48.04 Living Donor Liver Transplantation for PSC: Timely transplants with Excellent Outcomes

Posted on January 26, 2017

C. Ibarra1, D. C. Mulligan1, P. Yoo1, K. Giles1, K. Cartiera1, G. Babas1, C. DelaSancha1, A. Liapakis1, M. Schilsky1, C. Caldwell1, S. Emre1, M. I. Rodriguez-Davalos1  1Yale University School Of Medicine,Surgery – Transplant,New Haven, CT, USA

Introduction: Primary Sclerosing Cholangitis (PSC) is a chronic cholestatic liver disease secondary to a fibrotic inflammation of the intra and/or extra hepatic biliary tree that progresses to cirrhosis, portal hypertension and liver failure, and in some cases cholangiocarcinoma. Liver transplantation remains the only effective treatment for this disorder. Living liver donor transplant (LDLT) offers an option for timely transplantation of these patients. The aim of this study is to review patient and graft survival in a cohort of patients with PSC who underwent liver transplant at our center

Methods: Retrospective review of data from patients transplanted with LDLT or deceased donor organs for PSC between August 2006 and August 2016.  Demographics, type of donor, relationship between recipient and donor, type of transplant anastomosis and number of ducts, post-operative surgical complications, recurrence, patient and graft survival were analyzed

Results:Of the last 390 transplants at our center over 10 years, 19 transplants (4.8%) in 18 patients were performed for PSC. Eleven (57.8%) were LDLT; [7 Right lobes in 7 adults, 4 Left lobes in 3 adults and one pediatric patient] and eight (42.2%) received deceased donor organs (DD). Two underwent liver transplantation at other institutions and received graft for retransplantation (1-LD, 1-DD). 14 patients were males (77.7%) with a mean age of 39.9 years (9 – 66yr) and 80% were over the age of 18 yr.  IBD was associated in 15 patients; 13 Ulcerative Colitis (72.2%), 2 Crohn’s (11.1%) and 3 patients had no bowel disease (16.6%). Of 19 transplants performed at our institution, 18 survived [median f/u was 48 months, range 10-77 months]. One patient died (due to chronic rejection from non-compliance with immunosuppression) and 1 lost her left lobe donated graft within 90 days from antibody mediated rejection leading to graft loss and small for size syndrome, and was successfully re-transplanted with a DD; 5 year patient and graft survival was excellent at 89 and 90% respectively.  No cases of Cholangiocarcinoma (CCA) were found on explant pathology in this series. Biliary reconstruction was carried out by Roux en-Y hepaticojejunostomy to a single duct in 14 patients (77.7%), and to two ducts in 1 patient (5.5%), with duct-to-duct in 3 patients (16.6%). 

Conclusion:Living Donor Liver Transplantation is a excellent option for patients who have PSC to permit timely liver transplant and prevent severe complications from infections, liver failure or development of CCA.   Right lobe LDLT in adults may offer a greater margin of safety in preventing small for size syndrome with post op complications, however both right and left lobe LDLT was effective for PSC.

 

48.03 Do Objective Assessments Match Adolescent Transplant Patients’ Perceptions of Transition Readiness?

Posted on January 26, 2017

B. Cao1,2, F. C. Njoku1,3, Y. J. Bababekov1, A. King1, B. J. Luby1, D. C. Chang1, H. Yeh1  1Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 2University Of Rochester,School Of Medicine,Rochester, NY, USA 3University Of California – Irvine,School Of Medicine,Orange, CA, USA

Introduction:
The period of transition from pediatric to adult care in organ transplant patients is associated with increased risk of graft loss, which may be attributed to poor compliance secondary to knowledge gaps. Previous work has largely utilized subjective questionnaire tools to assess patient readiness to transition to the adult health care system. We observed anecdotally that patient perception of readiness did not always correspond to caregiver perception, so we developed a novel objective questionnaire to assess the accuracy of these perceptions.

Methods:
Pediatric kidney and liver transplant patients ≥ 15 years old completed paired subjective and objective transition readiness questionnaires measuring health knowledge, self-management skills, and psychosocial adjustment. Patients completed the surveys while being seen in the transplant clinic or over the telephone. Each paired survey question was considered in “agreement” if the patient’s answers to both the subjective and objective forms of the question matched; “overconfident” if the patient answered the subjective form of the question claiming full knowledge but was unable to answer the objective form of the question accurately; and “underconfident” if the patient answered the subjective form of the question doubting their knowledge but was able to answer the objective form of the question accurately. Non-parametric tests and regression analysis were used to determine differences in survey responses based on age, gender, time since transplant, and type of organ transplant. 

Results:
Of the 47 patients identified as age ≥ 15 years old, 21 completed the survey (44.7%). The patients ranged from age 15 to 25 years old. The median percent of paired questions scored as “agreement,” “overconfident,” and “underconfident” were 68.2% (IQR = 66.7%-77.3%), 18.2% (IQR = 9.1%-27.3%), and 9.5% (IQR = 4.5%-13.6%). Age >18 years old at the time of questionnaire completion and liver transplantation (vs. kidney transplantation) were associated with slightly higher rates of overconfidence, but these differences were not statistically significant. Male gender and greater time since transplant were associated with slightly lower rates of overconfidence, but again, these were not statistically significant.

Conclusion:
Accurately assessing transition readiness among pediatric transplant patients is vital in educating and supporting patients as they prepare to transition to independent care. We found that patients’ perception of their skills agreed with their demonstrated skills less than 70% of the time. This disconnect suggests that not all adolescent and young adult patients may be ready to make informed decisions regarding their care. Moreover, assessment tools depending only on subjective questionnaires may not adequately guide patient education or accurately determine readiness for transition and transfer. 
 

48.01 Access to Healthcare after Living Kidney Donation

Posted on January 26, 2017

W. Summers1, C. R. Baxter1, B. Shelton1, R. Reed1, P. MacLennan1, J. McLeod1, C. Carroll1, J. Locke1  1University Of Alabama,Birmingham, Alabama, USA

Introduction:  Live kidney donors are encouraged to regularly follow up with their primary care physician (PCP) to monitor kidney function and comorbid disease development. The impact of kidney donation on PCP visits and health insurance is unknown. The goal of this study was to explore post-donation trends in health insurance, PCP visits, and comorbid disease development. 

Methods:  Living kidney donors who are part of a multi-center, IRB-approved, cohort study were contacted and distributed a questionnaire designed to assess access to healthcare (defined as number of PCP visits per year and health insurance coverage). Medical records were also reviewed to evaluate development of post-donation comorbid disease (e.g. hypertension, diabetes, kidney disease). We used descriptive statistics to examine trends in access to healthcare pre and post-donation.

Results: 59 adult living kidney donors were studied; median age of 43.3 years (IQR: 38.9-56.7); 54 European American and 5 African American; with median follow-up of 6.6 years (IQR: 4.3-29.2). 19 donors (32.2%) developed post-donation comorbid disease. We observed a 10.2% increase in health insurance coverage from 86.4% before to 96.6% after donation. Although 6.9% of our cohort reported having trouble obtaining new health insurance after donation, 100% of donors who developed post-donation comorbidities were able to obtain health insurance post-donation. There was also an observed increase in utilization of PCP visits post- compared to pre-donation (84.7% vs. 74.6%), particularly among those donors who developed post-donation comorbidities (100%). 

Conclusion: One third of living kidney donors developed comorbid disease post-donation. Development of post-donation comorbidities did not negatively impact access to healthcare. In fact, access to healthcare as measured by PCP visits and health insurance increased after living kidney donation. 

 

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

Posted on January 26, 2017

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

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

 

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

 

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

 

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

 

47.19 Analysis of Online Fundraising for Pediatric Oncology Patients Using Crowdfunding

Posted on January 26, 2017

I. Schulte4, H. Garrigan3, S. Romo3, P. H. Chang1,2  1University Of Cincinnati,Surgery,Cincinnati, OH, USA 2Shriners Hospitals For Children-Cincinnati,Cincinnati, OH, USA 3Shriners Hospitals For Children-Boston,Boston, MA, USA 4Northeastern University,Boston, MA, USA

Introduction:

Due to the high cost of pediatric oncology care, many people have turned to online fundraising campaign websites, such as GoFundMe.com, to raise additional funds. These websites can be utilized to share the child’s story and recruit donors.  Our group had performed a previous analysis of burn patients on GoFundMe.org and had found several variables that were correlated with increased fundraising using GoFundMe.org.  This study aims to analyze the characteristics assoicated with increased fundraising for pediatric oncology patients on GoFundMe.org.

Methods:
Fifty profiles featuring pediatric oncology patients were accessed via GoFundMe.com. These profiles requested funds for a variety of medical expenses, such as for travel and the cost of dietary supplements for infants. Campaign characteristics such as age, diagnosis, date the fundraiser was posted online, amount of money raised, fundraising goal, and number of donators, Facebook shares, and updates were collected. Simple descriptive statistics were performed.

Results:
Across the 50 profiles, 27 (54%) featured males and 23 featured females (46%). The children featured ranged from ages 3 months to 18 years and were from either the United States or Canada. On average, profiles raised 42% of their goal (range 1.02-115.51%). The fundraising goals ranged from $1,000-100,000, and the average amount raised per day was $13.61 (+$16.05). The average amount raised per Facebook share was $16.21 (+$22.05) and the average Facebook shares per donor recruited was 12.76 (+$11.87) shares. 

Conclusion:
Given the increasing popularity of crowdfunding over the past few years, families of pediatric oncology patients have begun to use crowdsource funding websites to effectively pay for the expenses surrounding pediatric cancer treatment. While some profiles are created by family members, there were some instances where friends or coworkers of the parent started the GoFundMe profile. As seen in this study, these profiles have the potential to raise thousands of dollars by hundreds of independent donors. Understanding factors that lead to successful crowdfunding profiles can help guide future pediatric cancer patients in designing and distributing online campaigns.
 

47.18 Evolution of a Level I Pediatric Trauma Center: Changes in Injury Mechanisms and Improved Outcomes

Posted on January 26, 2017

C. Schlegel1, A. Greeno1, K. F. Collins1, H. N. Lovvorn1  1Vanderbilt University Medical Center,Nashville, TN, USA

Introduction:  Trauma is the leading cause of mortality among children. While much is written about improved outcomes among pediatric trauma patients treated by a pediatric specialist, either at a pediatric trauma center (PTC) or an adult trauma center with pediatric qualifications (ATC), little has been written comparing outcomes after transition from an ATC to PTC at a single institution. Additionally, as more PTC’s are established, a significant knowledge gap exists in understanding the evolution in patient population and outcomes at these new centers. Over the last decade at our medical center, pediatric trauma care has transitioned from an ATC Level 1 facility to a stand alone PTC. The aim of this study was to evaluate the impact of this transition on our single-center outcomes, specifically focusing on mechanism of injury, utilization of resources, and mortality. 

Methods:  A retrospective analysis of 1,188 children who presented as Level 1 traumas to our institution between 2005-2016 was performed. Patients were divided into those treated at our adult hospital preceding the transition (ATC), early at the initiation of a Level 1 PTC (E-PTC), and later following ACS review (L-PTC).  Comparisons were made using Pearson’s Chi-2, Wilcoxon rank sum, and Kruskal-Wallis tests.

Results: Of the 1,188 pediatric trauma patients, 245 were treated at ATC, 672 during E-PTC, and 271 during L-PTC periods. No differences were detected in age, gender, or injury severity. The predominant mechanism of injury for all groups was motor vehicle collisions, with increases in assaults (2.5% ATC vs 10.7% L-PTC) and other blunt mechanisms of trauma (4.5% ATC vs 9.6% L-PTC) (p<0.006), while an increasing trend was observed in violent firearm injuries (6.4% ATC vs 11.8% L-PTC). A significant decrease in ICU admissions was observed during L-PTC in comparison to E-PTC and ATC (51.3% vs 62.4% vs 66.5%, p<0.001). Transition to a PTC correlated with a significant increase in earlier operative intervention following arrival to the ED compared to ATC (20.7% vs 11.4%, p<0.005). Overall mortality trended down in the L-PTC group (12.2%), compared to either E-PTC (13.7%) or ATC (13.0%). This decrease was most notable in children<5 years of age, with mortality decreasing significantly from 22.2% at ATC and 20.7% at E-PTC to 15.7% at L-PTC  (p<0.002).

Conclusion: Changes in the mechanism of trauma presentation occurred following transition to a pediatric Level 1 trauma center, with notable increases in blunt trauma, including assault/NAT. Improvements in mortality and decreases in ICU admission occurred following the creation of an independent PTC when compared to our ATC or during the early evolution of our PTC, with the most drastic differences noted in younger age groups. Transition to a PTC is not only safe, with minimal changes in mortality during early evolution compared to ATC, but also ultimately results in improved pediatric trauma care.

47.17 Prenatal Prognostication of Congenital Diaphragmatic Hernia

Posted on January 26, 2017

S. Koehler1, K. Boyd4, E. Gross1, E. Peterson3, A. J. Wagner1  1Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 3Medical College Of Wisconsin,Maternal Fetal Medicine,Milwaukee, WI, USA 4Children’s Hospital Of Wisconsin,Pediatric Radiology,Milwaukee, WI, USA

Introduction:  The overall survival for neonates with congenital diaphragmatic hernia (CDH) is 65-70%.  Predicting which patients will survive allows pediatric surgeons to accurately counsel families during pregnancy.  Currently, several imaging modalities and various attributes of these images are used to help predict survival.  The complexity of these parameters can range from whether the stomach is in the chest on ultrasound, to the volume of the lung found on fetal MRI, to the ratio of the diameters of the right and left pulmonary arteries to the diameter of the aorta (McGoon index) on fetal echocardiogram.  The most useful modality would be user independent, easily reproducible and not labor intensive.  The aim of this study is to identify a modality that would fit these criterions.

Methods:  This is a case series performed as a quality improvement measure.  Patients were identified whom underwent both prenatal ultrasound diagnosis and fetal MRI assessment of congenital diaphragmatic hernia at a single tertiary institution from August 2014 until August 2016.  Patients were excluded if a lung-to-head ratio (LHR)was not calculated for the ultrasound or if a total lung volume was not calculated on the fetal MRI.   Prenatal and postnatal data were collected on all patients.

Results: Nineteen patients were identified who underwent both prenatal ultrasound and MRI imaging of CDH.  Diagnosis of the CDH was made by ultrasound from 13 weeks estimated gestational age (EGA) to 33.5 weeks EGA.  These patients underwent a total of 43 prenatal ultrasounds and each had a fetal MRI.  Thirty of the 43 recorded LHR correlated with the observed to expected fetal lung volume (O/E FLV).  Eighteen patients survived to delivery, eight to surgery and seven to discharge.  Two patients are still currently admitted.  The deceased patients included a twin who underwent radiofrequency ablation, a patient who had a severe intraventricular hemorrhage on ECMO, one was born at an outside hospital and did not survive to transfer,  4 of the patient's parents chose palliative care, and 3 had severe disease (O/E FLV < 15%).  Patients with only some or no stomach herniated into the thoracic cavity on fetal MRI had 100% survival to surgery and discharge with the exception of one patient who is still admitted

Conclusion: Accurate prognostication of CDH has proven difficult.  While improvements have been made in the last several decades, an ideal modality is still lacking.  Several studies have shown that the fetal stomach position on prenatal ultrasound is strongly associated with neonatal outcomes.  For instance, in one study, all patients with intra-abdominal stomachs survived without need for ECMO.  While prenatal ultrasound is nearly universally used, it is highly user dependent and associated with a steep learning curve.  We propose that a quick, easy, and reproducible technique to predict positive outcomes in CDH is assessment of stomach position on MRI.

47.16 Fulminant Clostridium difficile colitis in children: A disease of surgical relevance?

Posted on January 26, 2017

R. B. Interiano1,2, J. Wolf4,5, S. Arnold4, R. F. Williams1,2  1University Of Tennessee Health Science Center,Surgery,Memphis, TN, USA 2St. Jude Children’s Research Hospital,Surgery,Memphis, TN, USA 4University Of Tennessee Health Science Center,Infectious Diseases,Memphis, TN, USA 5St. Jude Children’s Research Hospital,Infectious Diseases,Memphis, TN, USA

Introduction: Clostridium difficile colitis is a common cause of antibiotic-associated diarrhea, with an increased incidence in adults and children over the past two decades.  While colectomy is associated with an increase in mortality in adults, little data exists as to the age-related outcomes for surgery in children with severe C. difficile infections (CDI).

Methods: Laboratory results, surgical interventions, and pathology reports were reviewed for all patients with a positive laboratory result for C. difficile at our two institutions from January 2003 to December 2012.  Thirty-day mortality was evaluated to assess whether the CDI had contributed to the demise of those patients.

Results: Six-hundred fourteen patients with positive laboratory results were identified at a primarily pediatric oncologic research hospital, while 448 patients were identified at an urban level 1 pediatric hospital.  Of these patients, no patients were found to have died within 30 days from the positive test as a result of the infection as assessed by clinical notes and autopsy results when available.  No patients in this study cohort required bowel resection or colectomy as a result of CDI.  Two patients were identified who required exploration – both for ascites causing respiratory insufficiency.  While the colon was noted to be either dilated or inflamed, neither patient required a bowel resection.

Conclusion: Fulminant CDI is a disease associated with a high mortality in the adult population, while the rate of fulminant disease requiring resection appears to be much lower in children.  Efforts to predict which pediatric patients may benefit from any surgical intervention may be hindered by the paucity in cases identified.

 

47.15 Neonatal Echocardiogram in Duodenal Atresia Is Unnecessary After Normal Fetal Cardiac Imaging

Posted on January 26, 2017

C. Stephens1, N. Hamilton1  1Oregon Health And Science University,Pediatric Surgery,Portland, OR, USA

Introduction:

Duodenal atresia is associated with congenital cardiac anomalies that may complicate the delivery of anesthesia during duodenal atresia repair and the perioperative hospital course.  As a result, neonatal echocardiograms (ECHOs) are often obtained prior to any surgical intervention for correction of duodenal atresia. However, most infants currently undergo high-resolution anatomic screening fetal ultrasounds, at which time most cardiac anomalies are identified. No studies have examined the utility of obtaining neonatal ECHOs in asymptomatic patients with duodenal atresia prior to surgical repair.

Methods:
We conducted an IRB-approved retrospective chart review of all patients with duodenal atresia treated at two tertiary care children’s hospitals between January 2005 and February 2016.  Demographic information and patient comorbidities were analyzed.  Prenatal ultrasounds were reviewed and compared to neonatal ECHOs to find any missed cardiac anomalies. Surgical timing and outcomes were examined.  Statistical analysis was performed using Chi square analysis and student t-tests.

Results:
We identified 61 infants with duodenal atresia, 47% of whom were female, and 28% of whom had trisomy 21.  The fetal ultrasound records were found for 58 (95%) patients.  Forty-one (65%) were diagnosed with duodenal atresia by fetal ultrasound.  Sixteen patients underwent fetal ECHO and 10 (16%) were found to have cardiac anomalies.  Fifty-two patients (85%) underwent neonatal ECHO, including 6 patients who had normal fetal ECHO. Cardiac lesions were identified in 9 patients, including 4 patients with trisomy 21 (one Tetralogy of Fallot, 2 atrioventricular canals and one ventricular-septal defect), all diagnosed prenatally (p<0.001).  One cardiac lesion (ventricular-septal defect) identified on fetal ECHO was no longer present. Only one patient required a delay in repair of duodenal atresia due to the cardiac anomaly which resulted in hemodynamic instability.  All other patients, both with and without cardiac lesions, underwent repair of duodenal atresia without intraoperative cardiac events.

Conclusion:
In patients with duodenal atresia in whom no cardiac lesions are identified prenatally, it is unlikely that any new clinically significant cardiac lesions will be found on further cardiac imaging and neonatal ECHO can be avoided.  In duodenal atresia patients with cardiac lesions identified on fetal imaging but who are asymptomatic, the addition of neonatal ECHOs result in no changes to clinical management and the imaging should not delay surgical care of duodenal atresia.  

47.14 Engaging Parents: Critical members of the Surgical Safety Checklist

Posted on January 26, 2017

M. A. Bartz-Kurycki1,2,3, K. T. Anderson1,2,3, K. M. Masada1,2,3, M. J. Ottosen1,2,3, J. Wang1,2,3, J. E. Abraham1,2,3, K. Tsao1,2,3  1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Department Of Pediatric Surgery,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),The University Of Texas Health Sciences Center At Houston,Houston, TX, USA

Introduction:  The pre-induction surgical safety checklist (SSC) provides an opportunity to exchange and confirm critical information prior to surgery. Recent literature has shown that enhanced patient/parent engagement in healthcare can reduce adverse events and improve outcomes. In our children’s hospital, we conduct this phase in pre-operative holding with anesthesia and nursing, often in the presence of parents. There is a paucity of data evaluating parental involvement in this process. We aimed to describe the current state of parent engagement in the pre-induction SSC.

Methods:  An 8-week observational study was conducted at a tertiary children’s hospital with convenience sampling of elective pediatric surgery operations. Trained observers evaluated the pre-induction SSC with attention to 6 of 17 checkpoints relevant to parental knowledge: patient identification, procedure, surgical site marked, weight, allergies and NPO status. Observers measured parental inclusion based on the perioperative team’s performance of the checklist with/without parent confirmation. New information provided by parents was recorded. Level of parental engagement was also determined with positive engagement exhibiting eye contact, positive body language and undivided attention during checklist proceedings. Anesthesia, nursing and parents were each interviewed post hoc for their perceptions of parental involvement during the checklist process. Cohen’s kappa statistic and Chi square test were used for analysis (p<0.05 was significant).

Results: 255 cases were observed and 68% of parents (n=174) were interviewed with a kappa of 0.85 (95% CI 0.79-0.88). The perioperative team completed 60.9% of checkpoints during the pre-induction SSC while only 36% were directly confirmed with parents (figure). 51 items of new information were provided by parents (range 0-3) with 23 items (45%) corresponding to measured checkpoints. Perceptions of parent engagement were mixed among the groups (p<0.01). During post-procedure interviews, almost all (98%) parents felt included in the checklist process. Similarly, anesthesia and nursing reported positive parental engagement in 72% and 89%, respectively. However, observers identified positive parent engagement in only 53% of cases.

Conclusion: Parental involvement in the pre-induction SSC can introduce new and important clinical information. Although almost all groups reported high levels of parental engagement and comfort in speaking up, observers identified parental engagement in only half of the interactions, suggesting opportunities for improvement. Identifying methods to create supportive perioperative environments and developing a parent-centered SSC would likely improve patient safety.

47.13 Giant Parathyroid Adenoma – Friend or Foe?

Posted on January 26, 2017

D. J. Goldberg1, J. Monchik1, T. Cotton1  1Brown University School Of Medicine,General Surgery,Providence, RI, USA

Introduction:

Giant parathyroid adenomas are poorly defined in the literature. There is limited data regarding preoperative localization and the incidence of multiglandular disease. The purpose of this study is to determine the utility of preoperative localization using ultrasound and sestamibi, as well as the incidence of multiglandular disease, in patients with a giant parathyroid adenoma.

Methods:

A retrospective review identified 870 patients who underwent surgery for primary hyperparathyroidism (PHPT) from January 2003 to September 2013.  A giant parathyroid adenoma, defined as a single gland with a weight >2 grams, was identified in 78 patients. Seven hundred ninety-two patients had adenomas <2 grams and were placed in the non-giant adenoma group.  All patients underwent ultrasound and sestamibi for preoperative localization.  Ultrasound and sestamibi results were compared with operative findings. The criteria for completion of surgery was an intraoperative parathyroid hormone fall of 50% from the highest level and into the normal range 10 minutes following parathyroid gland resection. Accuracy of various localization techniques, as well as the incidence of multiglandular disease, was then compared between groups.

Results:

In the giant adenoma group (>2 grams), surgery identified a single adenoma in 70/78 patients (89.7%) and double adenoma in 8/78 (10.3%).  There was no incidence of four gland hyperplasia.  In the non-giant adenoma group, surgery identified a single adenoma in 683/792 patients (86.2%), double adenoma in 88/792 (11.1%), and 4 gland hyperplasia in 21/792 (2.7%).  Giant adenomas were correctly localized by ultrasound in 60/78 patients (77%) compared to the non-giant adenoma group with 518/780 patients (66%, p=0.07).  Giant adenomas were correctly localized by sestamibi in 72/78 patients (92%) compared to the non-giant adenoma group with localization of 618/785 patients (79%, p=0.002).  Within the giant adenoma group alone, sestamibi was significantly more accurate at localizing the giant adenoma when compared with ultrasound (92% vs 77%, p=0.01).  Of the 8 patients with a double adenoma in the giant adenoma group, 4/8 (50%) correctly localized one of the two adenomas by ultrasound compared to 7/8 (88%) with sestamibi (p=0.28).

Conclusion:

Giant parathyroid adenomas are reasonably common, occurring in 9% of parathyroidectomies for PHPT over a 10 year period.  While 10.3% of giant adenoma patients had a double adenoma, none had four gland hyperplasia.  Patients with a giant adenoma localized better with sestamibi than ultrasound and were more likely to localize with either modality than patients with non-giant adenomas.  

 

47.12 Assessment of Surgeon Comfort with Pediatric Surgical Procedures within the Military Health System

Posted on January 26, 2017

L. M. Fluke2, J. L. Fitch2, C. S. McEvoy2, W. H. Ward2, R. L. Ricca1  1Naval Medical Center Portsmouth,Pediatric Surgery,Portsmouth, VA, USA 2Naval Medical Center Portsmouth,General Surgery,Portsmouth, VA, USA

Introduction: The American College of Surgeons and American Pediatric Surgical Association partnered to develop a strategy optimizing care of pediatric patients by focusing on available resources. Regionalization of care allows for placement of fellowship-trained surgeons in large medical centers capable of treating referrals from surrounding communities. It is unknown whether diminished exposure during training effects comfort level of general surgeons performing pediatric. Analyzed are differences in training, volume, and operative comfort of military surgeons with pediatric cases and how these data can affect surgical practice and the military mission.

Methods: Surveys were sent to 174 Navy surgeons concerning training, military station, and comfort level with pediatric surgical cases. Forty-seven surveys were returned. Comparisons were made between surgeons at a large, regional military treatment facility (MTF) and those at smaller facilities, training locations, and whether or not they completed fellowship training.

Results: There were no demographic differences between surgeons who did or did not perform pediatric surgeries (Table 1). Of the respondents, 42.5% perform surgical procedures on children; there were not pediatric fellowships at the hospitals where these surgeons underwent residency. There were no differences in reported comfort with pediatric surgical procedures in military and civilian trained surgeons. Fellowship-trained surgeons in a specialty other than pediatric surgery reported performing appendectomies and cholecystectomies in younger children. Comparing regional MTFs to smaller facilities, surgeons at non-MFTs were more likely to do more cholecystectomies in older children (median age 14), however there was a trend toward appendectomies in younger children compared to MTF colleagues (2.5 versus 5 years of age). MTF surgeons reported performing laparoscopic pyloromyotomies more than open pyloromyotomies.

Conclusion: All surgeons reported similar comfort levels with performing pediatric procedures. Smaller facility surgeons reported performing appendectomies in younger children. Further training in any fellowship is associated with surgeons reporting operating on children at a younger age. Identifying general surgeons or surgeons fellowship trained in other specialties comfortable performing pediatric procedures provides the military with opportunities to appoint these surgeons to hospitals where there is not a pediatric surgeon; contributing to high-quality regionalization of care. Surgeons comfortable with performing pediatric procedures can be utilized for humanitarian missions as the need within each country varies and surgeons with a larger operative repertoire may serve more patients.

 

47.11 Debriefing: The Forgotten Phase of the Surgical Safety Checklist

Posted on January 26, 2017

J. E. Abraham1,2,3, K. T. Anderson1,2,3, M. A. Bartz-Kurycki1,2,3, K. M. Masada1,2,3, C. K. Shoraka1,2,3, J. Wang1,2,3, A. L. Kawaguchi1,2,3, K. P. Lally1,2,3, K. Tsao1,2,3  1McGovern Medical School, University Of Texas Health Science Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),The University Of Texas Health Sciences Center At Houston,Houston, TX, USA

Introduction:  The effectiveness of the surgical safety checklist (SSC) has recently been questioned. Possibilities for failure include low adherence to checkpoints and poor fidelity or meaningful completion. The debriefing phase of the SSC provides the operative team an opportunity to share pertinent intra-operative information and to communicate post-operative plans. We developed a stakeholder-driven SSC and achieved >95% adherence to the pre-incision phase checkpoints. However, the debriefing phase has yet to be evaluated. The purpose of this study is to assess the current state of adherence to the debrief checklist in our institution to identify areas for improvement.

Methods:  A direct observational study was conducted from 2014-2016 in an academic children’s hospital. Direct observations of debriefings were performed annually over eight-week periods. Convenience sampling of cases was performed across 9 pediatric surgical specialties. During the 8-point debrief checklist, trained observers documented team members’ adherence to a priori defined checkpoints. Inter-rater reliability (kappa) was performed for checklist adherence. Descriptive statistics and the Kruksal-Wallis rank test were utilized (p <0.05 was significant).

Results: Over a three-year period, 654 debriefings were observed (2014 n=205; 2015 n=198; 2016 n=251). Interrater reliability for all intervals was >0.65. Overall, the debriefing checklist was conducted in 91%, 91%, and 95% of cases each year, respectively. The mean number of checklist items completed increased over time with 6.2, 6.5, and 6.6 out of 8, respectively (p=0.03). Nonetheless, half of cases did not fully complete the debriefing checklist and 9% did not debrief at all in 2014 and 2015 with 6% in 2016. The checklist items with lowest adherence and no improvement over time were identification and labeling of specimen, discussion of wound class, confirmation of correct instrument and needle counts, and discussion of equipment problems. Significant improvement was noted in the following checkpoints: surgery attending present for debrief, discussion of blood loss and transfusions, and discussion of intra-operative concerns and post-operative plans (figure).

Conclusion: There has been a slight increase in overall adherence to the post-operative debrief from 2014-2016; however, much work needs to be done to improve performance of each and every checklist item. Lack of checklist effectiveness may be due to poor adherence. Future efforts will include targeted interventions to ameliorate adherence to the debriefing phase and evaluate opportunities to improve patient safety and increase efficiency in the operating room.

47.10 Signing-In For Safety: Benefits of the Pre-Induction Checklist

Posted on January 26, 2017

K. T. Anderson2,3,4, M. Bartz-Kurycki2,3,4, M. J. Ottosen2,3,4, K. M. Masada2,3,4, J. E. Abraham2,3,4, J. Wang2,3,4, A. L. Kawaguchi2,3,4, L. S. Kao2,3,4, K. P. Lally2,3,4, K. Tsao2,3,4  2McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 3Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 4Center For Surgical Trials And Evidence-based Practices (C-STEP),Houston, TX, USA

Introduction: The WHO 3-phase surgical safety checklist (SSC) was introduced in 2008 with subsequent wide adoption, particularly of the pre-incision or “time-out” phase. Evidence demonstrating the efficacy of the “sign-in” phase, which is to be conducted prior to induction of anesthesia and going to the operating room, remains limited. Having achieved sustained overall adherence of >95% of pre-incision checkpoints completed in the past 3 years, the purpose of this study was to evaluate the performance and efficacy our pediatric-specific sign-in checklist.

Methods:  From 2014-2016, 3 annual observation periods of 8 weeks each were completed by trained observers in a tertiary, academic children’s hospital. The sign-in checklist is performed in the pre-operative area between the operating room circulating nurse and anesthesia provider. Adherence was defined as verbalization of checklist item. In 2016, observers also evaluated new information exchanged during the checklist. Eight sign-in checkpoints (patient identified with 2 identifiers, procedure stated, site marking noted, anesthesia consent confirmed, nursing pre-operative worksheet completed, anesthesia safety checklist completed, critical events and extubation plans discussed) were audited during all 3 observation periods. New information was identified by observation as well as interviews of parents, nurses and anesthesia staff. Descriptive statistics, the Kruskal-Wallis rank test and Pearson’s correlation were used for analysis. A p-value of <0.05 was considered significant.

Results: A convenience sample of 607 surgical cases was observed. The sign-in checklist was conducted 94% of the time (n= 570) and when performed, 92% were done at the patient’s bedside. Adherence to checklist items decreased significantly over time, with an average of 76% of items completed in 2014, 54% in 2015 and 52% in 2016 (p<0.01). In 2016, parents were present during the checklist in 96% of cases and despite low adherence, in 242 sign-in performances, items of new information were captured 54 cases (22%). Twenty-three items (43%) corresponded directly to checkpoints. New information included issues such as new allergies reported, wrong laterality identified, and revelation of previous anesthetic complications. There was a non-significant trend between new information and the number of sign-in checkpoints completed increased (p=0.52; figure).

Conclusion:

Despite low adherence to the sign-in phase of the surgical safety checklist, new information was identified by performing the checklist in almost a quarter of cases. Improving adherence to the checklist and involving parents may improve patient safety by facilitating the flow of accurate information.

47.09 Insurance Status and Outcomes in Pediatric Trauma

Posted on January 26, 2017

C. M. Courtney1, E. J. Onufer1, P. M. Choi1, N. A. Wilson1, A. M. Vogel1, M. S. Keller1  1Washington University,St. Louis, MO, USA

Introduction:  Healthcare disparities, based on insurance status, exist in trauma patients. We sought to determine if any disparities exist in pediatric trauma patients at our institution. Specifically, we looked at certain injury patterns and patients transferred from outside hospitals.

Methods:  A retrospective review of all pediatric trauma patients was conducted at a single, ACS and State verified Level-1 pediatric trauma center from 1/1/2009 to 12/31/2014. Patients were categorized by their insurance status [Private Insurance (PI), Medicaid (MC), or Self-Pay (SP)]. Continuous data were analyzed using analysis of variance (ANOVA). Categorical data were analyzed using chi-square test for frequencies.

Results:  A total of 7937 trauma patients were included, of which there were 3677 with PI (46.3%), 3725 patients with MC (46.9%), and 535 patients with SP (6.7%). Overall Injury Severity Scores (ISS) were low, and there were no statistically significant differences in between groups. There were also no differences in the total time spent in the Emergency Department (ED) or in the percentage of patients receiving CT scans between payer status.

We next examined management and outcomes based on insurance status. More SP patients were discharged home from the ED following evaluation compared to both PI and MC patients. The SP group had the highest mortality, followed by MC, and PI (SP: 3.4% vs MC: 1.3% vs PI: 0%, p < 0.0001). When specific injury patterns were analyzed, we found that the SP group had increased incidence of penetrating injury as well as an increased Chest Abbreviated Injury Score (Table 1). Mortality was also higher in SP patients suffering from blunt trauma (SP: 2.1% vs MC: 1.1% vs PI: 0%, p < 0.0001).

4892 patients (61.6%) were outside hospital transfers. In this cohort of patients, there were no differences in ISS between insurance groups. (PI: 5.4±0.1, MC: 5.6±0.1, SP: 5.7±0.5). There were also no differences in the percentage of patients receiving CT scans at outside hospitals according to payer status. This persisted even when patients were stratified by ISS.

Conclusion: Insurance status does not seem to impact the frequency of initial CT evaluation, even in patients transferred from outside hospitals. However, healthcare disparities continue to exist in pediatric trauma. This is particularly true in SP patients who are more commonly discharged home from the ED. These patients also have an increased frequency of both penetrating injury and mortality. Further research into healthcare disparities within this high risk population may reduce costs but also may save lives.
 

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

Posted on January 26, 2017

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

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

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

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

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

47.07 Initial Experience of Peroral Endoscopic Myotomy for Treatment of Achalasia in Children

Posted on January 26, 2017

W. C. Kethman1, C. Thorson1, T. Sinclair1, W. Berquist2, S. Chao1, J. K. Wall1  1Stanford University,Division Of Pediatric Surgery,Stanford, CA, USA 2Stanford University,Division Of Pediatric Gastroenterology,Stanford, CA, USA

Introduction:  Achalasia is a primary esophageal motility disorder characterized by aperistalsis of the esophagus and failed relaxation of the lower esophageal sphincter that presents rarely in childhood. Traditional surgical therapy of achalasia includes graded esophageal dilation or laparoscopic myotomy with partial fundoplication. The peroral endoscopic myotomy (POEM) procedure is an emerging treatment for achalasia in adults that is recently being introduced into pediatric surgical practice, necessitating an understanding of the challenges in training and translation of this procedure from adults to children.

Methods:  This is a prospective cohort study of all children referred to Stanford University Lucile Packard Children’s Hospital with manometry-confirmed achalasia who underwent a POEM procedure. Pre- and post-operative manometry, validated Eckardt scores, intra-operative functional lumen imaging, and procedural details were collected.

Results: The study has enrolled 10 subjects to-date between 7-17 years of age (M=13.4) with the majority having Type I (N=9) versus Type II (N=1) disease. The mean pre- and post-procedure esophageal diameters were 6.16 mm (SD=1.7) and 10.5 mm (SD=1.7) (p<0.005), respectively, and the mean pre- and 1-month post-procedure Eckardt scores were 7 (SD=2.5) and 2.7 (SD=1.9) (p=0.001), respectively. The mean tunnel length was 11.7 cm (SD=0.95), the mean myotomy was 7.1 cm (SD=1.4) and the mean number of endoscopic clips placed was 8.7 (SD=1.8). The mean procedure time for the entire cohort was 137 minutes (SD=64.7) and the mean procedure times for the first three cases compared to the last most recent three cases was 203 minutes (SD=49.7) and 72 minutes (SD=15) (p=0.012), respectively.

Conclusion: The POEM procedure can be completed in children with demonstrated short term post-operative improvement in symptoms. The learning curve is similar for pediatric surgeons compared to the adult experience. The adoption of advanced endoscopic techniques by pediatric surgeons will enable development of unique intraluminal approaches to congenital anomalies and childhood diseases.  

 

47.06 Geographic and Socioeconomic Distribution of Pediatric Firearm Injuries in Arizona

Posted on January 26, 2017

A. Safavi1, T. O’Keeffe1, R. S. Friese1, B. Joseph1  1University Of Arizona,Division Of Trauma, Critical Care, Emergency Surgery, And Burns, Department Of Surgery,Tucson, AZ, USA

Introduction:
Strict firearm legislation has been shown to decrease pediatric firearm injuries. However other factors may also play part, such as the effect of socioeconomic status.  The aim of this study is to identify the geographic distribution of pediatric firearm injuries in Arizona and examine the association of firearm incidence with household income of Arizonian families. 

Methods:
Patients younger than 18 years old with firearm injuries in Arizona were identified from the 2008-2012 Arizona trauma registry.  Primary outcome of interest was incidence of firearm injury per county and zip code of residence.  Secondary outcome was the socioeconomic status of the household of residence. Using US census bureau data, mean and median income for individual counties and zip codes were obtained.  Descriptive and linear regression analysis was then used to determine the association between socioeconomic status and incidence of pediatric firearm injury.

Results:
577 children with firearm injuries (male: female 493:84, mean age 15.6+3.5) were included, of which 31 (5%) were self inflicted. 279 (46%) of children were Caucasian followed by African American 68 (12%) and Native American 47 (8%).  Among counties, Pima (12.7) Yuma (10.2) and Maricopa (9.7) had the highest number of pediatric firearm injury per 100,000 populations. When analyzing by zip code of residence, 349 (60%) and 479 (83%) of injured children were residing in zip codes below 50 (53,893$) and 75 (67,843$) percentile of Arizona mean household income respectively. This was coherent with subgroup analysis of individual counties.  Residing in zip code with mean household annual income below 50 percentile was found to be predictive of higher pediatric firearm injury incidence in linear regression analysis  (β coefficient, 2.09; 95% confidence interval, 0.5-3.6; p = 0.007).

Conclusion:
Low household income is an independent predictor of pediatric firearm injury. Interventions to specifically target this high risk population may lead to more impactful intervention programs.

47.04 The effectiveness of protective devices in the prevention of pediatric traumatic brain injuries

Posted on January 26, 2017

T. J. Zens1, S. Chaiet2,3, A. Rogers1, J. Kohler1, Y. Shan4, C. M. Leys1  1University Of Wisconsin,Pediatric Surgery,Madison, WI, USA 2Univeristy Of Tennessee Health Science Center,Otolaryngology-Head & Neck Surgery,Memphis, TN, USA 3University Of Wisconsin,Otolaryngology-Head & Neck Surgery,Madison, WI, USA 4University Of Wisconsin,Statistics,Madison, WI, USA

Introduction:

Pediatric traumatic brain injuries (TBI) result in significant morbidity and mortality.  Our study aims to better understand national demographics for children with TBI, as well as, the role of safety belts and helmets in prevention of TBI.

Methods:

An analysis of the National Trauma Data Bank was conducted from 2007-2012.  ICD-9 codes were used to identify children with the following types of TBI: concussion, cerebral contusion, brainstem contusion, subarachnoid hemorrhage, subdural hemorrhage, and extradural hemorrhage.  The children were divided into groups (<1 year, 1-3 years, 4-7 years, 8-12 years, 13-15 years, and 16-18 years).  Demographics data and outcomes measures were determined for each group.  Using a logistic regression model and controlling for patient gender, race, ISS, and hospital pediatric trauma designation, odds ratios (OR) were calculated to determine the effectiveness of protective devices such as safety belts after motor vehicle collision (MVC), and helmets after motorcycle, ATV and bicycle accidents.

Results:

204,468 children with TBI were included in the analysis.  Children <1 year and >13 years had the highest rates of TBI.  The most common mechanism of injury across all age groups was motor vehicle crashes (MVC), except in children <1 year where falls were most common (52.9%).  Mean ISS (14.4±12.3), ICU days (5.4±7.7), and mortality (5.0%±8.7%) was highest in children 16-18 years.  Only, 30% of children with TBI were treated at a level trauma 1 peds center.  Children 13-15 years old with TBI were least likely to be wearing a safety belt (23.6%) and children <1 years old were most likely (51.8%).  Odds ratios for each age group demonstrated that children not wearing safety belts were more likely to die in MVCs than those wearing safety belts (OR 1.44-2.42).  Similarly, the rates of helmet use in children with head injuries ranged from only 4.5-23.5% in children involved in ATV crashes, 9-12.4% in children involved in bicycle crashes, and 12-47% in children in motorcycle crashes.  Despite this fact, those children in motorcycle, ATV, and bicycle accidents not wearing helmets were more likely to sustain a head injury than those wearing helmets (OR 1.5-2) in all age groups of children >1 yr old.

Conclusion:
Pediatric TBI account for almost 20% of trauma cases and carry significant morbidity and mortality.  When examining children with TBI after trauma, less than 50% are wearing safety belts and helmets despite the fact that these safety devices remain an extremely effective protective mechanism for children.  More education and legislation is still needed to promote the use of protective devices in children.
 

47.05 Small Bowel Obstruction in Children

Posted on January 26, 2017

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

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

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

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

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

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