13.02 The Management of Blunt Traumatic Retroperitoneal Hematomas in Children.

Posted on January 18, 2018

P. Dasari1, G. P. Wools2, L. S. Burkhalter2, F. G. Qureshi1,2  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA

Introduction:
Management of blunt traumatic Retroperitoneal Hematomas (RPH) in adults is dependent on anatomical classification.  Zone 1 is central, contains the aorta, inferior vena cava, renal vessel origins, partial duodenum/pancreas and requires mandatory exploration. Zone 2 includes the paranephric areas, renal vessels, kidneys, ureters, adrenals/colon and is explored for expanding hematoma.  Zone 3 includes iliac vessels, distal ureters, sigmoid/ rectum and may need surgical or radiologic interventional. This strategy has been used in children but has not been studied.  The aim of this study is to evaluate the management and outcome of children with retroperitoneal hematomas after blunt trauma. 

Methods:
With IRB approval, 10 year (2007-2016) retrospective review of all children with RPH from blunt trauma was performed.  RPH zone was determined by imaging and/or operative findings. Mechanism of injury, laparotomy, RPH explorations, and outcomes were collected.  Descriptive statistics provided mean, standard deviation, median and range. Comparative statistics identified univariate correlations using Fischer’s exact test. 

Results:
We identified 32 patients (84% male, mean age 10±4) with 43 RPH injuries, 14 zone 1, 25 zone 2 and 4 zone 3 injuries (table 1). Mechanisms included motor vehicle collision (75%), struck by object (19%), and pedestrian struck (6%). Nine (28%) patients were unstable on arrival and two expired in the emergency room. Laparotomy was performed in 17 patients, 10 immediately for instability, shock or peritonitis. 13 (30%) RPH zone injuries were explored; two zone 1, nine zone 2 and two zone 3. Four zone explorations required intervention: none in zone 1, four zone 2 (three nephrectomies, one packing) and none in zone 3.  RPH exploration had no post-operative surgical complications. Overall mortality was five (16%): two zone 1 before laparotomy (traumatic brain injury, TBI); two zone 1 after laparotomy (TBI and uncontrolled liver hemorrhage); and one zone 2 after laparotomy from chest injury.  Mortality was higher in unstable patients (p=0.0006). No mortality occurred from RPH exsanguination and RPH exploration did not impact mortality.

Conclusion:
Only a third of pediatric RPH injuries were explored which identified injuries requiring intervention in zone 2 but not zone 1 or 3.  RPH injury in children may require a different treatment paradigm compared to adults. Zone 1 injuries in an otherwise stable pediatric patient without peritonitis may benefit from non-operative management. Further larger scale studies will be required to understand the role of surgical intervention in RPH injury in children.
 

13.01 Underutilization of the Organ Injury Scaling System in a Pediatric Trauma Center

Posted on January 18, 2018

K. B. Savoie1, N. Jain2, R. F. Williams1  1University Of Tennessee Health Science Center,Department Of Surgery,Memphis, TN, USA 2University Of Tennessee Health Science Center,College Of Medicine,Memphis, TN, USA

Introduction:
The value of the American Association for the Surgery of Trauma (AAST) Organ Injury Scaling (OIS) system has been beneficial in managing solid organ injuries in adults. However, OIS may not correlate with pediatric solid organ injuries and thus may be inconsistently used at pediatric institutions. We hypothesized that radiologists inconsistently assign OIS grades for pediatric blunt solid organ injuries.

Methods:
All patients with blunt liver, spleen, and kidney organ injuries from a January 2009 to December 2014 at an urban tertiary pediatric hospital were identified from an institutional trauma database. Demographic information, imaging, radiologic grade of injury, and surgical grade of injury were collected.  Spearman’s correlation and weighted Kappa was used to evaluate radiologist and surgeon’s grading agreement of the injuries. 

Results:
A total of 352 patients were identified; OIS grading was assigned to 73% of patients; 37% had grading by a radiologist and 66% by a surgeon. Liver: 128/179 injuries were graded. 56 patients had grading by both radiologists and surgeons with a Spearman correlation of 0.70 and a weighted kappa of 0.59 (figure). OIS was associated with overall need for intervention (p <0.01) and specifically for need for transfusion (p <0.01) and operative intervention (p = 0.02); it was not associated with need for angiography. Spleen: 97/126 injuries were graded. 41 patients had grading by both radiologist and surgeons with a Spearman correlation of 0.93 and a weighted kappa of 0.86. Kidney: 30/47 injuries were graded. 9 patients had grading by both radiologist and surgeons with a Spearman correlation of 0.82 and a weighted kappa of 0.67. For spleen and renal injuries there was no correlation between OIS grade and need for overall intervention (spleen p=0.12, renal p=0.23) or specific types of intervention. There was no correlation between grade and complications for any type of injury.

Conclusion:
Pediatric surgeons utilized OIS more frequently than pediatric radiologists; there was higher correlation for spleen and renal injuries. Although OIS was associated with need for intervention in liver injuries, it was not associated with interventions for spleen and renal or for complications for any type of injury. Efforts to increase utilization or the development of a pediatric specific grading system may help standardize care for pediatric trauma patients.
 

12.19 Outcomes of Intercostal Nerve Cryoablation with the Nuss Procedure compared to a Thoracic Epidural

Posted on January 18, 2018

C. Harbaugh1, K. N. Johnson1, M. D. Jarboe1, R. B. Hirschl1, J. D. Geiger1, S. K. Gadepalli1  1University Of Michigan,C.S. Mott Children’s Hospital, Section Of Pediatric Surgery,Ann Arbor, MI, USA

Introduction: Video-assisted intercostal nerve cryoablation (INC) during minimally invasive repair of pectus excavatum (Nuss procedure) in adolescents may decrease postoperative pain, opioid use, and length of stay. We sought to evaluate intraoperative and postoperative outcomes in comparison to thoracic epidural (TE) at our center.

Methods: We retrospectively reviewed the hospital course of adolescent patients who underwent Nuss procedure with INC (n=19) or TE (n=13) from January 1, 2015 – August 15, 2017. We compared both groups with respect to patient demographics, postoperative complications, opioid (including oral and intravenous opioids, excluding intrathecal), and non-opioid pain medications (nonsteroidal anti-inflammatories, acetaminophen, and muscle relaxants). The primary outcome was length of stay and secondary outcomes were opioid use and complication rate. All opioid doses were converted to oral morphine equivalents (OME) in milligrams. Mann-Whitney U was used to compare medians, and chi-squared for postoperative complications.

Results: The mean age was 16.7 ± 2.0 years old and 86% of the patients were male. Haller Index was significantly higher in INC compared to TE (4.3±1.3 vs. 3.4±0.9, p=0.03), with no other significant differences in demographics. Length of stay was significantly shorter for INC as compared to TE (median (IQR): 4 (3-4) days vs 6 (4-6) days; p<0.001). Intraoperative opioids (75(48–87) OME vs 30(15–30) OME; p=0.003) and immediate postoperative intravenous opioids (77.4 (63.2–171.1) OME vs 0 (0–36) OME; p<0.001) were significantly higher in INC as compared to TE; however, opioid use at discharge were decreased (200 (200 – 266.7) OME; 266.7 (266.7–400) OME; p=0.024). There was no difference in postoperative complications (21.1% vs. 38.5%, p=0.28).

Conclusion: INC during Nuss procedure reduced length of stay and discharge opioid pain medications, but increased intraoperative and postoperative IV opioid requirements. This opioid trend may reflect the need for improved pain control until INC takes effect, when long-term pain control improves. Prospective evaluation of INC including neuropathy and costs will be necessary prior to recommending routine use with all Nuss procedures.

12.20 Hemorrhage After On-ECMO Repair of CDH is Equivalent for Muscle Flap and Prosthetic Patch

Posted on January 18, 2018

H. Nolan1, E. Aydin1, J. Frischer1, J. L. Peiro1, B. Rymeski1, F. Lim1  1Cincinnati Children’s Hospital Medical Center,Cincinnati, OH, USA

Introduction: The defect in severe congenital diaphragmatic hernia (CDH) often requires a prosthetic patch (patch) or muscle flap (flap) repair. The patch is easy to use but is synthetic, while the flap’s autologous tissue dissection has potential for increased bleeding. Hemorrhage can be further exaggerated when maintained on therapeutic anticoagulation for extracorporeal membrane oxygenation (ECMO), especially if clinical status demands on-ECMO repair. The purpose of this study was to assess bleeding complications for on-ECMO patch compared to flap repair of CDH.

Methods: We retrospectively reviewed on-ECMO CDH repairs from 2010-2016 at a single academic children’s hospital (IRB2017-2322). Exclusions included incomplete records or concomitant procedures that could result in additional blood loss. Patients were grouped by repair type and bleeding complications were captured with intra-operative blood loss, 48-hour re-operation rates for bleeding, and 48-hour post-operative blood product use.

Results: Twenty-nine patients met criteria for analysis. Thirteen (44.8%) had patch repair and 16 (55.2%) had flap repair. Eight (62.5%) of the patch and 13 (81.2%) of the flap group were left-sided defects (p=0.223). All had Type C or D defects with comparable distribution (Type C: patch 56%, flap 54%, p=0.596). There was no difference in mean gestational age at delivery (patch 37.5±0.9 weeks, flap 37.2±1.3 weeks, p=0.390) or mean age at time of repair (patch 7.46±6.6 days, flap 6.00±4.3 days, p=0.476). Both had similar total ECMO duration (patch 361.4±167.1 hours, flap 277.1±149.4 hours, p=0.170) and time from repair to decannulation (patch 7.77±6.0 days, flap 7.00±6.0 days, p=0.734). Only one patient in each group was decannulated within 48 hours of repair for bleeding. Seven patch patients (53.8%) and 9 flap patients (56.2%) survived to discharge (p=0.596).

 

Estimated intra-operative blood loss was equivalent (patch 35.3±53.9 mL, flap 24.2±18.4 mL, p=0.443). One patient (7.6%) in the patch group and two patients (12.5%) in the flap group required re-operation for bleeding (p=0.580). Transfusion requirements in the re-operative group were no different for the patch compared to the flap repair (282.0 mL/kg vs 208.5±21.9 mL/kg, p=0.054). Transfusion requirements for those who did not require a reoperation were also similar (patch 120.7±111.7 mL/kg, flap 118.4±89.9 mL/kg, p=0.561).

Conclusions: Our study demonstrates the feasibility of CDH repair while on ECMO for both flap and patch techniques. Bleeding risks were no different between the two groups with regard to estimated blood loss, reoperation rates, and post-operative transfusions.

12.18 Same Day Discharge vs Observation For Uncomplicated Laparoscopic Appendectomy: A Prospective Cohort

Posted on January 18, 2018

K. Gee1, S. Ngo1, A. Beres1  1University Of Texas Southwestern Medical Center,Department Of Surgery, Division Of Pediatric Surgery,Dallas, TX, USA

Introduction:  Appendicitis remains the most common gastrointestinal pediatric surgical emergency. With the introduction of laparoscopic techniques in the 1990s, recovery, pain and hospital stay after laparoscopic procedures have been significantly reduced. Through 2015 our institution routinely admitted uncomplicated appendicitis patients for overnight observation after laparoscopic appendectomy. Given the increasing body of evidence suggesting the safety and feasibility of same day discharge after uncomplicated appendectomies we elected to perform a prospective study evaluating the complication rates of same day discharge appendectomies compared to overnight observation.

Methods:  After IRB approval, all pediatric patients who underwent laparoscopic appendectomies for uncomplicated appendicitis in 2016 were observed. Decision for same day discharge was based on surgeon preference and parental agreement. Data regarding demographics, admission and discharge times and outcomes of complications, readmissions, return to the ED and non-scheduled clinic visits were collected and analyzing using chi-square and multivariate regression.

Results: A total of 1321 appendectomies were performed during the study period; 849 were uncomplicated, of which 382 were discharged same day and 467 were admitted for overnight observation. Univariate analysis revealed no statistical difference between readmission rates for same day vs observation (2 vs 6 patients, p=0.21) or in emergency department visits (22 vs 27 patients, p=0.98). There was also no difference between the number of surgical site infections or the number of patients who required an extra clinic visit. On multivariate logistic regression, controlling for age, gender and discharge from PACU vs floor, there was a significant difference only for calls related to pain favoring those who went home same day (OR=0.88, p value 0.008).

Conclusion: Same day discharge for laparoscopic non-complicated appendectomy is a safe and feasible alternative to post-operative admission and observation. In our prospective study of 849 patients there were no differences in outcomes between the two groups. This has the potential to yield significant healthcare cost savings.

12.16 Utility of Liver Biopsy in the Evaluation of TPN Cholestasis

Posted on January 18, 2018

C. Buonpane1,2, G. Ares1, G. Englert3, I. Helenowski3, F. Hebal1, C. Hunter1,3  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Geisinger Medical Center,General Surgery,Danville, PA, USA 3Northwestern University,Chicago, IL, USA

Introduction:
Cholestasis is a common and serious complication of total parenteral nutrition (TPN) in neonates, however the pathogenesis is poorly understood.  Approximately 50% of infants requiring long-term TPN develop hepatic dysfunction.  The diagnosis is made when there is development of cholestasis and an absence of other causes such as biliary obstruction, viral hepatitis, drug toxicity, and other metabolic disorders.  Liver biopsies may be requested to assess the severity of cholestasis and fibrosis; however, the impact on treatment strategies and patient outcomes has not been defined.  We hypothesize that liver biopsies in the evaluation of TPN cholestasis do not lead to changes in management or improved patient outcomes.

Methods:
This study is a single institution retrospective review of infants diagnosed with TPN cholestasis from January 2008 to January 2016.  Primary outcomes were length of stay (LOS), 30-day readmission, complication after biopsy, change in management after biopsy (Omegavan and Ursodiol) and mortality.  Univariate analysis was performed using Fisher’s exact test.

Results:

Ninety-five patients with TPN cholestasis were identified, of which 27 (28%) underwent a liver biopsy.  Nineteen (73%) patients had concurrent abdominal surgery for other indications at the time of liver biopsy. Sixty percent of patients with TPN cholestasis had short bowel syndrome and 78% of patients that had a liver biopsy had short bowel syndrome (P=0.036).  There was a significant difference in race (P=0.047) between neonates that had liver biopsies versus those that did not.  Forty eight percent of patients who underwent liver biopsy were African American.

Liver biopsy was associated with a significant change in medical management, including the initiation of Omegavan or Ursodiol.  Eleven (41%) patients were started on medical therapy as a result of liver biopsy, thirteen (48%) patients were on medical therapy prior to biopsy and three patients (11%) were unchanged. 

Patient total bilirubin levels normalized within 6 months of stopping TPN in 92% of cases, with or without liver biopsy.  There was no difference in LOS or mortality in patients with liver biopsy versus without; however, patients with liver biopsy had a higher rate of 30-day re-admission (40% vs 19%, P=0.04).  Five (19%) patients had complications after liver biopsy including bleeding requiring transfusion, need for additional procedures and apnea after anesthesia.

Conclusion:
Liver biopsy in patients with TPN cholestasis was associated with an increase in utilization of medical therapy but did not result in improved patient outcomes.   

12.17 A Pediatric Surgical Team Improves Surgeon Volume and Exposure to Index Pediatric Surgery Cases

Posted on January 18, 2018

W. G. Lee1, D. P. Puapong1,2, R. K. Woo1,2, S. M. Johnson1,2  1University Of Hawaii,John A. Burns School Of Medicine,Honolulu, HI, USA 2Kapi’olani Medical Center For Children,Honolulu, HI, USA

Introduction: High surgical volume for both surgeons and hospital systems has been linked with improved outcomes for complex pediatric surgical problems, yet the current number of accredited pediatric surgeons (PS) necessarily means case volumes per surgeon are diminishing nationally in complex pediatric surgery. Referral of complex patients to centralized high volume referral centers is one solution, but has high costs to families, hospital systems, and insurers especially in areas of geographic isolation. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve surgeon volume as well as team/system experience.

Methods: As a surgical group we incorporated a surgical team approach to complex pediatric surgical cases six years ago. We obtained IRB approval to review our PS index case volume experience to date. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases.

Results: A surgical team approach (2/3 BC surgeons working as co-surgeons or assistant) was used in the majority of cases for TEF/EA (77%), CPAM (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung’s disease (51.9%), CDH (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoplastoma surgery) (85-100%). Surgeon case exposure for all surgeons/all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations. Over the 5-year period, all surgeons were exposed to a high volume of studied index pediatric surgery cases when contrasted to published experience.

Conclusion: A surgical team approach to complex pediatric surgery exposes pediatric surgeons to higher complex case volumes and varieties. This model has implications for geographically isolated and smaller hospitals that specialize in pediatric surgical care and impacts resource allocation, systems development, and workforce allocation in pediatric surgery.

 

12.14 Predicting Outcomes in Necrotizing Enterocolitis: What is the Role of Surgery?

Posted on January 18, 2018

C. Chabuz1, S. D. Larson1, J. A. Taylor1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Objective: Necrotizing enterocolitis (NEC) is the most common condition in neonates that requires surgery. While the mortality in NEC is very high, it is unclear which factors are most responsible for poor outcomes. The purpose of this study was to understand the factors influencing mortality in a large cohort of neonates with NEC.  

Methods: Neonates diagnosed with NEC over an 8-year period (2008-2016) at UF Health were selected using ICD 9 and 10 codes. All patients’ charts were reviewed and only those with a definitive diagnosis of NEC that was in the initial NICU stay were included. Data regarding demographics, maternal and gestational history, presentation, lab and radiologic studies, interventions required, surgical management, and outcomes were collected and compiled. The primary outcome variable was mortality, with secondary outcomes of NICU LOS and neurodevelopmental status in survivors. The cohort was divided into those requiring surgical management (drain or laparotomy) vs. those treated medically. Uni- and Multi-variate analysis was carried out and p values of less than 0.05 were considered significant. 

Results:

A total of 245 cases of NEC were identified during the study period. Overall, the mean gestational age was 28.6 weeks, average birth weight was 1.21 kg, and mortality rate 16.3%. There were 75 patients who required surgical management, while 170 were treated medically. There was no difference between these two groups for race, gender, APGAR score, hematocrit, or length of stay (see table please). Surgical patients were significantly smaller and lower gestational age, had a lower platelet count and presented more often with distention. Univariate analysis noted a significant 5-fold higher mortality rate. Linear, multivariate regression analysis with mortality as the outcome variable noted that surgical management was not a significant predictor, while gestational age, APGAR score, weight at diagnosis of NEC, vasopressor requirement, and intubation were responsible for mortality.

Conclusions: The higher mortality rate in neonates with NEC that require surgery is in part due to the lower gestational age, lower APGAR, higher need for ventilator support at birth, and requirement for vasoactive drugs for circulatory support. Patients presenting with abdominal distention rather than hematochezia are at higher risk for requiring surgery. These data will be used to help predict outcome, plan therapy, and advise parents.

 

12.15 Perinatal Management of Congenital Diaphragmatic Hernia: Variability in Clinical Practice Guidelines

Posted on January 18, 2018

T. Jancelewicz1, M. E. Brindle2, P. A. Lally3, K. P. Lally3, M. T. Harting3  1University Of Tennessee Health Science Center,Department Of Pediatric Surgery,Memphis, TN, USA 2University Of Calgary,Department Of Surgery,Calgary, AB, Canada 3University Of Texas McGovern Medical School,Department Of Pediatric Surgery,Houston, TX, USA

Introduction:  Proper clinical management during the first hours of life for patients with congenital diaphragmatic hernia (CDH) is essential to avoid lung injury and optimize outcomes. However, the variability of neonatal CDH management strategies between centers is unknown. Our objective was to identify North American centers who have an established CDH clinical practice guideline (CPG), obtain/review these CPGs, and assess the degree of variability in general perinatal and neonatal management.

Methods:  Members of the CDH Study Group (CDHSG) and Pediatric Surgery Research Collaborative (PedSRC) were solicited via email to submit their CDH CPG. Standardized variables were created for CPG elements, and CPGs were screened by surgeons, with a 10% blinded second audit to ensure consistent abstraction. Review, descriptive analysis, and measures of variation were performed of perinatal and neonatal CPG components (delivery, resuscitation, vascular access, and sedation).

Results: Sixty-eight centers were solicited with 40 responses (59%). Of these, 29 (73%) had a CDH CPG and 11 (28%) did not; 27 CPGs were obtained for review. Estimated concordance between screeners was 95.0%. Just 5 CPGs (19%) had specified CDH delivery team members. Several key components of CDH resuscitation and general management were included in many CPGs (Table 1). One CPG recommended delayed umbilical cord clamping. An umbilical or right radial arterial line was recommended in 23 CPGs (85%). Initial venous access was mentioned in 21 (78%), with 95% of these recommending the umbilical vein. Sedative medications were addressed in 18 CPGs (67%). 

Conclusion: General perinatal management of infants with CDH is frequently addressed in North American CPGs, with variable inclusion of specific elements. There is relative consistency seen with certain elements of management. These data identify important targets for a consensus approach to CDH patient management, and progression toward multi-institutional CDH management standardization in NA. 

 

12.13 Echocardiographic Guidance During Neonatal and Pediatric ECMO Cannulation is Not Necessary in All Patients

Posted on January 18, 2018

P. A. Salazar1, D. Blitzer2, S. C. Dolejs1, J. J. Parent3, B. W. Gray1  1Indiana University School Of Medicine,Division Of Pediatric Surgery, Department Of Surgery,Indianapolis, IN, USA 2Indiana University School Of Medicine,Division Of Cardiothoracic Surgery, Department Of Surgery,Indianapolis, IN, USA 3Indiana University School Of Medicine,Section Of Pediatric Cardiology, Department Of Pediatrics,Indianapolis, IN, USA

Introduction: Internal jugular cannula position is traditionally confirmed via plain film at the conclusion of the ECMO cannulation procedure. However, it may be difficult to estimate the location of the right atrium on plain films. A misplaced cannula can result in need for repositioning and increased morbidity. Echocardiography (ECHO) may be used during cannulation as a more accurate means of guiding cannula position.  The aim of this study is to study the effect of a protocol encouraging the routine use of ECHO at the time of cannulation.

Methods: We performed a retrospective review of patients at Riley Hospital for Children who received ECMO support using jugular venous cannulation from January 2013 through October 2016. We compared those who underwent ECHO (ECHO+) at the time of cannulation with those who did not (ECHO-). Our primary outcome was need for cannula repositioning after initial cannulation, with secondary outcome being cannula-related morbidity.  For categorical variables, Fisher's exact or Chi-square tests were used to assess for significance. For continuous variables, the median with interquartile ranges (IQR) are presented, and the Wilcoxon rank sum test was used to assess for significance. All statistical analysis was performed on SAS version 9.4 (Cary, NC).

Results: 89 patients met inclusion criteria: 26 ECHO+ (29%), 63 ECHO- (71%). Most of ECHO+ patients underwent dual-lumen VV cannulation (n=17, 65%), while 32% of ECHO- patients required VV support (p<0.003). Seven (27%) ECHO+ patients and 18 (28%) ECHO- patients had a history of cardiac surgery prior to ECMO (p=0.88). All patients had CXR to verify cannula position, and fluoroscopy was used in 4 ECHO+ patients but no ECHO- patients. There was a major mechanical complication in each group: atrial perforation from a guidewire during cannulation in ECHO+ and late atrial perforation from a loose cannula in ECHO-. Subsequent to cannulation, there were 0.58 ECHO studies per patient to verify cannula position in the ECHO+ group compared to 0.22 ECHO per patient in the ECHO- group (p=0.02).  Two (8%) ECHO+ patients required a cannula repositioning procedure for misplacement during the ECMO run, while 6 (10%) ECHO- patients required repositioning procedures (p=0.78).  In the VV ECMO subgroup, ECHO+ patients required no respositioning, while 4 (20%) ECHO- VV patients required repositioning (p=0.1).  Repositioning procedures resulted in no additional complications.  Survival to discharge was similar in both groups: 54% ECHO+ and 62% ECHO- (p=0.51).

Conclusion: Implementation of a protocol to perform ECHO during jugular cannulations for neonatal and pediatric peripheral ECMO did not result in significantly less repositioning procedures, complications, or ECHO studies performed per patient.  ECHO should be used to guide VV cannulation, as need for repositioning approached significance, and it may be a useful adjunct for surgeons during difficult cannulations.

 

12.10 ECMO Duration Predicts Survival in Congenital Diaphragmatic Hernia

Posted on January 18, 2018

S. M. Deeney1, D. D. Bensard1, T. M. Crombleholme1  1Children’s Hospital Colorado,Department Of Pediatric Surgery,Aurora, CO, USA

Introduction:
Physicians caring for patients supported on extracorporeal membrane oxygenation (ECMO) with congenital diaphragmatic hernia (CDH) may wish to know the chance of survival based on time on ECMO. There are limited data reporting the predicted survival outcomes of these patients as a function of ECMO support duration. We aim to describe survival rates in patients with CDH repaired on ECMO in relation to their duration of ECMO support.

Methods:
Retrospective patient data of all patients who underwent repair of CDH while on ECMO from 2008 through 2015 was collected at our institution. Statistical analysis was by logistic regression analysis and chi square, p<0.05.

Results:
There were 22 patients with 10 surviving to discharge. The total number of time spent on ECMO predicted survival to discharge in CDH patients (p=0.006). For every additional day on ECMO, the odds of survival changed by a factor of 0.86 (0.75-0.99). The odds of survival was 50% after 12 days on ECMO, and 25% after 21 days. There was no survival in our patients after 26 days on ECMO.

Conclusion:
Duration of ECMO support predicts survival in patients with CDH repaired while on ECMO, with low survival after 3 weeks and no survivors after 4 weeks. This information may be useful in guiding goals of care conversations.
 

12.11 Using Surgeon-Reported Categorization of Pediatric Appendicitis Severity to Predict Patient Outcomes

Posted on January 18, 2018

K. J. Baxter1, H. L. Short1, C. D. Travers2, K. F. Heiss1, M. V. Raval1  1Emory University School Of Medicine, Children’s Healthcare Of Atlanta,Division Of Pediatric Surgery, Department Of General Surgery,Atlanta, GA, USA 2Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA

Introduction:  The purpose of this study was to evaluate a novel surgeon-reported categorization (SRC) schema for pediatric appendicitis severity.  We hypothesized that the SRC assigned prospectively at the time of surgery would be superior to standard surgical wound classification in predicting outcomes.

Methods:  We conducted an IRB-approved retrospective review of all appendectomies in children 1-18 years performed at two children's hospitals within a single institution from January to December 2016.  Interval appendectomies were excluded.  The SRC is defined as: simple acute (1), complicated gangrenous or adherent (2A), complicated with perforation and localized abscess (2B), or complicated with perforation and gross contamination (2C). Logistic regression was used to model surgical site infections (SSI) and returns to the system.  Cox proportional hazards survival analyses were used to model length of stay (LOS).  All models were adjusted for patient age, sex, and race.

Results:  The cohort included 397 children and the combined morbidity (SSI and revisits) rate was 9.8%.  Over the course of a 15 month implementation, surgeon compliance with SRC documentation increased from 33.5% to 85.9% and chart review revealed 100% concordance of SRC with reported operative findings.  When modeling combined morbidity, SRC displayed improved model calibration (Hosmer-Lemeshow statistic from 0.418 to 0.829), but had similar outcome discrimination to wound class (C-statistic 0.661 vs. 0.657).  SRC showed an advantage over wound class in predicting SSI alone (C-statistic 0.740 vs. 0.684).  SRC better predicted LOS compared to wound class (Figure).

Conclusion:  Despite an overall low morbidity rate in this cohort, SRC improved prediction of SSI and LOS when compared to wound class.  SRC implementation is feasible and provides a more granular assessment of appendicitis severity which may guide future quality improvement efforts through development of grade-specific care pathways.

 

12.12 Single-Visit Surgery Offers Added Convenience and Excellent Family Satisfaction

Posted on January 18, 2018

C. A. Justus1, A. Milewicz1, M. Wortley1, F. Denner1, R. Bogle1, K. Ceyanes1, S. Shah1  1Texas Children’s Hospital,Pediatric General Surgery,Houston, TEXAS, USA

Introduction: The traditional model for elective ambulatory surgical care includes three separate visits to the surgeon: an initial consultation, a second for outpatient surgery, and a third for postoperative follow-up.  Single-Visit Surgery (SVS) is an alternative model of ambulatory surgical care that increases convenience to patients and their families by decreasing the burden of multiple visits.  SVS consolidates care into a single appointment where patients with straightforward surgical problems are evaluated in the morning and undergo a surgical procedure later that same afternoon.  In April 2016 SVS was introduced at a tertiary-care freestanding children’s hospital for the following conditions: umbilical hernia (over 3 years), inguinal hernia (over 12 months), hydrocele (over 12 months), and epigastric hernia.  Our objective for this study was to evaluate our early experience and conduct a survey of our patient’s caregivers to evaluate their satisfaction with SVS.

Methods: We retrospectively reviewed the medical records of patients that were seen as part of SVS from April 2016 through December 2016.  Data collected included demographics, diagnoses, procedures performed, and distance traveled to the hospital.  Additionally, adult caregivers of SVS patients were contacted and asked to participate in a telephone survey.  The telephone survey evaluated their satisfaction with SVS using a 5-point Likert scale.

Results: There were 43 patients seen through SVS during the study period, and 63% were male.  The median age was 7-years-old (IQR, 4.5 – 10).  The median roundtrip patient commute to the hospital was 30 miles (IQR, 23 – 64).  Of the 43 patients evaluated through SVS, 40 (93%) of them underwent surgery.  The most common procedure performed was inguinal hernia repair (n=20), followed by umbilical hernia repair (n=17), and epigastric hernia repair (n=1).  Of the 40 patients that had surgery, 27 (68%) of the families were contacted and participated in the telephone survey. Of those responding, 93% were strongly satisfied, and 7% were satisfied with the care through SVS. All families said they would recommend the SVS program to a friend.

Conclusion: Single-Visit Surgery is an alternative model of ambulatory surgical care that adds convenience to the patient experience and results in excellent family satisfaction. 

 

12.08 Rigorous Failure Criteria Results in High Yield Post-Operative Imaging for Pediatric Appendicitis

Posted on January 18, 2018

K. T. Anderson1,2, M. A. Bartz-Kurycki1,2, K. Tsao1,2  1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction:  Use of computed tomography (CT) for the diagnosis of pediatric appendicitis is declining due to increased awareness of the harms of radiation exposure. However, CT is still frequently employed following appendectomy to evaluate for superficial surgical site infection, intra-abdominal abscess, and small bowel obstruction. The purpose of this study was to examine the efficacy of a post-operative failure criteria for post-operative imaging use in pediatric appendicitis patients and its impact on change in patient management.

Methods:  Pediatric patients who underwent appendectomy for appendicitis between July 2009 and May 2017 were included. Complicated appendicitis was defined as gangrenous or perforated based on surgical diagnosis. Patients who did not meet discharge criteria, defined by fever (temperature >38°C), leukocytosis (white blood cell (WBC) count >12,000/mm3), lack of diet tolerance and/or continued abdominal pain by post-operative day (POD) 5-7 were deemed non-responders. Imaging was recommended by departmental guidelines at POD 5-7 in non-responders. Imaging modality, ultrasound only (US), US and CT (US+CT) or CT only was at provider discretion. The primary outcome was any intervention, a composite of reoperation, drainage/aspiration procedures, opening a wound, or changing antibiotics.

Results: 3,214 pediatric appendectomy patients were identified, with 12% not responding to initial management. Most non-responders (78%) underwent post-operative imaging; CT only was the predominant modality (69%), followed by US+CT (19%), and US only (12%). Non-responders required a change in management only 32% of the time. On multivariate regression, complicated disease (OR 2.6, 95% CI 1.5-4.6) and presence of fever (OR 2.6, 95% CI 1.5-4.4) were associated with need for intervention but not leukocytosis (p=0.18), POD of diet (p=0.24), or continued abdominal pain (p=0.59). A patient with complicated disease and fever at POD 5, had an 87% probability of requiring an intervention. Given the positive likelihood ratios (+LR) of different imaging modalities (US only +LR= 0.8; US + CT +LR 2.1; CT only +LR=1.5), the post-test probability of requiring an intervention after imaging was 84% (US), 93% (US+CT), and 91% (CT).

Conclusion: In pediatric patients who did not respond to initial management, meeting strict failure criteria resulted in a high yield of those requiring intervention after appendectomy. However, type of post-operative imaging did not sufficiently discriminate between those who required a change in management, which will require further delineation. Reserving ionizing radiation to those who necessitate it for the intervention, such as a drainage procedure, may reduce unnecessary post-operative CT use.

 

12.09 Atresia and Gastroschisis: Results from a Multicenter Study

Posted on January 18, 2018

S. Raymond1, S. D. St. Peter1, C. Downard1, F. Qureshi1, E. Renaud1, P. D. Danielson1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Purpose:  Atresia is one of the most common associated anomalies in gastroschisis (GS), and renders the anomaly a complex one. A number of single center studies suggest that atresia has minimal effect on morbidity and mortality in GS, while others suggest otherwise. The purpose of this study was to report outcomes in the largest series of atresias in GS.

 

Methods: A retrospective cohort of GS from 8 institutions from 2006-2013 was created and clinical data collected for pre-, peri- and post-natal variables. Patients with a diagnosis of atresia were selected from this cohort for analysis, excluding those with bowel resection due to perforation or ischemia unrelated to atresia. Comparison was performed with other complex GS patients. Student’s t test and Fisher’s exact test were used for statistical evaluation and a p value of <0.05 was considered significant.  

 

Results: Out of 566 cases of GS, 123 (21.7%) were complex and 51 had an atresia. Atresias were primarily in the jejunum and ileum (67%), and 23.5% were multiple. Despite 84% of GS found prenatally, there was no prenatal atresia diagnosis. Atresia patients had a 9.8% mortality rate in the NICU and a 15.8% mortality at follow up. Atresia’s LOS was over 3 months and 70% required repeat laparotomy. At discharge, 43% of atresia patients required TPN. A comparison of atresia with other complex GS shows atresia to be associated with higher rate of intestinal failure and a trend to higher LOS, rate of sepsis, and readmissions (Table).

 

Conclusions: GS associated atresia carries high morbidity and mortality rates, and has significantly higher rates of intestinal failure than other complex GS. A majority required multiple operations, readmissions, and long-term central lines. Identification of an atresia with GS should prompt a transfer to a facility with higher capability. 

 

12.07 Predictive value of Ultrasonography in Diagnosis of Appendicitis in Children

Posted on January 18, 2018

J. A. McKean1, S. Ayub1, D. Rajderkar1, M. M. Mustafa1, J. A. Taylor1, S. D. Larson1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction:

Abdominal pain in children is one of the most frequent causes of an emergency department (ED) visit. Ultrasound evaluation for appendicitis in that setting has become almost standard of care imaging to reduce radiation exposure from computed tomography. However, this has led to a practice that encourages indiscriminate use of ultrasound (US) and potentially reduces its effectiveness as a diagnostic tool. The purpose of this study was to better understand the utilization and predictive value of US for diagnosis of appendicitis in children.

 

Methods:

All children who underwent an ultrasound evaluation for abdominal pain in the ED over a 5-year period were included in the study. Patients having US for trauma, or for gallbladder disease were excluded. Data regarding clinical presentation, laboratory evaluation, imaging results, and outcomes were collected. The entire cohort was divided based on age, gender, appendicitis score (PAS), and US results and comparative statistics performed. Students t test, Fischer’s exact test, and the Mann-Whitney tests were performed where appropriate and a p value <0.05 was considered significant.  

 

Results: 1650 patients were identified with US evaluation in the ED. A total of 746 children had evaluation for appendicitis. Overall mean age was 11 years, 50.8% were female, and the mean WBC count was 11.88/mm3. Seventy percent of the cohort had a moderate risk PAS score (4-7), while 21% were low risk and 9% were high risk. US results were 63.8% non-visualization (NV), 12.2% positive, and 23.9% negative for appendicitis; a definitive result on US was more likely during the daytime(P=0.002). Further analysis of the NV subset revealed no difference in age or gender, 74% had a moderate PAS score, and 22% underwent a subsequent CT scan. Table 1 shows the difference between NV US patients who were admitted for observation only, discharged from the ED, and who were admitted and underwent an appendectomy. Low risk PAS patients had a 60% NV US and 3% false positive rate. Patients with a high PAS had positive US diagnosis in 43% cases. 

Conclusion:

US utilization for children with abdominal pain is high, even in the setting of a low PAS, where it was not useful. There was a likely reduction in CT scans for patients with a high PAS. Patients with a NV appendix were very common and the use of laboratory and clinical criteria as well as the C-reactive protein were helpful in management. These data will be used to help refine the US use in children in the ED.

 

12.05 Engaging Families Through Shared Knowledge: RCT of Open Access to a Rapid Learning Healthcare System

Posted on January 18, 2018

D. O. Gonzalez1, Y. Sebastiao1, J. N. Cooper1, M. Levitt1, R. J. Wood1, K. J. Deans1  1Nationwide Children’s Hospital,Columbus, OH, USA

Introduction: A rapid learning healthcare system (RLHS) can deliver near-real time data to physicians and families about a disease and its outcomes based on specific patient characteristics. Giving families access to a RLHS may increase patient engagement, improve their knowledge, and lead to better outcomes. This study investigated the impact of allowing families of pediatric patients with complex colorectal diseases access to a RLHS on patient-centered outcomes. 

Methods:  We created a RLHS that integrates pre-specified data elements and validated surveys within the clinical workflow into the electronic health record. The RLHS is an interactive dashboard which contains information on a number of data points, including demographics, quality of life (QOL), surgical outcomes, complications, and continence. We performed a randomized trial of caregivers of children <18 years of age with an anorectal malformation, Hirschsprung disease, or functional constipation visiting our colorectal center. Prior to their initial office visit, participants were randomized to either standard surgical consultation or open access to the RLHS in addition to a standard consultation. To determine the effect of open access to the RLHS on patient-centered outcomes, we assessed healthcare satisfaction, quality of life (QOL), parent activation, health literacy, and caregiver knowledge about their child’s diagnosis. Outcomes between groups were compared at the end of the initial office visit and at 30 days. For participants randomized to the RLHS group, system usability was assessed and an exit interview conducted.

Results: Of 126 participants, 62 were randomized to the RLHS group and 64 were randomized to standard consultation. There were no differences in age, gender, or diagnosis between the patients and no differences in demographics between the caretakers in both groups. At the end of the initial clinic visit, there were no differences in healthcare satisfaction, QOL, parent activation, health literacy, and knowledge of disease between groups. After 30-day follow-up, there were no differences in healthcare satisfaction, QOL, and knowledge of disease. The usability and learnability of the RLHS were ranked 73.0 and 80.4, respectively, on a 100-point scale. Most participants reported that the RLHS included a lot of useful information and was easy to use. Approximately 25.0% of participants reported feeling overwhelmed when looking at the information on the RLHS, but only 3.6% reported that it increased their stress level. The majority of participants (83.9%) would recommend that we provide RLHS access to all families.

Conclusion: Although providing access to the RLHS did not affect patient-centered outcomes, the majority of patients recommended providing families access to this type of system. Although access to the information in the RLHS overwhelmed some of the patients, it did not affect the stress level of the vast a majority of patients.

12.06 Post-operative Complications in Children with Down Syndrome Correlate with Other Comorbidities

Posted on January 18, 2018

M. A. Bartz-Kurycki1,2, K. T. Anderson1,2, M. T. Austin1,2, L. S. Kao1, K. Tsao1,2, K. P. Lally1,2, A. L. Kawaguchi1,2  1McGovern Medical School, University Of Texas Health Sciences Center At Houston,Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA

Introduction:  Down syndrome (DS) is associated with multiple co-morbidities, which may increase the risk of post-operative complications. Physicians perceive that DS patients have a higher risk of post-operative complications; however, the literature remains unclear. This study evaluated the risk of post-surgical complications for abdominal and thoracic procedures in children with and without DS.

Methods:  The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was queried for patients under 18 years of age who underwent non-cardiac abdominal and thoracic operations (by CPT codes) between 2012 and 2016. Analysis compared patients based on the presence or absence of DS. The primary outcome was a composite of all post-operative complications as defined by NSQIP-P. Analysis utilized chi square, student’s t-test, and univariate and multivariate logistic regression. Potential pre-operative risk factors, including DS and those found in the NSQIP-P risk calculator, were evaluated for an association with post-operative complications. Variables were tested for interactions.

Results: 91,478 surgical patients were included with a mean age of 7.2 years ± 6.1 years. Of those patients, 57.8% were male and 1,476 (1.6%) had a diagnosis of DS. Baseline covariates demonstrated significant differences; patients with DS had higher rates of pre-operative nutritional support (38.8% vs. 15.0%), developmental delay (61.9% vs. 10.4%), and cardiac risk factors (76.5% vs 13.8%). The overall rate of post-operative complications was 10.9% and patients with DS demonstrated a higher proportion than controls (16.2% vs 10.8%, p<0.001). On univariate analysis, DS was associated with increased odds of post-operative complications (OR 1.6 95%CI 1.4-1.9) compared to the non-DS group; however, this risk was reversed when adjusting for all other covariates (aOR 0.86 95%CI 0.7-1.1; Table). Univariate analysis of individual surgical complications suggested an increased risk of sepsis (2.6 95%CI 1.8-3.6) and surgical site infection associated with DS (OR 1.6 95%CI 1.3-2.0) but were not statistically significant on multivariate analysis.

Conclusion: Although a greater proportion of post-operative complications were observed in patients with DS, when adjusting for other risk factors, DS was not an independent risk factor. The increased rate of complications is likely related to the presence of certain risk factors that are more common in DS, such as hematologic disorders, cardiac risk factors, nutritional supplementation, and ventilator dependence. Pre-operative counseling and optimization for patients with DS should be tailored to the individual based on their co-morbidities.

12.04 Nonoperative Anesthesia Time for Common Surgical Procedures in Young Children

Posted on January 18, 2018

K. Williams1, B. Nwomeh2, T. A. Oyetunji3  1Howard University College Of Medicine,General Surgery,Washington, DC, USA 2Nationwide Children’s Hospital,Columbus, OH, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Kansas City, MO, USA

Introduction: Increasing attention is being paid to the neurotoxicity and potential long-term cognitive effects of general anesthesia (GA) in children younger than 3 years old. This study aims to describe the most common pediatric surgical procedures requiring GA in children less than 3 years, and the potential discordance in nonoperative anesthesia time  and operative anesthesia time.

Methods: The National Surgical Quality Improvement Program Pediatric (NSQIP-P) database for 2012-2013 was queried for all children 3 years old or less who underwent GA for an inpatient pediatric general surgical procedure. Demographic data, procedure by Current Procedural Terminology (CPT) code, case type, operating time, anesthesia time, and American Society of Anesthesiologists (ASA) class were descriptively analyzed. Those who underwent additional procedures during the same anesthesia period were excluded. For each procedure, the difference between total anesthesia time and total operating time was calculated, yielding the nonoperative anesthesia time.

Results: A total of 5143 patients were identified. Of these, 63% were male and 68% were White. The median age at admission was 64 days (IQR 28-294) and 78% were infants. Most cases were elective (59%), and the most common ASA class was 2 (38%). The most common procedures performed in children younger than 3 years were pyloromyotomy (21%), laparoscopic gastrostomy (8.6%), and unlisted procedures on the stomach (6.6%). The median nonoperative anesthesia times were 45 mins (IQR 37,55), 48 mins (IQR 37, 64), and 48 mins (IQR 38, 62) respectively. (Table 1)

Conclusion: For the most common procedures requiring GA in children less than 3 years, the median nonoperative anesthesia time exceeds operative anesthesia time by more than 45 minutes, suggesting that this is a potentially modifiable target for decreasing anesthetic exposure. The provider and systems level factors that contribute to this time discordance need to be explored.

 

12.03 Earlier Feeding after Congenital Diaphragmatic Hernia Repair Associated with Shorter Hospitalization

Posted on January 18, 2018

S. M. Deeney1, D. D. Bensard1, T. M. Crombleholme1  1Children’s Hospital Colorado,Department Of Pediatric Surgery,Aurora, CO, USA

Introduction:
The benefits of early enteral feeding have been demonstrated in expedited recovery after surgery protocols for various procedures such as adult colorectal surgery. Little is known regarding the effect of earlier enteral feeding in patients after congenital diaphragmatic hernia (CDH) repair.

Methods:
Retrospective patient data of all patients who underwent CDH repair from 2008 through 2015 was collected at our institution, excluding patients who died prior to initiation of enteral feeding (n=64). Statistical analysis was by Student’s t test, chi square, and Fisher’s exact test, p<0.05.

Results:
Patients who started enteral feeding 5 days or earlier following CDH repair had a statistically shorter length of hospitalization than those fed 6 days or later postoperatively (51±42 vs 85±125 days, p=0.03). There was no significant difference between groups in survival to discharge (95% vs 85%, p=0.3), ventilator time (24±44 vs 95±167 days, p=0.07), postoperative total infection rates (38% vs 45%, p=0.16) and wound complication rates (2% vs 15%, p=0.09).

Conclusion:
There is an association between earlier enteral feeding and decreased length of hospitalization in patients who have undergone CDH repair. All other factors studied did not reach statistical significance, possibly due to underpowering. These results need to be validated in a prospective randomized, controlled study.
 

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