72.18 Morbidity and Healthcare Costs of Vascular Anomalies: a National Study of 7,485 Pediatric Inpatients

Posted on January 18, 2016

J. Kim1, Z. Sun1, B. C. Gulack1, E. Benrashid1, M. J. Miller2, A. C. Allori1, H. E. Rice1, C. K. Shortell1,2, E. T. Tracy1 1Duke University Medical Center,Surgery,Durham, NC, USA 2Duke University Medical Center,Radiology,Durham, NC, USA

Introduction:
With novel medical therapies, interventional procedures, and surgical techniques increasingly used to manage vascular anomalies, the quality of life for children with vascular anomalies has improved. This study aimed to define morbidities and costs related to modern-day care for children with vascular anomalies.

Methods:
We reviewed the 2003-2009 Kids’ Inpatient Database (KID) for pediatric patients (age < 21 years) hospitalized with hemangiomas, arteriovenous malformations (AVM), or lymphatic malformations (LM) as a primary diagnosis. Patients were grouped by type of vascular anomaly. Patient characteristics, comorbidities, complications, and hospital charges were compared.

Results:
In total, 7,485 pediatric patients with vascular anomalies were identified. Within this cohort, frequently associated comorbidities included chronic anemia (4.0%), hypertension (2.4%), and coagulopathy (1.8%). They also had nontrivial rates of sepsis (4.6%) and cellulitis (1.4%) associated with hospital care. Notably, children with AVM had the highest rate of in-hospital mortality (1.0%, p < 0.001). AVM also were associated with the highest median hospital charge ($38,574, p < 0.001), more than twice the cost for hemangiomas or LM. AVM care also had the greatest increase in median hospital charge (38.8%) from 2003 to 2009 (Figure).

Conclusion:
We found a significant rate of morbidity in children with vascular anomalies, most often from blood loss and infection. The greater cost of AVM care may be related to the higher mortality rate as well as the complexity of procedures required to treat them. Cost-effective management of vascular anomalies should target prevention and early recognition of both chronic comorbidities and acute complications.

72.15 Pediatric Near-Drowning Accidents: Do They Warrant Trauma Team Activation?

Posted on January 18, 2016

P. N. Chotai1, B. Eithun2, L. Manning1, J. Ross3, J. W. Eubanks1, A. Gosain1 1Univeristy Of Tennessee Health Science Center,Pediatric Surgery, Le Bonheur Children’s Hospital,Memphis, TN, USA 2University Of Wisconsin,Pediatric Trauma Program, American Family Children’s Hospital,Madison, WI, USA 3University Of Wisconsin,Division Of Pediatric Emergency Medicine, Department Of Emergency Medicine, American Family Children’s Hospital,Madison, WI, USA

Introduction:
Drowning and near-drowning events remain a leading cause of accidental deaths in children. Currently, many American College of Surgeons (ACS) designated pediatric trauma centers activate the trauma team on receipt of drowning or near-drowning patients. The purpose of this study is to determine the incidence of traumatic injuries, factors associated with mortality and need for Pediatric Trauma Surgery involvement for children involved in drowning and near-drowning events.

Methods:
Following IRB approval, retrospective chart review was performed for patients presenting with drowning and near-drowning events at either of the two ACS Level I Pediatric Trauma Centers between 1/1/2011-12/31/2014. Patients with ICD-9 codes for fatal/nonfatal drowning or E-codes for fall into water, accidental drowning, or submersion were included. Patient demographics, drowning characteristics, level of trauma activation, transfer, Glasgow coma scale (GCS) and body temperature at arrival, cervical spine and head imaging, admission and discharge details, mortality, need for surgical intervention in first 24 hours, and other associated injuries were recorded. Univariate analysis using chi-square or Fisher exact test for nominal variables and student t-test for continuous variables was performed.

Results:
104 patients, with a median age of 4.0 years (range, 18 days to 17 years), met the inclusion criteria. 27 (26%) were female and 77 (74%) were male. The most frequent site of drowning was the pool (78.1%), followed by bathtub (14.4%), and natural water (6.7%). A witnessed fall or dive was reported in 35.6% patients, 39.4% patients did not fall or dive and 25% had an unwitnessed near-drowning event. Most (72.1%) patients did not undergo any cervical spine imaging. Brain/Head imaging was obtained in 33.7% patients. Notably, none of the patients, at either site, required any form of surgical intervention in the first 24 hours after presentation, other than placement of monitoring lines. Only 6.7% patients were admitted to the Pediatric Trauma Surgery service. The majority of patients (59.6%) were admitted to the pediatric intensive care unit, or to general pediatric floor (34.6%). A small proportion of patients (5.8%) were discharged home from the emergency department. Overall mortality was 17.3%. Factors associated with mortality included transfer from outside hospital (p=0.016), presence of hypothermia on arrival (p<0.0001), GCS of 3 on arrival (p<0.0001), or drowning in a pool compared to bathtub or freshwater (p=0.013).

Conclusion:
The incidence of associated traumatic injury in drowning and near drowning patients is low. In this series, we did not find any traumatic injures requiring immediate surgical attention. Additionally, the majority of patients are admitted to non-surgical services for their inpatient management. These data suggest that routine Pediatric Trauma Surgery service involvement in patients with near-drowning accidents may be unnecessary.

72.16 10 Year Analysis of Benign Teratomas: Outcomes and Follow-up

Posted on January 18, 2016

B. P. Blackwood1,2, C. J. Hunter1, H. Sparks1, M. Browne3 1Ann And Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Rush University Medical Center,General Surgery,Chicago, ILLINOIS, USA 3Children’s Hospital, Lehigh Valley Health Network,Pediatric Surgery And Urology,Allentown, PA, USA

Introduction: Benign teratomas account for 80% of all teratomas. Surgical resection remains the standard of care. However, evidence-based recommendations for post-operative follow up are lacking. In some centers, patients may receive no long term follow up; whereas at others institutions, long-term care for several years may be provided. Our aim was to review outcomes of patients that have undergone therapy for benign teratomas in an effort to generate a decision tree for the follow up of these patients.

Methods: After IRB approval, the electronic medical records of patients at the Lurie Children's Hospital of Chicago (January 1st, 2005 to January 1st, 2015) were queried. Patient age, sex, classification of teratoma, surgical procedure, alpha fetoprotein levels (AFP), pathology, follow up plan, follow up time, and recurrences were recorded. Patients with the pathological diagnosis of sacrococcygeal teratoma were excluded. Statistical analysis was completed with Student’s T-test and ANOVA using Graph Pad Prism 6 software.

Results:We identified 73 patients with a pathologic diagnosis of a teratoma. Of these, there were 65 ovarian teratomas (4 immature, 61 mature), 5 mediastinal teratomas (all mature), and 3 retroperitoneal (1 immature, 2 mature). Ages ranged from 2 days to 21 years. There was a significant difference in the initial AFP level between the groups. The immature teratomas had an average AFP of 2239.2 and the mature teratomas had an average AFP of 3.15 (p<0.0004). There were no significant differences in follow-up time (p=0.895). There was one recurrence in the immature group and no recurrences in the mature group (p=0.0001). Overall, there was a 1.3% recurrence rate. The only recurrence was that of an immature ovarian teratoma with an initially elevated AFP of 1978. Post-operative AFP levels were not elevated, even during episodes of recurrence. We identified high variability in the recommended follow up (10 different strategies). Most commonly, an ultrasound and AFP every 3 months for 1 year, every 6 months for the next 2 years, and then yearly till 5 years postoperatively.

Conclusion:Our data indicates that patients with a diagnosis of ovarian, mediastinal, or retroperitoneal teratoma are at a low risk of recurrence after complete surgical resection. Our findings correlate with current literature in that immature teratomas may have an increased risk of recurrence as compared to the mature teratomas. Based on our review, patients with mature teratomas do not need to be followed past the initial post-operative period. However, surgeons may consider following patients with benign teratomas with immature elements, especially patients with elevated preoperative AFP, for at least one year post-operatively.

72.17 To Wrap or Not? Antireflux Procedures after Gastrostomy in Infants

Posted on January 18, 2016

K. A. Nestor1, S. Larson1, J. A. Taylor1, D. W. Kays1, S. Islam1 1University Of Florida College Of Medicine,Pediatric Surgery,Gainesville, FL, USA

Introduction: There is controversy regarding the need for an antireflux procedure in infants who require feeding access. A Cochrane review on this topic noted a lack of evidence and recommended further studies. The purpose of this report was to assess outcomes in infants who underwent a gastrostomy alone vs. gastrostomy plus fundoplication.

Methods: A retrospective review of all neonates and infants who had a gastrostomy placed at a single institution from 2009-2014 was conducted. Demographics, comorbidities, hospital course, procedure, and outcomes were recorded. The cohort was then divided into gastrostomy and gastrostomy plus fundoplication. Main outcome variable was need for further antireflux procedures.

Results: There were 226 cases – 104 gastrostomy and 122 with fundoplication. The cohorts were similar in gender, gestational age, race, weight, median age, LOS, and proportion neurologically impaired. Preoperative diagnosis of reflux was significantly higher in the fundoplication cohort (22 vs. 87%). There was a trend to increased overall complications in the gastrostomy group (31 vs. 20%), including minor issues. Postoperative need for antireflux medications was significantly increased for gastrostomy patients compared to preoperative use (p=0.01). Readmission for respiratory issues or aspiration events was equivalent (Table). Post-op reflux requiring a fundoplication or GJ tube was noted in 21/104 gastrostomy cases (25%), and compared to the remaining gastrostomy patients (n=83), the incidence of neurologic impairment, type of feeds, and age at surgery, were similar.

Conclusion: There was a high rate of reflux in patients who had a gastrostomy alone with a significant number requiring a secondary antireflux procedure, despite the ‘high-risk’ patients undergoing a fundoplication already. These results suggest that a more liberal use of concomitant fundoplication may be justified in these patients.

72.13 Sub-specialty Surgical Care and Outcomes for Pediatric EGS Patients in a Low-Middle Income Country

Posted on January 18, 2016

A. Shakoor4, A. Shah2, C. K. Zogg1, A. H. Haider1, R. Riviello3, A. Latif6, F. G. Qureshi7, T. Oyetunji8, A. Mateen5, H. Zafar5 8Children’s Mercy Hospital And Clinics,Department Of Surgery,Kansas City, MO, USA 1Brigham And Women’s Hospital,Center For Surgery And Public Health, Harvard Medical School, Harvard T H Chan School Of Public Health,BOSTON, MA, USA 2Mayo Clinic In Arizona,Department Of Surgery,Phoenix, AZ, USA 3Brigham And Women’s Hospital,Division Of Trauma, Burns And Surgical Critical Care,Boston, MA, USA 4West Virginia University School Of Medicine,Department Of Pediatrics, Charleston Area Medical Center (CAMC),Charlston, WV, USA 5Aga Khan University Medical College,Department Of Surgery,Karachi, Sindh, Pakistan 6Johns Hopkins University School Of Medicine,Department Of Anesthesia,Baltimore, MD, USA 7Children’s National Medical Center,Department Of Surgery,Washington, DC, USA

Introduction:
Whether adult general surgeons, in addition to pediatric specialists, should handle pediatric emergency general surgery (EGS) remains controversial. Unlike surgical centers in higher income countries, resource-limited settings in low-middle income countries often lack staff, resources, and training needed to maintain ready access to specialist care, making treatment by general surgeons an imperative. The objective of this study was to examine differences in surgical outcomes among children/adolescents managed by pediatric versus adult surgical teams for EGS conditions presenting to a regional tertiary hospital in South Asia with split patient coverage between pediatric and adult surgical teams.

Methods:
Pediatric patients (<18y) admitted to the Aga Khan University Hospital in Karachi, Pakistan, with an EGS diagnosis (defined by the AAST) between March 2009 and April 2014 were included. Patients were dichotomized into those managed by adult versus pediatric teams. Differences in length of stay (LOS), mortality, and major complications were compared between the two groups using descriptive statistics and multivariable linear (family gamma; link log)/logistic regression. Propensity scores accounted for potential confounding associated with demographic/clinical factors.. Quasi-experimental counterfactual models examined hypothetical differences in outcomes, assuming that all patients were managed by pediatric teams.

Results:
A total of 2,323 patients were included. Average age was 7.1y (±5.5 SD); most were male (77.7%). The majority, n=1,958, was managed by pediatric specialty teams; however, 365 patients received treatment from adult general surgery teams. 42 patients (1.8%) developed complications; 21 (0.9%) died (all adult general surgery). Relative to patients managed by pediatric surgery, patients managed by adult surgery had 5.42 times higher risk-adjusted odds of developing complications (OR[95%CI]: 5.42[2.10-14.00]) and longer average LOS (predicted mean difference: 1.87[1.45-2.31] days). Counterfactual models suggest that patients at Aga Khan would have experienced 39.8% fewer complications and a 36.7% relative reduction in average LOS if all patients had been managed by pediatric surgery.

Conclusion:
In light of recent work by the Lancet Commission and DCP3, it becomes important now, more than ever, to address questions related to relevant development efforts in both burgeoning and established global surgical fields. Beyond efforts to establish surgical capacity, the results of this study speak to a need for health systems strengthening, suggesting that, where possible in resource-constrained settings, efforts should be allocated to promote development/staffing of diverse surgical teams.

72.14 Institutional and Patient Factors Affecting Pediatric Patient Transfer in Testicular Torsion

Posted on January 18, 2016

D. L. Lodwick1, J. N. Cooper1, K. J. Deans1, P. C. Minneci1, D. McLeod1,2 1Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OH, USA 2Nationwide Children’s Hospital,Urology,Columbus, OH, USA

Introduction: Acute testicular torsion is a surgical emergency that requires prompt diagnosis and treatment to maximize testicular salvage. Delays in care increase the chance that a patient will undergo orchiectomy rather than orchidopexy. Interhospital transfers represent a potential delay in care, and the patient and hospital level factors influencing the decision to transfer remain unclear. This population-based study aimed to determine patient and institutional factors associated with transfer for pediatric testicular torsion.

Methods: This retrospective cross-sectional study utilized the National Emergency Department Sample (NEDS) from 2006 to 2012. Encounters by males aged 1 to 21 years with one of the diagnosis codes for testicular torsion (608.2, 608.20, 608.21, or 608.22) were included. Visits at freestanding children’s hospitals were excluded. All analyses were weighted to produce nationally representative estimates. Associations of interhospital transfer with patient and institutional characteristics were evaluated using Rao-Scott chi square tests then multivariable logistic regression.

Results: During 2006 to 2012, there were 11,435 ED visits for testicular torsion by males aged 1-21 years who were either admitted or transferred to another hospital. In multivariable logistic regression, we found that the probability of transfer decreased significantly with increasing age (Figure) and was lower for patients living in zip codes in the highest income quartile (OR=0.69, p=0.003), or who had any listed comorbidity (OR=0.55, p<0.001). Patients were less likely to be transferred at hospitals in the Northeast region of the United States (OR=0.28 compared to the Midwest, p<0.001), at urban hospitals (OR=0.31, p<0.001), at teaching institutions (OR=0.55, p<0.001), and at level 1 or 2 trauma centers (OR=0.31, p<0.001). There was also a decreasing probability of transfer with increasing annual pediatric ED volume (OR=0.95 per 1000 patients seen, p<0.001). The probability of interhospital transfer increased significantly over the study period from 23.6% to 38.8% (p<0.001).

Conclusion: Older adolescents with testicular torsion are significantly more likely to be transferred than young adults. Interhospital transfers in these patients may represent a potential target for improving outcomes in testicular torsion. Future work should focus on evaluating the effect of transfer on the risk for undergoing orchiectomy.

72.11 Premature Babies with Inguinal Hernias: When Should we Repair?

Posted on January 18, 2016

N. Zeidan1, S. D. Larson1, J. A. Taylor1, D. W. Kays1, D. Solomon1, S. Islam1 1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: The survival of increasingly premature neonates continues to improve with excellent neonatal intensive care (NICU). About 10-13% of premature babies will have an inguinal hernia diagnosed, and the timing of repair of these is controversial, as the data balancing risks of general anesthesia vs. incarceration are not clear. The purpose of this study was to understand outcomes from inguinal hernia repair in premature babies performed before or after discharge from the NICU.

Methods: A retrospective analysis was performed on all babies who had inguinal hernia repair performed at a single institution over a 5 year period. Babies with a gestational age at birth less than 35 weeks were included in this analysis and data regarding clinical course, surgery, and postoperative course were collected and analyzed. Primary outcomes of incarceration and anesthesia related complications were chosen.

Results: Overall, 226 premature babies had inguinal hernia repair, with a 3.3:1 male preponderance, mean birth weight of 1.24 kg, and mean gestational age of 29.3 weeks. The cohort was stratified by timing of repair into before or after NICU discharge. Those repaired before discharge were significantly smaller, had more comorbidities, repaired earlier, longer postoperative hospital stay, and higher rates of delayed extubation. Complication rates, use of laparoscopy, gender, and race were similar, but operative times tended to be longer in the group before discharge (table). More babies were on oxygen at the time of surgery in the NICU group. Incarceration rates were similar, and none required a bowel resection.

Conclusion: While there was no difference in recurrence, complications or incarceration rates whether surgery was performed before or after discharge, the operations tended to take longer and there were more respiratory issues in those repaired in the NICU. Despite the retrospective nature of these data, it suggests that delayed repair in selected neonates may be warranted. A prospective, multicenter study would help understand this better.

72.12 Long Term Central Venous Access in a Pediatric Leukemia Population

Posted on January 18, 2016

A. Fu1, E. Hodgman2, L. Burkhalter1, R. Renkes1, T. Slone3, A. C. Alder1,4 1Children’s Medical Center,Division Of Pediatric Surgery,Dallas, TX, USA 2University Of Texas Southwestern Medical Center,Department Of General Surgery,Dallas, TX, USA 3University Of Texas Southwestern Medical Center,Department Of Pediatrics,Dallas, TX, USA 4University Of Texas Southwestern Medical Center,Department Of Pediatric Surgery,Dallas, TX, USA

Introduction: Central venous access devices (CVADs) play an important role in the management of pediatric oncology patients; unfortunately, they are also associated with potentially serious peri-operative and long-term complication rates. Our aim was to evaluate the rates of peri-operative and long-term complications as well as risk factors for premature catheter removal among patients with acute leukemia at a single pediatric tertiary referral center.

Methods: We retrospectively studied clinical characteristics and procedure records for all patients admitted with a leukemia diagnosis at our institution from May 2009 – July 2014. Patient data, including demographics, CVAD type (subcutaneous port or tunneled catheter), complications, and patient outcomes were collected. Peri-operative complications (≤24 hours of surgery) include pneumothorax, hematoma, hemothorax, arterial puncture, and catheter malposition. Long-term complications (>24 hours after surgery) include deep venous thrombosis (DVT), line-associated infection (blood stream and/or port site infection), and line malfunction (kinks, leaks, breaks). Chi square, t-tests, and multivariable logistic regression were performed (significance p<0.05).

Results: A total of 292 CVADs were placed in 198 patients during the study period; these CVADs remained in place for an average of 488 ± 399.8 days and a total of 142,607 catheter-days are included in this study. Our observed peri-operative complication rate was 6%, including 3 hematomas, 1 hemothorax, and 10 catheter malpositions. Over 70% of lines had at least one long-term complication (thrombosis, catheter-related blood stream infection, or unexplained line malfunction). Seventy-five lines were removed prematurely: 31 due to infection, 36 due to malfunction, and 8 due to malposition. Obesity (OR 6.9, 95% CI 1.62-29.43), pre-operative dosage of packed red blood cells (OR 3.13 , 1.07-9.21), blood stream infection (OR 5.75, 1.69-19.56) were associated with increased risk of premature catheter removal; unexplained malfunction was associated with a lower risk (OR 0.28, 0.09-0.93).

Conclusion: While the rate of peri-operative complications is low, our observed long-term complication rate was higher than expected. Obesity, the preoperative dosage of packed red blood cells, presence of a blood stream infection, and unexplained line malfunction are significant predictors of premature CVAD removal in a pediatric leukemia population. Patients with these characteristics may represent a subset population that warrant closer CVAD surveillance and may benefit from additional prophylatic thrombolytic therapy. This study represents the largest recent evaluation on CVAD complications within a single institution and is also the largest report on a Hispanic pediatric leukemia population to date.

72.09 Factors Predictive of Complicated Appendicitis in Children

Posted on January 18, 2016

X. D. Pham1, V. F. Sullins1, D. Y. Kim1, B. Range3, A. Kaji2, C. DeVirgilio1, S. L. Lee1 1Harbor-UCLA Medical Center,General Surgery,Torrance, CA, USA 2Harbor-UCLA Medical Center,Emergency Medicine,Torrance, CA, USA 3University Of California – Los Angeles,Los Angeles, CA, USA

Introduction: The ability to predict whether a child has complicated appendicitis at initial presentation may influence clinical management. However, it is controversial whether complicated appendicitis is associated with prehospital factors (age, symptom duration, serum sodium, and WBC count) or in-hospital factors (time from admission to appendectomy). We investigate which of these factors are associated with predicting complicated appendicitis.

Methods: A retrospective review of all pediatric patients (≤12 years) with appendicitis treated with appendectomy between 2000-2013 was performed. The main outcome measure was intraoperative confirmation of gangrenous or perforated appendicitis. A multivariable analysis was performed and the main predictors of interest were age, symptom duration >24 hours, leukocytosis (WBC count >12 103/ml), hyponatremia (sodium <135 mEq/L), and time from admission to appendectomy.

Results: Of 392 patients, 179 (46%) had complicated appendicitis at the time of operation. Results of univariate analysis are listed in Table 1. Predictors of complicated appendicitis on multivariable analysis included symptom duration >24 hours (OR=5.1, 95% CI=3.2-8.2, p<0.001), hyponatremia (OR=3.2, 95% CI=2-5.1, p<0.001), age <5 years (OR=2.7, 95% CI=1.3-5.4, p=0.007), and leukocytosis (OR=1.9, 95%CI=1-3.4, p=0.04). Increased time from admission to appendectomy was not a predictor of complicated appendicitis (OR=0.75, 95% CI=0.5-1.1, p=0.2).

Conclusions: Complicated appendicitis is a prehospital occurrence. Hyponatremia is a novel marker associated with complicated appendicitis and may be more predictive than WBC count or age. Delaying appendectomy does not increase the risk of complicated appendicitis. This information may help guide resource/personnel allocation, timing of appendectomy, and decision for non-operative management of appendicitis in children.

72.10 Imaging Gently? Higher Rates of CT Imaging for Pediatric Appendicitis in Non-Children's Hospitals

Posted on January 18, 2016

K. T. Anderson1,2, L. R. Putnam1,2, T. Ostovar-Kermani1,2, E. Hamilton1,2, D. H. Pham1,2, M. T. Austin1,2, A. L. Kawaguchi1,2, L. S. Kao3, K. P. Lally1,2, K. Tsao1,2 2University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA 3University Of Texas Health Science Center At Houston,General Surgery,Houston, TX, USA 1Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA

Introduction: Growing concerns regarding radiation exposure in children has led to recommendations to minimize CT imaging, especially in pediatric appendicitis. However, these practices are not always adopted by non-pediatric specialties. We hypothesized that within a metropolitan hospital system (one children’s hospital (CH) and eight non-children’s hospitals (NCHs)), use of pre-operative CT is much higher in NCHs. We aimed to determine differences in pre-operative imaging and any associated demographic variables.

Methods: A retrospective study of patients <18 years undergoing appendectomy for acute appendicitis from April 2012 to April 2015 in a 9-hospital system was conducted. Patient demographics, pre-operative location, and imaging modality (computed tomography (CT) and ultrasound (US)) were evaluated. Patients were attributed to the hospital in which the pre-operative imaging was performed and not the location of appendectomy. Chi-squared, Student’s t-test, and multivariate regression were performed; p<0.05 was significant.

Results: 1448 pediatric patients were identified (CH=215, 15%; NCHs=1233, 85%). The median (range) number of patients triaged per NCH was 154 (85-193). Children seen at the CH were younger (mean 10.2 ± 4.0 vs 12.2 ± 3.9, p<0.01), more likely non-white Hispanic (68% vs 46%, p<0.01), and publically insured (58% vs 49%, p=0.04). CH patients underwent significantly fewer CT scans (23% vs 70%, p<0.01) and more US (75% vs 20%, p<0.01). For all patients, on multivariate regression, increased preoperative CT use was significantly associated with NCHs (OR 7.5, 95%CI 5.3-10.6), older age (age >10: OR 2.3, 95%CI 1.8-2.9), and female gender (OR 1.34, 95%CI 1.05-1.71). For patients triaged at NCHs, older age (age >10: OR 2.4, 95%CI 1.8-3.1) and female gender (OR 1.33, 95%CI 1.02-1.73) remained significantly associated with CT use. No patient characteristics were associated with increased CT use at CH. Children presenting at CH were more likely to undergo US (OR 11.8, 95%CI 8.3-16.9). Younger age (age ≤ 10: OR 1.9, 95%CI 1.5-2.5) and female gender (OR 1.5, 95%CI 1.1-1.9) were predictive of US use overall.

Conclusions: Within our hospital system, there are significant differences in utilization of imaging modalities for suspected pediatric appendicitis between CH and NCHs. Pediatric patients are 7.5 times more likely to receive a CT scan if initially evaluated in NCHs. Further investigation is needed to identify other factors contributing to imaging preference in the pediatric population in order to establish clinical practice guidelines to reduce radiation exposure in children.

72.06 Hospital Variation in Rates of Concurrent Fundoplication during Gastrostomy Enteral Access Procedures

Posted on January 18, 2016

A. M. Stey1, C. Vinocur4, B. L. Hall3,5, M. E. Cohen3, K. Kraemer3, B. Kenney2, R. Moss2, C. Ko3,6, L. Berman4 1Mount Sinai School Of Medicine,Department Of Surgery,New York, NY, USA 2Nationwide Children’s Hospital,Columbus, OH, USA 3American College Of Surgeons,Division Of Research And Optimal Patient Care,Chicago, IL, USA 4Nemours/Alfred I. DuPont Hospital For Children,Surgery,Wilmington, DELAWARE, USA 5Washington University,Surgery,St. Louis, MO, USA 6David Geffen School Of Medicine, University Of California At Los Angeles,Surgery,Los Angeles, CA, USA

Introduction: Indications for concurrent fundoplication during gastrostomy enteral access procedures are not well established. This study aimed to determine whether 1) the propensity for concurrent fundoplication during gastrostomy varies among hospitals, and 2) whether postoperative morbidities differ significantly among institutions performing fundoplication more or less frequently.

Methods: The American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-P) dataset was queried to identify children who underwent gastrostomy with or without concurrent fundoplication. We created a hierarchical multivariate regression to model the propensity for concurrent fundoplication. The model included preoperative clinical variables associated with concurrent fundoplication after gastrostomy. The excess effects that hospitals exerted over the propensity of concurrent fundoplication were estimated as odds ratios. Hospitals were identified as having low, intermediate, or high odds ratios for the use of concurrent fundoplication. The risk-adjusted postoperative morbidity rates were compared among hospitals designated as low outliers, average hospitals, and high outliers in odds of concurrent fundoplication.

Results: 3,775 children underwent gastrostomy at 54 ACS-NSQIP-P participating hospitals between 2011-2013. The mean concurrent fundoplication rate was 11.7% (unadjusted range 0% to 64%). There was no significant difference in unadjusted morbidity rate in children with concurrent fundoplication, 11.0% compared to 9.7% in children without concurrent fundoplication. After controlling for clinical variables, 8 hospitals were identified as low outliers (mean observed fundoplication rate of 0.4%) and 16 hospitals were high outliers (mean observed fundoplication rate of 34.6%). The average unadjusted morbidity rate among hospitals with low, intermediate and high odds of concurrent fundoplication were 9.6%, 10.6% and 8.6% respectively (p=0.78). The added morbidity rate attributed to a concurrent fundoplication among hospitals with low, intermediate and high odds of concurrent fundoplication were 0.1%, 0.2% and 0.1% respectively (p=0.34).

Conclusion: Hospitals appear to vary significantly in propensity for concurrent fundoplication during gastrostomy in this small observational dataset yet short term morbidity did not differ significantly among the groups. These findings could demonstrate the need to clarify indications for concurrent fundoplication and the need for longer follow up to evaluate the success as well as morbidity of the procedure over time.

72.07 Safety and Cost-Effectiveness of Port Removal Outside of the Operating Room

Posted on January 18, 2016

T. F. Devji1,2, A. Madenci1,3,4, E. Carpino1, M. Samnaliev1,4, C. Weldon1, J. Cravero1 1Boston Children’s Hospital,Boston, MA, USA 2Harvard School Of Dental Medicine,Boston, MA, USA 3Brigham And Women’s Hospital,Boston, MA, USA 4Harvard Medical School,Boston, MA, USA

Introduction: Unprecedented access to health insurance coverage with the Affordable Care Act necessitates cost-conscious delivery of care. As such, health systems must optimize value without sacrificing safety or outcomes. Elective surgical procedures represent one healthcare area that may be value-enhanced by moving to a more cost-efficient setting. The purpose of this study was to assess the safety and cost of performing the removal of implantable central venous access devices (‘ports’) in settings other than the main OR.

Methods: We compared port removal in three settings, specifically: 1) Main OR, 2) Satellite OR, and 3) Clinic procedure room. This was a mixed-methods study, including a retrospective review of health records and prospective observation/interviewing. To calculate cost without the inherent biases of hospital charges, costs, and payments, we utilized the methodology of Time-Driven Activity Based Costing. Specifically, we recorded time spent by the patient in hospital facilities and with hospital personnel. This duration was weighted with the hourly cost of each professional and hospital space. Demographic information and 30-day procedure-related complications data were obtained retrospectively. Time spent by the patient was obtained retrospectively from electronic timestamps. When this information was unavailable, a proxy was obtained from the median time spent during prospective observation. The Mann-Whitney U test compared the continuous variables of time and cost across the three sites. Overall cost at each site was divided by overall cost at the referent site (Main OR) to obtain a ratio of cost savings.

Results: A total of 120 patients (40 per site) were included in the analysis. Demographic and clinical factors were not significantly different between sites. No complication occurred with port removal at any site. Patients in the Main OR spent more time in the procedure room, which was the highest-cost space (Main OR median 56 min vs. Satellite OR 42 min, P<0.001; vs. Clinic 41 min, P<0.001). Median overall cost was decreased by 25% in the Clinic (ratio=0.75, 95% confidence interval [CI]=0.66-0.87) and by 6% in the Satellite OR (ratio=0.94, 95% CI=0.89-1.02), compared to the Main OR (referent; P<0.01).

Conclusion: In this study, port removal in the Clinic procedure room was significantly more cost-effective and not significantly associated with an increased risk of negative outcomes, compared to port removal in the Main OR. Re-locating routine port removal to a non-OR setting, such as a clinic procedure room, appears to be safe and may result in substantial cost savings.

72.08 Outcome Assessment Of Renal Replacement Therapy In Newborns

Posted on January 18, 2016

I. I. Maizlin1, M. C. Shroyer1, L. Perger2, M. K. Chen1, E. A. Beierle1, C. A. Martin1, S. A. Anderson1, V. E. Mortellaro1, D. A. Rogers1, R. T. Russell1 1Children’s Hospital Of Alabama, University Of Alabama,Division Of Pediatric Surgery,Birmingham, Alabama, USA 2Scott & White Healthcare/Texas A&M Health Science Center College Of Medicine,Department Of Surgery,Temple, Texas, USA

Introduction: Recent advances in renal replacement therapy (RRT) have allowed for significant increase in rates of dialysis initiation for neonates with kidney failure or inborn errors of metabolism. Methods of RRT in neonates include peritoneal dialysis (PD), continuous renal replacement therapy (CRRT) and intermittent hemodialysis (HD). The purpose of this study was to assess morbidity and mortality following initiation of dialysis in newborn patients (<30 days) on those modalities.

Methods: Retrospective chart review was performed on all patients who had RRT initiated in the first 30 days of life between 2006 and 2014, excluding patients receiving RRT following congenital heart surgery. All charts were queried for birth history, underlying etiology for RRT, operative history, and route of RRT (HD and/or PD). We also reviewed the surgical complications associated with RRT and mortality rate.

Results: Total of 49 patients were identified, 39 boys and 10 girls. Median gestational age and birth weight were 36 (30-41) weeks and 2.85 (1.66-4.52) kg respectively. Thirty-two patients (65%) had end stage renal disease (ESRD), 11 (22%) had inborn errors of metabolism and 6 (12%) required dialysis due to other pathologies. Initial therapy was continuous veno-venous hemofiltration (CVVH) in all patients. Median age at onset of RRT was 6 (4-14) days and median weight of 3.1 (2.7-4.0) kg. Patients with ESRD spent a median of 8.5 (2-38) days on CVVH, while metabolic error and other etiology patients spent a median of 4 (3-7) days and 4.5 (1-10) days respectively. Overall mortality was 65.3% (71.9% among ESRD patients, 45.5% metabolic disease). Fifty-six percent (18 of 32 total deaths) of all deaths occurring within the 1st 30 days of life and 94% (30 of 32) occurred within the 1st year of life. Most common cause of death was sepsis (30%) among ESRD patients, and ARDS (40%) among metabolic patients. Total of 201 surgeries were performed. Excluding catheter revisions, 83 new HD lines and 28 new PD catheters placed, with a maximum of 6 HD lines and 4 PD lines placed in a single patient. Two patients died within 24 hours of catheter placement due to respiratory failure. Catheter-associated morbidities occurred in 100% of patients. Most common complications for HD included circuit clotting (87%), bleeding (68%) and bacteremia (40%), and for PD patients included peritonitis (83%), catheter complications (72%), and PD catheter leaks (55%). Among 9 survivors that required long term RRT (median follow-up of 5.3 years), 4 were severely and 2 were moderately developmentally delayed.

Conclusion: RRT is increasingly utilized for the neonatal population with renal and metabolic diseases. However, while RRT is becoming more technically feasible, it remains associated with significant morbidity and mortality. Pediatric surgeons must be aware of the challenges of neonatal dialysis and take them into account when considering the care of these critically ill children.

72.04 Institutional Experience of Ultrafiltration in Neonates with Congenital Diaphragmatic Hernia on ECMO

Posted on January 18, 2016

P. E. Lau2,4, S. M. Cruz2,4, D. L. Cass1,2,4, S. E. Horne2, T. C. Lee1,2,4, S. E. Welty3, D. Lazar2,4, J. Garcia-Prats5, O. O. Olutoye1,2,4 1Texas Children’s Hospital,Texas Children’s Fetal Center,Houston, TX, USA 2Texas Children’s Hospital,Pediatric Surgery,Houston, TX, USA 3Texas Children’s Hospital,Pediatrics,Houston, TX, USA 4Baylor College Of Medicine,Department Of Surgery,Houston, TX, USA 5Texas Children’s Hospital,Section of Neonatology,Houston, TX, USA

Introduction:
Several children with severe congenital diaphragmatic hernia (CDH) require extracorporeal membrane oxygenation (ECMO) for the management of respiratory failure. Fluid restriction is typical on ECMO, and on occasion ultrafiltration (UF) is used as a rescue measure. Since early 2012, our institution established a protocol introducing the routine use of ultrafiltration on ECMO (ECMO-UF). We hypothesized that routine ultrafiltration on ECMO (ECMO-UF) is associated with better fluid management, shorter ECMO duration, improved nutritional status and ultimately better long term outcomes without compromising renal function post-ECMO.

Methods:
A retrospective review of CDH cases from January 2004 to January 2015 was conducted at a pediatric tertiary center. Neonates with CDH who required ECMO therapy were included in the analysis. ECMO-UF was started within the first 6-12 hours of ECMO initiation in the Neonatal Intensive Care Unit. Prior to this, UF use was rarely used as rescue modality (ECMO group). Outcomes of patients admitted after 2012(ECMO-UF) were compared to the ECMO group. Net fluid balance, nutritional status after 48 hours on ECMO, renal function, survival and long term pulmonary outcomes were assessed. Statistical analysis was performed using Student’s t-test and Mann-Whitney U Test for continuous measurement and Fischer’s exact for categorical measurement.

Results:
During the study period 214 CDH patients were cared for, 62 (29%) patients required ECMO. Of these, 15 (24%) had UF initiated within 6-12 hours after ECMO cannulation. Patients in the ECMO-UF group had significantly greater caloric intake with higher TPN rates at 48 hours, 47.7+11.1 vs 65.7+11 (p<0.01), and greater total fluid output on ECMO (p=0.017). There was no significant difference in renal function. No significance was seem in length of tracheal intubation, with a median number of days of 37 (20-359) in the ECMO group vs 42 (20-186) in the ECMO-UF (p=0.91). Overall 6 month survival was equivalent in both group 62.2% vs 60.9%, (p=0.25).

Conclusion:

The use of routine UF allows for better optimization of parenteral nutrition while maintaining a more favorable net fluid balance without adverse effect on renal function. Larger studies may help identify other potential benefits of routine UF in long term outcomes in infants with CDH on ECMO.

72.05 Practice Variation in Pectus Excavatum Repair within a Single Institution

Posted on January 18, 2016

C. N. Litz1, S. M. Farach1, C. Snyder2, J. P. Jacobs2, J. Davis2, E. K. Amankwah3, P. D. Danielson1, N. M. Chandler1 1All Children’s Hospital Johns Hopkins Medicine,Pediatric Surgery,Saint Petersburg, FL, USA 2All Children’s Hospital Johns Hopkins Medicine,Cardiothoracic Surgery,Saint Petersburg, FL, USA 3All Children’s Hospital Johns Hopkins Medicine,Clinical And Translational Research Organization,Saint Petersburg, FL, USA

Introduction:
Minimally invasive repair of pectus excavatum (PE) is the current standard of care for repair of PE; however, there exists variations in the technical aspects and the clinical management. The purpose of our study was to determine practice variations and compare outcomes between two surgical services (SS) performing PE repair at a single institution.

Methods:
A retrospective review of all patients undergoing minimally invasive PE repair from July 2013 through June 2015 was performed. General admission, demographic and outcome data were collected. Patients were grouped by surgical service (SS1 vs SS2) performing PE repair and outcome measures were compared. Statistical significance was set at p<0.05.

Results:
A total of 74 patients underwent PE repair during the study period (SS1 n=36, SS2 n=38). There was no significant difference in age (14.9 ± 3.7 vs 15.4 ± 2 years, p=0.494) or total hospital length of stay (3.6 ±0.8 vs 3.3 ± 1.1 days, p=0.221) between the groups. There was a significant difference in total operating room time (147 ± 24 vs 98 ± 30 minutes, p<0.001). Total charges for PE repair were significantly higher for SS1 compared to SS2 (57,579 ± 7,429 vs 40,776 ± 5,727 USD, p<0.001) as were charges for operating room services (13,577 ± 1,709 vs 4,098 ± 584 USD, p<0.001), anesthesia (3,292 ± 373 vs 2,404 ± 323 USD, p<0.001), radiology (1,399 ± 407 vs 342 ± 145 USD, p<0.001), and laboratory studies (1289 ± 801 vs 452 ± 394 USD, p<0.001). Compared to the SS2 group, patients undergoing PE repair by the SS1 group had a greater number of radiology studies (4.7 vs 1.3, p<0.0001), laboratory studies (11.9 vs 3.4, p<0.0001), and ICU days (1.7 vs 0.1, p<0.0001) per patient. Standardized practice plans were initiated with a resultant decrease in ICU, radiology, and laboratory utilization for both groups over 3 years (Table 1).

Conclusion:
There are significant variations in the surgical care of patients undergoing PE repair among surgical services, even within a single institution. Implementation of standardized practice plans help to reduce unnecessary hospital resource utilization. Recognition of these differences may provide valuable information for the purposes of improving patient outcomes while decreasing health care costs.

72.02 Cost Modeling for Gastroschisis Management Strategies

Posted on January 18, 2016

J. Wu1, S. Lee1, D. A. DeUgarte1 1UCLA And Harbor-UCLA,Department Of Surgery – Division Of Pediatric Surgery,Los Angeles, CA, USA

Introduction: Several non-operative strategies have been described to repair gastroschisis including ‘sutureless’, ‘ward reduction’, ‘plastic’, and ‘flap’ techniques. Non-operative strategies have the potential advantages of avoiding intubation and general anesthesia, decreasing pain, and improving cosmesis. Their disadvantage is that the majority of patients without formal fascial closure will develop hernias, a proportion of which will require delayed repair. We hypothesized that routine utilization of non-operative strategy results in cost-savings in uncomplicated cases of gastroschisis.

Methods: We constructed a decision tree to compare three different strategies for the management of uncomplicated gastroschisis: non-operative management, primary operative closure, and routine silo placement. Model variables (including probability of management failure and hernia development as well as anticipated length of stay and treatment costs) were abstracted from a literature review and the Medicare Physician Fee schedule. Uncertainty surrounding model parameters was assessed via one-way and probabilistic sensitivity analyses.

Results: According to our model, non-operative management of uncomplicated gastroschisis was the least costly strategy, which cost $198,085 per patient. Primary closure cost $208,763 per patient. Routine silo placement was the most costly, $239,038 per patient. One-way sensitivity analysis suggested the cost of primary closure would be less costly than non-operative management if the initial success rate of non-operative management was less than 35.4% or if the initial success rate of primary operative closure was greater than 87.8%. Probabilistic sensitivity analysis found that non-operative management was the least costly strategy among 97.4% of 10,000 Monte Carlo simulations.

Conclusion: Non-operative management of uncomplicated gastroschisis appears to be more cost-effective than attempted primary closure and routine silo placement strategies. Furthermore, given the potential for avoiding general anesthesia, routine adoption of non-operative management of uncomplicated gastroschisis should be considered and deserves prospective evaluation.

72.03 Variability in Inhaled Nitric Oxide Use among Patients with Congenital Diaphragmatic Hernia

Posted on January 18, 2016

L. R. Putnam1,2, K. Tsao1,2, F. Morini3, P. A. Lally1,2, K. P. Lally1,2, M. T. Harting1,2 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3Ospedale Pediatrico Bambino Gesù,Rome, , Italy 1University Of Texas Health Science Center At Houston,Pediatric Surgery,Houston, TX, USA

Introduction:

Inhaled nitric oxide (iNO) is often used in the management of congenital diaphragmatic hernia (CDH). There is a paucity of strong evidence supporting the efficacy of iNO for CDH patients. We sought to identify the spectrum of iNO use among CDH patients and the correlation between iNO use and important clinical variables and outcomes.

Methods:

We performed an analysis of data from the international CDH Study Group registry, which comprises voluntary and prospectively collected data from over 60 international centers. We analyzed the following variables: iNO use/dose, gestational age, defect size, pulmonary hypertension (pHTN) as defined by right ventricular systolic pressure >2/3 systemic systolic pressure, operative characteristics, and extracorporeal membrane oxygenation (ECMO) use. Chi-square, Mann-Whitney U test, and regression analyses were performed.

Results:

A total of 3,367 patients were identified from 2007-2015. iNO was used in 2,047 (61%) of all patients. The median (range) iNO dose was 20 (0.1-80 ppm), treatment duration was 8 (0-100 days), and day of life at initiation was 1 (0-189 days). Seventy (3%) patients received 2 iNO treatments, and 7 had >2 treatment periods. Of those patients with evaluable pHTN data (n=3117, 93%), 2,174 (70%) had pHTN, of which 1,613 (74%) were treated with iNO. Of the 943 patients without pHTN, 343 (37%) were treated with iNO. On multivariate regression analysis, iNO use was associated with worse pHTN on initial echocardiogram, larger defect size, ECMO use, and center (all p<0.05). Mean iNO use by center was 62% (0-100%) and its use was inversely associated with the trend in survival (Figure). On multivariate regression analysis, mortality was significantly associated with iNO use (OR 2.8, 95%CI 1.9-4.1), ECMO use (OR 4.1, 95%CI 3.1-5.3), and defect size (A: reference; B: OR 3.4, 95%CI 1.2-9.6; C: OR 8.9, 95%CI 3.2-25; D: OR 18, 95%CI 6.7-52).

Conclusion:

Our analysis revealed that iNO use is associated with pHTN, ECMO use, and defect size. However, we found its use highly variable among centers and over 1/3 of patients without pHTN received iNO. Without strong evidence to support its use, future studies should aim to evaluate its efficacy and standardize its application in order to optimize patient outcomes and ensure cost-effective practices.

71.19 Impact of Obesity on Post-Gastrectomy Outcomes and Survival of Patients with Gastric Cancer

Posted on January 18, 2016

D. H. Kim1, C. E. Cauley1, E. Fuentes1, R. Ahmad1, D. C. Chang1, D. W. Rattner1, J. T. Mullen1 1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA

Introduction: Given the epidemic of obesity and the increased incidence of gastric cancer among overweight and obese patients in the United States, it is important to understand the impact of obesity on gastric cancer surgery outcomes. Previous studies have reported conflicting results. Thus, we sought to evaluate the impact of body mass index (BMI) on both short-term postoperative outcomes and long-term survival after potentially curative gastrectomy for gastric cancer in a large, single institution cohort of US patients.

Methods: We identified 442 patients who underwent potentially curative gastrectomy for gastric adenocarcinoma between 1995 and 2014. Clinicopathologic characteristics, operative details, lymph node yield, postoperative complications, and oncologic outcomes were collected, and patients were stratified according to BMI as underweight (BMI < 18.5 kg/m2), normal weight (BMI 18.5 – 24.9), overweight (BMI 25.0 – 29.9), and obese (BMI ≥ 30). We controlled for clinically relevant confounders using Cox logistic regression analysis to identify predictors of five-year mortality.

Results: Most patients had a normal BMI (n = 175, 39.6%), followed by overweight (n = 159, 36.0%), obese (n = 83, 18.8%), and underweight patients (n = 25, 5.7%). Overweight and obese patients were more likely to be young and male and to undergo esophagogastrectomy than underweight and normal weight patients, though there were no differences in tumor location, tumor stage, or extent of lymphadenectomy across groups. When stratified by BMI, there were no significant differences in the overall postoperative complication rates or in the rates of specific types or grades of complications. Specifically, there were no differences in the 30-day incidence of wound infection, anastomotic leak, or death across the BMI groups. Similarly, there were no significant differences in the length of stay or readmission rates across BMI groups. For the entire cohort, the median number of examined and positive lymph nodes was 18 and 2, respectively, and there was no difference in lymph node yield across the BMI groups. BMI was not an independent predictor of overall survival (P > 0.05) (see Figure).

Conclusion: In contrast to what many groups have previously reported, we found that BMI has no impact on postoperative complication rates, nodal yields, or long-term survival in patients undergoing potentially curative gastrectomy for gastric cancer.

71.22 Using IntegriSense 750 for Fluorescence-Guided Surgery in a Head and Neck Cancer Model

Posted on January 18, 2016

T. Ramesh1, L. Moore1, S. Bevans1, M. Limdi1, E. Rosenthal2, J. Warram1 1University Of Alabama,School Of Medicine,Birmingham, Alabama, USA 2Stanford University,School Of Medicine,Palo Alto, CA, USA

Introduction:
The integrin avb3 is overexpressed in pathologic processes associated with tumor growth and invasion, including in tumor cells and angiogenic blood vessels. IntegriSense 750 (Perkin Elmer) is a targeted fluorescent imaging agent composed of a selective av?b3 antagonist and a near-infrared fluorochrome. We hypothesize IntegriSense 750 can effectively produce contrast for applications in fluorescence-guided surgery as demonstrated in flank xenograft, orthotopic tongue, and lymph node metastatic disease models of head and neck cancer. A dose escalation study was performed at three doses (1.25μg/mouse, 2.5μg/mouse, and 5μg/mouse) in mice bearing luc+ SCC1 flank xenografts (n=5). Mice bearing orthotopic tongue (n=3) and lymph node (n=3) models received 2.5μg of IntegriSense 750 per mouse.

Methods:
Fluorescence imaging was performed twice daily after infusion using commercially available open-field NIR and closed-field NIR imaging systems. NIR renderings of resected specimens were compared to bioluminescence images to confirm localization of probe to tumor. Tissue fluorescence was correlated with histology. Progressively smaller tumor fragments were re-introduced into the wound bed in order to determine the smallest cancerous mass detectable using this agent. Exploratory surgeries were performed to demonstrate agent localization to orthotopic tumors and lymph node metastases. A biodistribution study was performed four days after dosing.

Results:
Intraoperative imaging successfully differentiated tumor from normal tissue with mean tumor-to-background ratios of 3.73, 5.35, and 9.62 on day 4 for the 1.25μg, 2.5μg, and 5μg doses, respectively. Tumor-to-background ratios for all three groups peaked at four days post-infusion. Tumor fragments as small as 0.5mg were visualized in all three dosing cohorts. 3/3 diseased lymph nodes were fluorescently visible in situ in mice during exploratory surgeries. The 5μg dose was found to be the optimal dose for applications in fluorescence-guided surgical oncology in this study.

Conclusion:
IntegriSense 750 appeared to be effective for use in fluorescence-guided surgical applications as demonstrated in flank xenograft, orthotopic, and lymph node metastatic disease models of head and neck cancer.

72.01 Do Secondary Signs Matter in Ultrasound Reporting for Suspected Appendicitis in Children?

Posted on January 18, 2016

K. N. Partain1, A. Patel2, C. Travers3, C. McCracken3, J. Loewen4, K. Braithwaite4, K. F. Heiss5, M. V. Raval5 1Emory University School Of Medicine,Atlanta, GA, USA 2Emory University,Atlanta, GA, USA 3Emory University School Of Medicine,Department Of Pediatrics, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 4Emory University School Of Medicine,Division Of Pediatric Radiology, Department Of Radiology And Imaging Services, Children’s Healthcare Of Atlanta,Atlanta, GA, USA 5Emory University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery, Children’s Healthcare Of Atlanta,Atlanta, GA, USA

Introduction: Ultrasound (US) of the right lower quadrant (RLQ) is often the initial imaging modality for evaluation of appendicitis in children. Frequently, the appendix is not fully visualized, and these equivocal US result in subsequent computed tomography scans (CT) or admissions. Our purpose was to determine if the inclusion of secondary signs (SS) observed in equivocal RLQ US reports improves diagnostic accuracy.

Methods: Using retrospective chart review, we identified 825 children (ages 5–18 years) presenting to a pediatric emergency department with concern for appendicitis and a RLQ US. Final US reports were evaluated for primary and SS of appendicitis. The primary sign of appendicitis was a fully visualized appendix (unequivocal US) with a diameter ≥6mm. SS included fluid collections representative of an abscess, significant free fluid, echogenic fat, regional hyperemia, enlarged lymph nodes, hypoperistalsis of adjacent bowel, and appendicoliths. US reports were classified into four categories: 1. Normal; 2. Equivocal without SS; 3. Equivocal with SS; and 4. Appendicitis. Review of operative and pathology reports confirmed appendicitis. Logistic regression models identified which SS were associated with appendicitis, and test characteristics were calculated.

Results: Of the 825 patients, 530 (64%) had equivocal US reports resulting in 114 (22%) CT and 172 (32%) admissions. Of the 114 patients with equivocal US undergoing CT, those with SS were more likely to have appendicitis (48.6% vs 14.6%, p<0.001). Of the 172 patients with equivocal US admitted for observation, those with SS were more likely to have appendicitis (61.0% vs 33.6%, p<0.001). On univariate analyses, all SS were associated with appendicitis except enlarged lymph nodes. After fully adjusting for age, sex, race, and other SS, the SS that were associated with appendicitis included fluid collection (adjusted odds ratio (OR) 13.3, 95% Confidence Interval (95%CI) 2.1-82.8), hyperemia (OR 11.97, 95%CI 1.5 – 95.5), free fluid (OR 9.78, 95%CI 3.8 – 25.4), and appendicolith (OR 7.86, 95%CI 1.7 – 37.2). Wall thickness, hypoperistalsis of adjacent bowel and echogenic fat were not associated with appendicitis in the fully adjusted model. There was no difference in accuracy in the categorization of cases as normal or appendicitis between unequivocal US and equivocal US when SS were used (Table). Equivocal US that included hyperemia, a fluid collection, or an appendicolith had a specificity of 96% and accuracy of 88%.

Conclusion: There is potential to improve the diagnosis of appendicitis. When using SS, equivocal US are as accurate as unequivocal US. Appropriate use of SS can guide clinicians and reduce unnecessary CT and admissions.

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