73.20 Single-port laparoscopic appendectomy is as safe as traditional 3-port appendectomy

Posted on January 18, 2016

N. A. Hamilton1, M. Wieck1, S. Krishnaswami1 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction: Laparoscopic appendectomy has become the preferred management for acute appendicitis. The use of a single laparoscopic umbilical incision (SPA), where the appendix is suture ligated in an extracorporeal manner similar to open appendectomy, has been proposed as a more cost effective alternative to 3-port appendectomy (3PA) which typically uses more ports and expensive surgical staplers. However, there have been concerns surrounding postoperative outcomes between the two techniques. We sought to review our experience with SPA and 3PA to identify any difference in clinical outcomes between the two techniques.

Methods: The charts of all children (ages 0-17) with a suspected diagnosis of acute appendicitis who underwent appendectomy at a tertiary pediatric referral center from January 2011-January 2014 were retrospectively reviewed. The surgical technique (SPA vs 3PA) was identified, as were any infectious complications. Data was analyzed using Chi square analysis to compare the outcomes in the two groups.

Results: Three-hundred thirty seven patients underwent appendectomy (141 SPA and 197 3PA), 35.6% of whom (40 SPA, 80 3PA) had perforated appendicitis. Of patients with perforated appendicitis, 20.8% developed intra-abdominal abscesses (5 SPA, 20 3PA, p=0.15). Eleven patients developed wound infections (4 SPA, 7 3PA, p=0.77).

Conclusion:SPA does not result in increased infection rates for acute or perforated appendicitis and should be considered an equivalent technical alternative to 3PA in the surgical management of appendicitis.

73.15 Nutritional Adequacy and Outcome in Neonatal and Pediatric Extracorporeal Life Support

Posted on January 18, 2016

K. A. Ohman1, T. CreveCouer1, A. M. Vogel2 1Washington University,Department Of Surgery,St. Louis, MO, USA 2Washington University,Division Of Pediatric Surgery,St. Louis, MO, USA

Introduction: Nutritional adequacy (NA) in intensive care unit patients is low and inversely correlated with morbidity and mortality. Neonatal and pediatric patients requiring extracorporeal life support (ECLS) represent a subset of critically ill patients whose nutritional delivery by enteral (EN) and parenteral (PN) routes has not been well characterized. Barriers to providing nutrition, particularly EN, exist although multiple studies document the feasibility and safety and current guidelines recommend EN for neonates on ECLS. This study describes nutritional delivery in neonatal and pediatric patients who received ECLS with a focus on NA and outcome.

Methods: A single-center, retrospective review of all neonatal and pediatric patients who underwent ECLS from January 1, 2013 through December 31, 2014 was performed. Demographic, clinical, and outcome data was abstracted. Daily energy and protein prescriptions and amount administered were recorded. NA for energy and protein was defined as the mean percentage of what was prescribed and defined as low (<50%), moderate (50-80%), and high (>80%). Patients whose duration of ECLS was < 48 hours were excluded. Congenital diaphragmatic hernia patients were excluded from EN analysis. Descriptive statistical analyses were performed.

Results: We identified 70 patients; 57.1% were male and median age was 4 months (IQR 72 months). 54 (77.1%) were initiated on venoarterial and 16 (22.9%) on venovenous ECLS. Overall survival was 62.9%. Mean ECLS duration was 220.1 hours; mean duration of mechanical ventilation was 20 days. Categories included: 12 (17.1%) neonatal respiratory, 14 (20.0%) pediatric respiratory, 16 (22.9%) neonatal cardiac, and 28 (40.0%) pediatric cardiac. 23 (32.9%) received nutrition prior to ECLS, but only 8 (11.4%) achieved goal EN prior to ECLS. Mean time to initiation of nutrition was 1.1 ± 1.3 days; mean time to initiation of EN was 4.2 ± 3.4 days. Mean time without any nutritional prescription was 1.4 ± 1.4 days; when nutrition was prescribed, mean energy NA was 92% of the daily goal for energy and 100% for protein. Energy NA, when prescribed, for neonatal respiratory, pediatric respiratory, neonatal cardiac, and pediatric cardiac was 89%, 88%, 95%, and 92%, respectively. However, EN only accounted for 24% of the NA goal. However, when all ECLS days are accounted for, including days without nutrition, only 27.1% achieve high NA. There was no direct correlation with survival. Gastrointestinal complications occurred in 13.6% of survivors and 26.7% of non-survivors.

Conclusion: NA in this neonatal and pediatric ECLS population is poor and utilization of enteral nutrition is low. When nutrition is prescribed, NA is met, but overall NA remains poor due to delayed onset and days without nutrition. Survival was not directly associated with NA as there are confounding variables, but improving NA may represent an opportunity to improve outcome in these critically ill patients.

73.16 Gastroschisis: Impact of delivery planning on patient outcomes

Posted on January 18, 2016

S. Burjonrappa1,2, A. Ivanovic2, S. Burjonrappa1,2 1Albert Einstein College Of Medicine,Bronx, NY, USA 2Saint Barnabas Medical Center,Livingston, NJ, USA

Introduction: Success rates of gastroschisis interventions have been increasingly examined but little data is available regarding the impact of the timing of these interventions as well as fetal delivery itself on outcomes. This study aimed to examine the relationships between overall outcomes of patients diagnosed with gastroschisis and timing of delivery (planned versus non planned) and mode of delivery (cesarean section versus vaginal delivery). The primary outcome evaluated was the length hospitalization, and secondary outcomes evaluated included: time to extubation, age at return of bowel function, and time to tolerance of oral feeds.

Methods: This work was performed as a ten-year retrospective chart analysis including patients from 2005 to 2013. Inclusion in the study required a pre-operative diagnosis and a surgical intervention for gastroschisis. We identified 29 patients of interest who were filtered based on availability of the specific timing of each intervention. Chi-square test was used to determine statistical differences amongst categorical variables and the student t-test was used to determine differences amongst continuous variables.

Results: The major factors influencing the Length of hospitalization were age at return of bowel function (p = 0.0213) and age at tolerance of oral feeds (p = 0.0116). Further early extubation was also correlated to a shorter hospital (p = 0.0003). Analysis of mode of delivery, comparing vaginal delivery to Cesarean section, showed that patients delivered by Cesarean section had a reduced length of hospitalization as compared to those delivered vaginally (p = 0.0080). Mode of delivery did not significantly impact the other patient outcomes but we did find that time to oral feeds was increased in those patients undergoing unplanned deliveries (p = 0.0176). No other outcomes were impacted by undergoing a planned versus unplanned gastroschisis delivery. Further, our results show a significant and positive correlation between birth weight and gestational age (p = 0.0164).

Conclusion: Our data suggests that patients delivered without prior planning will have an extended time to tolerance of oral feeds. In addition, we find that patients delivered by Cesarean section will have shorter lengths of hospitalizations. Factors influencing length of stay after gastroschisis, such as return of bowel function and time to tolerance of oral feeds may be related to mode and timing of delivery. Many present studies focus solely on the impact of silo and primary closure in determining gastroschisis outcomes. We recommend that future analysis of larger databases should focus also on peri-partum factors that may influence outcomes in gastroschisis.

73.17 Management of Gallbladder Abnormalities in Pediatric Patients with Metachromatic Leukodystrophy

Posted on January 18, 2016

J. Kim1, Z. Sun1, V. K. Prasad2, J. Kurtzberg2, H. Rice1, E. T. Tracy1 1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke University Medical Center,Pediatrics,Durham, NC, USA

Introduction:
Metachromatic leukodystrophy (MLD) is a lysosomal storage disease (LSD) that leads to progressive neurological deterioration without hematopoietic stem cell transplantation (HSCT). Visceral involvement, including sulphatide deposition in the gallbladder wall, is known to occur in MLD. Our objective was to examine the incidence and outcomes of gallbladder abnormalities in children with MLD compared with children with similar LSDs, such as adrenoleukodystrophy (ALD) and Krabbe Disease.

Methods:
We conducted a retrospective review of 24 consecutive children with MLD and 64 consecutive children with either ALD or Krabbe disease who underwent HSCT at our institution between 1994-2009. Baseline characteristics and unadjusted outcomes were compared using the Kruskal-Wallis test for continuous variables and Pearson χ2 test for categorical variables, with significance defined as p < 0.05.

Results:
In total, gallbladder abnormalities were present in 17 (71%) MLD patients compared with 17 (27%) ALD/Krabbe patients (p < 0.001). In the MLD group, these abnormalities included sludge (54%), wall thickening (38%), contracted gallbladder (42%), cholelithiasis (12%), and polyposis (8%). Prior to HSCT, gallbladder abnormalities were found in 5 (21%) MLD patients and 2 (3%) ALD/Krabbe patients (p = 0.006). After HSCT, an additional 12 (50%) MLD patients and 12 (19%) ALD/Krabbe patients developed gallbladder abnormalities (p = 0.008). Follow-up imaging was available for 14 of the 17 MLD patients who had gallbladder abnormalities. In 13 (93%) MLD patients with follow-up imaging, the gallbladder disease persisted or progressed. Definitive management—laparoscopic cholecystectomy or percutaneous cholecystostomy—was ultimately recommended for 3 (13%) MLD patients and 1 (2%) ALD/Krabbe patients.

Conclusion:

Children with MLD have a significantly greater incidence of gallbladder abnormalities than children with other LSDs, both prior to and after HSCT. Given these findings, children with MLD undergoing HSCT should receive gallbladder imaging pre-transplant and at regular intervals post-transplant. Laparoscopic cholecystectomy should be considered for persistent, symptomatic gallbladder abnormalities.

73.13 The Effect of Growth on Serial Haller Indices

Posted on January 18, 2016

A. S. Poola1, B. G. Dalton1, K. W. Gonzalez1, D. C. Rivard2, J. F. Tobler2, C. W. Iqbal1 1Children’s Mercy Hospital – University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA 2Children’s Mercy Hospital – University Of Missouri Kansas City,Radiology,Kansas City, MO, USA

Introduction:
The Haller Index (HI) has been used as a marker for severity of pectus excavatum. However, how the HI may be affected by growth of the chest wall over time is unknown. Understanding this effect would be valuable in determining if the HI is a useful and objective measure of correction in pectus excavatum; specifically, patients undergoing investigational techniques for repair such as magnetic correction which results in a more gradual change of the chest wall

Methods:

A single institution, retrospective chart review from 2004-2014 was conducted. Patients aged 0-18 years without known chest wall deformities that underwent at least 5 computed tomography (CT) scans were included to assess for changes in the anterior-posterior (AP) dimension, transverse dimension, and the HI.

Results:
Forty-four patients were identified. All patients had an oncologic diagnosis for which serial chest CT scans were obtained. 59 percent of the patients were male. The mean age at initial CT evaluation was 12 years (range: 4-16 years). The mean time between initial and 5th CT scan was 41 months (range: 7-80 months). Over that period, the mean change in height was 10 cm (range: 0-32 cm). Thirty two patients grew more than 5 cm during this time. The mean AP diameter changed at a different rate than the mean transverse diameter (0.9 versus 1.6 cm, p=0.005). This affected the HI over that time which differed by a mean of 0.2 (range: 0.0-0.8).

Conclusion:
Based on serial CT imaging, the rate of growth of the AP diameter and the transverse diameter of the chest varies over time which can affect the HI by as much as 0.8. Therefore, other objective measures should be sought that may more effectively measure pectus excavatum severity for use in investigational trials.

73.14 Initial Spontaneous Pneumothorax in Children and Adolescents: Operate or Wait?

Posted on January 18, 2016

L. M. Soler1, D. W. Kays1, S. D. Larson1, J. A. Taylor1, S. Islam1 1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: The management of primary spontaneous pneumothorax (PSP) in children is controversial, with some studies suggesting a recurrence rate of 50% over a 4 year period and advocating no surgery for the first occurrence. The purpose of this study was to understand the optimal management of a first episode of spontaneous pneumothorax.

Methods: A retrospective cohort at a single center over 12 years (2002-2014) was studied. Cases of PSP in the 5-19 year age group were selected and other pneumothoraces excluded. Data regarding pre, hospital, and post hospital course was collected and analyzed, with recurrent PSP the primary outcome variable.

Results: 362 cases of pneumothorax in children were found, and 81 met the inclusion criteria for PSP. An overall recurrence rate of 44.4% was noted, with 89% within 12 months of the initial PSP. Recurrent PSP cases were older and taller, but were similar to the non recurrent ones in use of chest tubes, and in the proportion of initial CXR being moderate or larger pneumothorax. CT scan use was not significantly different between recurrent and non recurrent groups, and 5/6 CT scans read as ‘normal’ had recurrence. Thoracoscopic surgery resulted in a significantly lower rate of recurrent PSP (Table). Patients who did not undergo surgery had a 50% recurrence rate with 90% within 12 months of the initial PSP.

Conclusion: Recurrence after PSP in children and adolescents was high and a majority occurred within a year requiring readmission. A negative CT scan for subpleural blebs still had a high recurrence, while thoracoscopic blebectomy and pleurodeisis had significantly lower recurrence. These data may suggest a more aggressive surgical approach to initial PSP in children.

73.11 Small Bowel Volvulus in Pediatric Patients: a Nationwide Population-Based Analysis

Posted on January 18, 2016

D. M. Schwartz1, Z. V. Fong1, D. C. Chang1 1Massachusetts General Hospital,General Surgery,Boston, MA, USA

Introduction:
Small bowel volvulus in children is a devastating condition that most commonly occurs in patients with congenital malrotation. Failure of normal rotation and fixation of the intestine leads to a narrowed mesenteric root, which predisposes these patients to midgut torsion. The resultant bowel ischemia and obstruction require expedited surgical management to avoid the serious consequences of short gut syndrome, sepsis and death. Small bowel volvulus predominately affects the pediatric population with up to 80% of patients affected within the first month of life and 90% within the first year. Current clinical knowledge of this disease is based mainly on analyses of single institution experiences or case studies. Using a national database inquiry, we aim to characterize the epidemiology and outcomes of this disease at the population-level and to define predictors of mortality.

Methods:
The Nationwide Inpatient Sample database, was retrospectively reviewed for patients 18 years old or less with small bowel volvulus (International Classification of Diseases, 9th Edition [ICD-9] code 560.2 excluding gastric/colonic procedures) from 1998 to 2010. Bivariate analysis was performed to define the demography of patients with small bowel volvulus. Baseline characteristics of patients who required small bowel resection were compared using bivariate statistical tests (Fisher Exact and Student’s T-tests). Predictors of mortality were modeled using logistic regression.

Results:
There were 2422 hospitalizations for small bowel volvulus, and of these, 1751 (72.3%) required surgical intervention. Small bowel volvulus occurred more frequently in male (61.3%) than female (38.7%, ratio 1.6 to 1) patients. Most cases presented emergently (86.1%), and the majority of patients were treated at urban (91.3%) and teaching hospitals (72.3%). The overall mortality rate was 3.1%. Mean age was 7.2 years (SD 6.4 years), and this average was unchanged when the cohort was restricted to only those patients with volvulus as their primary diagnosis. Patients who required small bowel resection were more likely to present with shock (50% vs. 19.5%, p<.0001) or peritonitis (46.9% vs. 19.6%, p< .0001), and more likely to be premature (20.3% vs. 33.3%, p<.014). On multivariate regression, predictors of mortality identified included vascular insufficiency (incidence 18.5%, OR 30.5, 95% C.I. 10.3 – 90.1, p<0.001) and shock (incidence 3.7%, OR 8.8, 95% C.I. 2.6 -29.3, p<0.001).

Conclusion:

This epidemiological study demonstrates an analysis of the trends of small bowel volvulus in a pediatric populace that accurately represents the national population. Male predominance of this disease is confirmed and a real world mortality rate of 3.1% is defined. Mean age for this cohort is higher than has been described previously. Vascular insufficiency and shock were strong predictors of mortality, and should be incorporated in future clinical nomograms and risk-calculators.

73.12 Protocoling post-operative care in pyloromyotomy patients: Minimizing variance improves outcomes

Posted on January 18, 2016

K. Zirschky1, N. A. Hamilton1, K. Lofberg1, T. L. Sims1, K. Azarow1 1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction: Clinical practice guidelines, which direct care of medical conditions and performance of clinical procedures, are increasingly common in medicine. However, benefits of clinical guideline implementation for surgical procedures and post-operative care in the pediatric population have not yet been well documented. One area of patient care with significant variability in physician practice is the postoperative management of infants with hypertrophic pyloric stenosis.

Methods: We established clinical practice guidelines for the postoperative care of patients with pyloric stenosis as agreed upon by faculty consensus. A retrospective chart review was designed to evaluate the effects of the implementation of the guidelines. All infants diagnosed with hypertrophic pyloric stenosis at our two major referral children’s hospitals from October 2012 to March 2013 were included in the control group. We allowed for a 6 month period for implementation of the protocol. Those diagnosed with hypertrophic pyloric stenosis from September 2014 to February 2015 were included in the protocol study group. Exclusion criteria for both groups included significant co-morbidities. Charts were reviewed for compliance to the protocol, post-operative complications (as defined by NSQIP), re-admission rates, and length of post-operative hospital stay. The two study groups were then compared using standard statistical analysis, including student t-test to compare the mean length of hospital stay between the control and protocol groups.

Results: There were 41 patients eligible for the study. The control group (n = 24) and protocol group (n = 17) had similar characteristics in terms of age and gender distribution. The mean postoperative hospital stay of the control group and protocol group was 33.81 and 27.43 hours, respectively (p<0.05). No NSQIP complications were noted in either group and there was no significant difference in readmission rate (0 vs 0.05, p=N.S., respectively).

Conclusion:
The implemented guidelines for post-pyloromyotomy care significantly decreased length of hospital stay after surgery without significant impact on complication or re-admission rates.

73.08 Neuroimaging in CDH Patients Requiring ECMO: Does it Predict Neurodevelopmental Outcome?

Posted on January 18, 2016

A. K. Rzepecki1, M. Coughlin1, N. L. Werner1, H. Parmar2, M. Ladino Torres2, S. Patel2, G. B. Mychaliska1 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA 2University Of Michigan,Pediatric Radiology,Ann Arbor, MI, USA

Introduction: Patients with congenital diaphragmatic hernia (CDH) that require extracorporeal membrane oxygenation (ECMO) are at risk for poor neurodevelopmental outcomes. The aim of this study was to compare the head ultrasound (US) and MRI of these patients and correlate neuroimaging findings to neurodevelopmental outcome.

Methods: We conducted an IRB-approved retrospective review of all patients treated at C.S. Mott Children’s Hospital between 2006-2015 with a diagnosis of CDH who required ECMO. Patients were included if they had a head US and MRI in the neonatal period. Baseline patient characteristics, hospital course, and survival data were collected. Neurodevelopmental impairments were classified as 0=normal, 1=mild, 2=moderate, or 3=severe based on Peabody scores and clinical records from a multidisciplinary CDH clinic. MRIs were graded based on severity of abnormality as 0=no abnormality, 1=mild (ventricular dilation or small extra-axial hemorrhages), 2=moderate (large parenchymal hemorrhage or combination of mild hemmorrhagic and non-hemorrhagic abnormalities), or 3=severe lesions (multiple large parenchymal hemorrhage, diffuse atrophy, diffuse leukomalacia). Spearman’s rho was used to calculate a correlation coefficient between neurodevelopmental impairments and MRI grades.

Results: There were 64 patients with a diagnosis of CDH that required ECMO. 22 of these patients had both head US and MRI evaluation. The overall survival of this cohort was 77%. The defect was left-sided in 77%. The mean length of stay was 99±60 days, and the mean ventilator-free days in 60 days of life was 16±17. The mean duration on ECMO was 15±7 days. Median follow up among survivors (17/22) was 1,038 days (IQR 196-1,665). US did not demonstrate acute bleeding in any patients, but did identify dilated ventricles and prominence of extra-axial spaces in 14%. MRI of these patients also did not show significant bleeding, but found 2/22 (9%) with no abnormality, 7/22 (32%) with mild lesions, 3/22 (14%) with moderate lesions, and 10/22 (45%) with severe lesions. Neurodevelopmental impairment was mild in 6/17 children (35%), moderate in 3/17 (18%), severe in 5/17 (29%), and absent in 3/17 (18%). Spearman’s rho correlation coefficient between neurodevelopment impairments and MRI grades was 0.55 (Figure).

Conclusion: This study suggests that brain MRI and US correlate in the detection of major findings such as bleeding, however MRI is more accurate than US in detecting subtle changes such as volume loss in CDH patients that required ECMO. Correlation between MRI and neurodevelopmental outcomes was weak. These data suggest the importance of close surveillance for neurodevelopmental outcome regardless of early MRI findings.

73.09 Do All Intestinal Malrotations Require a Ladd Procedure? Prophylactic vs Post-Symptomatic Outcomes

Posted on January 18, 2016

S. E. Covey1, L. R. Putnam1,2, K. T. Anderson1,2, K. P. Lally1,2, K. Tsao1,2 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA

Introduction: Intestinal malrotation can lead to midgut volvulus resulting in sepsis, short bowel syndrome, and death. Treatment includes the Ladd procedure to correct intestinal malrotation for symptomatic patients. However, debate remains regarding the timing of the procedure for asymptomatic infants with known malrotation. We hypothesized that the benefits of prophylactic Ladd procedure outweigh the risks of post-symptomatic repair.

Methods: A retrospective chart review of pediatric patients undergoing the Ladd procedure was performed. Prophylactic Ladd procedures were identified as those that occurred prior to any malrotation-related symptoms (i.e. abdominal pain, distention, nausea, emesis, constipation, or feeding intolerance). Results were analyzed with Mann-Whitney U and chi-squared tests.

Results: From 2011-2014, 42 patients (prophylactic=19, post-symptomatic=23) underwent the Ladd procedure for intestinal malrotation. The median (interquartile range) age of patients was 9.6 (3.9-18) months and 18 (2.4-52) months for prophylactic and post-symptomatic patients, respectively (p=0.38). In patients who underwent post-symptomatic Ladd procedures, 9 (39%) were found to have volvulus and 1 (4.3%) had bowel necrosis at time of surgery. No prophylactic Ladd procedure patients required reoperation while 6 (26%) post-symptomatic patients required reoperation for gastrointestinal-related complications (p=0.02). Prophylactic versus post-symptomatic Ladd procedure patients required a median (interquartile range) of 5.0 (3.3-6.8) days vs 7.4 (5.0-11) days to tolerate full enteral feeds (p=0.11) and 8.0 (6.1-11) days vs 11 (7.5-32) days until discharge (p=0.09). There was one respiratory-related death in each group.

Conclusion: Although the post-symptomatic group represents sicker children, the postoperative complications appear to be higher. For infants with known malrotation, prophylactic operations may be beneficial and should be considered. A larger, prospective study comparing prophylactic Ladd procedures to observation is needed to demonstrate its comparative effectiveness and generalizability.

73.10 Temporal Distribution of Pediatric Extracorporeal Life Support

Posted on January 18, 2016

K. W. Gonzalez1, B. G. Dalton1, K. L. Weaver1, A. K. Sherman1, S. D. St. Peter1, C. L. Snyder1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: Extracorporeal life support (ECLS) has proven to be a lifesaving measure for patients with cardiovascular collapse. Although several studies address the uses and outcomes of ECLS, no studies have specifically evaluated the impact the time of cannulation has on clinical outcomes. We sought to compare the incidence of complications based on timing of cannulation during the work day.

Methods: A retrospective review was conducted in patients less than 18 years of age who were placed on ECLS at a pediatric tertiary care center between May 2004 and May 2015 by the pediatric general surgery service. Data analyzed included gender, age at cannulation, timing of cannulation and decannulation, total duration of ECLS, diagnosis, complication and survival to discharge. Patients placed on ECLS during the work day were compared to those placed on ECLS after hours using 2-tailed Student t-tests and Pearson chi-square.

Results: There were a total of 176 patients placed on ECLS. The most common indications for cannulation were congenital diaphragmatic hernia (n=58), primary pulmonary hypertension (n=41), meconium aspiration (n=19), and respiratory failure (n=18). There was a male predominance (61%), and the median age of cannulation was 2 days (0, 5526 days). One hundred sixty two patients underwent preoperative echocardiogram; 83% of these had cardiac dysfunction, most often pulmonary hypertension. Forty one (23%) patients were placed on ECLS between the hours of 12 AM to 7:59 AM, 56 (32%) patients between 8AM and 3:59 PM, and 79 (49%) patients between 4 PM and 11:59PM (p < 0.01). When comparing scheduled operative hours (8 AM-3:59 PM) versus off hours (4PM-7:59AM), there was no statistically significant difference in total complications, central nervous system derangement, mortality on ECLS, hemorrhage (non intracranial source), or cannula repositioning (Table). Conversion from venovenous to venoarterial bypass (1.8% versus 3.4%, p=0.35) and survival to discharge (62.5% versus 60.0%, p=0.75) were also similar. The timing to decannulation was comparable (240 ± 172 hours versus 207 ± 120 hours, p=0.21).

Conclusion: More patients were placed on ECLS in the evening compared to other time frames. Despite the natural concern for the initiation of ECLS during off hours, we found no significant difference in patient outcomes.

73.05 No Difference in Reliability and Efficacy of Caudal versus Penile Block in Circumcision

Posted on January 18, 2016

K. Malik3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada

PURPOSE: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple local analgesia techniques including caudal block (CB) and penile block (PB) have been utilized and championed as offering optimal pain control during circumcision in toddlers and older children with no clear consensus. This meta-analysis investigates the efficacy of CB and PB during circumcision and their impact on postoperative analgesic requirements in the pediatric population age 16 months to 18 years.

Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled Trials (1966-2015) was completed for all published randomized control trials (RCTs). Keywords searched included ‘circumcision’, ‘caudal block’, and ‘penile block’. Inclusion criteria were limited to the comparison of PB versus CB in children 16 months to 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed.

Results: 9 RCTs involving 574 children, 287 undergoing PB and 287 undergoing CB, were included. There was no difference between the efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia (standardized difference in mean (SDM) = 0.510, CI = -0.07 to 1.09; p = 0.066). Time to first micturition (SDM = 0.767, CI = 0.51 to 1.02; p < 0.001) and duration of motor blockade (SDM = 0.788, CI = 0.08 to 1.50, and p = 0.03) was significantly greater for CB. No differences were observed between CB and PB for the incidence of vomiting (RR = 1.56, CI = 0.91 to 2.67, and p = 0.11) and length of stay (SDM = 0.741, CI = -0.05 to 1.53 and p = 0.066). No differences between levobupivacaine and bupivacaine are observed in regards to the efficacy of the blocks (p = 0.570), time to first micturition (p = 0.196), duration of prolonged motor blockade (p = 0.098), and risk of vomiting (p = 0.825).

Conclusion: CB and PB offer equivalent anesthetic outcomes in pediatric patients’ age 16 months to 18 years undergoing circumcision. CB is associated with a longer time to urination and ambulation. Additional adequately powered studies are needed to further investigate optimal medication dose and anesthetic choice.

73.06 Ultrasound Guided Central Venous Catheter Placement Increases Success Rates in Pediatric Patients

Posted on January 18, 2016

C. S. Lau1,3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3Saint George’s University,Grenada, Grenada, Grenada

Introduction: Real-time ultrasound guidance for central venous catheter (CVC) insertion has been shown to increase cannulation success rates and reduce complications in adults. Literature regarding ultrasound guided CVC placement in children remains limited and conflicting. This meta-analysis examines the impact of ultrasound guided CVC placement among pediatric patients in regards to success rate, number of attempts required, incidence of accidental carotid artery puncture, and time to cannulation.

Methods: A comprehensive literature search of all published randomized control trials (RCTs) assessing the use of real-time ultrasound guided CVC insertion in pediatric patients <18 years of age was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Keywords searched included ‘ultrasound guided’ and ‘central venous catheter’. Studies comparing the use of real-time ultrasound CVC insertion with anatomic landmark CVC placement in pediatric patients <18 years of age were included. Primary outcomes analyzed were cannulation success rate, number of attempts required, incidence of carotid artery puncture, and time to cannulation.

Results: 8 RCTs involving 760 patients (367 via ultrasound guidance and 393 via anatomic landmark placement) were analyzed. Ultrasound guided CVC insertion significantly increased success rates by 31.8% (Relative Risk (RR) = 1.318; 95% CI, 1.101 – 1.576; p=0.003) and decreased the mean number of attempts required (Mean Difference (MD) = -1.261; 95% CI, -1.711 to -0.812; p<0.001). A trend towards a decrease in the risk of accidental carotid artery puncture with the use of ultrasound guided CVC insertion was also observed (RR = 0.359; 95% CI, 0.118 – 1.093; p=0.071). Ultrasound guided CVC insertion was not associated with a significantly longer time to CVC placement (MD = 1.175 = -0.287 to 2.636; p=0.115).

Conclusion: Ultrasound guided CVC placement is associated with significantly higher success rates and decreased mean number of attempts required for cannulation. There is also a trend towards a decrease in accidental carotid artery puncture, which was not statistically significant likely due to inadequate sample size. Ultrasound guided CVC insertion improves success rates, efficacy, and safety among pediatric patients. Additional studies are required to determine the efficacy and safety of ultrasound guided CVC insertion in specific age populations of neonates compared to older children, and in the various healthcare settings.

73.07 Impact of Body Mass Index on Outcomes of Single-Incision Laparoscopic Appendectomy

Posted on January 18, 2016

C. N. Litz1, S. M. Farach1, P. D. Danielson1, N. M. Chandler1 1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FL, USA

Introduction:
Single-incision laparoscopic appendectomy (SILA) has emerged as a less invasive alternative to conventional laparoscopy and has been reported to be safe in appendicitis. However, little is known about the clinical implications of obesity on outcomes following SILA. The purpose of this study was to assess the impact of body habitus on outcomes following SILA.

Methods:
A retrospective review of 413 patients who underwent SILA from July 2012 through April 2015 was performed. Body mass index (BMI) was calculated and the BMI percentile was obtained according to CDC guidelines for gender and age. Standard definitions for overweight (BMI 85-94%) and obese (BMI>95%) were used. General admission, demographic, and outcome data were collected and analyzed. Statistical significance was set at p<0.05.

Results:
SILA was performed in 413 patients during the study period, of which 66.3% were normal weight, 16% were overweight, and 17.7% were obese. There were no significant differences in age at presentation (11.58 ± 3.75 vs 11.87 ± 3.23 vs 10.83 ± 3.53 years, p=0.196), WBC (14.74 ± 5.15 vs 15.41 ± 5.0 vs 15.74 ± 5.51, p=0.3) or time to diagnosis (128 ± 176 vs 120 ± 94 vs 118 ± 92 min, p=0.868) among the groups. Severity of appendicitis was determined intraoperatively as follows: acute (55.5% vs 51.5% vs 50.7%), suppurative (13.5% vs 12.1% vs 23.3%), gangrenous (11.3% vs 18.2% vs 8.2%), perforated (10.2% vs 15.2% vs 12.3%), normal (1.1% vs 0.0% vs 2.7%) and interval appendectomy (8.4% vs 3.0% vs 2.7%). There were no significant differences in intraoperative findings among normal, obese, and overweight patients (p=0.122). Furthermore, there were no significant differences in operative time (26.99 ± 9.11 vs 27 ± 9.80 vs 28.37 ± 9.41 minutes, p=0.514), postoperative length of stay (0.97 ± 1.65 vs 1.53 ± 4.15 vs 1.14 ± 2.27 days, p=0.214), 30 day complications (6.9% vs 8.2% vs 12.1%, p=0.377), ED visits (8.4% vs 11% vs 10.6%, p=0.726) or readmissions (4.7% vs 4.1% vs 4.5%, p=0.972).

Conclusion:
Our results indicate that obesity does not significantly impact outcomes following single-incision laparoscopic appendectomy. SILA can be performed in overweight and obese children without increased rates of perforation, longer operative times, longer length of stay or an increased complication rate. SILA should continue to be offered to overweight and obese children.

73.03 Optimizing Fluid Resuscitation in Hypertrophic Pyloric Stenosis

Posted on January 18, 2016

B. G. Dalton1, K. W. Gonzalez1, S. R. Boda1, P. G. Thomas1, A. K. Sherman1, S. D. St. Peter1 1Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction: Hypertrophic pyloric stenosis (HPS) is the most common diagnosis requiring surgery in infants. Electrolytes are used as a marker of resuscitation of prior to general anesthesia induction. Often multiple fluid boluses and electrolyte panels are needed, delaying operative intervention. We have attempted to predict the amount of IV fluid boluses needed for electrolyte correction based on initial values.

Methods: A single center retrospective review of all patients diagnosed with HPS from 2008 through 2014 was performed. Abnormal electrolytes were defined as Chloride < 100 mmol/L, bicarbonate ≥ 30 mmol/L or potassium > 5.2 or < 3.1 mmol/L.

Results: During the study period 542 patients were identified with HPS. Of the 505 that were analyzed 202 patients had electrolyte abnormalities requiring IV fluid resuscitation above maintenance, and 303 patients had normal electrolytes at time of diagnosis. Weight on presentation was significantly lower in the patients with abnormal electrolytes (3.8 vs 4.1kg, p<0.01). Length of stay was significantly longer in the patients with electrolyte abnormalities, 2.6 vs 1.9 days (p<0.01). Fluid given was higher over the entire hospital stay for patients with abnormal electrolytes (106 vs 91 ml/kg/d, p<0.01). The number of electrolyte panels drawn was significantly higher in patients with initial electrolyte abnormalities, 2.8 vs 1.3 (p<0.01).

Chloride was the most sensitive and specific indicator of the need for multiple saline boluses. Using an ROC curve, parameters of initial Cl– < 80 mmol/L and the need for 3 or more boluses AUC was 0.71. Modifying the parameters to initial Cl– ≤ 97mml/L and 2 boluses AUC was 0.65. Sensitivity and specificity values are shown for various initial Cl– levels are shown in table 1. These findings show that a patient with an initial Cl- < 85 will need three 20ml/kg boluses 73% (95% CI 52% to 88%) of the time. A patient with an initial Cl- ≤ 97 will need two 20ml/kg boluses at a rate of 73% (95% CI 64% to 80%).

Conclusion: Children with electrolyte abnormalities at time of diagnosis of HPS have a longer length of stay; require more fluid resuscitation and more lab draws. This study reveals high sensitivity and specificity of presenting chloride in determining the need for multiple boluses. We recommend the administration of two 20ml/kg saline boluses separated by an hour prior to re-checking labs in patients with initial Cl– value ≤97 mmol/L. If the presenting Cl– < 85 three boluses of 20ml/kg of saline separated by an hour are recommended. If implemented these modifications have potential to save time by not delaying care for extraneous lab results and money in the form of fewer lab draws.

73.04 ‘Masqueradors of Appendicitis: Incidence of Atypical Diagnoses in 6816 Pathologic Specimens’

Posted on January 18, 2016

Z. Farzal1, Z. Farzal1, N. Khan2, S. Cope-Yokoyama3, A. C. Fischer4 1UT Southwestern Medical Center,Dallas, TX, USA 2Honor Health,Phoenix, AZ, USA 3Cooks Children’s,Pathology,Fort Worth, TX, USA 4Beaumont Health System,Pediatric Surgery,Royal Oak, MI, USA

~~Introduction: Given the newly evolving paradigm of non-operative management of appendicitis, our goal was to identify the incidence of atypical diagnoses including tumors, detected among appendectomy specimens to better elucidate those potentially missed in non-operative management. The possibility of missing an alternative or co-incidental diagnosis such as carcinoid tumor in the non-operative management of appendicitis merits knowing the actual risks of nonoperative management.

Methods: An IRB-approved (062012-049) retrospective review of pediatric patients (n=6816) who underwent appendectomies at an independent children’s hospital over an 11 year period from January 2000 to December 2010 was performed. Demographics analyzed and the various multiple classifications of appendicitis was captured. Inclusion criteria required age <17 and surgery for presumed appendicitis thus excluding incidental appendectomies (n=269) from this sample with a final review of 6547 specimens.

Results: 5998 (91.6%) subjects showed true appendicitis including acute non-perforated, perforated, chronic, suppurative, gangrenous, and catarrhal appendicitis. In 224 subjects (3.4%), diagnoses other than appendicitis were identified: non-inflammatory obstruction (n=71), other infectious etiologies (n=58), non-specific inflammatory changes (n=58), extra-appendiceal pathology (n=31), tumors (n=4), and foreign body (n=2). Additionally, 6 patients with true appendicitis had co-existing carcinoid tumors. 325 specimens (5.0%) were documented as negative appendicitis.

Conclusion: This is the largest analysis of the incidence of pathologies that masquerade as appendicitis in the pediatric population conveying a broad overlap of diagnoses that present similarly or coincidently. Given the common diagnosis of appendicitis, follow-up for routine appendectomies has been streamlined and expedited in such a way that review of pathology may be overlooked; the number of infectious etiologies and tumors detected reinforces the increasing importance of pathology review in post-operative follow-up to appropriately diagnose uncommon conditions that may necessitate further work-up and treatment. Incidence of carcinoids and infections was low but will need to be considered in nonoperative management with persistence of symptoms or in follow up.

73.02 Patients Presenting as Transfers for Intussusception have an Increased Risk for Surgical Management

Posted on January 18, 2016

B. P. Blackwood1,2, F. Hebal1, C. J. Hunter1,3 1Ann And Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Rush University Medical Center,General Surgery,Chicago, IL, USA 3Northwestern University Feinberg School Of Medicine,Pediatrics,Chicago, IL, USA

Introduction: Intussusception is a potentially life-threatening condition and is the most frequent cause of bowel obstruction in the first two years of life. Multiple attempts at reduction are sometimes required, however intussusceptions are successfully treated with therapeutic enemas in 75-90% of cases. We hypothesized that patients who transferred from outside community hospitals (OSH) to a large academic children’s hospital with intussusception were more likely to require operative management for their intussusception than those who were directly admitted.

Methods: After IRB approval the electronic medical record was queried for patients presenting to Ann and Robert H. Lurie Children's Hospital of Chicago with a diagnosis of intussusception (July 1st, 2009 – July 1st, 2014). Age, sex, symptom duration, radiologic management, and surgical care were recorded. Additionally, OSH and transfer reports were analyzed for those patients that presented as a transfer. Statistical analysis was performed with Student’s T-test and ANOVA using Graph Pad Prism 6 Software.

Results:We identified 270 patients with intussusception confirmed radiographically with ultrasound or CT. Of these patients, 212 (78.5%) were successfully treated non-surgically, and 58 (21.5%) required surgical management. Of the patients requiring surgery, there were 38 reductions (24 laparoscopic, 14 open) and 20 bowel resections (1 laparoscopic, 19 open).There were 120 (47.2%) transfers from OSH. Of those patients requiring surgery, 37 (63.8%) had presented as a transfer from an OSH. We found that transferred patients, requiring surgery, spent a mean 7.77 hours at the OSH compared to 4.03 hours for the transferred patients that did not require surgery (p=0.0188). There was no significant difference in transport time (p=0.44).

Conclusion:In conclusion, intussusception can be managed non-operatively 78.5% of the time based on our experience. We have identified the amount of time patients spend at hospitals without pediatric surgical capabilities as an independent risk factor necessitating surgical management of intussusception. These data suggest that patients with the diagnosis of intussusception who present to hospitals without pediatric radiology or pediatric surgery, should be transferred in an expedited fashion. Furthermore, in the event of a failed enema reduction at an OSH the transport of the patient should not be delayed as this may result in a higher likelihood of surgical management.

72.19 A Systematic Review of Thymectomy for Juvenile Myasthenia Gravis (JMG)

Posted on January 18, 2016

A. L. Madenci1, G. Z. Li1, C. B. Weldon2 1Brigham And Women’s Hospital,Boston, MA, USA 2Children’s Hospital Boston,Boston, MA, USA

Introduction: Treatment of JMG stems from experience with pharmacologic agents, immunoglobulins, and surgery among adults. Thymectomy may eliminate the production of auto-antibodies, but its role among pediatric patients has never been defined by a prospective, randomized trial. We performed a systematic review to evaluate the complications and outcomes of thymectomy for JMG.

Methods: We performed a computerized search of MEDLINE from January 2000 to March 2015, supplemented with manual searches. Using a priori criteria, we evaluated 118 studies. Case series with fewer than 10 thymectomies were excluded. Data extraction was performed by independent reviewers and included demographic characteristics, timing of thymectomy, serology data, severity of JMG, peri-operative complications, surgical pathology, study design, and potential confounders.

Results: Twelve retrospective studies met inclusion criteria. Of 653 total participants with JMG, 400 (61%) underwent thymectomy. The majority of thymectomies were performed via transsternal approach (n=295, 69%). Median (or mean) time to thymectomy was less than one year in 4 (44%) of 9 studies that specified time to thymectomy. Pre-operatively, patients were primarily Osserman stage I (n=135, 45%), followed by stages II (n=99, 33%), III (n=47, 16%), and IV (n=21, 7%). Elevated anti-acetylcholine receptor (AChR) antibodies were found in 87% (n=65/75) of thymectomized patients tested. Surgical pathology most often showed thymic hyperplasia (n=283, 87%), followed by normal thymus (n=35, 11%), and thymoma (n=8, 2%). Mean post-operative follow-up ranged from 2 to 5 years. Post-operative complications were not well documented. Post-operative improvement in JMG severity was recorded in 89% (n=281/316), including 28% (n=90/316) patients with complete sustained remission. Twenty-four (8%) patients had unchanged symptom severity post-operatively and nine (3%) patients had worsening of symptoms post-operatively. Two patients died post-operatively. Comparisons of thymectomy to non-operative management were mixed. One study reported a trend toward higher remission rate with thymectomy (55% vs. 38%, p=0.06). A second reported similar incidences of complete remission with and without thymectomy. One study found no effect of anti-AChR antibody status on response to thymectomy. Outcomes specific to surgical pathology findings were limited. No study stratified outcome of thymectomy by severity of JMG or timing of thymectomy for JMG.

Conclusion: Existing data studying thymectomy for JMG is entirely retrospective and does not support a clear benefit toward decreasing severity of disease. Reported complications were rare. Overall, the included studies were limited by power and heterogeneity with respect to timing of surgery, serology, patient age, and severity of JMG. Prospective, randomized study of thymectomy for JMG is warranted.

72.20 Extent of Peritoneal Contamination on Resource Utilization in Children with Perforated Appendicitis

Posted on January 18, 2016

C. Feng1, S. Anandalwar1, F. Sidhwa1, C. Glass1, M. Karki1, D. Zurakowski1, S. Rangel1 1Children’s Hospital Boston,Surgery,Boston, MA, USA

Introduction: The degree of peritoneal contamination can be widely variable in children with perforated appendicitis and its effects on disease severity has not been characterized. The purpose of the study was to explore this relationship in the post-operative setting using measures of resource utilization as surrogate markers for disease severity.

Methods: Intraoperative findings were collected prospectively from attending surgeons using a standardized survey at a single children’s hospital from 2011 to 2014. Peritoneal contamination (defined as the presence of purulent fluid or fibrinous exudate) was categorized as ‘localized’ (confined to the right lower quadrant and pelvis) or ‘extensive’ (extending to the liver as a marker for uncontained perforation) in patients with perforated disease. Imaging utilization, postoperative length of stay (PLOS), hospital cost, and readmission rates were compared using chi-square statistics for proportions and the Mann-Whitney U-test for continuous data.

Results: Eighty-eight patients were identified with perforated disease, of which 38% (34/88) were found to have extensive peritoneal contamination. Groups were similar on the basis of age, weight, gender, race, insurance status, preoperative WBC count and maximum temperature. Patients with extensive peritoneal contamination had significantly higher rates of postoperative abdominal imaging (58.8% vs 27.7%, p<0.01) and a 30% higher median hospital cost ($17,663[IQR $12,564-$23,697] vs $13,516[IQR $10,546-$16,686], p<0.01, figure) compared to patients with localized contamination. Median PLOS was 50% longer for patients with extensive contamination (6 days [IQR 4-9] vs 4 days [IQR 2-5], p<0.01, figure), and the readmission rate was nearly four-fold higher compared to children with localized contamination (20.6% vs 5.6%, p=0.04).

Conclusion: In children with complicated appendicitis, extensive peritoneal contamination is associated with greater postoperative imaging, length of stay, cost, and readmission rates. These findings may have important severity-adjustment implications for reimbursement and comparative performance reporting for hospitals that serve populations where late presentation and more severe disease are common.

73.01 30-day Outcomes for Children and Adolescents undergoing Sleeve Gastrectomy at a Children’s Hospital

Posted on January 18, 2016

A. L. Speer1, J. Parekh1, F. G. Qureshi2, E. P. Nadler1 1Children’s National Medical Center,Pediatric Surgery,Washington, DC, USA 2University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA

Introduction:
Morbid obesity affects millions of children and adolescents and its prevalence continues to rise. The incidence of obesity-related comorbidities in the pediatric population has also increased with a concomitant decrease in age of onset. Nonsurgical options do not result in significant or sustained weight loss in these children and thus bariatric surgery has become an increasingly utilized option. Bariatric surgery is known to be a safe and effective weight loss solution in morbidly obese adults, however, limited data exists regarding safety and efficacy for pediatric bariatric surgery outside of NIH-funded centers. We sought to assess the perioperative outcomes and safety of children and adolescents undergoing laparoscopic sleeve gastrectomy for morbid obesity at a free-standing children’s hospital which is not part of the NIH consortium.

Methods:
We retrospectively reviewed demographics, comorbidities, and 30-day complications for all patients who underwent laparoscopic sleeve gastrectomy during a 5 year period from 2010-2015 at a single free-standing children’s hospital that is not a member of the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study.

Results:
A total of 105 patients underwent 107 laparoscopic sleeve gastrectomy procedures (2 revisions). The mean age was 17.3 years (4.5-24.8). The male to female ratio was 1:3.6. The majority of the patients were Black (56.2%), followed by White (22.9%), and Hispanic (17.1%). The mean Body Mass Index was 51.0 m2/kg (37.4-86.8). The most common comorbidities included obstructive sleep apnea (61.3%), hypertension (14.2%), diabetes (11.3%), nonalcoholic fatty liver disease (9.4%), and dyslipidemia (6.6%). Average length of stay (LOS) was 1.8 days (1-7). One patient was excluded from LOS as she was awaiting heart transplant and her LOS exceeded the 30-day outcome period. There were no deaths. Major complications occurred in 3 patients (2.9%) during their initial postoperative hospitalization requiring reoperation and in 1 patient (1.0%) after discharge before the 30th postoperative day. The reoperations were for gastric leak, epigastric bleed, and splenic parenchymal laceration. The fourth patient did not require reoperation but did require anticoagulation for pulmonary embolus and deep venous thrombosis. Minor complications were observed in 4 patients (3.8%). These included one submucosal hematoma requiring 2 weeks of TPN and three patients with decreased oral intake secondary to edema which required readmission for intravenous fluid hydration and steroids.

Conclusions:
Laparoscopic sleeve gastrectomy is a safe treatment option for morbidly obese children and adolescents and can be successfully performed at a non-NIH funded center. Future studies and more longitudinal data are necessary to confirm the long-term safety profile as well as the efficacy of bariatric surgery in the pediatric population.

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