96.18 Clinician Satisfaction after Implementation of Intussusception Management Protocol

Posted on January 31, 2019

J. S. McLeod1, W. Wendt2, M. Macy2, E. Dunbar2, A. Gavulic3, M. Hilu3, N. Sroufe2, E. E. Perrone1  1University of Michigan,Division Of Pediatric Surgery,Ann Arbor, MI, USA 2University of Michigan,Department Of Emergency Medicine,Ann Arbor, MI, USA 3University Of Michigan,Undergraduate School,Ann Arbor, MI, USA

Introduction:   Previous studies have demonstrated that pediatric patients with low risk, uncomplicated intussusception can be reduced by enema and discharged from the ED after observation. Few studies have reviewed clinician satisfaction after protocol implementation. The purpose of this study was to assess clinician experiences after implementation of a new protocol involving emergency department (ED) observation of children after successful enema reduction of uncomplicated intussusception

Methods:   An ED observation protocol was implemented at a level 1 pediatric trauma center in March 2017 for children who presented with uncomplicated intussusception. They were treated with air enema reduction, followed by 6-hours of ED observation, and discharged home. In April 2018, a survey was sent to Emergency Medicine (EM), Surgery, and Pediatric (Peds) clinicians. Only those who had cared for an intussusception patient took the survey, which consisted of 25 Likert-type-scale questions with 4 domains: satisfaction, safety, clinician burden, and family burden/cost.  SPSS and excel were used to collect descriptive statistics.  The survey will remain open for 2 more weeks and comparisons by provider group will be conducted once survey is closed. 

Results:  Surveys were sent to 242 staff (16.5% Surgery, 34.7% EM, 48.8% Peds). In the first 48 hours the survey was open, 93 responses were received (57% residents, 18.3% attendings, 16.1% nurses, 7.5% fellows, 1.1% PAs), and 42 were excluded. EM had the highest number of respondents (49.5%), then Peds (40.9%), and surgery (9.7%). 77.5% had positive satisfaction with the new protocol, 17.8% were neutral, and 4.6% negative satisfaction. Most felt the protocol was safe (82%). 58.5% felt that it was efficient and decreased clinician burden, 21.7% were neutral, and 19.8% thought that this was not decreased. Nearly half thought that family burden and cost were decreased (48.9%), 35.5% were neutral, and 15.6% felt it did not improve this area (Figure 1). 

Conclusion:  The survey suggests that clinicians are overall satisfied with the ER observation intussusception protocol and believe this protocol is safe with low risk of complications. Most felt that the protocol was efficient and decreased clinical burden, but some were either neutral or thought it hindered clinician efficiency.  Continued work will further evaluate provider responses, patient satisfaction surveys, and cost. 

 

96.17 Method for Distinguishing Children’s Hospitals from Non-Children’s Hospitals in Claims Data Sources

Posted on January 31, 2019

K. Piper2, K. J. Baxter1, I. McCarthy3, M. V. Raval5  1Emory University School Of Medicine,Division Of Pediatric Surgery,Atlanta, GA, USA 2Emory University,Rollins School Of Public Health,Atlanta, GA, USA 3Emory University,Department Of Economics,Atlanta, GA, USA 5Feinberg School Of Medicine – Northwestern University,Department Of Surgery, Division Of Pediatric Surgery, Ann & Robert H. Lurie Childen’s Hospital Of Chicago,Chicago, IL, USA

Introduction: Children’s hospitals (CH) provide high volume, specialized, and resource intense care to children. Though CH comprise less than 5% of all hospitals in the United States, they account for 40% of pediatric inpatient days and 50% of pediatric healthcare costs. Because these hospitals represent a disproportionate amount of pediatric healthcare costs, it is important to determine if the care provided by CH is justified by improved health outcomes. When using large administrative and claims data sources, the first methodological step needed to compare health outcomes is to classify hospitals as CH and non-children’s hospitals (NCH). There are currently no systematic or standardized methods for classifying hospitals. The purpose of this study was to describe a novel and reproducible hospital classification methodology.

Methods: Using data from the 2015 American Hospital Association (AHA) Survey, 4,464 hospitals were classified into four categories (Tiers A-D) based on self-reported proportion of pediatric admissions as well as presence of pediatric specific structural elements and service lines. Tier A included hospitals that only provided care to children. Tier B included non-Tier A hospitals that had key pediatric services including pediatric emergency departments, pediatric intensive care units, and neonatal intensive care units (NICU). Tier C included non-Tier B hospitals that provided limited key pediatric services. Tier D hospitals provided no key pediatric services. We then validated the classifications using publicly available data related to hospital memberships and participation in a variety of child health related programs. 

Results: 51 hospitals were classified as Tier A, 228 as Tier B, 1,721 as Tier C, and 1,728 as Tier D. The majority of Tier A hospitals were members of the Children’s Hospital Association (90.2%), while half of Tier B hospitals and very few Tier C/D hospitals were members. Similar trends were observed for membership in the Children’s Oncology Group, designation as a Level 1 Pediatric Trauma Center, performance of pediatric solid organ transplantation, provision of congenital heart surgery services, designation as a level 3 or 4 NICU, and membership in the National Surgical Quality Improvement Program-Pediatric (See Table).

Conclusion: Using AHA survey data is a feasible and valid method for classifying hospitals into CH (i.e. Tier A) and NCH (i.e. Tiers B, C, and D) categories using a reproducible multi-tiered system.  For specific studies and research questions, investigators may elect to consider both Tier A and Tier B hospitals as CH.  Further clinical validation of this hospital classification method is needed through application to administrative data sources.

96.16 Racial Disparities in Receipt of Postoperative Opioids after Pediatric General Surgery Procedures

Posted on January 31, 2019

A. E. Lawrence1, K. J. Deans1, D. Chisolm1, S. Wrona1, P. C. Minneci1, J. N. Cooper1  1Nationwide Children’s Hospital,Columbus, OH, USA

Introduction: Pediatric postoperative opioid prescribing has come under scrutiny as a result of the ongoing opioid epidemic. Surgeons must balance providing adequate pain control for their patients while minimizing the risk of accidental or non-medical use of these substances. Previous research has demonstrated that African American adults are less likely to receive analgesics, particularly opioids, after surgery, even after controlling for pain severity. We sought to examine racial disparities in the filling of opioid prescriptions by pediatric surgical patients.

Methods: We studied patients aged 1 to 18 years of age who were enrolled in Ohio Medicaid and underwent one of fifteen frequently performed pediatric otolaryngology, orthopedic, general surgery, or urologic procedures after which opioids are commonly prescribed. Procedures performed in January 2013 – July 2016 were included. The percentage of patients who filled a postoperative opioid prescription within 14 days of their procedure was compared between black and white patients using Pearson chi square tests for specific procedures and Cochran-Mantel-Haenszel tests for all evaluated procedures across a specialty.

Results: We identified 41,173 patients undergoing common pediatric otolaryngology, orthopedic, general surgery, and urologic procedures. Across general surgery procedures, there was a significant racial disparity in postoperative opioid prescription filling (p=0.002; Table). White children were more likely to fill a prescription than black children following appendectomy, inguinal hernia repair, and cholecystectomy (Table).  There was no racial disparity in postoperative opioid prescription filling after otolaryngology, orthopedic, or urologic procedures.

Conclusion: Black children in our state are less likely to fill an opioid prescription after common pediatric general surgery procedures. This disparity may result from differences in prescribing or filling practices. Further research is needed to clarify the nature of this disparity and to determine whether it has been impacted by recent state and federal opioid-related policies.

 

96.15 Do Disparities Exist in Pediatric Surgery? A Systematic Review of Outcomes in Pediatric Appendectomy

Posted on January 31, 2019

M. E. Ingram1, K. Calabro2, S. Polites3, C. E. McCracken4, G. Aspelund5, B. S. Rich6, R. L. Ricca7, R. Dasgupta3, D. H. Rothstein2, M. V. Raval8  1Emory University School of Medicine,Department Of Surgery,Atlanta, GA, USA 2University at Buffalo Jacobs School of Medicine and Biomedical Sciences and John R. Oishei Children’s Hospital,Department Of Surgery,Buffalo, NY, USA 3Cincinnati Children’s Hospital,Division Of Pediatric Surgery, Department Of Surgery,Cincinnati, OH, USA 4Emory University School Of Medicine,Department Of Pediatrics,Atlanta, GA, USA 5Maria Fareri Children’s Hospital,Department Of Surgery,New York, NY, USA 6Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Cohen Children’s Medical Center, New Hyde Park, NY,Division Of Pediatric Surgery,New Hyde Park, NY, USA 7Naval Medical Center,Department Of Surgery,Portsmouth, VA, USA 8Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago,Division Of Pediatric Surgery, Department Of Surgery,,Chicago, IL, USA

Introduction:
The impact of social, racial, and economic disparities on health and surgical outcomes in adults has been well-documented, but little is known about how these sociodemographic variables affect surgical outcomes in children.  

Methods:
A systematic review using PubMed search terms related to disparities in care of pediatric appendicitis identified 20 titles that were narrowed to 12 abstracts and then 11 full texts.  After final review, 9 retrospective studies were included for analysis.  Data included >350,000 cases (simple and complicated) treated across the United States from 1983-2010.  Outcomes examined included length of stay (LOS), appendiceal perforation rate (AP), laparoscopic vs open approach, and rate of misdiagnosis.

Results:
Only 2 papers reported the impact of a shared set of variables for any given surgical outcome (Figure 1), limiting the ability to perform a meta-analysis.  The 2 most frequently reported outcomes were LOS (6 of 9 studies) and AP (6 of 9 studies).  AP was higher for young children (48% for <6yo vs. 25% for >10yo), those in rural settings (42% vs. 26% in urban settings), and for children receiving care at children’s hospitals (35% vs. 22% at non-children’s hospitals).  Longer LOS was associated with young age in 3 studies (2-5 days for age <10 years vs 1-3 days for age >11 years), race in 4 studies (1.5-3 days for African American children vs. 1-2 days for other races), and lower family income in 2 studies (2-4 days vs. 1-3 days for highest-income).  Disparities based on age and race are also reported in use of laparoscopy, time to surgery, and misdiagnosis. One paper reported on discrepancy in time to surgery being influenced by race.  Another paper described age, sex, and children’s hospitals vs non-children’s hospital settings as positively associated with a higher likelihood of misdiagnosis. 

Conclusion:
While limited, the existing literature suggests that social, racial, and economic disparities impact surgical management and outcomes in pediatric appendicitis.  Specifically, a patient’s race, age and locality correlate with marked disparities in LOS and AP.  A paucity of studies limit more robust pooled meta-analysis.  More studies are needed to better describe and mitigate disparities in the surgical care of children.
 

96.14 Surgical Outcomes of Gastrostomy Tube Insertion in Children

Posted on January 31, 2019

T. Kuriakose1, F. D. Arias1, Y. Lee1,2  1Rutgers Robert Wood Johnson Medical School,Division Of Pediatric Surgery, Department Of Surgery,Piscataway, NJ, USA 2Robert Wood Johnson University Hospital,Bristol-Myers Squibb Children’s Hospital,New Brunswick, NJ, USA

Introduction:  Gastrostomy tubes can be inserted using percutaneous endoscopic technique (PEG), laparoscopic or open. The choice of technique is usually determined by surgeon preference. The fear of complication has deterred many pediatric surgeons from performing PEG in young children. Evidence supporting this claim is scant. We hypothesize that PEG can be safely performed in children. 

Methods:  We conducted a retrospective review of gastrostomy tube insertion in children age 0-21 at an academic medical center from 1/2014 to 4/2018. Gastrostomy tube insertions were identified by CPT codes. Patients were excluded from analysis if they had prior gastrostomy tube, concurrent major surgery or incomplete records. Data collected included operative time, length of stay from procedure to discharge, rates of conversion to a different technique and complication. Complications are defined as return to emergency department (ED), return to operating room (OR), and hospital readmission within 30 days of procedure. 

Results: 116 gastrostomy tube patients were identified, and after applying exclusion criteria, 83 were analyzed. There were 30 girls and 53 boys. 49 of these patients were younger than 2 years of age. 56 patients underwent PEG placement. The average operative time was 37.1 minutes (95% CI: 31.3-42.8). Average length of stay was 4.67 days (95% CI: 3.19-6.15). 5.4% (3/56) of PEG procedures required conversion to laparoscopic or open. 7.1% (4/56) of these patients visited the ED within 30 days of procedure; 3 of whom required tube replacement. 1.8% (1/56) of these patients had a GI-related readmission (erythema at tube site). 10 patients underwent laparoscopic gastrostomy tube placement. The average operative time was 88.8 minutes (95% CI: 66.9-110.7). The average length of stay was 4.1 days (95% CI: 2.24-5.96). 10% (1/10) required conversion to open. None of laparoscopic group had an ED visit or a GI-related readmission within 30 days of procedure. 17 patients underwent open gastrostomy tube placement. The average operative time was 76.7 minutes (95% CI: 55.1-98.3). The average length of stay was 9.06 days (95% CI: 0.37-17.75). 5.9% (1/17) of these patients visited the ED within 30 days of procedure; none required gastrostomy tube replacement. 5.9% (1/17) of these patients had a GI-related readmission (erythema and drainage at tube site) within 30 days of procedure. In our study, only one case returned to OR within the study period for gastrostomy tube revision, and the initial technique use was open. 

Conclusion: PEG is associated with the shortest operative time of all procedures. Laparoscopic gastrostomy tube insertion is associated with longest operative time but the shortest postoperative length of stay. There is no complication identified in the laparoscopic group. Open gastrostomy tube insertion is associated with the longest postoperative length of stay, and a comparable rate of complication as compared to PEG.

 

96.13 A Unique and Helpful Perspective: Parental Input on Pediatric Patient Safety

Posted on January 31, 2019

K. E. Anthony1, N. B. Hebballi1, K. Sheppard1, K. Tsao1, A. L. Kawaguchi1  1McGovern Medical School at UTHealth and Children’s Memorial Hermann,Department Of Pediatric Surgery,Houston, TX, USA

Introduction:  While patient safety research often focuses on the perspective of healthcare providers and patients, the parents of pediatric patients also play a significant role in their children’s healthcare.  We hypothesized that parents will offer unique observations on their children’s healthcare safety that may be useful to improve patient care.

Methods:  We conducted a cross-sectional study on a medical-surgical pediatric unit within a tertiary children’s hospital. Over a ten-week period in 2018, English-speaking parents and legal guardians were asked to complete a paper or electronic survey about patient safety adapted from the validated inpatient Safety Attitudes Questionnaire. The survey contained 20 questions on a 5-point Likert scale representing three domains: safety climate, perception about management, and teamwork. Two additional open-ended questions were included to identify their top three patient safety issues and viewpoints on patient safety in the hospital.

 

Results: 150 of the 168 (89%) patient families approached agreed to participate. 58 of the 150 surveys were returned (39%). 53 were paper surveys and 5 were submitted electronically. Patients had a median length of stay of 3 days (range 1-17 days), with 48% a first hospitalization, and a wide variety of diagnoses.  Overall, 96% of the responses were slightly or strongly positive. Safety climate statements were 95% positive, teamwork statements were 98% positive, and perception of management statements were 97% positive. The statements with the least positive parental responses are listed in the table below.  The top three most common parental responses to the open-ended questions included concerns about security at the entrance of the floor, handwashing by staff, and bed height for pediatric patients.

Conclusion: Parents have a unique perspective on safety concerns regarding their child’s care while in the hospital. A focus on improving communication, improving information exchange, and empowering parents to speak up for their child’s care may be useful to help improve the care of pediatric patients.

 

 

96.12 Financial Burden of Initial Hospitalizations for Pediatric Firearm Injuries in the United States

Posted on January 31, 2019

J. S. Taylor1, S. Madhavan2, J. M. Chandler1, S. D. Chao1  1Stanford University,Pediatric Surgery / Surgery / Stanford School Of Medicine,Stanford, CA, USA 2Stanford University,Statistics,Stanford, CA, USA

Introduction: Pediatric firearm-related injuries pose a significant public health problem within the U.S., yet the financial burden associated with these injuries has not been well-described. This study examined the incidence of pediatric firearm-related injuries and the cost associated with the initial hospitalization.

Methods:  The Healthcare Cost and Utilization Project Kids’ Inpatient Database (KID) from the years 2003, 2006, 2009, and 2012 was used to identify all patients under 21 years of age who were admitted with firearm-related injuries. We compared demographic and discharge-level data including injury severity score (ISS), hospital length of stay (LOS), income quartile, injury intent, inflation-adjusted hospital costs across age groups (0-5, 6-9, 10-15, 16-20 years).

Results: There were 8,196 ± 1,095 pediatric firearm-related admissions each year, with an average hospital cost of $24,686 ± $2,318 per patient. Annual initial hospitalization costs for pediatric firearm injuries were approximately $189 million dollars during the study period. Pediatric firearm-related injuries predominately occur among older teenagers (84%, 16-20 years), males (90%), black individuals (56%), or those from the lowest income quartile (53%). We found significant cost variation based on patient race, income quartile, ISS, intent, LOS, disposition, and hospital region. Inflation-adjusted hospitalization costs have increased significantly over the study period (p < 0.001).

Figure 1. A) Intent of pediatric firearm-related injuries by race. B) Intent of pediatric firearm-related injuries by age group. C) Average hospital cost per admission for pediatric firearm-related injuries by payer type. All data from 2003-2012.

Conclusion: Pediatric firearm-related injuries are a large financial burden to the U.S. healthcare system. There are significant variations in cost based on predictable factors like hospital LOS and ISS; however, there are also substantial discrepancies based on hospital region, patient race and income quartile that require further investigation.

 

96.11 Effect of Parental Health Literacy on Patient Outcomes in Intestinal Failure

Posted on January 31, 2019

A. M. Waters1, C. Onwubiko1, M. C. Shroyer1, J. S. Graham1, L. Wilkinson1, D. P. Galloway1, C. A. Martin1  1University Of Alabama at Birmingham,Pediatric Surgery,Birmingham, Alabama, USA

Introduction:  Health literacy is estimated to be low in over one third of the US population and lower health literacy has been associated with higher morbidity and mortality rates. In the pediatric patient population, there is a significant role that parents/caregivers play in the health of their children. Children with intestinal failure have complex care requirements and effective communication between caregivers and medical providers is essential to patient well-being.  We aim to evaluate the ability of the medical providers to assess parental medical knowledge.

Methods:  We utilized the validated Parental Health Literacy Activities Test (PHLAT-8) assessment tool to measure parental understanding.  The assessments were given to the primary caregiver during their child’s clinic appointment or hospital admission. Raw scores were used to categorize health literacy (inadequate = 1, moderate = 2, or adequate = 3). The survey responders’ level of education was also recorded. Providers (MD and NP) were also then surveyed to anticipate the mental capacity of the caregivers for these patients. Additionally, providers were recorded during patient interactions and the Flesch-Kincaid reading level of the transcript was determined to assess their ability to effectively communicate with patient’s caregivers.

Results: A total of 54 patient caregivers completed the PHLAT-8 assessment.  Of the responders, 4.7% had a GED certificate, 51.2% high school diploma, 18.6% associates degree, 16.3% bachelor’s degree, and 9.3% had an advanced degree. The average health literacy was 2.62 +/-0.6, or less than the adequate range. Provider surveys estimated the caregiver’s level health literacy to range from 2.24 to 2.61.  While providers underestimated caregiver’s health literacy, the average reading level of the recorded conversations were determined to be 10.4 with a range of 8.2 to 12.5. 

Conclusion: This study is useful to incorporate into our clinical practice to help identify those caregivers who need extra education or resources to be able to properly care for children with intestinal failure and their associated complex medical issues.  It also highlights the need for medical providers to be mindful of their manner of speech to ensure that caregivers of all levels can understand information given to them regarding their child’s healthcare.

 

96.10 An Epidemiological Analysis of Pediatric Dog Bite Injuries Over a Decade

Posted on January 31, 2019

J. A. Cook1, T. Soleimani3, S. T. Greathouse4, B. L. Eppley5,7, M. W. Chu6, S. S. Tholpady1,2,5  4Reid Plastic & Reconstructive Surgery,Richmond, IN, USA 5Riley Hospital for Children,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA 6Kaiser Permanente West Los Angeles,Division Of Plastic & Reconstructive Surgery,Los Angeles, CA, USA 7Eppley Plastic Surgery,Indianapolis, IN, USA 1Indiana University School Of Medicine,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA 2R.L. Roudebush Veterans Affairs Medical Center,Division Of Plastic & Reconstructive Surgery,Indianapolis, IN, USA 3Michigan State University,Department Of Surgery,Lansing, MI, USA

Introduction:  An estimated 800,000 dog bites require medical attention per year.  Previous studies of dog bite injuries have predominantly focused on patient and dog-specific characteristics to characterize the nature of these injuries.  The purpose of this study is to investigate changes in the incidence and epidemiology of dog bite-related hospitalizations in the United States over a decade.

Methods:  The Kids’ Inpatient Database (KID) was interrogated for dog bite injuries in patients younger than 18 years of age over a ten-year period. Data points collected were age, race, primary payer, and median household income quartile for the patient’s zip-code.  Site of injury, rate of cellulitis, and presence of fractures were included. Outcome measures of interest were incidence of hospitalization, rate and type of surgical procedures, and length of stay.

Results: A total of 6,308 patients were identified over the study period. Average age at time of injury was 6.4 years. The majority of the patients were male (56.1%), Caucasian (64.8%), and under 11 years of age (83.9%). Over the study period, the percentage of children younger than 5 years old increased significantly from 39.3% to 44.7% (p <0.001) while the percentage of those aged 5 to 11 decreased from 45.8% to 39.8% (p <0.001).  Patients in the lowest median income quartile had the largest number of patients with injuries (27.8%). Dog bites affecting the head and neck were the most affected site of injury (55.7%), followed by upper extremity (35.3%) and lower extremity (14.6%) sites. Over the study period, rates of cellulitis increased from 33.7% to 44.8% over the study period (p <0.001). More than 50% of the patients underwent at least one surgical procedure, 31.2% of the patients underwent invasive surgical procedures, and 5.1% of the hospitalized patients required skin grafts or flaps. 

Conclusion: Dog bites are one the most common causes of non-fatal pediatric injuries and impose a significant burden on families as well as the health care system. Head and neck injuries were of greatest significance in the pediatric population, and cellulitis was the most common complication.  Evaluating the characteristics of pediatric dog bite injuries will help develop future educational efforts.  

96.09 Sterile Pyuria an Indication of Acute Appendicitis in Children

Posted on January 31, 2019

S. Lewis1, C. St. Laurent1, A. Ruiz-Elizalde1  1University Of Oklahoma College Of Medicine,Oklahoma City, OK, USA

Introduction:   Appendectomy is one of the most common surgical procedures performed in children. Acute appendicitis is one of the leading pathologies requiring hospitalization in children. Delays in diagnosis of acute appendicitis can be catastrophic and has been proven to directly increase morbidity and mortality in this patient population.   Even with advancement in imaging and scoring systems used for diagnosis of acute appendicitis, there are a subset of patients who have a delay in diagnosis resulting in increased hospital stay, operation time, and more invasive surgical procedures. One condition that can share clinical symptoms of acute appendicitis in the pediatric population is urinary tract infection; both can present with abdominal pain, fever, nausea, vomiting, and leukocytosis. With children being less adept to elucidate their specific symptoms, these two diagnoses can easily be included in the differential together. The diagnostic techniques use to clearly delineate these two entities include imaging, whether abdominal CT or ultrasound, and urine analysis (UA).  With the deliberate avoidance of ionizing radiation in the pediatric population and ultrasound operator/patient dependent limitations, this can lead to heavy reliance on UA for diagnostic clarity. It has been referenced, that pyuria can be present in the urine of a patient with acute appendicitis, but the statistical percentage of patients has not been defined. The aim of this study was to prove that sterile pyuria is present in a statistically significant number of patients with acute appendicitis and pyuria should be an expected diagnostic finding.

Methods: After IRB approval, a retrospective chart review of all pediatric surgical patients (ages 2-14) who underwent an appendectomy, from January 2015 through December 2017, and had a pre-operative UA was performed. Pyuria was defined as >5 WBC in the urine with sterility defined as negative urine culture or resolution of symptoms without treatment of urinary tract infection.  

Results: Of the 219 patients who met inclusion criteria, 52 patients had pyuria (24%). Of these, 31/52 had a urine culture collected at the time of the UA and only 4 (13%) were positive. The other 21 patients did not have urine cultures but had resolution of symptoms status post appendectomy. We therefore found a 25% sterile pyuria rate in our patients who underwent appendectomy as compared to the published rates of sterile pyuria in the general pediatric outpatient population of 9-13%.

Conclusion: Our pediatric patients with appendicitis had a 2 fold increase in the rate of sterile pyuria over the general pediatric outpatient population, which suggests an association between intraabdominal inflammation and sterile pyuria. Pyuria in the presence of abdominal pain, does not always indicate urinary tract infection and providers should keep acute appendicitis high on their list of differential diagnoses.

 

96.08 Quantifying Institutional Differences in Pediatric Renal Sonography Techniques and Interpretation

Posted on January 31, 2019

V. Richardson1, J. A. Whitley2, A. Taylor2, K. Kieran1,2  1University Of Washington,Seattle, WA, USA 2Seattle Children’s Hospital,Urology,Seattle, WA, USA

Introduction: Identifying opportunities for patients to receive medical care closer to home may reduce financial and temporal costs for families.  We wondered whether there were differences in imaging techniques and/or quality of radiographic interpretation among studies performed at freestanding children’s hospitals and those performed at other institutions.  We undertook this study to describe differences in RBUS image and report quality associated with the type of institution where the imaging study was obtained.

Methods:  We identified all new patients with RBUS seen in the urology clinic of a single free standing, university affiliated children’s hospital, (FCH) between January 1 and December 31, 2017. Patients for whom RBUS were ordered at or before the new visit and for whom radiographic interpretation was available were included.  We recorded the number of longitudinal and transverse views of each renal unit and of the bladder, and the number of cine loops included in each study.  We also recorded whether the interpreting radiologist commented on renal parenchymal echogenicity (RPE) and upper tract dilatation (UTD).  RBUS performed at FCH and non-FCH institutions (NFCH) were compared.

Results: 637 patients met inclusion criteria.  388 (61.1%) children had RBUS at FCH.  Children undergoing RBUS at FCH and NFCH were similar in age (median 5.58 [range 0-19.3] vs. 5.42 [range 0-19.6] years, p=0.58) and gender (51.7% vs 43.0% female, p=0.14).  RBUS performed at FCH had similar renal imaging, but more bladder imaging (Table 1), and were less likely to have cine loops recorded (OR=0.85, 95% CI: 0.61-1.19) than RBUS from NFCH.  When cine loops were recorded, NFCH recorded more loops than FCH (median 4 [range 1-20] vs 2 [range 1-10], p=0.0003).  FCH radiology reports were more likely to describe RPE (OR=101.8, 95% CI: 24.8-418.7) but equally likely to comment on UTD (OR=2.87, 95% CI: 0.95-8.67) than those from NFCH. For patients with UTD, FCH reports were more likely to utilize formal nomenclature (Upper Tract Dilatation [UTD] or Society for Fetal Urology [SFU] classifications) than NFCH reports (OR=69.3, 95% CI: 34.6-138.5).  When a formal classification method was utilized, more reports from FCH than NFCH utilized the newer UTD system (98.4% vs 69.2%, p<0.0001).

Conclusion: RBUS from FCH were quantitatively similar to those from NFCH, with similar static images of the kidneys but more bladder images and fewer cine loops at FCH.  Radiology reports were more detailed at FCH than at NFCH, particularly regarding assessment of RPE and utilization of standardized nomenclature to describe UTD.  Although RBUS are widely available and may offer cost and time savings for families, these findings should be considered by providers ordering RBUS locally.

 

96.07 Use of Computerized Process Tracing to Evaluate Family Hospital Choice in Pediatric Surgery.

Posted on January 31, 2019

L. C. Pruitt1, D. K. Cao1, D. E. Skarda1, B. T. Bucher1  1University Of Utah,Division Of Pediatric Surgery, Department Of Surgery, School Of Medicine,Salt Lake City, UT, USA

Introduction:
Little is known about what hospital factors families take into account when selecting a hospital where their child will undergo surgery. These decision-making processes are becoming increasingly important during the regionalization of pediatric surgical care. New technology including computerized process tracing allows us to explore this question in greater complexity.

Methods:
Using a cross-sectional study design, families were recruited from the pediatric surgery outpatient clinic at a single center. Both new consults and post-operative patient families were eligible, as were families of children of any age who had presented to the clinic. Non-English-speaking families were excluded. Using the computerized process tracing tool Mouselab WEB four hospital selection scenarios were developed around elective outpatient pediatric surgical procedures. Each scenario gave participants a choice between three hospitals; for each hospital three factors were given: travel time, in- or out-of-network for insurance, and presence of a fellowship-trained surgeon. The movement of the mouse was tracked allowing the study of what factors they looked at, as well as what they self-reported to be important. In addition to the computerized scenarios, each participant filled out a brief demographic questionnaire and the AHRQ REALM-SF to assess health literacy.

Results:
In this pilot study 24 families were recruited. Health literacy was high in our sample with 83% having a high school or above reading level. In our sample 67% had at least one child who had previously undergone surgery. A hospital was selected that had a fellowship trained surgeon present 89% of the time. Parents of a child of Latino/Hispanic ethnicity were less likely to select a hospital with a fellowship-trained surgeon (X2 (1, N=96)= 4.24, p = 0.04). A hospital was selected that was in-network for insurance 55% of the time. Families selected the hospital with the shortest travel time 67% of the time. Parents reported that the presence of a fellowship-trained surgeon was the most important hospital characteristic to them 58% of the time. In-or out-of-network for insurance was the most important for 42%. None of the families felt that travel time was the most important factor when selecting a hospital. There was no statistically significant difference in the percentage of time they spent looking at the three hospital factors.

Conclusion:
This pilot data shows the feasibility of using computerized process tracing tools in the setting of clinical research to better understand patient and family decision-making. All of the participants were able to use the computerized tools without difficulty and the resulting data gives an additional layer of complexity when compared to simple self-reported survey results. The pilot data suggests that patients are willing to travel further and potentially go to a hospital out-of-network in order to take their child to a center with a fellowship-trained surgeon.
 

96.06 Wide Variations in Management of Endometriosis in Adolescents and Young Adults?

Posted on January 31, 2019

Y. Hung1,2, M. L. Westfal1,2,3, D. C. Chang1,2, C. M. Kelleher2,3  1Massachusetts General Hospital,Surgery,Boston, MA, USA 2Harvard School Of Medicine,Brookline, MA, USA 3MassGeneral Hospital for Children,Boston, MA, USA

Introduction:   Current literature lacks data-driven guidelines for surgical treatments of adolescents and young adults (AYA) with endometriosis. We hypothesized that there is a significant variation in treatment, which may be an indicator of over or under treatment by some providers. The goal of this study is to review trends of different surgical treatments over time and across regions of the United States. 

Methods:  We completed a retrospective population-based analysis of the Nationwide Inpatient Sample from 1998 to 2011, including AYA patients 9-25 years old with endometriosis or chronic pelvic pain. We excluded patients who may have undergone pelvic or abdominal procedures for other reasons. Trends of diagnostic laparoscopy, biopsy, excision and hysterectomy were calculated. Logistic regression was performed to determine the risk of intervention, adjusting for patient demographics.

Results: A total of 50,464 AYAs were analysed. Median age at diagnosis was 21 (IQR 17-23). Overall intervention rate was 15.9% (3.5% diagnostic laparoscopy, 0.5% for biopsy, 7.6% for excision/ablation, 4.3% for hysterectomy). Rate of hysterectomy increased in the late 2000s while rates of all other interventions decreased (Figure 1). On adjusted analysis, patients with private insurance were more likely to receive interventions than patients with Medicaid (OR 1.3, 95% CI 1.2-1.4). In addition, patients treated in rural and non-teaching hospitals were more likely to undergo interventions than those treated in urban teaching hospitals (OR 1.2 95% CI 1.1-1.3, OR 1.1 95% CI 1.0-1.2, respectively). 

Conclusion: There is wide variation in treatment patterns of endometriosis in AYA patients across the country and between types of institutions. Of concern, the rate of hysterectomy has increased over time. There is a need for data-directed treatment guidelines for the management of AYAs with endometriosis to reduce possible unnecessary surgeries and to expand value-based surgical care.?

 

96.05 Imaging Patterns & Outcomes for Children Undergoing Appendectomy for Acute Uncomplicated Appendicitis

Posted on January 31, 2019

R. L. Massoumi1, C. P. Childers1,3, J. Q. Dworsky1,3, R. Shenoy1, M. Maggard-Gibbons1, S. L. Lee2, M. M. Russell1,4  1David Geffen School Of Medicine, University Of California At Los Angeles,General Surgery,Los Angeles, CA, USA 2David Geffen School Of Medicine, University Of California At Los Angeles,Pediatric Surgery,Los Angeles, CA, USA 3University Of California – Los Angeles,Health Policy & Management,Los Angeles, CA, USA 4Veterans Affairs Greater Los Angeles,Surgery,Los Angeles, CA, USA

Introduction:
Appendicitis is the most common cause of emergency general surgery in children. Despite improvements in the outcomes of children undergoing surgery, there remain challenges such as overutilization of computed tomography (CT), and poor outcomes such as negative appendectomy and postoperative morbidity. Contemporary data are needed to inform patient and family expectations, identify areas for improvement, and support the design of nonoperative appendicitis trials.   Our objective was to provide contemporary data for the pre-, peri-, and postoperative management and outcomes for children undergoing surgery for acute uncomplicated appendicitis.

Methods:
We performed a retrospective cohort review of children (<18y/o) undergoing appendectomy in the 2016 National Surgical Quality Improvement Program Pediatric appendectomy-targeted file. To focus on cases of uncomplicated appendicitis, we excluded patients undergoing: (1) elective surgery, (2) surgery for an indication other than acute abdominal pain (eg, interval appendectomy), (3) surgery performed on or after hospital day 2, (4) surgery performed by a provider other than a pediatric or general surgeon (eg, gynecology), and (5) complicated appendicitis (eg, perforation) based on the surgeon’s operative note. Primary outcomes included rates of CT, negative appendectomy, and 30-day morbidity. Covariates included patient (eg, age and sex), provider (eg, approach and specialty), and system (transferred in vs. locally managed) variables. Multivariable models were fit using conceptually-driven covariates of interest for each outcome.

Results:
The final sample included 8,017 appendectomies for acute uncomplicated appendicitis. The population was predominantly male (60.1%) and 6-12 y/o (55.6%).  Only 3.1% (245/8017) of patients did not have imaging before surgery. Overall, 40.2% (3224/8017) received a CT scan, however, patients transferred with imaging received CT scans at 3.4 times the rate of those with only local (i.e. operating hospital) imaging (Rate ratio 3.4 [CI 3.2-3.7], p<0.001).  Negative appendectomy and complication rates were 3.6% (277/7655) and 2.4% (195/8017), respectively. Children ≤5 y/o had over twice the odds of negative appendectomy (Odds ratio[OR] 2.6 [CI 1.9-3.7], p<0.001) and complications (OR 2.2 [CI 1.4-3.3], p<0.001) than children 6-17 y/o, after controlling for confounders.

Conclusion:
Despite guidelines against their use, almost half of children in this cohort received a CT scan prior to surgery, driven predominantly by transferring hospitals. Children ≤5 y/o have not been included in many nonoperative trials, yet, with increased rate of negative appendectomy and complications, they may have the most to gain.
 

96.04 Evaluating severe Haller Indices in postoperative pectus patients with otherwise corrected chest wall

Posted on January 31, 2019

E. Port1, F. Hebal1, C. Hunter1,2, F. Abdullah1,2, B. Malas1, M. Reynolds1,2  1Ann and Robert H Lurie Children’s Hospital of Chicago,Pediatric Surgery,Chicago, IL, USA 2Feinberg School Of Medicine – Northwestern University,Surgery,Chicago, IL, USA

Introduction: Assessment of Pectus Excavatum (PE) deformity in patients undergoing surgery is limited to Haller Index (HI), a preoperative measurement of severity, requiring use of computed tomography (CT). This measure has been used for over 20 years though there is little data validating its accuracy in PE versus non-PE patients. In our clinical experience, patients with normal chest appearance have registered HI beyond 3.25, a threshold frequently used to qualify patients for surgery and insurance reimbursement. A Correction Index (CI) measuring the ratio of the PE defect to a “healthy” chest diameter has been previously proposed as an alternative to HI with promising results. Our prior study demonstrated the accuracy of extrapolating post-operative HI and CI without CT radiation using White Light Scanning (WLS), a novel 3D imaging modality to measure PE deformity parameters. The purpose of this study was to demonstrate that a significant proportion of postoperative PE patients register severe HI despite a normal appearing chest and normal measurements by another validated metric of severity.

Methods: We conducted a prospective study of pre and postoperative WLS scans in PE patients from 2015-2018. HI and CI were measured in these scans and descriptive analysis assessed the postoperative change in severity indices. Patients with postoperative HI beyond 3.25 despite normal chest appearance and normal CI measurements were identified. Postoperative CI <5% was considered normal, and logistic regression was used to determine if other parameters are associated with a severe HI measurement in an otherwise normal chest. Metrics of chest dimensions assessed include mediolateral (ML) diameter, midclavicular anteroposterior (AP) diameter, and circumference at the level of defect.

Results: A total of 41 patients who underwent repair for PE had complete scan data available for analysis. Nine(22%) patients had estimated HI  ?3.25 despite normal CI and chest wall appearance on post-operative scans. Greater chest circumference (OR: 1.04; CI: 1.01-1.07; p<0.02) and shorter midclavicular AP diameter (OR: 0.91; CI: 0.82-0.98; p<0.03) were significant factors associated with a HI >3.25 despite an otherwise normal chestwall. Figure 1 shows pre and postoperative measurements with common thresholds.

Conclusion: This study demonstrates that HI can register a severity warranting surgical intervention in patients with a corrected PE defect and flat appearing chest. In a preoperative cohort these findings represent a potential for mischaracterization of severity in PE patients that could warrant unnecessary intervention. Future studies will examine modifications to HI and alternatives to improve assessment of severity of PE.

 

96.03 Use of Cryoanalgesia for Pain Management for the Modified Ravitch Procedure in Children

Posted on January 31, 2019

M. Pilkington1, C. M. Harbaugh2, R. B. Hirschl1, J. D. Geiger1, S. K. Gadepalli1  2University Of Michigan Medical School,Department Of Surgery,Ann Arbor, MI, USA 1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction:  Intercostal nerve cryoablation is one component of the pain management armamentarium for post-thoracic surgery analgesia.  It has been shown to reduce length of stay in the minimally invasive Nuss procedure but its role in the Modified Ravitch has not been explored.  This study aimed to determine the effect of cryoanalgesia on length of stay, opioid use, and complications.

Methods:  We performed a retrospective review of all pediatric patients (<21 years) undergoing a Modified Ravitch procedure between January 1, 2015 and July 31, 2018 at our center. Postoperative analgesia included intercostal cryoablation (IC; n = 9), thoracic epidural (TE; n = 19), or noninvasive analgesia alone (NI; n = 14) at the treating team’s discretion.  Length of stay (LOS), complications, parenteral intraoperative opioids, inpatient analgesic use, and outpatient analgesic prescribing were collected.  Opioids were converted to oral morphine equivalents per kilogram (OME/kg) for comparison. Chi-squared analysis was performed for categorical variables and Kruskal-Wallis H test was used for continuous variables.

Results: The groups had similar patient characteristics except age (IC median 15 years [IQR 14-16]; TE 16 [14-17]; NI 17.5 [17-18.8]; p < 0.001) and chest wall profile (dominant defect pectus carinatum versus excavatum; IC 44.4% carinatum, TE 15.8%, and NI 92.9%; p < 0.01). There was no difference in overall complication rate (IC 33.3%, TE 36.8%, NI 28.8%; p = 0.9). Length of stay, OR time, and opioid use are shown in the table below. 

The use of cryotherapy reduced length of stay compared to patients with a thoracic epidural (4 days vs. 6 days, p < 0.01) and did not impact time in the OR (312 minutes vs. 335 minutes, p = 0.3) or operative time (261 minutes vs. 270 minutes, p = 0.4).  Intraoperative parenteral opioid use was lowest in patients with a TE (0.53, p < 0.01) but did not differ between IC and NI (1.10 vs. 0.89; p = 0.2).  The amount of opioid utilized as an inpatient did not differ (IC 1.48 OME/kg, TE 1.04 OME/kg, NI 1.87 OME/kg) nor did the number of outpatient opioids and refills prescribed (IC 3.34 OME/kg and 22.2%, TE 4.87 OME/kg and 15.8%, NI 3.63 OME/kg and 14.3%; p = 0.3 and p = 0.8).

Conclusion: This is the first study on the use of IC in patients who underwent the Modified Ravitch procedure. In pediatric patients that received invasive analgesia, IC reduced length of stay and provides analogous postoperative pain management with similar use of opioids as compared to patients with a thoracic epidural. The use of cryoanalgesia does not prolong length of time in the operating room, surgical time, nor increase complications compared to thoracic epidural. 

96.02 Laparoscopic Common Bile Duct Exploration for Treatment of Choledocholithiasis in Children

Posted on January 31, 2019

R. E. Overman1, L. Hsieh1, T. Thomas1, S. Gadepalli1, J. Geiger1  1University Of Michigan,Pediatric Surgery,Ann Arbor, MI, USA

Introduction:
The treatment of choledocholithiasis in pediatric patients can be challenging, and the optimal approach has not been identified. Laparoscopic intraoperative cholangiogram (IOC) with common bile duct exploration (CBDE) and endoscopic retrograde cholangiopancreatography (ERCP) are the two interventions commonly utilized in the treatment of choledocholithiasis. We compare our experience with these two techniques in our institution. 

Methods:
With the approval of the University of Michigan IRB, we identified 81 pediatric patients under 18 years of age with suspected choledocholithiasis who underwent laparoscopic cholecystectomy (LC) with IOC/CBDE or ERCP from May 1, 2006 to December 31, 2016. Primary outcomes analyzed were success of intervention and complications.

Results:
Of the 81 patients with suspected choledocholithiasis, 23 patients (28%) underwent an endoscopic intervention prior to LC [20 ERCP, 3 endoscopic ultrasound (EUS)]. Of patients who underwent EUS/ERCP first, 17 had stone or sludge cleared endoscopically, while 6 had normal common bile ducts without evidence of stones or obstruction. Of a total of 34 patients who underwent endoscopic intervention, there were 5 with post-ERCP complications, including pancreatitis, bleeding requiring repeat EGD, and retained CBD stone requiring repeat ERCP. Of the 58 (72%) patients who underwent laparoscopic intervention first, 37 had a negative IOC and required no further intervention, 2 could not have IOC completed, and 19 had IOC positive for choledocholithiasis. 15 patients underwent attempted CBDE, 8 of which were successful. None of the patients who underwent a successful CBDE suffered post-operative complications or required further procedures. Of the 7 patients in whom CBDE was unsuccessful, 5 underwent ERCP with stone extraction, 1 underwent ERCP with no evidence of CBD stone, and 1 had choledocholithiasis resolve without intervention.  In our series, 1 patient suffered cystic duct leak after LC (1.2%).

Conclusion:
Patients with choledocholithiasis who underwent laparoscopic intervention first had fewer complications, and many also avoided a second anesthetic associated with the need for ERCP after LC. While our success rate remains moderate, we believe that with increased standardization, availability of the tools needed, and increased volume that the success rate will increase over time. Our evidence suggests that patients with suspected choledocholithiasis should undergo laparoscopic cholecystectomy first with IOC and CBDE if indicated, with ERCP reserved for patients whose ducts cannot be cleared laparoscopically.

96.01 Practice Patterns and Work Environments that Influence Gender Inequality among Pediatric Surgeons in the US

Posted on January 31, 2019

B. Zhang1,2, M. L. Westfal1,2,3, C. L. Griggs1,2,3, Y. Hung2, D. C. Chang1,2, C. M. Kelleher1,2,3  1Harvard Medical School,Boston, MA, USA 2Massachusetts General Hospital,Department Of Surgery,Boston, MA, USA 3Massachusetts General Hospital,Department Of Pediatric Surgery,Boston, MA, USA

Introduction:
Anecdotally in surgery, female surgeons have less robust practices and perform less advanced or less sub-specialized surgical cases than their male colleagues. It is unclear whether these anecdotes are isolated incidents or are true of surgeons throughout the system.

Methods:
Analysis of inpatient and ambulatory cases of board-certified pediatric surgeons in the New York Statewide Planning and Research Cooperative System dataset from 2000-2015 was performed. Two measures of surgeon practice patterns were compared by surgeon gender: (1) percent of case volume that is pediatric surgery-specific (% peds) and (2) Herfindahl-Hirschman Index (HHI), a measure of case mix that quantifies each surgeon’s degree of focus within pediatric surgery. Additionally, surgeons’ work environments were assessed in five ways as based on "network" – the group of colleagues who operated at all hospitals in which the surgeon worked that year: (1) total network case volume (2) network pediatric surgery-specific case volume (3) number of surgeon colleagues (4) proportion of network case volume that each surgeon performed and (5) type of hospital at which each surgeon performed the majority of their cases each year, academic or non-academic. 

Results:
51 surgeons were analyzed (10 female, 19.6%) for 461 surgeon-years (64 female, 13.9%), and 94,979 cases (10,151 female, 10.7%). Case mix of female surgeons had significantly fewer pediatric-specific cases (14.1% peds vs 16.7% peds, respectively, p=0.04) and was less focused than that of male surgeons (HHI 0.16 vs 0.20, p=0.03). Female surgeons worked in networks with fewer surgeon colleagues (7.2 vs 12.1, p<0.01) and with lower total case volumes (388 vs 734, p<0.01) and lower pediatric surgery-specific case volumes (83 vs 159, p<0.01) (Fig. 1). In addition, female surgeons performed a greater proportion of all available work within their networks than male surgeons (49% vs 36%, p=0.04), and the percentage of female surgeons operating at academic surgical centers was not different from that of the male cohort (74.2% vs 72.3%, p=0.99).

Conclusion:

Despite achieving the same levels of sub-specialty training as their male peers and maintaining competitive appointments at academic surgical centers in equal proportion, female pediatric surgeons operate in smaller networks with fewer cases and fewer colleagues. Even though female surgeons perform a greater share of all work that is available to them, they have less sub-specialized practices and caseloads with fewer expertise-building, pediatric surgery-specific cases. Gender disparity in professional achievement may be due to lack of sponsorship and access to large physician networks rather than lower female surgeon productivity.
 

95.20 The Effect of Operative Time During Pancreaticoduodenectomy on Length of Stay

Posted on January 31, 2019

S. Parikh1, G. Sugiyama1, C. Choy1, G. Coppa1, P. Chung2,3  1Zucker School of Medicine Hofstra Northwell,Department Of Surgery,Manhasset, NY, USA 2SUNY Downstate Medical Center,Department Of Surgery,Brooklyn, NY, USA 3Coney Island Hospital,Department Of Surgery,Brooklyn, NY, USA

Introduction:
Cancer of the head of the pancreas is an aggressive disease with high rates of mortality. At this time surgical resection via a pancreaticoduodenectomy is the only potentially curative procedure. Although the procedure has in recent times become safer, the role that operative time has on postoperative outcomes is not well defined. Using the American College of Surgeons National Surgical Quality Improvement Program data, we sought to determine the role that operative time might play in length of stay.

Methods:
Using the 2010-2015 ACS NSQIP Participant Use Files (PUF) we identified cases in which pancreaticoduodenectomy was performed (CPT code 48150) in the setting of a postoperative diagnosis of pancreatic cancer (ICD9 code 157.0). We excluded cases that had emergency admissions, intraoperative wound classification of III or IV, and disseminated cancer. Cases with missing preoperative albumin, operative time, and total length of stay (LOS) data were excluded. We also excluded cases that had an operative time <15 minutes, and LOS >30 days. Multiple imputation for missing sex, race, functional status, and ASA classification was performed. Operative time was divided into quartiles (1st Quartile: <292.8 minutes; 2nd Quartile: 292.8 – 373.0 minutes; 3rd Quartile: 373.0 – 465.0 minutes; 4th Quartile: >465.0 minutes). Primary outcome was length of stay, for which negative binomial regression adjusting for age, sex, race, obesity, history of diabetes, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), dyspnea, bleeding disorder, ascites, hypertension, renal failure, dialysis dependent, functional status, smoking status, steroid use, weight loss, preoperative transfusion within 72 hours of surgery, preoperative albumin levels, ASA class, and operative time, was performed.

Results:
3,424 patients that met inclusion/exclusion criteria were identified. Of these, 1,758 (51.3%) were male, majority were White (88.1%), and mean age was 66.1 years. Median LOS was 9.0 (SD 5.4) days. Negative binomial regression showed that presence of bleeding disorder (IRR 1.17, p=0.0035), 4th vs 1st quartile operative time (IRR 1.16, p<0.0001), and history of COPD (IRR 1.10, p=0.022) were associated with increased LOS. Higher preoperative albumin status was associated with decreased LOS (IRR 0.88, p<0.0001).

Conclusion:
We performed a large observational study using a national database. We found that increased operative time, even after adjusting for multiple preoperative and intraoperative risk factors, is independently associated with increased LOS in patients that undergo pancreaticoduodenectomy for pancreatic cancer.  Further prospective studies are warranted to determine whether operative time should be used as a quality metric for patients undergoing pancreaticoduodenectomy.
 

95.19 Outcomes for Pancreaticoduodenectomy for Locally Advanced Right Colon Cancers

Posted on January 31, 2019

L. M. Daniels1, M. Khalili1, N. Grandhi1, A. Thandoni1, F. Burg1, L. Holleran1, E. M. Gleeson1, W. F. Morano1, W. B. Bowne1  1Drexel University College Of Medicine,Surgery,Philadelphia, Pa, USA

Introduction:  

Pancreaticoduodenectomy (PD) in conjunction with a right hemicolectomy (RH) has been performed to treat locally advanced right colon cancers (LARCC). Herein, we characterize clinicopathologic factors and evaluate outcomes of en bloc PD and RH for LARCC.

Methods:  

A systematic review of the world literature was conducted on PubMed using MeSH search terms [“pancreaticoduodenectomy” OR “pancreas/surgery” OR “duodenum/surgery” OR “colectomy”] AND [“colonic neoplasms”]. Data was extracted from patients who specifically underwent an en bloc PD and RH for primary colon cancer. Exclusion criteria included articles not published in English, those from which individual patient data could not be extrapolated, patients without primary colonic malignancy, and those with metastatic disease. Factors investigated included patient presentation, surgical and pathological parameters, postoperative complications, and disease recurrence and survival. Standard statistical tests were used.

Results:

Search yielded 28 articles from 1980-2017 with a cohort of 106 patients, including one case from our institution. Most patients were male (62.1%) with median age 58 years (range 34-83). Surgical procedures performed included en bloc RH with PD (n=91, 85.8%) and en bloc RH with pylorus-preserving pancreaticoduodenectomy (PPDP), (n=15, 14.2%). Median follow up was 21 months. R0 resection was reported in 63 patients. Of patients who experienced one or more complications (n=63, 52.4%), the most common included pancreatic fistula (n=15, 23.8%) and delayed gastric emptying (n=11, 17.5%). Fifty-three patients (50%) reportedly experienced no recurrence, 27 (25.5%) recurred, and 26 (24.5%) cases did not specify. Median recurrence free survival was not met. The average time to recurrence was 18.6 months; 60% of patients were disease free at 5 years. Median survival was 168 months. Survival after resection was 74.1% at 2 years and 63.2% at 5 years (Figure 1). Overall survival was improved with earlier diagnosis (IIC versus IIIC, p<0.005) and younger age at time of resection (<60 versus ≥ 60, p=0.031). Patients with stage IIC had an 84.9% 5 year survival versus 46.4% for patients with stage IIIC. Five year survival for patients <60 years was 70.9% versus 62.9% for patients ≥ 60 years. There were 2 postoperative mortalities.

Conclusion:

These data demonstrate that en bloc PD and RH is rarely performed, yet can be a safe procedure and potential treatment option in patients with LARCC. Patients less than 60 years of age and patients with less advanced disease had significantly improved outcomes. 

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