87.03 Parent Assessment of a Tablet-Administered BOQ-P Feedback System in the Outpatient Surgery Setting

Posted on January 18, 2018

P. H. Chang1,3, J. Nelson1, L. Fowler1, P. Warner1,3, S. Romo2, M. Murphy2, R. Sheridan2,4  1Shriners Hospitals For Children,Cincinnati, OH, USA 2Shriners Hospitals For Children,Boston, MA, USA 3University Of Cincinnati,Division Of Plastic/Burn Surgery,Cincinnati, OH, USA 4Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA

Introduction:
Parent proxy questionnaires are an important tool in the assessment of outcomes in the pediatric burn population.  Surveys performed via mail suffer from low response rates.  Surveys performed in an outpatient clinic suffer from the time pressures of a busy clinical schedule.  Our group has been utilizing the Burn Outcomes Questionnaire for 5-18 year olds and the 17-item Pediatric Symptom Checklist (BOQ+P) using a tablet in a group of pediatric burn patients undergoing outpatient procedures.  The objective of this study was to assess parental attitudes about the survey.

Methods:
The BOQ+P was administered to 39 patients, aged 5-18 years, undergoing a scheduled outpatient surgical procedure at a single pediatric burn center.  The BOQ+P was administered on iPads using the TonicHealth© app to parents while the patients were undergoing pre-operative preparation.  Additionally, parents were then administered a separate survey on paper asking for their opinions about the experience of taking the survey on the iPad.

Results:
39 patients were enrolled in the study at this particular site with 23 male and 16 female.  The average ages of the males was 11.43 and females was 12.31 years (ranges 5-18 years).  36 parents responded to the post-BOQ-P survey.  97% of parents reported that the iPad was easy to use and were either very satisfied to satisfied with the experience.   100% of parents reported that the results of the BOQ-P were discussed during the visit.  89% of parents felt that the discussion with the burn clinician was helpful because of the results from the BOQ-P iPad survey.   86% of parents expressed a desire to see the BOQ-P on iPad utilized for future outpatient visits.

Conclusion:
The highly favorable responses of the parents towards administration of the BOQ+P on iPad demonstrate the perceived value of the instrument as a clinical tool to enhance communication between burn care provider and family.  Furthermore, tablet administration of the BOQ+P was deemed a user-friendly means to complete the surveys.  Use of a parent-proxy questionnaire is feasible in the outpatient surgical setting.  Clinical providers have the opportunity to discuss findings from the questionnaire in a setting where parents and burn providers can talk privately while the children are recovering post-anesthetically in another area.
 

87.04 Outcomes for Correction of Long-Gap Esophageal Atresia: A 22-Year Experience

Posted on January 18, 2018

L. A. McDuffie1, A. Jensen1, E. Groh1, F. Rescorla1  1Indiana University School Of Medicine,Pediatric Surgery,Indianapolis, IN, USA

Introduction:

Long-gap esophageal atresia (LGEA) precludes immediate primary anastomosis. Native esophagus is considered the ideal conduit for reconstruction. When delayed primary repair (DPR) is not possible, the optimal reconstructive approach is controversial. The study purpose is two-fold: 1) To evaluate short and long-term outcomes for DPR of long-gap esophageal atresia, and 2) To evaluate short and long-term outcomes of reverse gastric tube (RGT) as a salvage therapy when primary repair is infeasible. 

Methods:  

Billing records for years 1994-2016 were queried for the diagnosis of esophageal atresia. Medical records were retrospectively reviewed for patients with long-gap esophageal atresia, defined by the technical impossibility of an immediate primary repair. Mann-Whitney U and Chi-squared tests were used for data analysis.

Results: 

218 patients with esophageal atresia were treated during this period; 37 were identified as having long-gap esophageal atresia. The mean gap length was 3.31 cm at time of repair. 33 patients underwent some form of repair, all of which were managed initially with a gastrostomy tube and bolus feeds. 25 patients underwent DPR.  22 of these (89%) never required revision, and 86% of these have excellent function on long-term follow-up. In eight patients, esophageal length was never adequate for primary repair. Six were reconstructed with RGT, and two underwent gastric transposition. One RGT failed immediately to ischemia requiring colon interposition. The remaining grafts are all functional: one has severe neurologic impairment precluding oral feeds; one requires supplemental gastrostomy feeds due to oral aversion; and three sustain their intake with oral feeding alone. There was no significant difference in complications, need for revisions, ventilator days, number of dilations, NICU stay, overall length of stay, weight percentiles, height percentiles, BMI, BMI percentiles, or conduit function between children undergoing RGT compared with DPR at a median follow-up of 62.8 and 68.3 years, respectively.

Conclusion:

Surgical treatment of LGEA is complex, and controversy exists regarding the optimal repair method when primary repair is not feasible. In this series, delayed anastomosis after gastrostomy tube feeds often allows for sufficient esophageal lengthening to permit primary esophagoesophagostomy. Long-term esophageal function is usually satisfactory following DPR and is accompanied by excellent growth outcomes. When adequate length for primary anastomosis is not attainable, these data suggest that RGT is a viable conduit with favorable short-term and long-term outcomes.

 

 

 

 

87.02 Trends in the Surgical Mangement of Pediatric Empyema

Posted on January 18, 2018

K. Shaffer3, J. Boura1, P. Brahmamdam2,3  1Beaumont Health System Research Institute,Royal Oak, MI, USA 2Beaumont Children’s Hospital,Pediatric Surgery,Royal Oak, MI, USA 3Oakland University William Beaumont School Of Medicine,Surgery,Royal Oak, MI, USA

Introduction: Despite widespread use of pneumococcal vaccines in children, pediatric empyema continues to be a major cause of hospitalization and morbidity. Recent literature suggests that non-surgical treatment such as tube thoracostomy with instillation of fibrinolytics into the pleural space have similar outcomes to primary treatment with video-assisted thoracosopic (VATS) decortication. The purpose of this study is to examine trends in management of empyema on a national level and to evaluate outcomes of surgical vs. nonsurgical management of pediatric empyema.

Methods: A retrospective analysis was done using the Kids’ Inpatient Database (KID) for 2009 and 2012. ICD-9-CM discharge diagnosis codes 510.0 and 510.9 were used to define empyema patients with or without fistula. Additional codes were used to define patients undergoing tube thoracostomy only (34.04) versus surgery, which included VATS (34.52, 34.21, 34.06), or open thoracotomy (34.51). Patients undergoing tube thoracostomy alone were considered a non-surgical group.  Patients were excluded if they were transferred to or from another hospital. Statistical analysis with Pearson’s Chi-square, Fisher’s Exact, and Kruskal-Wallis tests were performed using SAS for Widows 9.3, Cary, NC.

Results: A total of 3,251 patients were identified. The proportion of patients who underwent tube thoracostomy alone increased from 18.3% in 2009 to 26.3% in 2012. Concurrently, the proportion of patients who underwent any surgery for empyema decreased from 63.6% in 2009 to 52.9% in 2012. The proportions of patients undergoing any surgery vs. tube thoracostomy alone in 2009 vs. 2012 were significantly different, p<.001. The proportion of patients undergoing open thoracotomy decreased from 10.8% in 2009 to 8.4% in 2012, p<.001. A significantly higher proportion of all patients who underwent tube thoracostomy alone were mechanically ventilated compared to those who underwent any surgical therapy, 23.9% vs. 18.3%, p<.002. The median length of stay was longer for patients undergoing tube thoracostomy vs. any surgery, 12 vs. 11 days, p<.001. 5.3% of patients undergoing tube thoracostomy alone were coded as having a pneumothorax vs. 2.5% of the surgical group, p<.001.  2.8% of patients undergoing tube thoracostomy died in hospital vs. 0.5% of patients in the surgical group, p<.001.

Conclusion: Pediatric empyema remains a challenging disease with an evolving management. We found that the proportion of empyema patients undergoing non-surgical treatment increased from 2009 to 2012, yet, the majority of patients are still undergoing some type of surgical procedure. Even amongst those who underwent surgery, more patients are undergoing minimally invasive procedures than open thoracotomy. Our study confirms the trend towards minimally invasive management in pediatric empyema.

86.20 Trends and Attributable Costs of Anorectal Involvement in Pediatric Crohn’s Disease

Posted on January 18, 2018

C. G. DeLong1, A. N. Kulaylat1, A. S. Kulaylat1, C. S. Hollenbeak1,3, R. E. Cilley1,2, D. V. Rocourt1,2  2Penn State Children’s Hospital,Division Of Pediatric Surgery,Hershey, PA, USA 3Penn State College Of Medicine,Department Of Public Health Sciences,Hershey, PA, USA 1Penn State Hershey Medical Center,Department Of Surgery,Hershey, PA, USA

Introduction:
While the incidence of pediatric Crohn’s disease (CD) has been increasing, less is known about the frequency of anorectal involvement and its influence on healthcare resource utilization. We sought to characterize trends in the prevalence of pediatric CD with anorectal involvement and the associated costs of care.  

Methods:
Patients (< 21 years of age) with an ICD-9 diagnosis of Crohn’s disease (555.X) were identified in the Kid’s Inpatient Database (2003, 2006, 2009, 2012), and stratified by anorectal involvement based on ICD-9 diagnosis and procedural codes. Patient characteristics and resource utilization (length of stay [LOS] and costs) were compared between CD patients with and without anorectal involvement using univariate and multivariable analyses.  Costs were obtained using a cost-charge ratio methodology. Propensity score matching was used to estimate attributable LOS and costs.

Results:
There were 26,029 patients with CD identified in the study interval.  Of these, 1,706 (6.6%) had anorectal involvement.  Those with anorectal disease were younger (age 16 vs. 17 years old), more likely to be male (59.4% vs 49.9%) and Black or Hispanic (24.7% vs 18.2%), and were more commonly treated in urban teaching hospitals compared to rural or non-teaching hospitals (83.2% vs 70.9%) (p<0.001 for all).  The proportion of patients with anorectal involvement increased significantly over time (OR 1.03 annually, 95% CI 1.02 to 1.05). After propensity score matching, attributable LOS and costs for pediatric CD with anorectal involvement were 0.5 days and approximately $1,600, respectively (p<0.001 for both). 

Conclusion:
There has been an increase in the proportion of pediatric CD hospitalizations with anorectal manifestations.  This pattern of disease is associated with higher costs and longer hospitalization compared to CD alone.   Further research is required to understand the underlying etiology of these observed trends.
 

86.19 Analysis of Multidisciplinary Pediatric Clinic Weight Reduction Program: Are parents disengaged?

Posted on January 18, 2018

B. D. Hughes1, C. B. Cummins1, O. Nunez-Lopez1, J. Prochaska2, E. Lyons3, D. Jupiter2, K. Perino3, A. Glaser4, R. S. Radhakrishnan1,4, K. D. Bowen-Jallow1  1University Of Texas Medical Branch,Division Of Surgery,Galveston, TX, USA 2University Of Texas Medical Branch,Preventive Medicine And Community Health,Galveston, TX, USA 3University Of Texas Medical Branch,Department Of Nutrition And Metabolism,Galveston, TX, USA 4University Of Texas Medical Branch,Department Of Pediatrics,Galveston, TX, USA

Introduction:
Pediatric obesity is a major public health concern. Severe obesity affects approximately 6.8% of adolescents in the U.S. This subgroup has been ascertained to be the most rapidly growing of those diagnosed with obesity. Efforts to prevent and eliminate obesity have highlighted the importance of parental engagement. There is evidence linking parents’ knowledge, attitudes, and behavior with childhood obesity.

Methods:
Parents and obese adolescents are evaluated in our multidisciplinary clinic for an intensive weight reduction program. After the initial clinic visit, subsequent visits are planned for every 4-6 weeks. During the initial visit and every 3 months thereafter, the parents and participants are independently administered a 57 and 64 question survey created by our research team, respectively. This study focuses on parental engagement based on questions selected from the survey which had an emphasis on self-perception, goal-setting, individual effort, and utilization of technology for weight reduction. 

Results:
Of the categories selected, the differences between the obese adolescents and their caretakers are reported. The main stem of each question is the same: only words to appropriately address the cohorts as either caretakers or adolescents were modified. The percentage difference between categorical responses of participants is provided, as well as the number of participants who answered ‘yes’ to the question, with its’ associated percentage (adolescent versus parents,  respectively): Self-perception: 4% (40[44%] vs. 36 [40%]); Goal-

Setting: 28% (38[73%] vs. 24 [45%]);  Individual Effort: 10% (26[29%] vs. 17[19%]); Utilization of technology: 2% (19 [21%] vs. 17 [19%]).  

Conclusion:
Parental engagement is imperative for weight reduction efforts in obese youth. Programs aimed at weight reduction should incorporate methods to survey parents and obese participants. In this study we found parents’ knowledge of self-perception, individual efforts, and utilization of technology to align with responses from the obese youth participants. An area of discordance was related to goal setting and may signify a barrier to weight loss. Goal setting could represent an area of potential impact as interventions advance in the curriculum. Comparison data between the initial visit and planned subsequent visits are necessary to validate these findings. 
 

86.17 Lack of Disparities in Screening for Associated Anomalies in Children with Anorectal Malformations

Posted on January 18, 2018

L. V. Veras2, J. Smith2, A. Gosain2  2Univeristy Of Tennessee Health Science Center,Pediatric Surgery,Memphis, TN, USA

Introduction:
Patients with anorectal malformations (ARM) are at risk for associated anomalies (VACTERL: vertebral, anorectal, cardiac, tracheal, esophageal, renal, limb) and should undergo several screening exams in the first year of life. We hypothesized that racial and socioeconomic disparities exist in the screening processes for these patients.

Methods:
Following IRB approval, a retrospective review of patients with anorectal malformation born between 2005 and 2016 was performed at an urban, quaternary care children’s hospital. Demographics including gender, race, insurance, and zip code were collected. Zip code was used as a surrogate for median income. Chart review was performed to identify anomaly type and whether chest x-ray, skeletal survey, “babygram”, spine and renal ultrasounds, echocardiogram, and spine MRI were performed within one year of age. Descriptive statistics and Chi square analysis were performed.

Results:
101 patients (59.4% male, 79% low malformation) were identified. Black and white subjects each represented 41% of the population, and 69% of subjects had government insurance. Mean number of studies per patient was 5 +/- 1.7. There was no difference in median number of studies when comparing by race, insurance, or income group. Patients with high anomalies received a greater number of studies (p= 0.0153). None of the studies were found to be completed in 100% of the patients during the study period (Table 1). However, of the studies that were done, 100% of chest x-rays, skeletal surveys, babygrams, and spine ultrasounds were performed within one year of life. 98.9% of renal ultrasounds and 97.8% of echocardiograms were performed within one year. Spine MRI had the lowest rate of completion. Of those studies that were completed within one year, the most common to show abnormal results were echocardiograms (90%), spine ultrasounds (40.3%), and skeletal surveys (38.9%). There were no differences in the proportion of completed studies when comparing race, insurance, or income group, with the exception of skeletal surveys. More African-American patients received a skeletal survey (80.5%) than Caucasians (58.5%, p=0.0429). With respect to the time from birth to completion of a study, there were some significant differences noted when comparing insurance types and income groups, however no pattern of systematic bias was identified. For patients with abnormal study results, there were no differences in time to study completion by race or income; however, subjects with government insurance and abnormal spine ultrasounds had a longer median time to ultrasound than subjects with other insurance types (p=0.0140).

Conclusion:

There do not appear to be racial or socioeconomic disparities in screening for VACTERL anomalies in patients with ARM. However, overall gaps in screening still exist, and work must be done to appropriately screen all patients for associated anomalies.

86.18 Measuring the Impact of Surgical Intervention in Pediatric Pectus Excavatum

Posted on January 18, 2018

F. Hebal1, L. Eckstein2, C. Hunter1, M. Reynolds1  1Ann & Robert H. Lurie Children’s Hospital Of Chicago,Pediatric Surgery,Chicago, IL, USA 2Bowdoin College,Brunswick, MAINE, USA

Introduction:

Assessment of Pectus Excavatum (PE) deformity in patients undergoing surgical correction is limited to preoperative measurement of severity using computed tomography (CT). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure. White Light Scanning (WLS), a novel 3D imaging modality, offers a potential alternative to ionizing radiation that is quick, inexpensive, and safe both pre- and post-surgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate the feasibility of using WLS to measure the severity pre- and post-surgical intervention of PE deformities and assess corrected difference between the two scans.

Methods:

We conducted a prospective review of preoperative WLS scans in pediatric patients with PE from 2015-2017. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data.

Results:

Of 32 patients with preoperative CT, 26(81%) received WLS preoperatively. Of these, 6(23%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.41 (SD: 0.14) and 2.65 (SD: 1.35) in CT-derived HI. Pearson correlation for preoperative HI and HMI was very strong (r=0.92, p<0.01, n=6), consistent with full cohort data (r=0.85, p<0.0001, n=26). Table 1 shows individual patient HMI and HI data.

Conclusion:
Utilizing this technique, we have the ability to measure the impact of surgical correction on the severity of PE deformity.
 

86.15 Enteric Duplication in Children

Posted on January 18, 2018

J. A. Sujka1, J. Sobrino1, L. A. Benedict1, H. Alemayehu1, S. St. Peter1, R. Hendrickson1  1Children’s Mercy Hospital,Kansas City, MO, USA

Introduction:
Enteric duplication is a rare congenital anomalies with varied clinical presentations that requires surgical resection for definitive treatment. Historically this has been approached with laparotomy for resection, but with the advent of laparoscopic techniques this is changing. The purpose of our study was to determine the patient demographic, natural history, operative interventions and outcomes of pediatric enteric duplication cysts in a contemporary cohort. 

Methods:
With IRB approval a retrospective chart review of all patients less than 18 years old treated for enteric duplication between Jan 2006 and Aug 2016 was performed.  Demographics, patient presentation, diagnostic testing, operative technique, intraoperative findings, hospital course, and follow up were evaluated. Descriptive statistical analysis was performed; all medians reported with interquartile range.

Results:

Thirty two patients underwent surgery for enteric duplication, with a median age of surgery of 7 months (IQR 2.5-64), 62% (n=20) were less than 1 year old. They had a median weight of 7.3kg (IQR 6-23). The most common patient presentations included prenatal diagnosis of 37% (n=12), abdominal pain 28% (n=9), and bilious emesis 15% (n=5). Thirty one patients had their cyst approached laparoscopically with only two requiring conversion to an open operation. Operative time was a median of 82 minutes (IQR 54-124) with 25 of 31 patients requiring bowel resection. The median length of bowel resected was 5cm (IQR 3.2-7).

The most common site of duplication were ileocecal (n=15, 46%), followed by, jejunum (n=6, 18%) and esophagus (n=5, 16%). Twenty two (68%) of the duplications had a common wall with the GI tract whereas only 11 (34%) had a luminal connection with the bowel. Postoperative median hospital length of stay was 3 days (IQR 2-4.5) and median number of days to regular diet was 3 (IQR 1.5-4). No patients required re-operation during their hospital stay with only a single surgical site infection was reported, with a median length of follow-up of 24 days (IQR 20-31).

Conclusion:

Currently most enteric duplication cysts are diagnosed prenatally. These can be managed laparoscopically with minimal short term, even in neonates and infants.

86.16 Intestinal Function After Early vs. Late Appendectomy in Children with Perforated Appendicitis

Posted on January 18, 2018

A. N. Munoz1, R. Hazboun1, I. Vannix1, V. Pepper1, T. Crane1, E. P. Tagge1, D. C. Moores1, J. E. Baerg1  1Loma Linda University School Of Medicine,Division Of Pediatric Surgery,Loma LInda, CA, USA

Introduction:

To prospectively document the impact of early vs. late operation on intestinal function in children undergoing planned appendectomy at initial presentation of perforated appendicitis.

Methods:

After IRB approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. Pathologist-confirmed transmural perforations were included.  Antibiotics and intra-operative irrigation were standardized.  The median time to operation after first abdominal pain was 3 days (range: 1-9 days).  Operation at day 2 or before (early) was compared to day 3 or after (late).  Vomiting, nasogastric tubes (NGs) placed for vomiting, and time to tolerate diet evaluated intestinal function.  Categorical and continuous variables were analyzed by chi-square and t-tests. A p<0.05 achieved significance.  Data were reported as mean and standard deviation, median and range.

Results:

125 children with abdominal pain and suspected perforated appendicitis underwent appendectomy (99% laparoscopic), 101 had a confirmed perforation and were included.  They were 67% male, 80% Hispanic and none were Asian.

There were 45 in the early and 56 in the late group, with 22/56(39 %) operated on day 3 (range: 3-9 days).  Follow-up evaluation was documented in 44/101 (41%), median: 41.5 days (5-81 days)

Children with early appendectomy were significantly younger (p=0.02), 7.8(3.5) vs. 9.5(3.8) years.

Pre-appendectomy, over 80% of each group were vomiting (p=0.84).  There were no significant differences in NGs (p= 0.07), WBC (p=0.62), fever (p=0.29), diarrhea (p=0.17) or imaged-abscesses (p=0.97) reported. The maximum imaged-abscess diameter was significantly greater in the late group (p=0.02), none were drained. 

At appendectomy, reported purulent fluid (p=0.41), fecaliths (p=0.48) and operation time (p=0.07) did not differ significantly.  

Post-appendectomy, 5(5%) developed abscesses (p=0.38) treated with drainage and antibiotics; 4 recovered.  One in the late group had persistent obstruction and required laparotomy 12 days after appendectomy.   The late group had a significantly longer hospital stay 3.5 (2.2) vs 5.6 (4.3) days (p=0.01).  All 44 with documented follow-up evaluation recovered completely

Conclusion:

A cohort of younger children with rapid progression of perforated appendicitis that recover after appendectomy was prospectively identified. Over 80% vomited before operation, but by the second post-operative day, only 18% persisted in vomiting. If appendectomy is performed on the third day of pain or later, significantly more NGs are placed and the time to tolerate diet is significantly prolonged. Early operation for perforated appendicitis is beneficial in children. 

 

 

 

86.14 Analysis of Outcomes in Adolescents and Young Adults with Pilonidal Disease

Posted on January 18, 2018

M. N. Abraham1, S. L. Raymond1, A. Iqbal1, S. D. Larson1, M. M. Mustafa1, J. A. Taylor1, S. Tan1, S. Islam1  1University Of Florida,Pediatric Surgery,Gainesville, FL, USA

Introduction: Pilonidal disease is a chronic and recurring condition which occurs at the natal cleft. For patients initially presenting with symptoms of acute infection with pilonidal sinus, incision and drainage is recommended and has shown to be curative in 60% of patients. However, the remaining 40% of patients experience recurring infections and pain which requires repeated treatment. There are various definitive surgical treatments, including excision with midline primary closure, off-midline primary closure, and secondary healing. These techniques vary on a range of factors such as recurrence rates and wound complications. Due to the wide array of available treatments and the lack of consensus on the best approach, we proposed to study our experience treating pilonidal disease in adolescents and young adults at a large, academic medical center.

 

Methods: A retrospective review was conducted of all patients between 5 and 24 years of age who underwent management of pilonidal disease at our institution, a 996-bed tertiary medical center, between 2011 and 2016. We utilized ICD 9/10 and CPT codes specific to pilonidal disease and procedures to ensure that all patients were captured. Patients who underwent surgical intervention at an outside facility were excluded. Data including demographics, disease course, surgical management, and outcomes were entered into a specifically designed REDCap database and exported for comparative analysis.

 

Results: Two hundred forty-five patients were identified with pilonidal disease. The average age was 18.4 years (range 11-24) and 49% were male. One hundred thirty-three patients underwent operative management for pilonidal disease. Prior to surgery, 49% of the operative group had incision and drainage of an abscess compared to 83% of the non-operative group (p<0.0001). Among the operative group, 68 patients underwent primary closure, whereas 65 patients were allowed to heal by secondary intention. There was no significant difference in the recurrence rate of patients who underwent resection with primary closure compared to those who underwent resection with secondary healing (primary 18%, secondary 11%; p=0.3245). However, surgical patients who were allowed to heal by secondary intention had a significantly lower wound complication rate compared to those with primary closure (primary 51%, secondary 23%; p=0.0012). Specifically, patients who underwent resection with off-midline primary closure had the highest percentage of wound complications (off-midline 61%, midline 41%, secondary 23%; p=0.0007).

 

Conclusion: We compared the outcomes of various surgical approaches for the treatment of pilonidal disease in adolescents and young adults. By comparing common surgical techniques, we hope to understand the most and least efficacious treatments and to implement these recommendations as a prelude to a multicenter study.

 

86.12 Does age affect surgical outcomes following ileo-pouch anal anastomosis in children?

Posted on January 18, 2018

N. Bismar1, A. S. Patel1,2, D. Schindel1,2  1University Of Texas Southwestern Medical Center,Pediatric Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA

Introduction:
To determine if younger children having a laparoscopic restorative proctocolectomy, mucosectomy and ileo-pouch anal anastomosis (LRS-IPAA) have comparable outcomes to older counterparts in the treatment of ulcerative colitis (UC) and familial adenomatosis polyposis (FAP).

Methods:
After IRB approval, a review of 65 children with FAP and UC who underwent LRS-IPAA at a children's hospital from 2002 to 2017 was performed.  The study population was separated into two groups based on age: Young group (YG) (5- 12yrs); Older group (OG) (13-18yrs). Patient demographics, post-procedure course and outcomes data was collected.  A statistical analysis of the data was performed using Graphpad® San Diego, CA.

Results:
There were 65 children identified.  YG, n=22 (13 with UC; 9 with FAP). There were 15 females and 7 males in YG.  OG, n=43 (UC; n=28), (FAP; n=15). There were 20 females and 23 males in OG.  Following LRS-IPAA, continence, appetite recovery, use of antidiarrhea medications, and complications were not significantly different between groups. The incidence of pouchitis was 21.5% (14): YG (n=5);  OG (n= 9) (p=NS).  The incidence of anastomotic stricture was 13.8% (9): YG (n=2) and OG (n=7) (p=NS).  Two children (one in each group) required re-operative adhesiolysis after presenting with a bowel obstruction (p=NS).  Three children elected to have a loop ileostomy constructed secondarily to chronic rectal pain and failure to achieve full continence following LRS-IPAA: all three were in the OG (p=NS).

Conclusion:
There are no significant differences in the outcomes of younger children when compared to older pediatric patients following LRS-IPAA in the treatment of FAP or UC.  While numbers are small, these data suggest that a younger age should not be a deterrent when contemplating LRS-IPAA in the treatment of UC and FAP in the pediatric population.
 

86.13 Health-Related Needs of Pregnant Women and Caregivers with Prenatal Surgical Fetal Diagnoses

Posted on January 18, 2018

M. E. Danko1, J. R. Robinson1,2, R. K. Skeens3, G. P. Jackson1,2  1Vanderbilt University Medical Center,Department Of Pediatric Surgery,Nashville, TN, USA 2Vanderbilt University Medical Center,Department Of Biomedical Informatics,Nashville, TN, USA 3Vanderbilt University Medical Center,Department Of Pediatrics, Division Of Neonatology,Nashville, TN, USA

Introduction:  Pediatric surgeons are asked to address challenging problems in newborn infants. Congenital anomalies are often diagnosed prenatally, providing an opportunity for early parental education and decision-making. Prior research has shown that many pregnant women and caregivers have unanswered questions during pregnancy. We examined health-related needs of pregnant women and caregivers with prenatal surgical diagnoses to design better educational resources for this population.

 

Methods:  We enrolled English and Spanish speaking adult pregnant women and caregivers in a mixed-methods study of health-related needs during pregnancy. Pregnant women < 36 weeks gestational age were recruited from an advanced maternal-fetal center and group prenatal care practice. Pregnant women could invite caregivers (i.e., anyone significantly involved in the care of mother or baby) to participate. Study subjects completed sociodemographic surveys and semi-structured interviews. Needs were categorized by two research team members by semantic type using a validated consumer health needs taxonomy with four main categories (i.e., informational, logistical, medical, and social/emotional) and the degree to which they were met (i.e., met, partially met, or unmet).

 

Results: One hundred participants (71 pregnant women, 29 caregivers) were enrolled in the study; 29 (20 pregnant women, 9 caregivers) had fetuses with surgical diagnoses, which included congenital heart disease (10), spina bifida (7), gastroschisis (6), hydrocephalus (5), cleft lip/palate (4), omphalocele (1), and congenital diaphragmatic hernia (1). Health-related needs data are shown in Table 1. Participants expressed 323 needs, 240 from pregnant women and 83 from caregivers. The most common need subtype was informational needs about specific therapeutic interventions (31 needs, 9.6%). A total of 101 needs (31.3%) were unmet, with the majority in the informational category (57 needs, 56.4%). The most common specific subtype of unmet needs for all participants was logistical, usually questions pertaining to the healthcare facilities, policies or personnel. The most common subtype of unmet needs was the need for emotional support in pregnant women and logistical needs about healthcare facilities, policies, or personnel for caregivers.

 

Conclusion: Despite receiving care in advanced maternal fetal care settings, pregnant women and caregivers with surgical fetal diagnoses have significant unmet health-related needs during the pregnancy. Pregnant women and their caregivers have differing types of health-related needs. Some unmet needs, such as questions about facilities or details of surgical procedures, can be easily addressed, and meeting them may improve the perinatal experience. 
 

86.10 Withholding Foley Catheters in Children Receiving Patient Controlled Analgesia

Posted on January 18, 2018

J. Sobrino1, J. Axt1, J. Sujka1, L. Wedel1, D. Millspaugh1, S. St.Peter1  1Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction: In some institutions Foley catheters (FC) have been placed in all patients receiving opioid patient-controlled analgesia (PCA) because of the increased incidence of urinary retention.  Our institutional data demonstrated no FC replacements in 48 children who had PCA for perforated appendicitis who had their catheters removed before discontinuation of the PCA.  As part of a quality improvement initiative we discontinued the practice of requiring FC each time a PCA was used for perforated appendicitis.  

Methods: A prospective list of patients with perforated appendicitis was maintained.  Data were gathered regarding 65 consecutive patients.

Results:Twenty five percent (16) received a FC with 14 of these being placed in the operating room for physician preference.  No patients required replacement of the catheter once removed.  Two FCs were placed outside of the OR for urinary retention.  In addition mean post-operative length of stay was 119 hours in those with FC and 98 in those without (p 0.06).    Mean time on PCA was 80 hours in those with FC and 64 in those without (P 0.02). 

Conclusion:FC can be withheld from patients with perforated appendicitis who are placed on PCA with a very low replacement rate.  In addition there is a strong trend toward shorter hospital stay and a statistically significant shorter time on PCA for those who do not receive a FC.

 

86.11 Prolonged Extracorporeal Membrane Oxygenation Is Associated With Poor Neurologic Outcomes

Posted on January 18, 2018

G. J. Ares1,2, C. Buonpane2, I. Helenowski3, F. Hebal2, C. J. Hunter2  1University Of Illinois At Chicago,Department Of Surgery,Chicago, IL, USA 2Ann & Robert H. Lurie Children’s Hospital Of Chicago,Division Of Pediatric Surgery,Chicago, IL, USA 3Northwestern University,Department Of Surgery,Chicago, IL, USA

Introduction:
Extracorporeal membrane oxygenation (ECMO) has been used as a rescue intervention in neonates and infants in acute cardiopulmonary failure. However, these patients are at high risk for long term morbidity including neurologic dysfunction and mortality. While survival has been reported with ECMO courses >14 days, no studies have looked at meaningful survival and recovery after prolonged ECMO >21 days which has been cited as an arbitrary cut-off time in some centers. We hypothesized that patients with prolonged ECMO courses (>21 days) would have poor overall survival and quality of life.

Methods:
We performed a single institution, retrospective review of medical records for patients <18 years old receiving ECMO for >/= 21 days for any indication, between the years 2007 and 2017. The primary outcome was survival to hospital discharge. Secondary outcomes included neurologic dysfunction and other morbidities documented following the initial hospitalization. 

Results:
Fourteen patients met inclusion criteria. Survival to hospital discharge for this group was 36%, which is significantly lower than the reported 60% survival for children requiring ECMO <14 days. Patients who started ECMO after 100 days of age were more likely to survive (p=0.03). Patients requiring ECMO support for congenital cardiac or pulmonary conditions had decreased survival compared to those with acquired etiologies (2/2 patients with acquired cardiac failure, and 3/6 patients with acquired pulmonary indication for ECMO survived, compared to 0/6 survivors for congenital cardiac or pulmonary etiologies (p=0.03)). Patients who were progressively weaned from ECMO support were more likely to survive, compared to those who discontinued ECMO secondary to minimal progress or circuit complications (p=0.005). Only 1 of the 5 survivors made a full recovery without residual neurologic deficits. The other 4 had adverse neurologic outcomes, including ischemic/hemorrhagic stroke, behavioral and learning disabilities, extremity amputation or contractures impairing ambulation, epilepsy, cortical blindness, sensorineural hearing loss, and/or inability to achieve pulmonary independence. 

Conclusion:
Prolonged ECMO courses of >21 days are associated with decreased survival to hospital discharge. There are minimal data to support prolongation of ECMO for neonates with congenital cardiac or pulmonary failure. Furthermore, long term outcomes for prolonged ECMO survivors are characterized by neurologic impairments, learning disabilities, and impaired mobility. These need to be considered with families in the discussion to justify prolonged support.
 

86.09 Pediatric Perforated Appendicitis: A Scoring System to Classify Degrees of Peritoneal Contamination

Posted on January 18, 2018

R. Jones1,2, J. S. Davis1,2, L. Burkhalter2, R. Foglia1,2  1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2Children’s Medical Center,Department Of Surgery,Dallas, Tx, USA

Purpose: Pediatric perforated appendicitis (PA) comprises a spectrum ranging from localized purulence to contamination in all four quadrants. We believe that the degree of peritoneal contamination affects both clinical outcomes and resource utilization. This pilot study develops a severity scoring system (SSS) for PA based on operative dictations, and validates the SSS between users.

Methods: Our children’s hospital performs approximately 1,200 appendectomies annually.  After IRB approval, the Electronic Health Record and operative reports were reviewed from randomly selected patients who underwent laparoscopic appendectomy for PA between 2012-2014. A faculty attending and resident utilized these reports to develop a SSS, which divided patients into two groups: (A) periappendiceal or right lower quadrant localized purulence alone; and (B) purulence in two or more quadrants. To test inter-rater reliability, a pediatric surgical fellow then used the SSS to independently review the same operations, and SSS designations were compared. Patients were excluded if operative reports were insufficiently detailed, if they were immunocompromised or if drains had been placed preoperatively. 

Results: Of 237 dictations, 150 (63.3%) were appropriate for scoring. The remaining 87 reports lacked sufficient detail. The senior faculty and resident placed 49 patients in group A (33%) and 101 patients in group B (67%). After scoring by the fellow, we compared the fellow’s SSS designations to the original and found a 91% concordance. The kappa coefficient was 0.81, indicating high agreement.

Conclusion: We developed a SSS for pediatric PA and identified that one third of patients had localized contamination, in contrast to two thirds of children who had a large degree of contamination in multiple quadrants. The SSS showed a high degree of inter-rater reliability. Unfortunately, over 60% of the operative notes reviewed were excluded due to a lack of information regarding peritoneal purulence. This study highlights the importance of precise documentation in operative dictations. The next step is to determine if there is correlation between SSS designations, clinical outcomes, and resource utilization. This information may have significant financial implications for the hospital, and will allow professional reimbursement to appropriately reflect disease severity.

86.06 Recurrence of pilonidal disease: our best is not good enough

Posted on January 18, 2018

D. R. Halleran1,2, J. J. Lopez1,2, A. E. Lawrence1,2, K. L. Leonhart2, Y. V. Sebastião2, B. A. Fischer2, J. N. Cooper2, P. C. Minneci1,2, K. J. Deans1,2  1Nationwide Children’s Hospital,Division Of Pediatric Surgery,Columbus, OH, USA 2Nationwide Children’s Hospital,The Center For Surgical Outcomes Research,Columbus, OH, USA

Introduction:  Pilonidal disease is a common and painful disorder among adolescents and young adults, affecting males at a rate of 2 to 4 times that of females. Approximately 1% of the population will be diagnosed with pilonidal disease between the ages of 15-30 years. Patients with recurrent pilonidal disease can develop chronic wounds and draining sinuses that incur long term morbidity, disability, and decreased quality of life. Recurrence rates have been conservatively reported at 16% and as high as 30%. The aim of this study was to characterize rates of recurrence in patients with pilonidal disease treated by pediatric surgeons.

Methods:  We conducted a retrospective review of patients at our institution diagnosed with pilonidal disease and evaluated by surgery from 2010-2015. Demographic and clinical characteristics were collected from the electronic medical record. Summary measures were used to examine patient demographics and clinical outcomes. This study was approved by our institutional review board. 

Results: In 360 patients with pilonidal disease treated at our institution over the study period, 51% were male with a median age at initial evaluation of 16 years (IQR 14-17) and a median BMI of 28.3 kg/m2 (23.5-34.0). Recurrent pilonidal disease was seen in 34.4% of the patients in our cohort with approximately 22% of patients having a recurrence within the first year of initial evaluation (Table). In patients treated after their first episode of disease, recurrence rates were 21.3% after treatment with antibiotics only, 26.8% after treatment with incision and drainage, and 30.4 % after surgical excision. Approximately 66% of patients underwent surgical excision of their pilonidal disease in our cohort.

Conclusion: Pilonidal disease has a substantial recurrence rate even after surgical excision.  Future studies investigating treatments that can prevent disease recurrence are needed.

86.08 Suspected Appendicitis Pathway Continues to Lower CT Rates in Children Two Years After Implementation

Posted on January 18, 2018

L. A. Gurien1,2, M. S. Dassinger1, M. Crandall2, J. J. Tepas2, S. D. Smith1  1Arkansas Children’s Hospital,Pediatric Surgery,Little Rock, AR, USA 2University Of Florida College Of Medicine – Jacksonville,General Surgery,Jacksonville, FL, USA

Introduction:
A protocol to evaluate pediatric patients with suspected appendicitis was implemented at our institution in July 2012. Ultrasound (US) was chosen as the initial imaging modality to decrease radiation exposure in our pediatric population.  A computerized tomography scan (CT) was obtained only after surgical consultation. We sought to evaluate rates of CT utilization as well as the diagnostic accuracy of the pathway two years after pathway implementation.

Methods:
After receiving exemption from the Institutional Review Board, all charts of patients who underwent abdominal imaging with CT or US in the Emergency Department of a freestanding children’s hospital were reviewed.  Subjects were excluded if they were 18 years of age or older, arrived with imaging from an outside source, or underwent imaging for a suspected disease process other than appendicitis.  CT rates were compared before (July 2011 – June 2012) and after (January 2013 – June 2014) implementation of the protocol using Chi-square test, and monthly CT rates during the post-pathway period were calculated to assess trends in CT utilization.  Criteria to confirm adherence to the pathway included: (1) US only was performed; (2) US and surgical evaluation were obtained prior to CT; or (3) CT was obtained in patients with a BMI ≥ 35.  Pathology results were reviewed to determine effect on diagnostic accuracy. 

Results:
CT use decreased significantly following pathway implementation from 94.2% (130/138) to 27.6% (78/283) with p<0.0001.  Linear regression of monthly CT utilization demonstrated that CT rates continued to trend down two years after pathway implementation (Figure 1).  Adherence to the pathway was 90.1% (255/283).  In the post-pathway period, US sensitivity was 70.8% and US specificity was 96.5%, while CT sensitivity was 91.3% and CT specificity was 90.9%.  Negative appendectomy rates remained low in the post-pathway period at 2.4% (2/85). 

Conclusion:
Adherence to a pathway designed to evaluate pediatric patients with suspected appendicitis using ultrasound as the primary imaging modality has led to a sustained decrease in computed tomography use without compromising diagnostic accuracy.  Continued adherence to and effectiveness of a voluntary pathway that relies on safe imaging is reassuring and highlights the importance of ongoing assessment of the long-term impact of an institution’s pathways.
 

86.04 Non-traumatic Surgical Emergencies in Children: An Examination of ED Visits across the US

Posted on January 18, 2018

A. A. Shah1, K. Williams1, E. Cornwell1, T. Oyetunji3, B. Nwomeh2  1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Nationwide Children’s Hospital,Pediatric Surgery,Columbus, OH, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Pediatric Surgery,Kansas City, MO, USA

Introduction:  Pediatric patients comprise a quarter of emergency department (ED) visits in the US. Utilization of ED services by children for surgical emergencies has not been well studied. The aim of this study is to identify the most common pediatric surgical emergencies presenting to the ED.

Methods:  The Nationwide Emergency Department Sample (2009-2012) was queried for pediatric patients (≤18 y) with a primary diagnosis of strangulated/incarcerated hernias, intestinal obstruction, volvuli, intussusception, peri-anal/rectal abscesses, appendicitis and cholecystitis. Patients with traumatic injuries were excluded. Univariate analysis was then performed to describe patient demographics, payor status, discharge disposition, hospital characteristics and outcomes. Any major diagnostic or major therapeutic procedures performed were regarded as major operative intervention. Primary outcome measures were inpatient admission and operative intervention after admission.

Results: A total of 113,699 records were analyzed weighted to present 509,606 ED visits nationally. Average age was 11.4 (±4.9) years with a male preponderance (60.2%). Appendicitis was the most common reason for the presentation to the ED (82.5%), followed by intestinal obstruction (6.3%) and abscesses (3.9%). A total of 58.3% required inpatient admission, whereas 14.2 % were transferred to other facilities. Of those requiring admission, 89.3% underwent major surgical intervention. Highest rates of operative interventions were observed for appendicitis (96.3%), followed by hernias (93.4%) and volvuli (89.0%). Median length of hospital stay was 2 days (IQR:1-3). Routine discharge home was common (97.2%), followed by home with home health (1.8%) and transfer to a short term care facility (1.0%).

Conclusion: Among the common pediatric surgical emergencies examined, more than half require inpatient admission with greater than three-quarters undergoing operative intervention. Discharge to home was routine after hospital admission. Appropriate identification of children at risk for admission can help expedite ED triage and ensure timely surgical care delivery.
 

86.05 Pediatric Breast Masses: Should They Be Excised?

Posted on January 18, 2018

C. M. McLaughlin1, J. Gonzalez-Hernandez5, M. Bennett3, H. G. Piper2,5  5University Of Texas Southwestern Medical Center,Dallas, TX, USA 1Baylor University Medical Center,General Surgery,Dallas, TX, USA 2Children’s Medical Center,Pediatric Surgery,Dallas, Tx, USA 3Baylor Scott & White Health,Office Of The Chief Quality Officer,Dallas, TX, USA

Introduction:
Pediatric breast masses can be a diagnostic challenge. Nearly all are benign, but there is no consensus on which should be removed. The purpose of this study was to describe children who underwent breast mass excision at a single pediatric hospital and define which patients can be safely observed. 

Methods:
We performed a retrospective review of children (≤18 years) who underwent breast mass excision at a single institution from 2008-2016. Male patients with gynecomastia, those who had needle biopsy without formal excision, and those who had debridement or incision and drainage procedures were excluded. 

Results:
One hundred ninety-six patients were included (96% female). Mean age was 15.2 +/- 2.9 y. Most (71%) had painless masses. Pre-operative ultrasound was obtained in 70%. Pathology included fibroadenoma (81.5%), tubular adenoma (5%) benign Phyllodes tumor (3%), benign fibroepithelial neoplasm (0.5%) and other benign lesions (10%). There were no malignant lesions. Ultrasound size had a Pearson correlation of 0.84 with pathologic size (p < 0.0001). There was no association between the size and pathologic diagnosis. 

Conclusion:
The overwhelming majority of breast masses in children are benign, most commonly fibroadenoma. Ultrasound is an accurate predictor of size, but large lesions do not necessarily confer a high malignancy risk. Observation is appropriate for asymptomatic breast masses in children. 
 

86.02 Nationwide Survival Analysis of Sentinel Lymph Node Biopsy in Pediatric Malignancies

Posted on January 18, 2018

P. P. Parikh1, J. E. Sola1, E. A. Perez1  1University Of Miami,Surgery,Miami, FL, USA

Introduction: There remains a paucity of literature on survival outcomes related to sentinel lymph node biopsy (SLNB) use in pediatric cancer cases with surgical management often extrapolated from the adult experience. The purpose of this study was to determine the surgical management (SLNB with or without lymph node dissection (LND) vs none) and survival outcomes of several types of cancers in pediatric patients.

Methods: The Surveillance, Epidemiology, and End Results (SEER) registry was analyzed for all patients <20 years old with a malignancy from 2003-2014. Patients were stratified by those who underwent SLNB, with or without subsequent LND either during simultaneous or follow-up surgery, or no SLNB. Parameters analyzed included demographics, tumor type, disease severity and surgical management. Chi-square analysis for categorical and Student’s t test for continuous data were used. Multivariate analysis was performed to identify independent predictors of survival.

Results: Overall, 2,770 patients were identified as having a malignancy including malignant melanoma (39%), thyroid cancer (25%), other non-rhabdomyosarcomas (25%) and rhabdomyosarcoma (11%). The average age was 14 ± 4 where most patients were white (83%) and female (62%). When stratified by disease severity, most patients had localized disease (77%) followed by regional (23%) disease. Whereas majority of patients had no SLNB performed (80%), SLNB (with or without LND) was performed in 20% of patients. On univariate analysis, 15-year survival for all patients was not significantly greater for those undergoing SLNB and subsequent LND vs no SLNB (94% vs 92%, respectively; P=0.118). However, when stratified by tumor type, there was significant difference in 15-year survival between patients who underwent SLNB and subsequent LND vs no SLNB for malignant melanoma (95% vs 97%, respectively; P=0.009). On multivariate analysis, SLNB and subsequent LND vs no SLNB was not an independent predictor of survival. This was true for the whole group as for each tumor in independent multivariate models. Regional disease was associated with significantly greater 15-year survival when SLNB and subsequent LND were performed vs no SLNB (89% vs 80%, respectively; P=0.018).

Conclusion: Overall, limited surgical management for certain pediatric malignancies that are localized or regionally metastasized may be adequate treatment. More extensive surgery involving SLNB and subsequent LND may be of limited utility for optimizing patient survival, but further studies need to be performed to clarify the utility of SLNB in the pediatric patient

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