Colin G. Knight

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

BACKGROUND/PURPOSE This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

HYPOTHESIS The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway. DESIGN Prospective cohort study. SETTING Tertiary care childrens hospital. PATIENTS Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children. INTERVENTIONS Same-day discharge vs overnight admission. MAIN OUTCOME MEASURES Operative details, postoperative length of stay, adverse events, and parental satisfaction. RESULTS Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again. CONCLUSION Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy

BACKGROUND Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

Diagnosis and laparoscopic treatment of ileoileal intussusception secondary to heterotopic pancreas in an infant: case report and review of the literature

Small bowel intussusception in infancy owing to a pathologic lead point is a rare event requiring immediate surgical attention. We report a case of a 7-month-old patient presenting with ileoileal intussusception with isolated heterotopic pancreas as the lead point. We review the literature of small bowel intussusception focusing on diagnosis and treatment. In contrast to comparable previous reports of infants with heterotopic pancreas and intussusception, the diagnosis was based solely on ultrasound findings followed by operative management using a laparoscopically assisted surgical approach.

Management of spontaneous pneumomediastinum in children

PURPOSE We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway. METHODS All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome. RESULTS We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7-16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n=91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1-2) for non-ICU admissions and 3 days (IQR: 2-3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38-1.50, p=0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n=81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis). CONCLUSION Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.

A simple postoperative umbilical negative-pressure dressing.

Application of umbilical wound dressings is challenging because of the shape and depth of the navel. Dressing changes and umbilical wound cleaning as practiced by many surgeons are painful procedures. The authors describe a simple and durable postoperative umbilical vacuum dressing, providing the advantages of topical negative-pressure wound therapy.

Application of a Surgical Robot to Open Microsurgery: The Equipment

Background: Computer-assisted robot-enhanced surgery can enhance minimally invasive surgery by providing a wrist at the end of the instruments and by scaling motion and filtering tremor. Motion scaling and tremor filtration are most enabling at high magnification. Goal: To explore the possibility of using a surgical robot designed for minimally invasive surgery during open microsurgical procedures. Materials and Methods: Using the Zeus MicroWrist™ Robotic Surgical System in conjunction with the triple-alpha port, we performed suture tasks on a glove box with microsurgical suture (8-0 to 10-0) in three different configurations. First, we used a standard 10- mm laparoscope, camera, and the Zeus monitor. Next, we used an operating microscope for visualization with the surgeon at the operative table while controlling the instruments. Third, we allowed the surgeon to sit at the standard Zeus console and transmitted the image from the microscope to the monitor at the Zeus console. Results: In all three configur...

Early transition to oral antibiotics for treatment of perforated appendicitis in pediatric patients: Confirmation of the safety and efficacy of a growing national trend

PURPOSE We performed a quality improvement initiative to monitor the change in protocol from purely intravenous therapy for perforated appendicitis to oral antibiotics at discharge once patients could tolerate eating. METHODS Standardized prospective data were gathered on all children with perforated appendicitis treated under the new oral protocol from January 1 to December 31, 2014. Retrospective data through chart review were gathered on all children treated for perforated appendicitis during 2013. We compared demographics, clinical parameters, and hospital charges. RESULTS Comparing 115 patients in 2013 and 144 in 2014, demographics and clinical characteristics were similar. In 2014, 95% of patients were discharged on oral therapy. Compared to the intravenous group, the enteric group had statistically lower rates of repeat ultrasound imaging (49.6% vs 35.1%) and PICC placement (98.3% vs 9.1%) and similar rates of intraabdominal abscess (20.9% vs 16.0%) and antibiotic change (26.1% vs 22.2%). In 2014, 55% of patients were discharged by postoperative day 5, compared to 33% in 2013. Total antibiotic days and readmission rate were similar, while hospital charges decreased by half. CONCLUSION Our results reaffirm that transition to oral antibiotics is safe, effective, and cost-efficient in treatment of perforated appendicitis in the child.

Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge

Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Students t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic (n = 104) and narcotic (n = 103) groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (P = 0.049). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction.

Single-Incision Single-Instrument Adnexal Surgery in Pediatric Patients

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery. Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal. Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate. Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.