47.03 What To Do With A Non-Diagnostic Ultrasound For Children With Suspected Acute Appendicitis?

Posted on January 26, 2017

A. F. Tyson1, R. Sola1, S. Lawson1, A. E. Furr1, R. Cordle1, A. M. Schulman1, G. H. Cosper1  1Carolinas Medical Center,Charlotte, NC, USA

Introduction:  Acute appendicitis (AA) is the most common surgical condition in children in the United States, yet the diagnosis remains a challenge. Ultrasound is the recommended diagnostic study of choice in pediatric patients, but up to 63% of ultrasounds are non-diagnostic. In a previous study, we found that 39% of pediatric patients with a non-diagnostic ultrasound in our ED received a surgical consultation and 30% were admitted to the hospital. In that population, only 10% of patients were ultimately diagnosed with AA. The purpose of this project was to develop an evidence-based algorithm for the workup of pediatric patients with concern for AA and a non-diagnostic ultrasound.

Methods:  Pediatric patients (≤18 years old) presenting to the pediatric ED with symptoms concerning for AA who had a non-diagnostic ultrasound were included in the population, and the ED staff was encouraged to follow the algorithm for these patients. Specific outcome measures including rates of surgical consultation, hospital admission, appendicitis, and compliance with the algorithm were tracked to assess improvements in outcomes following implementation of the protocol. We followed a Plan-Do-Study-Act format for quality intervention and met monthly with the ED staff to solicit feedback and adjust the algorithm as necessary.

The primary goal of this quality improvement project was to achieve ≥90% compliance with the algorithm by December 31, 2016. The secondary goal was to determine whether compliance with the algorithm decreased the rate of hospital admission or surgical consultations, without increasing the rate of missed appendicitis in the pediatric population.

Results: Thus far, 85 children have been included in the study. The average age is 10 years and 48% are male. The average modified Alvarado score is 4.1 (range 0-9). The overall rate of surgical consultation thus far is 28%, although this has decreased from 38% for the first three months to 19% for the next three months. Twelve patients have been admitted for suspected appendicitis (14%) and 4 of these patients were eventually diagnosed with AA (4.7%). There were no cases of missed appendicitis. The overall compliance to date is 84%, although compliance fluctuated between 80% and 100% over the past four months.

Conclusion: The rate of AA in children with non-diagnostic ultrasounds is low and children ultimately diagnosed with AA can be appropriately identified using the algorithm. Our results demonstrate that greater than 90% compliance with the algorithm is possible. Although preliminary, the results suggest that compliance with the algorithm may decrease the number of surgical consultations and hospital admissions to rule out appendicitis in this population. In the future, we hope to be able to determine whether compliance with the algorithm can decrease resource utilization, cost, and length of stay in the pediatric emergency room, thereby making these patient encounters more efficient and cost-effective.

47.02 Intracranial Pressure Monitoring In Pediatric Traumatic Brain Injury: Is It Time To Rethink Its Utility??

Posted on January 26, 2017

V. Pandit1, A. Azim1, T. O’Keeffe1, A. Tang1, K. Ibraheem1, N. Kulvatunyou1, G. Vercruysse1, L. Gries1, B. Joseph1  1University Of Arizona,Trauma,critical Care, Burn And Emergency Surgery/Department Of Surgery,Tucson, AZ, USA

Introduction:
Brain Trauma Foundation (BTF) guidelines recommend intracranial pressure (ICP) monitoring for traumatic brain injury (TBI) patients; however their impact on patient outcomes in pediatric TBI patients remains unclear. The aim of this study was to assess outcomes in pediatric TBI patients meeting BTF guidelines for ICP monitoring. We hypothesized that ICP monitoring improve outcome after TBI

Methods:
The National Trauma Data Bank (2011-2012) was queried to include patients with isolated blunt TBI with age ≤18 years and Glasgow Coma Scale (GCS) score ≤9. Patients were stratified into two groups: ICP and No-ICP. Missing value analysis was performed after which patients in the two groups in a 1:2 ratio (ICP: No-ICP) were matched for age, gender, GCS, Head abbreviated injury scale (AIS), and admission vital parameters. Outcome measures were mortality, discharge disposition, hospital and ICU length of stay.

Results:
A total of 1106 patient met BTF criteria for ICP monitoring of which only 11.7% (n=130) patients received ICP. After propensity matching a total of 390 patients were included. Table 1.

Conclusion:
Our data suggests that use of ICP monitoring in pediatric TBI patients is low. Patients with ICP monitoring had higher mortality rate and worse outcomes compared to similar matched cohort of patients without ICP. This finding should provoke re-evaluation of the indication and utility of ICP monitoring in pediatric TBI patients
 

47.01 Infidelity: Cheating on the Pre-Incision Surgical Safety Checklist

Posted on January 26, 2017

J. Wang1,2,3, K. T. Anderson1,2,3, M. Bartz-Kurycki1,2,3, K. M. Masada1,2,3, J. E. Abraham1,2,3, C. K. Shoraka1,2,3, M. T. Austin1,2,3, A. L. Kawaguchi1,2,3, K. P. Lally1,2,3, K. Tsao1,2,3  1McGovern Medical School, The University Of Texas Health Sciences Center At Houston,Houston, TX, USA 2Children’s Memorial Hermann Hospital,Pediatric Surgery,Houston, TX, USA 3Center For Surgical Trials And Evidence-based Practices (C-STEP),Houston, TX, USA

Introduction:  In 2008, the World Health Organization published guidelines for implementation of a 3 phase Surgical Safety Checklist (SSC) with the goal of reducing patient harm due to surgical care. We previously demonstrated high checklist performance (>95% adherence) of the pre-incision, or “timeout” phase through a stakeholder-driven, iterative process including annual mandatory education on checklist and OR safety for all surgical team members. We recently introduced three new checkpoints to improve OR safety (establishing safe zone, fire risk and plan, maximum allowable dose of on-field medications). We hypothesized that mere inclusion of new checkpoints would demonstrate high adherence and fidelity (meaningful completion) when incorporated into an already high functioning pre-incisional checklist performance. 

Methods: Trained observers, using a priori definitions, documented surgical team adherence for the pre-incision checklist during 3 periods between 2014 and 2016. Fidelity – a measure of complex completion of a checklist point requiring inter-team communication and coordination above simple verbalization – was recorded for 6 checkpoints during all years. Three new checkpoints, establishment of a safe zone for sharps, discussion of fire risk and plan and description (concentration, maximum dose) of field medications, were introduced prior to the 2016 observation period. Fidelity was assessed by checkpoint and surgical specialty. Interrater reliability was evaluated using Cohen’s kappa. Kruskal-Wallis test by ranks and Student’s t-test were used to evaluate variation in fidelity. A p-value <0.05 was significant. 

Results: 277 pediatric surgical operation pre-incision checklists were observed across 9 specialties in 2016, 211 cases in 2015, and 207 cases in 2014. Interrater reliability was greater than 0.70 for all years. Average fidelity for the 6 checkpoints evaluated during all observation periods increased between 2014 and 2016 (from 71% to 92%, p<0.01). All but one the specialties, Dental surgery, which was not observed during 2016, improved their fidelity significantly (figure). Fidelity was significantly lower than the 2016 average for the 3 new pre-incision checkpoints (safe zone fidelity= 79%, fire risk fidelity= 83%, field medication fidelity= 38%, all p<0.01).

Conclusion: Overall meaningful pre-incision checklist performance has improved annually from 2014-2016. However, new checklist items without strategic implementation strategies demonstrate lower fidelity. Changes to established processes require targeted intervention to maintain high performance. 

 

46.20 The Lack of Surgical Consequences of Eclampsia and HELLP for the Neonate, a surprising finding.

Posted on January 26, 2017

W. P. Boyan1, B. Shea1, N. Fiore2, Y. Fenig1, I. T. Cohen1  2St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada 1Monmouth Medical Center,Surgery,Long Branch, NJ, USA

Introduction:
Knowledge of the correlation between maternal conditions, especially during pregnancy and fetal outcomes is paramount to optimal care in pediatrics. One which has not been frequently commented on in the literature is pre-eclampsia, eclampsia and hemolysis, elevated liver enzymes and low platelets (HELLP). This spectrum, which starts with hypertension and proteinuria in the pregnant mother, pre-eclampsia, affects 2-8% of all pregnancies. The transition to eclampsia occurs with seizures. Finally, 10-20% of severe cases result in HELLP, which carries a 1% mortality to the mother. Preterm delivery is increased in pre-eclampsia and HELLP at 25.5% and 50% respectively, which indicates the severe consequences of this disease for both mother and child. Intuitively, a disease which is caused by deranged blood flow and coagulation factors must have an effect on the developing fetus. This begs the question, why is there a paucity of information about these diseases and the consequences to the child? 

Methods:
A retrospective review of all documented cases of pre-eclampsia, eclampsia and HELLP was done at a community Regional Neonatal Center. Over a five year period, 291 mothers were diagnosed with one of the three conditions and gave birth to 318 children. The children were stratified for gestational age, birth weight and any conditions within the first year of life. The characteristics of the neonates and incidence of all conditions were stratified for contributing factors and compared to established data. 

Results:
Of the 318 neonates, two were still births and one mother died from intracranial hemorrhage in the face of HELLP. Two hundred and twelve (66.67%) were born before 37 weeks, which is higher than the expected rate for these conditions. A total of 114 neonates were low birth weight (36%), while 75 were very low birth weight (23%). The incidence of hematologic, cardiac, pulmonary and renal problems all initially appeared higher than expected, but once stratified for prematurity and birth weight, all but cardiac and renal abnormalities fit into expected ranges. Hernias, intestinal conditions and intracranial hemorrhages appeared on the low end of expected incidence. 

Conclusion:
Eclampsia and HELLP are serious conditions in the pregnant patient, which significantly increase rates of preterm delivery as well as correlates with low birth weights. As with all maternal conditions, thought must be given to the effect of these derangements on the developing fetus. Conditions such as necrotizing enterocolitis (NEC) caused by low flow sates and intestinal atresias, thought to occur with vascular incidents, were not seen at a higher rate in these patients once stratified for gestational age and birth weight. The authors conclude that although pre-eclampsia, eclampsia and HELLP are a risk factor for prematurity and low birth weight, they are not themselves an independent risk factor for any identifiable neonatal surgical condition
 

46.19 Treatment Options for Pediatric Empyema: Video-Assisted Thoracoscopic Surgery vs. Fibrinolytics

Posted on January 26, 2017

N. A. Vaughan1, N. Spendlove2, L. S. Burkhalter1, A. L. Beres1,2, D. L. Diesen1,2  1Children’s Medical Center,Department Of Pediatric Surgery,Dallas, Tx, USA 2University Of Texas Southwestern Medical Center,Department Of Surgery,Dallas, TX, USA

Introduction:   Video-assisted thoracoscopic surgery (VATS) and fibrinolytics via tube thoracostomy (TT) have both been used as treatment for empyema in children.  Early literature supported improved outcomes with early VATS, however, more recent data suggests equal efficacy with the exception of lower cost with fibrinolytic therapy.  The addition of DNase to TPA has superior outcomes compared to either fibrinolytic alone or placebo in the adult literature.  As our institute has transited from early VATS to fibrinolytic therapy with both TPA and DNase, we reviewed our experience with treatment of pediatric empyema.

Methods:   We performed a retrospective review of patients less than 18 years old that underwent tube thoracostomy with administration of fibrinolytics or VATS between 2009 and 2014.  T-test, one way ANOVA, and Chi squared were used to analyze the patient presentation, treatment, and outcomes.  Statistical analysis was performed using GraphPad software, San Diego, CA.

Results:  One-hundred and fifty-two patients were identified with 83 (55%) treated with VATS, 49 (32%) TT with TPA, and 20 (13%) TT with TPA/DNase.  The VATS and fibrinolytic groups were similar in regards to age, weight, days of symptoms, oxygen support, WBC, and the number of visits prior to admission.  There was no significant difference in days of oxygen support, narcotic utilization, fever, duration of TT, ICU stay, duration of intubation, or hospital length of stay.  There was more utilization of sonography in the fibrinolytic group (1.3 vs 0.7, p=0.0001), but no difference in computed tomography.  There was no significant difference in cost of hospitalization or readmission rate.  Five patients (7%) required VATS for definitive therapy.

Conclusion:  Both VATS and fibrinolytics are reasonable treatment options for pediatric empyema.  There was a higher utilization of ultrasound with the fibrinolytic therapy without a significant effect on overall hospital cost.  Our experience shows a conversion rate of 7% from fibrinolytic therapy to VATS that is lower than the reported literature. Further review and prospective study would be beneficial to elucidate differences for these findings.

 

46.18 Infectious Outcomes in Gastroschisis Patients with Intra-operative Hypothermia

Posted on January 26, 2017

R. M. Landisch2, R. Massoumi3, M. Christensen1, A. J. Wagner1,2  1Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 2Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 3University Of California – Los Angeles,Surgery,Los Angeles, CA, USA

Introduction:  Perioperative hypothermia results in decreased nutrient and oxygen delivery to tissues secondary to vasoconstriction. In recent adult studies, it correlates with increased morbidity from infectious complications. Gastroschisis, a relatively common congenital abdominal wall defect whereby much of the viscera are exposed at birth, places infants at risk for hypothermia by nature of excessive heat loss. Although hypothermia is a known cause of mortality in patients with gastroschisis, the rate of infectious complications in this at-risk cohort has not yet been delineated. 

Methods:  A retrospective cohort study was performed at our single tertiary-referral hospital, evaluating all gastroschisis infants who underwent operative closure. Patient and operative characteristics were assessed. Intraoperative temperatures were recorded, defining hypothermia as mild (35.5-35.9°C), moderate (35.0-35.4 °C), or severe (< 35 °C). Temperature nadirs were classified as occurring during the procedure (i.e., surgeon operative period) vs anesthetic period. The primary outcome was 30-day surgical site infections. Secondary outcome measures included additional infectious episodes requiring antibiotic therapy. 

Results: Among 43 gastroschisis neonates undergoing operative closure, 21 (48.8%) had hypothermia, which was classified as mild in 2 (9.5%), moderate in 8 (38.1%) and severe in 11 (52.4%). The temperature nadir occurred during the procedural vs anesthesia period in 13 (61.9%) vs 8 (38.0%) infants, respectively. Infectious complications were found in 15 (35.9%) patients, with 23.3% of the gastroschisis cohort developing surgical site infections (9 incisional, 1 deep space), with no significant association to hypothermia. Hypothermic and normothermic cohorts were similar with respect to patient characteristics and procedural time, including a comparable prevalence of complex gastroschisis between cohorts. Notably, normothermic infants were more likely to have silos placed with delayed closure than hypothermic patients (63.6% vs 23.8%, p = 0.01), but on subgroup analysis procedural times and infectious rates were again similar between silo and non-silo infants.

Conclusion: Infants with gastroschisis are at high risk for hypothermia and infectious complications. Patients with silos and delayed closure are less subject to temperature lability without decreased infectious risk. A multi-institutional study with greater power is needed to further investigate the relationship between perioperative hypothermia and surgical infectious complications.

 

46.17 Limitations of Current Prenatal Clinical Prediction Models for Congenital Abnormalities

Posted on January 26, 2017

J. Chang1,2, C. Lundquist1, J. S. Lutz1, B. S. Wessler1, D. M. Kent1, H. C. Jen1,2  1Tufts Medical Center,Predictive Analytics And Comparative Effectiveness Center,Boston, MA, USA 2Floating Hospital For Children,Pediatric Surgery,Boston, MA, USA

Introduction:

Advances in fetal medicine have led to the identification of risk factors associated with clinical outcomes for different congenital abnormalities. Prenatal clinical prediction models (prenatal-CPMs) incorporate these risk factors to estimate the probability of outcomes and have the potential to improve decision making and individualized care in fetal medicine. The aim of our study was to analyze existing prenatal-CPMs and identify strategies to enhance prenatal-CPM development.

Methods:

We conducted a systematic literature review for articles containing prenatal-CPMs for surgically correctable congenital abnormalities published before December 31, 2015. Prenatal-CPMs were defined as models that were developed from a fetal cohort with at least two independent risk factors that predicted a clinically significant outcome. Prenatal-CPM characteristics such as index condition, covariates, predicted outcomes, model development method, model performance, and model evaluation were extracted according to the CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies (CHARMS) Criteria.

Results:

Of the 478 abstracts that were screened, only 9 (1.88%) articles were included in our study (Figure). There were 4 unique index conditions, including congenital cardiac abnormalities (n=4 prenatal-CPMs), congenital diaphragmatic hernias (n=2), twin-twin transfusion syndrome (n=2), and micrognathia (n=1). The majority of prenatal-CPMs included in the study were retrospective (66.6%), single-centered (88.9%), prognostic (77.8%) studies that produced a clinical score (55.5%) predicting perinatal mortality (77.8%) using data during the second trimester (66.7%). Only 1 prenatal-CPM (11%) explicitly addressed sampling bias from elective termination of pregnancies (TOP). All prenatal-CPMs excluded TOPs from the analysis. In addition, two prenatal-CPMs (22%) also excluded fetal deaths from final analysis. Only one prenatal-CPM addressed how missing data was handled. In terms of model performance, model discrimination was only available for 3 prenatal-CPMs (33.3%) while one model provided calibration statistics. Furthermore, only one study provided internal validation.

Conclusion:

Our study revealed that only a handful of prenatal-CPMs were developed over the last decade for the management of fetal congenital malformations. Current prenatal-CPMs show significant methodological limitations, such as selection bias, and lack reporting on model performance measures and on handling of missing data. Transparent and systematic reporting of multivariate prediction models and novel statistical methods that take into account the selection bias from fetal loss are needed in future prenatal-CPM development.

46.16 Simultaneous Bilateral Thoracotomy Performed for Pulmonary Metastasectomy in Children

Posted on January 26, 2017

S. J. Commander1, M. Goss1, Y. Shi1, R. Flores2, S. Vasudevan1  1Baylor College Of Medicine,Pediatric Surgery,Houston, TX, USA 2Baylor College Of Medicine,Hematology/ Oncology,Houston, TX, USA

Introduction:  Metastasectomy of lung nodules is an accepted surgical therapy for many pediatric malignancies after local control of the primary tumor has been achieved. For bilateral lung nodules staged, sequential thoracotomies have been the traditional approach to clearing metastatic disease. Our institution has focused on reducing the number of anesthetics by combining procedures when possible and providing a dedicated pain management service to our surgical patients; therefore, we began performing bilateral, simultaneous, muscle-sparing thoracotomies for metastatectomy.

Methods:  The clinical data of 12 children (< 18 years old) with pediatric solid tumors and bilateral lung metastases who underwent simultaneous or staged bilateral thoracotomies for metastatectomy from January 2011 to August 2016 were retrospectively collected at a single institution. Length of stay and days requiring thoracic epidural were summated for the two surgeries in the staged thoracotomy group. 

Results: Seven pediatric patients who underwent simultaneous bilateral thoracotomies (BT) and five who underwent staged thoracotomies (ST) for metastatic pulmonary disease were identified. Eight patients had osteosarcoma, two hepatoblastoma, and one synovial sarcoma. A muscle-sparing technique was utilized for all thoracotomies performed in both groups. The median operative times for the BT group was 315 minutes versus the combined median operative time of 525 minutes for the ST group. Median length of hospital admission was 8 days for BT and 14 days for ST, with thoracic epidural in place for a median of 5 days post-operatively for BT and 7 days for ST.  Number of lung nodules resected on each patient in the BT group ranged from 5 to 33 (median = 8), while the ST group ranged from 5 to 35 (median = 16). One patient in each group experienced an intra-operative complication, and one patient in the BT group presented with a post-operative complication. None of the complications had long-term effects and only one patient in the BT group required a return to the operating room to drain bilateral wound hematoma/seroma.  

Conclusion: Simultaneous bilateral muscle-sparing thoracotomies should be considered as an effective and well tolerated approach in patients with bilateral pulmonary metastases who require metastatectomy. 

 

46.15 Utilizing Stricture Indices to Predict Dilation of Strictures after Esophageal Atresia Repair.

Posted on January 26, 2017

R. M. Landisch1, S. Foster3, D. Gregg3, T. Chelius1, L. Cassidy1, D. Lerner4, D. R. Lal1,2  1Medical College Of Wisconsin,Surgery,Milwaukee, WI, USA 2Children’s Hospital Of Wisconsin,Pediatric Surgery,Milwaukee, WI, USA 3Children’s Hospital Of Wisconsin,Radiology,Milwaukee, WI, USA 4Children’s Hospital Of Wisconsin,Gastroenterology,Milwaukee, WI, USA

Introduction:  Anastomotic stricture is the most common post-operative complication in infants undergoing repair of esophageal atresia with or without tracheoesophageal fistula (EA/TEF), with an incidence reported as high as 60%. Several stricture indices (SI) based on measurements derived from early post-operative esophagrams have been proposed as a way to predict which infants will develop an anastomotic stricture requiring dilation. We sought to examine which SI more accurately predicted the need for anastomotic dilation. 

Methods:  An IRB approved retrospective study of infants undergoing primary repair of EA/TEF between 2008-2013 was performed. Digital esophagrams were analyzed to calculate one of four stricture indices: Upper (U-EASI) and Lower (L-EASI) Esophageal Anastomotic Stricture Index, Lateral SI and Anterior/Posterior SI. The primary outcome was stricture resulting in dilation. All esophagrams and dilations in 2-year follow up period were included. Logistic regression analysis was performed to determine if SI was associated with needing anastomotic dilation. A receiver operating characteristic (ROC) curve measured the accuracy of the regression model based on stricture indices to predict dilation. Statistical significance was determined at p-value < 0.05. 

Results: Forty-five infants underwent primary repair of their EA/TEF. Anastomotic strictures requiring dilation occurred in 20 (44%) at a median of 95 days post-operatively (range 24-649). Median SI's were calculated from the 1st post-operative esophagram (median 7 days) to categorize the cohort. Only U-EASI as a continuous variable was predictive of need for dilation (p=0.03), however the median U-EASI threshold of ≤  0.37 as a discrete variable was not significant. Infants with a low U-EASI were dilated at a median of 50.5 days after surgery, with 70% dilated in < 3 months. No association was found between U-EASI and number of dilations required, nor did early dilation decrease the frequency of dilations. In comparison to the 1st post-operative esophagram, the 2nd esophagram (median 28 days, range 10-884) median threshold U-EASI of ≤ 0.39 was significantly associated with dilation (OR 8.51, 95% CI: (1.16, 62.61), p=0.035). The area under the ROC curve of the U-EASI model controlling for days to esophagram demonstrated improved predictive ability from 1st (AUC 0.73) to 2nd esophagram (AUC 0.81).

Conclusion: SI's were not associated with future need for dilation when calculated using the first post-operative esophagram. U-EASI measured on the second post-operative esophagram of ≤ 0.39 should be considered a marker for increased risk of requiring dilation.

 

46.14 Efficacy of Sclerotherapy for Non-Parasitic Splenic Cysts in Children

Posted on January 26, 2017

J. J. Lopez1,2, D. Lodwick1,2, J. Cooper2, M. Hogan3, D. King1, P. Minneci1,2  1Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OHIO, USA 2Nationwide Children’s Hospital,Center For Surgical Outcomes Research,Columbus, OHIO, USA 3Nationwide Children’s Hospital,Pediatric Radiology,Columbus, OHIO, USA

Introduction: Non-parasitic splenic cysts, both true cysts and pseudocysts, are the most commonly seen type of splenic cyst seen in children in Western countries.  Sclerotherapy (ST) is a newer and less invasive procedure to treat splenic cysts than splenectomy. However, there are no large studies examining the long-term efficacy of ST.

Methods: We performed a retrospective chart review and prospective follow-up imaging study of pediatric patients treated for non-parasitic splenic cysts at our institution during 2006-2015. Patients were identified using International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes 289.59 and 759.0. Included patients were also required to have had either a procedure order for “IR Body Sclerotherapy” or a partial splenic operation (partial splenectomy, cyst excision, or marsupialization). Charts were reviewed for patient presentation, demographics, radiographic findings, number and types of ST treatments or operative interventions, and complications. For the prospective study, all patients successfully contacted were asked to return for ultrasonography to evaluate for resolution/recurrence of the splenic cyst. Success of therapy was defined as decrease in the size of the cyst or complete ablation on follow-up imaging.

Results: Eight patients who underwent surgical intervention and nineteen patients who underwent ST were identified. Patients underwent a median of 4 ST treatments. The overall initial success rate for ST was 89.5% (17/19). Of the 2 ST patients without complete resolution of their cyst, one patient had ST with sotradecol/ethanol for 8 treatments, then returned to the ED with fever and underwent total splenectomy. The other patient failed to show improvement with ST and underwent partial splenectomy. Twelve patients have been contacted and agreed to undergo follow-up ultrasound. In the first 5 patients (4 patients treated with ST and 1 treated with partial splenectomy), 1 former ST patient was found to have a return of a small asymptomatic cyst on imaging. The other 4 patients remain cyst-free on follow-up imaging. Prospective imaging in all patients will be complete by 12/2016.

Conclusions: Pediatric patients with non-parasitic splenic cysts may benefit from treatment with ST, but should expect that it will require multiple treatments. Prospective evaluation of the durability of splenic cyst ST as compared to partial splenic surgery is needed and is ongoing.

 

46.13 Interpretation of Ultrasounds That Fail to Visualize the Appendix in A Community Hospital Setting

Posted on January 26, 2017

J. M. Held1, C. McEvoy1, S. Foster1, R. Ricca1  1Naval Medical Center Portsmouth,Pediatric Surgery,Portsmouth, VA, USA

Introduction: Appendicitis is a common cause of abdominal pain in children.  Ultrasound is the primary imaging tool used for evaluation of appendicitis in children. Visualization of the appendix is the gold standard for diagnosis; however, the quality of the study is dependent upon the ultrasonographer and radiologist’s expertise.  Recent studies performed at tertiary care hospitals, presumably interpreted by fellowship-trained pediatric radiologists, suggest that presence of secondary signs of appendicitis can be used diagnostically in ultrasounds that do not visualize the appendix.  There have been no similar studies conducted in the community hospital setting.

Methods: Right lower quadrant ultrasounds, performed in children aged 2-17 due to clinical suspicion for appendicitis in a one-year time period, were studied. Those which identified the appendix were excluded. Secondary signs of inflammation, free fluid, ileus, fat stranding, abscess and lymphadenopathy were documented.  Patients were followed for one year for the primary outcome of appendectomy. Data was analyzed using Mann-Whitney, Pearson’s Chi Squared, Fisher’s Exact Tests as well as logistic regression to determine whether the presence or absence of these signs can be used to make or exclude the diagnosis of appendicitis.

Results: 138 right lower quadrant ultrasounds were performed; 91 did not identify the appendix. Of these, 11 (12.1%) identified at least 1 secondary sign of inflammation. Of the 91 patients, 33 (36.3%) were admitted for observation, 20 had additional imaging (17 CT, 2 MRI, 1 CT and MRI) and 12 (13.2%) were ultimately taken for appendectomy. There was no statistically significant relationship between presence of secondary signs on ultrasound and diagnosis of appendicitis.  A subset analysis compared patients admitted for serial abdominal exams without further imaging to those who had a CT or MRI; there was no difference in diagnosis of appendicitis between these groups. The appendix was unable to be found in 87% (79/91) of the patients without appendicitis making this the most predictive factor. 

Conclusion: Prior studies at tertiary care hospitals have shown utility in using secondary signs of inflammation present on ultrasound with a non-visualized appendix.  Our data suggest that this may not be applicable in the community setting although non-visualization of the appendix alone may be diagnostic. The secondary sign that was most strongly associated with a diagnosis of appendicitis was presence of free fluid; however, the association was not statistically significant. Observation alone after a non-diagnostic ultrasound may be as useful as further imaging.  Expansion of the time period analyzed to include more patients and increase the power of this study will be conducted to further delineate utility of secondary signs, as well as whether children can be safely observed to avoid the cost and radiation risk associated with potentially unnecessary imaging.

 

46.12 Outcomes of Fetuses with Primary Hydrothorax that Undergo Prenatal Intervention

Posted on January 26, 2017

R. Mon1,2, G. Mychaliska1,2, D. Berman2, M. C. Treadwell2, J. Kreutzman1,2, E. Perrone1,2  1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA 2University Of Michigan,Fetal Diagnosis And Treatment Center,Ann Arbor, MI, USA

Introduction:
Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The associated pulmonary hypoplasia also increases perinatal morbidity and mortality. We reviewed our experience with prenatal management of fetuses diagnosed with primary hydrothorax

Methods:
We retrospectively reviewed the records of patients evaluated for prenatally diagnosed hydrothorax in our Fetal Diagnosis and Treatment Center between 2006 and 2016.  We excluded fetuses with cardiac or chromosomal abnormalities, structural anomalies, infections and those cases undergoing termination of pregnancy.  

Results:

Pleural effusions were identified in 175 patients.  Primary hydrothorax was identified in 9.7%(17/175),  and was bilateral  in 70%(12/17). Of these patients, 94%(16/17) underwent prenatal interventions. Mean gestational age at the time of prenatal intervention was 27±3.7 weeks. One fetus had intrauterine demise prior to any fetal intervention.  Overall, 76% (13/17) had hydrops at presentation.  The four patients that did not have hydrops underwent thoracentesis with no re-accumulation requiring further intervention.  Of the patients with hydrops, 84% (11/13) chose to undergo shunt placement.  One patient with hydrops presented in labor at 29 weeks and underwent thoracentesis preceding Cesarean delivery.  The other patient with hydrops presented at 30 4/7 weeks and underwent thoracentesis.  The pleural fluid re-accumulated and she delivered 3 days later with another thoracentesis preceding delivery prior to any shunt placement.   

Shunt complications were seen in 66%(7/11), including dislodgement and obstruction. These 7 patients underwent repeat shunt placement; one patient had 4 shunts placed in total. Follow up data was available for 68%(11/16) of patients, ranging from 1 to 19 months. All of these 11 patients were live born.  Post-natal intervention was required in 63% (7/11).  Conservative treatment (chest tube, NPO, ± Octreotide) was efficacious in 71% (5/7).  A thoracotomy with pleurectomy was required in 29% (2/7).  Of these patients, 72% (8/11) survived to discharge. Complications associated with pulmonary hypoplasia accounted for death in 28% (3/11). There were no immediate or long term maternal or fetal complications from fetal treatment identified.

Conclusion:
This data suggests that fetal intervention for the treatment of fetal hydrothorax is safe and effective. Compared to historical controls, fetal treatment appears to confer a survival advantage, particularly in the setting of hydrops. Shunt complications remain an unsolved problem.

46.11 Ultrasound Guidance for Difficult IV Access in the OR

Posted on January 26, 2017

B. Carr1, M. Ralls1, S. Gadepalli1, M. Jarboe1  1University Of Michigan,Department Of Surgery,Ann Arbor, MI, USA

Introduction:
Securing adequate intravenous (IV) access for children undergoing surgical procedures can be a point of delay in the operating room (OR), leading to additional time under anesthesia and decreased OR efficiency.  Furthermore, with each unsuccessful attempt, there is loss of potential sites, increasing difficulty.  We examined outcomes of ultrasound-guided peripheral IV placement for patients with difficult veins, compared to preceding attempts. We hypothesized that use of ultrasound could consistently “rescue” difficult access situations despite previous attempts.

Methods:
This study included children who underwent surgery at C. S. Mott Children’s Hospital from 10/2015 to 05/2016, in whom securing IV access proved difficult for the anesthesia team. Patients underwent IV attempts by the anesthesia team using un-guided or near-infrared-guided methods at their discretion, according to the current institutional standard of care. Once anesthesia had attempted and failed, and felt that future success in IV access was unlikely, the surgical team offered to attempt IV placement under ultrasound guidance. Demographic data, time attempted by anesthesia, number of sticks attempted by anesthesia, and time and number of sticks required by the surgical team with ultrasound guidance were assessed. Data were prospectively recorded by the surgical team. Paired t-test was used to evaluate statistical significance, with p<0.05 considered significant.

Results:
Ten patients underwent IV attempts by both surgical and anesthesia teams.  The median age was 19.5±70.2 months, the median weight was 9.8 kilograms (IQR 3.9-30.5), and 30 percent were female, with a median ASA score of 3 (IQR 2-4).   The average time in the OR prior to incision was 60.3±18.6 minutes. Including five patients where anesthesia attempts took greater than 30 minutes, the average time spent by anesthesia teams was 27.7±15.3 minutes, while the average time spent for ultrasound-guided IV placement was 2.2±0.9 minutes (p=.0004). Including three patients that underwent more than 10 anesthesia attempts, the average number was 6.8±5.1, while the average number of ultrasound-guided attempts was 1.2±0.4(p=.0027).

Conclusion:
Cases of difficult intravenous access can have a significant impact on operating room efficiency and anesthesia time for the patient.  Ultrasound-guided IV placement by experienced surgeons can dramatically decrease both the time and number of sticks required for success. Using ultrasound in the OR is a feasible strategy to “rescue” difficult access situations despite previous attempts, and may improve OR efficiency if employed early by appropriately trained surgeons.
 

46.10 Are Foley Catheters Needed Following Minimally Invasive Repair of Pectus Excavatum?

Posted on January 26, 2017

T. C. Friske1, R. Sola3, Y. R. Yu1,2, A. R. Jamal1, E. Rosenfeld1,2, H. Zhu2, S. D. St. Peter3, S. R. Shah1,2  1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA 2Texas Children’s Hospital,Division Of Pediatric Surgery,Houston, TX, USA 3Children’s Mercy Hospital,Division Of Pediatric Surgery,Kansas City, MO, USA

Introduction: High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Intraoperative Foley catheters are often placed to minimize the risk of this complication; however, there is variation in this practice. The objective of this study is to determine the urinary retention rate in this population to guide future practice.

Methods: A retrospective review was performed of all patients that underwent MIRPE from 1/2012–7/2016 at two academic children’s hospitals. Data collected included patient demographics, body mass index (BMI), severity of pectus defect [Haller Index (HI)], postoperative pain management, and incidence of urinary retention and urinary tract infections (UTI). Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley. Statistical analysis was performed using the Wilcoxon rank test, Fisher’s exact test, and univariate and multivariable logistic regression analyses to identify risk factors for urinary retention.

Results:A total of 305 patients (mean age 15.9 ± 2.6 years) underwent MIRPE (205 at Hospital 1 and 100 at Hospital 2). An intraoperative Foley was placed in 84 (41%) patients at Hospital 1, and 80 (80%) patients at Hospital 2 (p<0.0001). Overall, mean HI was 4.4 ± 1.5 and there were 257 (84%) males. The mean IV morphine equivalents received was 1.4 ± 1.2 mg/kg/day per patient with a mean hospital length of stay of 4.7 ± 1.1 days. There were 195 (64%) patients who exclusively had patient-controlled analgesia (PCA), 95 (31%) exclusively had an epidural, and 15 (5%) had both for postoperative pain management. An intraoperative Foley was placed in 164 (54%) patients. Gender, BMI, and HI were not factors in determining Foley placement. However, patients with epidurals were more likely to have an intraoperative Foley (OR 2.1, 95% CI 1.3–3.5, p<0.01). There were no UTIs in the entire population. The urinary retention rate was 38% (n=53) for patients without an intraoperative Foley, and 1.8% (n=3) in patients after removal of intraoperatively placed Foley (p<0.0001). Adjusting for age, gender, BMI, HI, and pain control regimen, the only significant risk factor for urinary retention in patients without an intraoperatively placed Foley was having an epidural (OR 2.8, 95% CI 1.2–6.4, p=0.02); however, patients on a PCA without an intraoperatively placed Foley still had a urinary retention rate of 32%.

Conclusion:Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection following minimally invasive repair of pectus excavatum. Based on high rate of retention in those managed without an intraoperative Foley, we suggest surgeons discuss these findings with patients and families to determine the preference for Foley catheter placement during minimally invasive repair of pectus excavatum.

46.09 Discrepancy Between On-scene and ED GCS in Pediatric Trauma Patients

Posted on January 26, 2017

S. DiBrito1,2, M. Cerullo1,2, S. Goldstein1, L. Martin1, M. Ladd1, S. Ziegfeld1, D. Stewart1, I. Nasr1  1Johns Hopkins University School Of Medicine,Pediatric Surgery,Baltimore, MD, USA 2Johns Hopkins School Of Public Health,Baltimore, MD, USA

Introduction:  Inaccurate prehospital assessment of Glasgow Coma Score (GCS) following pediatric trauma can result in inappropriate triage and misappropriation of resources. This study sought to characterize differences in GCS measurements taken in the field versus those taken in the emergency department (ED).

Methods:  Pediatric trauma team activations from January 2000 to December 2015 at a Level 1 pediatric trauma center were reviewed. For each patient the difference between reported on-scene and ED GCS (delta-GCS) was ascertained. Associations between patient characteristics and the presence of a nonzero delta-GCS was modeled using multivariable logistic regression, adjusting for demographic/clinical covariates including race, insurance status, transport time, and revised trauma score (RTS).

Results: We identified 5,551 patients and a 19% rate of nonzero delta-GCS. 14.4% (n=799) patients had an ED GCS greater than on-scene GCS, while only 4.3% (n=237) had an ED GCS that was lower than on-scene GCS. An improved ED GCS was most common among ages 0-3 years (24.5%, n=238), compared to ages 3-6 years (17.4%, n=154), ages 6-9 years (10.0%, n=92), and ages >9 years (11.4%, n=315) (Figure). On multivariable analysis, improved ED GCS was associated with younger age (<3 years) (odds ratio [OR]=2.47, 95% confidence interval [CI]=2.07-2.96), transport by helicopter (OR=1.32, 95%CI: 1.11-1.57), and admission to a higher level care unit (OR=1.61, 95%CI: 1.25-2.07), and an extended transport time (OR=1.58, 95%CI=1.01-2.47).

Conclusion: GCS taken in the field is commonly discrepant  with that taken in the ED, most often lower in the field. Moreover, after adjusting for injury severity and transport time, younger age shows a clear association with higher ED GCS compared to on-scene GCS. Further study is needed to determine whether this trend represents improvement in clinical status during transport, or an opportunity to improve prehospital assessment and triage. Improved modalities in addition to on-scene GCS are needed for determining triage priority in pediatric trauma patients. 
 

46.08 Prognostic Significance Of Fetal MRI On Airway Outcomes Affected By Venolymphatic Malformations

Posted on January 26, 2017

D. Schindel1,2, D. Twickler2, N. Frost1,2, D. Walsh2, P. S. Munoz2, R. Johnson1,2  1Children’s Medical Center Dallas,Dallas, TX, USA 2UT Southwestern Medical Center,Dallas, TX, USA

Introduction: Fetuses with venolymphatic malformations of the face and neck (VLMFN) are often referred to fetal centers for advanced imaging, consultation, and management.   Post natal staging systems have suggested that anatomical involvement of the larynx, tongue and upper airway by the VLMFN correlates with a long-term need for tracheostomy.   The purpose of this study is to determine if fetal antenatal MRI images can similarly be applied to predict postnatal airway outcomes in affected children.

Methods: After IRB approval, a retrospective review of all fetuses evaluated for VLMFN at our fetal center was performed.   Antenatal MRI images were reviewed and a stage assigned based on anatomical findings in accordance to a published VLMFN staging system.  Stage 1:  no evidence of polyhydramnios with free egress of amniotic fluid and clear visualization of the aryepiglottal folds and larynx.  Stage 2:  lesions of the tongue or epiglottis but with normal aryepiglottal folds without polyhydramnios.  Stage 3:  lesions of the tongue or larynx; non-visualization of the aryepiglottal folds without free egress of amniotic fluid along with polyhydramnios.   Postnatal findings on laryngoscopy and bronchoscopy (DLB) and long-term airway outcomes were compared with published outcomes according to the stage

Results: Thirteen fetuses with VLMFN were identified.  Six fetuses met stage 1 criteria on antenatal imaging. None had undergone an EXIT.  Postnatal evaluation revealed an uninvolved airway.  No child subsequently developed airway involvement by the malformation.  Two fetal images met stage 2 criteria.  Both fetuses had been treated by EXIT and intubated via rigid bronchoscopy.  A DLB was performed.  One child had minimal involvement of the upper airway by the lesion, was extubated and has had no subsequent airway issues noted.  The second child had involvement of the tongue and larynx and a tracheostomy was performed.  This child has remained cannulated at follow up.  Five fetuses were assigned stage 3. All had been delivered by EXIT and successfully intubated.  Postnatal DLB and MRI in all 5 cases showed involvement of the upper airway by the lesion and were managed with tracheostomy.  All children requiring a tracheostomy remain cannulated due to persistent symptomatic lesions noted at follow up DLB (RR 4.0 Cl 1.2-13.3).  Median follow up was 4 years (range 2-7 years).

Conclusion:While numbers are small, these data suggest that anatomical details obtained by antenatal fetal MRI appear to correlate with previously published staging systems that predict short and long term airway outcomes in children affected by a VLMFN.  This information may be useful when counseling expectant families of affected fetuses predicting need for EXIT management and guiding long-term airway expectations.

 

46.07 Laparoscopic Converted to Open Appendectomy: Outcomes Comparison using Propensity Score Analysis

Posted on January 26, 2017

A. E. Wagenaar1, J. Tashiro1, J. C. Langer2, E. A. Perez1, J. E. Sola1  1University Of Miami,Surgery,Miami, FL, USA 2University of Toronto,Surgery,Toronto, Ontario, Canada

Introduction:  We hypothesized that clinical outcomes differ between laparoscopic appendectomy (LA) and laparoscopic converted to open appendectomy (CA).

Methods:  We queried the Kids’ Inpatient Database (1997-2012) for simple (540.9) and complicated (540.0, 540.1) appendicitis treated with LA or CA. Propensity score (PS)-matched analysis compared outcomes associated with LA and CA, using 41 pre-procedure variables (demographic and socioeconomic variables, hospital characteristics, facility preference for laparoscopy).

Results: Overall, 327,748 cases of simple appendicitis were treated with LA (98.9%) and CA (1.1%), whereas 64,394 cases of complicated appendicitis had LA (92.4%) and CA (7.6%).

On 1:1 propensity score (PS)-matched analyses of simple appendicitis (1976 LA: 2073 CA), CA had higher rates of wound infection (odds ratio: 4.2), pneumonia (4.0), transfusion requirement (3.7), sepsis (3.5), and other infections (2.0), p<0.04. Length of stay (LOS), total charges (TC), and cost were higher in CA vs. LA, p<0.001.

For complicated appendicitis (2747 LA: 2777 CA), CA had higher rates of incision and drainage of wound (17.9), intraoperative perforation (17.9), surgical misadventure (8.9), transfusion requirement (2.8), pneumonia (2.0), wound infection (1.9), sepsis (1.8), p<0.002. CA patients were more likely to require home healthcare upon discharge (2.9), p<0.001. LOS, TC, and cost were higher in CA vs. LA, p<0.001.

Conclusion: Conversion from laparoscopic to open is more common for complicated appendicitis and an indicator of significantly higher morbidity and resource utilization for both simple and complicated appendicitis. In a PS-matched comparison (including facility procedure preference) higher complication rates, LOS, TC, and cost were associated with cases converted to open.
 

46.05 Patient Preferences Regarding Postoperative Clinic Visits After Routine Operations

Posted on January 26, 2017

C. N. Litz1, M. McGuire1, P. D. Danielson1, N. M. Chandler1  1Johns Hopkins All Children’s Hospital,Division Of Pediatric Surgery,St. Petersburg, FL, USA

Introduction: Postoperative clinic visits are routine practice in the field of surgery; however, their value is unclear after low-risk operations. The purpose of this study was to determine patient preferences regarding clinic visits after routine operations and evaluate the utility of these visits by determining if any interventions were performed.

Methods: Patients aged 18-21 years of age or the parents/legal guardians of patients aged 0-17 years of age who underwent appendectomy, pyloromyotomy, umbilical hernia repair, inguinal hernia repair, circumcision, or supernumerary digit removal between 11/18/15-8/1/16 were approached at the postoperative visit to complete a survey. The survey was created and analyzed using a web-based survey platform. The variables included demographic information, work and/or school missed, travel time, internet access and frequency of use, visit information, and perceived comfort with and usefulness of alternative means of follow-up. In addition, medical records were reviewed to determine if interventions were performed during the clinic visit.

Results: There were 329 operations performed (66% non-elective and 34% elective) and 235 patients (71%) followed up in clinic during the study period. The survey was completed by 131 patients or guardians. Demographic data is shown in Table 1. Overall, 70% preferred an in-person clinic visit over follow-up via a phone call, email or internet portal and this did not significantly differ by parental age, education level, elective or non-elective operation, time traveled, work and/or school missed, or frequency of email use. Patients with concerns that were addressed were more likely to prefer clinic follow-up (81%) compared to those with concerns that were not addressed (44%) or those without concerns (43%) (p<0.01). Patients evaluated by surgeons were more likely to prefer follow-up in clinic (74%) compared to those evaluated by advanced practice providers (58%); however, the difference was not statistically significant (p=0.09). The most common reasons respondents preferred follow-up via electronic communication were missed work (57%), long travel (48%), and missed school (33%). Additional measures performed as a result of the visit, including prescribing medication, performing an intervention, ordering laboratory or radiologic studies, and scheduling an additional clinic appointment, were performed in six patients (5%).

Conclusion: Postoperative clinic visits after routine operations in pediatric patients have low utility. However, despite the significant time required to travel to the clinic and decreased productivity from missing work and/or school, the majority of our patients prefer in-person follow-up in clinic.

 

46.06 Necrotizing Enterocolitis: A Temporal and Predictive Model for Disease Development

Posted on January 26, 2017

J. Primus1, I. Caban1, M. Collins1, C. Coghill1,3, C. Roane1, M. Estes1, P. Tarr2, C. Martin1  1Children’s Hospital Of Alabama,Pediatric Surgery,Birmingham, ALABAMA, USA 2Washington University In St. Louis,Pediatric Gastroenterology,St. Louis, MISSOURI, USA 3Children’s Hospital Of Alabama,Neonatal Intesive Care,Birmingham, ALABAMA, USA

Introduction:  Necrotizing enterocolitis (NEC) is an inflammatory disorder affecting the GI tract of premature infants and is a significant cause of morbidity and mortality.  The development of a mathematical model that can predict the timing of onset in at risk infants can lead to the implementation of directed surveillance strategies and treatments early in life. 

Methods:  A single institutional retrospective review was conducted which included data from the Children’s Hospital Neonatal Database for Children’s Hospital of Alabama from the years of 2010-2016.  Our criteria for perforated NEC and medical NEC was based off of the Vermont Oxford Network criteria. Patients were analyzed based on multiple variables including Apgar scores (categorized as >7 versus ≤7) Birthweight (categorized as Extremely Low Birth Weight with weight<1500 grams versus others with weight ≥1500 grams) and Gestational Age (categorized as Extremely preterm with age<28 weeks versus other with age≥28 weeks). The primary outcome reported was the timing to the diagnosis of NEC.  Analyses were done separately for those managed medically and surgically. Kaplan-Meier curves were constructed and log-rank tests were performed to compare the distributions of the time to diagnosis for different categories by Apgar scores 1 and 5, birth weight and gestational age. A parametric survival model was fitted separately for medically and surgically managed patients to examine the relationship between time to diagnosis and Apgar scores 1 and 5, birth weight and gestational age adjusted for covariates such as gender, delivery mode, and insurance type.

Results:  Our study included 113 de-identified neonates all of whom developed NEC. Most were treated with surgery (n=82).  Of those who underwent surgery 29 died.  Medically managed babies with gestational age <28 weeks have a longer time to diagnosis (median 42, 95% CI: 24-56) relative to those with age≥28 weeks (22, 95% CI: 8-27). Similarly, babies with birthweight <1500 grams have a longer time to diagnosis (median 42, 95% CI: 24-56) relative to those with birthweight ≥1500 grams (22, 95% CI: 8-27). For those surgically managed, babies with Apgar scores ≤7 have longer time to diagnosis (median 42, 95% CI: 24-56) relative to those with scores >7 (22, 95% CI: 8-27). In fitting the parametric survival model with all these variables plus gender, insurance type and delivery mode, only Apgar 1 showed to be a significant predictor of the time for those surgically managed.

Conclusion:  Although counterintuitive the data suggests that infants at high risk including ELBW, and extreme age may develop NEC later.  The retrospective design of this study limits our ability to fully explain this outcome.   We speculate that this finding may be due to  high surveillance by healthcare providers and less aggressive feeding strategies.  Future studies will validate this finding in  large multi-institutional administrative databases
 

46.04 Jet Ventilation During Esophageal Atresia Repair: Better for the Baby, Better for the Surgeon

Posted on January 26, 2017

N. J. Ahn1, M. Ehlers1, C. Pezzano1, C. M. Whyte1, E. Renaud1  1Albany Medical College,Albany, NY, USA

Introduction:  Infants with esophageal atresia often have limited pulmonary reserve. The need for high airway pressures and aggressive ventilation can complicate both patient stability and operative exposure during surgical repair, particularly when thoracoscopy is used.  High frequency jet ventilation utilizes lower airway pressures and allows for adequate gas exchange while maximizing ipsilateral lung deflation and improving visualization. The purpose of this study was to demonstrate the feasibility of jet ventilation use during operative repair of esophageal atresia and to compare outcomes with those of patients repaired under conventional ventilation.

Methods:  This study is an IRB approved retrospective cohort study of patients who underwent esophageal atresia repair at a single institution between 2010 and 2015. Demographics, intra-operative events, and post-operative outcomes were collected for comparison between patients repaired under High Frequency Jet Ventilation (HFJV) and those repaired under conventional ventilation (CV). Operative reports of the HFJV patients were reviewed for subjective evalutation of the surgeon’s experience.

Results: Fifteen neonates with esophageal atresia were identified. Six patients were switched to jet ventilation after an initial attempt at conventional ventilation; nine were repaired under conventional ventilation. No patients were on jet ventilation pre-operatively. The two groups were similar in characteristics including gestational age, birth weight, comorbidities, and preoperative hemodynamics and respiratory status. Mean operative time was 221 (range 136-282) minutes for the HFJV and 284 (151-373) minutes for the CV. While those in the HFJV experienced lower intra-operative pH (lowest pH 7.03 (6.88-7.1) HFJV vs. 7.17 (7.07-7.26) CV (p=0.035)) and higher intraoperative pCO2 (highest pCO2 89.5 (70-100) HFJV vs. 64.4 (52-86) CV (p=0.005)), all patients were able to be conventionally ventilated immediately post-operatively. There were no significant differences between groups in the intraoperative conversion rate from thoracoscopic to open, arterial blood gas values at the 3 hours post-operative time point, number of post-op intubation days, and overall complications. All operative reports of HFJV patients noted the use of jet ventilation and the improvement in visualization or ventilator status, or both.

Conclusion: Jet ventilation is safe and feasible for use during esophageal atresia repair.  It is a useful adjunct for those patients who are more difficult to ventilate and can improve operative exposure for the surgeon. Post-operatively, patients experience a recovery course similar to that of patients conventionally ventilated during surgery. Future prospective and multi-institutional studies could delineate further the potential role of jet ventilation during esophageal atresia repair and other neonatal thoracic procedures.

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