Afif N. Kulaylat

An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis

BACKGROUND Recent efforts have been directed at reducing ionizing radiation delivered by CT scans to children in the evaluation of appendicitis. MRI has emerged as an alternative diagnostic modality. The clinical outcomes associated with MRI in this setting are not well-described. METHODS Review of a 30-month institutional experience with MRI as the primary diagnostic evaluation for suspected appendicitis (n=510). No intravenous contrast, oral contrast, or sedation was administered. Radiologic and clinical outcomes were abstracted. RESULTS MRI diagnostic characteristics were: sensitivity 96.8% (95% CI: 92.1%-99.1%), specificity 97.4% (95% CI: 95.3-98.7), positive predictive value 92.4% (95% CI: 86.5-96.3), and negative predictive value 98.9% (95% CI: 97.3%-99.7%). Radiologic time parameters included: median time from request to scan, 71 minutes (IQR: 51-102), imaging duration, 11 minutes (IQR: 8-17), and request to interpretation, 2.0 hours (IQR: 1.6-2.6). Clinical time parameters included: median time from initial assessment to admit order, 4.1 hours (IQR: 3.1-5.1), assessment to antibiotic administration 4.7 hours (IQR: 3.9-6.7), and assessment to operating room 9.1 hours (IQR: 5.8-12.7). Median length of stay was 1.2 days (range: 0.2-19.5). CONCLUSION Given the diagnostic accuracy and favorable clinical outcomes, without the potential risks of ionizing radiation, MRI may supplant the role of CT scans in pediatric appendicitis imaging.

Determinants of 30-d readmission after colectomy

BACKGROUND Readmission after colectomy has become an important metric for measuring quality of care. Our aim was to investigate the impact of patient and hospital characteristics on 30-d readmission rates among patients undergoing colectomies in Pennsylvania. METHODS Data were obtained from the Pennsylvania Health Care Cost Containment Council, which included all patients undergoing colectomy during 2011 (n = 10,155). Characteristics of non-readmitted and readmitted patients were compared with univariate tests. The primary outcome was 30-d readmission, which was modeled using multivariable logistic regression. RESULTS Of the 10,155 patients who underwent colectomy, 1492 (14.7%) were readmitted within 30 d of discharge. Readmission was influenced by the underlying diagnosis (P < 0.001). Additionally, readmission was more likely with a Charlson comorbidity index ≥ 2 (odds ratio [OR] = 1.57, P < 0.001), emergent admission (OR = 1.26, P = 0.001), an in-hospital complication (OR = 1.46, P < 0.001), lowest quartile for surgeon volume (OR = 1.24, P = 0.01), and construction of an ileostomy (OR = 2.31, P < 0.001). Factors associated with decreased likelihood of readmission included laparoscopic surgery (OR = 0.73, P < 0.001). No association with hospital volume was found. CONCLUSIONS A 30-d readmission after colectomy is influenced by numerous patient- and surgeon-related factors. Reducing in-hospital complications, and improving patient education after ileostomy construction, provide substantial targets for intervention. Our data also suggest that there may be a critical range of colectomies performed annually by surgeons, greater than which no additional benefit is conferred in reducing readmissions, but below which there is an increased risk of readmission. Further research is needed to determine the influence of laparoscopic surgery in reducing readmission in equally matched patient populations.

Traumatic bile leaks from blunt liver injury in children: a multidisciplinary and minimally invasive approach to management.

BACKGROUND Selective non-operative management (NOM) of hemodynamically stable pediatric patients with blunt hepatic trauma is the standard of care. Traumatic bile leaks (TBL) are a potential complication following liver injury. The use of endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of TBL is described in adults, but limited in the pediatric literature. We report our experience with a multidisciplinary and minimally invasive approach to the management of TBL. METHODS This was an IRB-approved 13-year retrospective review (January 1999-December 2012) of an institutional pediatric trauma registry; 294 patients (≤ 17 years old) sustained blunt hepatic injury. Those with TBL were identified. Patient demographics, mechanism of injury, management strategy and outcomes were reviewed. RESULTS Eleven patients were identified with TBL. Hepatobiliary iminodiacetic scan (HIDA) was diagnostic. Combinations of peri-hepatic drain placement, ERCP with biliary stenting and/or sphincterotomy were performed with successful resolution of TBL in all cases. No child required surgical repair or reconstruction of the leak. Cholangitis developed in one child. There were no long-term complications. CONCLUSIONS A multidisciplinary and minimally invasive approach employing peri-hepatic external drainage catheters and ERCP with sphincterotomy and stenting of the ampulla is a safe and effective management strategy for TBL in children.

Comparing 30-day outcomes between thoracoscopic and open approaches for resection of pediatric congenital lung malformations: Evidence from NSQIP

BACKGROUND/PURPOSE Thoracoscopic surgery has been increasingly utilized in treating pediatric congenital lung malformations (CLM). Comparative studies evaluating 30-day outcomes between thoracoscopic and open resection of CLM are lacking. METHODS There were 258 patients identified in pediatric NSQIP with a CLM and pulmonary resection in 2012-2013. Comparisons of patient characteristics and outcomes between surgical approaches were made using standard univariate statistics. In addition, a propensity score match was performed to evaluate outcomes in similar patient cohorts. RESULTS One-hundred twelve patients (43.4%) received thoracoscopic resections and 146 patients (56.6%) received open resections. Patients undergoing open resections were more likely to be less than 5 months of age and have a comorbidity/preoperative condition (47.3% vs. 25.0%, p<0.001). The extent of resection was a lobectomy in 84.8% of thoracoscopic and 92.5% of open resection patients. Median operative time was similar between both groups (thoracoscopic 172 vs. open 153.5 minutes). On univariate analysis, thoracoscopic resection was associated with decreased postoperative complications (9.8% vs. 25.3%, p=0.001) and LOS (3 vs. 4 days, p<0.001). However, after adjusting for similar patient and operative characteristics, no significant differences were encountered between techniques. CONCLUSIONS Thoracoscopic and open resection provide comparable 30-day outcomes and safety in the management of congenital lung malformations.

Transumbilical laparoscopic-assisted appendectomy is associated with lower costs compared to multiport laparoscopic appendectomy.

BACKGROUND/PURPOSE Single-incision laparoscopic appendectomy has been associated with improved cosmetic benefits, and decreased postoperative pain. Less is known about costs and other outcomes. Our aim was to evaluate the costs and outcomes between transumbilical laparoscopic-assisted appendectomy (TULAA) and multiport laparoscopic appendectomy (MLA). METHODS IRB-approved retrospective review (September 2010-July 2013) of institutional medical records identified 372 pediatric patients undergoing laparoscopic appendectomy. Outcomes included costs, LOS and readmission. Costs were fully loaded operating costs from the hospitals cost accounting database. Generalized linear regression was used to assess costs of MLA and TULAA. A subgroup analysis was performed using only patients with non-perforated appendicitis. RESULTS There were 132 patients (35.5%) that underwent TULAA while 240 patients (65.5%) underwent MLA. Compared to MLA, TULAA was associated with decreased operative time (0.6 vs. 1.0h, p<0.0001), used in comparable proportions of interval appendectomies, but was performed less often for perforated appendicitis (9.8% vs. 22.9%, p=0.002). Readmission and postoperative complications were similar between both groups. In the setting of non-perforated appendicitis, TULAA was associated with lower costs of

Alternative diagnoses at paediatric appendicitis MRI

1378 relative to MLA (p=0.009). CONCLUSIONS In non-perforated appendicitis, TULAA is associated with lower costs and comparable rates of readmission and postoperative complications.

A national survey of educational resources utilized by the Resident and Associate Society of the American College of Surgeons membership.

As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institutions experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.

Impact of smoking on the surgical outcome of Crohn's disease: a propensity-score matched National Surgical Quality Improvement Program analysis

BACKGROUND Contemporary surgical education includes online resources, mobile platform applications, and simulation training. The aim of this study was to characterize educational tools used by surgical residents. METHODS An anonymous web-based survey was distributed to 9,913 members of the Resident and Associate Society of the American College of Surgeons. RESULTS We received 773 completed surveys. To prepare for examinations and expand fund of knowledge, most respondents used printed textbooks, online textbooks, and Surgical Council on Resident Education modules, respectively. Respondents used online textbooks and journal articles most often to investigate timely patient care issues. In contrast, mobile platform applications and online videos/lectures were used least. Fewer than half of respondents used simulators, limited by clinical duties, absence of feedback/supervision, and lack of working supplies. CONCLUSIONS Traditional educational resources dominate trainee preferences, although utilization of the Surgical Council on Resident Education curriculum continues to grow. Simulators remain a required tool for laparoscopic training, and incorporation of structured feedback and improved supervision may improve utilization.

Determinants of Medicare Costs for Elderly Patients With Oral Cavity and Pharyngeal Cancers

Smoking is known to have a deleterious effect on Crohns disease (CD). The present study addressed the specific impact of smoking on the outcome of surgery for CD.

Overall survival by pattern of recurrence following curative intent surgery for colorectal liver metastasis.

IMPORTANCE In the United States, nearly 8400 patients die each year from oral cavity and pharynx cancers, most of whom are 65 years and older; however, the costs attributable to these cancers are not well described. OBJECTIVE To identify the primary determinants of cost in patients with oral and pharyngeal cancer. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort analysis of data from Medicare and Surveillance, Epidemiology, and End Results hospitals (January 1, 1995, through December 31, 2005), we studied patients 66 years and older with newly diagnosed oral cavity (n = 6724) and pharyngeal (n = 3987) cancers. MAIN OUTCOMES AND MEASURES Five-year cumulative costs, defined as Medicare Parts A and B payments, were estimated using inverse probability weighting. Linear regression analysis with inverse probability weighting was used in multivariate analyses of costs to estimate the effects of covariates on cumulative costs. RESULTS In multivariate analyses, costs were significantly increased by demographics, comorbidities, and treatment selection. Compared with white patients, African Americans accumulated