total length of stay by 6 days (p=0.01).  Births at Level IIA/B had a significantly longer time on a ventilator at 5.2 days (p<0.001) and longer length of stay at 5.5 days (p=0.16). IIIC NICUs had shorter time on a ventilator by 2.1 days (p<0.0001) and a shorter length of stay by 6.6 days (p=0.005).  Lower hospital NICU volume and VLBW volume trended towards higher mortality, more days on ventilation, and longer length of stay, but were not statistically significant predictor variables. Hospital volumes for both gastroschisis births and repairs were not associated with the outcome variables.

Conclusions:

Outcomes for gastroschisis in the state of California varied by NICU AAP Level designation and were less dependent on annual hospital gastroschisis births and repair volume. We also find that AAP NICU designation is more important then either overall NICU volume, or VLBW volume as a surrogate for experience with complex newborn care. Taken together, these data suggest that neonatal outcomes are sensitive to the level of comprehensive care provided in the NICU for congenital surgical anomalies of moderate technical complexity like gastroschisis.

 

08.07 Establishing Ventilatory Management in Neonates with Congenital Diaphragmatic Hernia

Posted on January 25, 2017

S. M. Cruz1, S. E. Horne1, O. O. Olutoye1, P. E. Lau1, T. C. Lee1, C. J. Fernandes2, J. M. Adams2, S. E. Welty2, J. R. Kaiser2, C. J. Rhee2, D. L. Cass1  1Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Neonatology,Houston, TX, USA

Introduction:

A “gentle” ventilation strategy is recommended in the management of neonates with congenital diaphragmatic hernia (CDH) with limits to peak inspiratory pressure (PIP) of 25-26 cm H2O. We hypothesized that neonates treated with conventional ventilator PIPs >26 cm H2O or with high-frequency oscillatory ventilation (HFOV) were more likely to die or require extracorporeal membrane oxygenation (ECMO) than those who did not.  

Methods:

The charts of all neonates treated for CDH (admission at <24 hours of life) January 2011-November 2015 were reviewed with emphasis on ventilator parameters and outcomes. All infants were treated with a “gentle” ventilation strategy that followed stepwise escalation from conventional ventilation, to HFOV, and then to ECMO.  Statistical analysis was performed using Student's t-test and Mann-Whitney U Test for continuous variables and Fischer's exact for categorical variables.

Results: 

Of 88 neonates, 74% had “liver-up” morphology, 69% received a patch, and survival was 78%. Two neonates had EXIT-to-ECMO; 86 were treated with conventional ventilation; 40 (47%) were transitioned to HFOV, and 24 (28%) were advanced to ECMO (see Figure). Of 46 infants treated with conventional ventilation alone, 32 had PIPs >25 cm H2O, and 6-month survival was 96%. Of 40 infants advanced to HFOV, 16 did not receive ECMO, and survival was 63%. Those treated with ECMO had the worst fetal imaging markers (96% liver up, 67% liver herniation (LH) >20%, 81% observed-to-expected total lung volume (o/e-TFLV) <35%), and survival was 67%. 

Conclusion: 

In the management of neonates with CDH using a gentle ventilation strategy, judicious use of peak inspiratory pressures greater than 25 can lead to favorable outcome without the need for HFOV or ECMO.  Use of HFOV can avoid the need for ECMO in about 40% of infants.  These data argue against CDH management protocols that have strict limits to ventilator pressures. Given that the group who received ECMO had worst fetal imaging markers and yet slightly higher survival, one can question the role of HFOV as an intermediate step in these infants.

 

08.06 Teenage Trauma Patients are at Increased Risk of 30-day Readmission For Mental Disorders

Posted on January 25, 2017

J. Parreco1, A. Payson1, S. Scurci1, J. Tashiro1, J. Sola1  1University Of Miami,Miami, FL, USA

Introduction:
Previous studies have shown that readmission for mental disorders and diseases represents a significant burden after trauma that is treatable as an outpatient. The purpose of this study was to elucidate the risk factors for mental disorders and diseases after trauma that require readmission.

Methods:
The Nationwide Readmission Database (NRD) was queried for all patients with nonelective admissions in 2013 with primary or secondary diagnoses of trauma and with nonelective readmissions within 30-days. Multivariate logistic regression identified risk factors for readmission with a major diagnostic category of mental disorders and diseases. The diagnoses on readmission were evaluated and the total cost of readmissions was calculated.

Results:
During the study period, there were 47,913 patients with readmissions within 30 days after admission for trauma and 1,746 (3.6%) of these readmissions were for mental disorders and diseases. The estimated total cost of 30-day readmissions for mental disorders and diseases was $15,074,957.59 with a nationwide weighted total cost of $32,354,234.43. The strongest predictors for readmission for mental disorders and disease after trauma were penetrating trauma (OR 3.60, p<0.001, 95% CI 3.12 to 4.16), age 13 to 17 (OR 2.47, p<0.001, 95% CI 1.87 to 3.28) and primary expected payer medicare or medicaid (OR 1.86, p<0.001, 95% CI 1.65 to 2.08). The most common primary diagnoses on readmission for mental disorders and diseases after trauma were unspecified psychosis (139, 8.0%) and unspecified schizoaffective disorder (119, 6.8%). While the most common primary diagnosis for all other patients were unspecified septicemia (3,279, 7.1%) and unspecified pneumonia (1,545, 3.3%).

Conclusion:
Penetrating trauma and teenage are significant risk factors for readmission for mental diseases and disorders after trauma. Further research needs to be conducted to determine the most effective methods to treat individuals with these risk factors.
 

08.04 Optimal Timing of Cholecystectomy in Children with Gallstone Pancreatitis

Posted on January 25, 2017

F. O. Badru1, Y. Puckett1, R. Breeden1, M. Bourdillon1, C. Fitzpatrick1, K. Chatoorgoon1, J. Greenspon1, D. Vane1, G. Villalona1  1St. Louis University,Pediatric Surgery,St. Louis, MO, USA

Introduction:  Little data exists regarding the recurrence of pancreatitis in pediatric patients with gallstone pancreatitis awaiting cholecystectomy. It is also unclear whether factors such as preoperative common bile duct (CBD) size and endoscopic retrograde cholangiopancreatography (ERCP) with stent placement reduce the risk of recurrence. This study evaluates the recurrence rate of pancreatitis after acute gallstone pancreatitis based on the timing of cholecystectomy in pediatric patients. We hypothesized that there is an increased recurrence of pancreatitis when cholecystectomy is not performed during the index admission.

Methods:  A retrospective chart review of all consecutive patients admitted with gallstone pancreatitis to a large pediatric center from 2007 to 2015 was performed. Children were divided into five groups depending on the timing of cholecystectomy. Group 1 had surgery during the index admission, group 2 had surgery within 2 weeks of discharge, group 3 had surgery between  2 to 6 weeks post discharge, group 4 had surgery 6 weeks after discharge and group 5 patients had no surgery. Demographic data including type of surgical procedure, age, sex, and race were obtained. The recurrence rates of pancreatitis were calculated for all groups.

Results: A total of 195 patients were treated for pancreatitis in the 8 year period, of which 48 (24.6%) had gallstone pancreatitis. There were 11 (22.9%) males and 37 (77.1%) females, with a median age of 14.4 years (range 1.7 – 17.8 years). Median BMI was 25.8 (15.1 – 48.3). Cholecystectomy was performed in 19 of 48 patients (39.6%) during the index admission, with no recurrence of pancreatitis. Of the remaining 29 patients, nine (31%) had recurrence of pancreatitis or required readmission for abdominal pain prior to cholecystectomy. There recurrence rates were 2/8 in group 2 (25%), 3/8 (37.5%) in group 3, 3/5 (60%) in group 4, and 1/8 (12.5%) in group 5. No children in group 5 had demonstrable gallstones at presentation, but only sludge in their gallbladder. Total mean hospital days for patients in group 1 was 4 days while total mean hospital days for patients in groups 2-4 was 6 days. This resulted in a potential health care dollar savings of $3,664 per patient if cholecystectomy was performed at index admission, without additional patient complications.

Conclusion: Cholecystectomy during the index admission is associated with no recurrence or readmission for pancreatitis. If cholecystectomy is delayed, the rate of recurrent pancreatitis is proportionally increased with time from index admission. Therefore we recommend that cholecystectomy be performed after resolution of an episode of gallstone pancreatitis during index admission. This clinical pathway is not associated with increased surgical complications or bile duct injuries and results in a potential savings of $72,744 for this small group of patients if surgery during the index admission is performed.

08.03 Imaging For Acute Appendicitis at Non-Pediatric Centers Exposes Children to Excess Radiation

Posted on January 25, 2017

F. O. Badru1, Y. Puckett1, N. Piening1, A. To1, P. Xu1, C. Fitzpatrick1, K. Chatoorgoon1, G. Villalona1, J. Greenspon1  1St. Louis University,Pediatric Surgery,St. Louis, MO, USA

Introduction:
Acute appendicitis (AA) is primarily a clinical diagnosis. Nonetheless, radiography is often used to aid the diagnosis with computed tomography (CT) imaging being the most common modality used at non-children’s hospitals. Radiation exposure is the reason for the decreased utilization of CT in pediatric centers (PC) as well as the development of low radiation dose protocols at PCs. We sought to compare the radiation dose exposure of CT imaging performed at outside hospitals (OH) versus PC in pediatric patients with AA.

Methods:
A retrospective review of all patients managed at our PC for AA from January 2011 to  March 2016 was performed. Patients who had CT imaging for AA at OH were compared to those who underwent CT for appendicitis at our PC. Only patients who both received a CT scan and had dose information were included in this study. Demographic data, type of imaging used, location of imaging, CT dose used, use of intravenous contrast (IV) with CT were collected. Radiation dosing was compared using the dose index (CTDI [mGY]) and dose length product (DLP [mGYcm]). Independent samples t-test was used to compare means for radiation dose. Chi Square analysis was used to compare demographic data.

Results:
A total of 956 patients were treated for AA during the study period. A total of 379 patients met inclusion criteria, 59.6% of which were males. Mean age was 11.6 years and 64.6% were Caucasian. Mean duration of symptoms was 2.7 days. There were no difference between both groups demographically. There were 59.4% (225) patients treated primarily at our PC and 40.6% (154) patients were transferred from an OH. When performed at OH, 6.5% of CTs were considered non-diagnostic as they were done without IV contrast compared to 1.3% in our PC. Mean CTDI was 6.9 at our PC and 11.8 at OH ( p<0.0001). Mean DLP at PC was 296.2 versus 456.8 at OH ( p <0.0001). An excess radiation dose of 4.9 mGY and 160.5 mGYcm was noted when CT scan was performed at OH vs PC. Management of all patients were the same regardless of availability and type of imaging performed.

Conclusion:
Using DLP as a gauge of radiation exposure, CT imaging performed at OH has a 44% higher radiation rate relative to the exposure at PC. In cases of suspected AA at a facility without pediatric surgeons, early transfer to PC prior to imaging is advocated.
 

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