Daniel S. Rhee

An evaluation of surgical site infections by wound classification system using the ACS-NSQIP

BACKGROUND Surgical wound classification has been the foundation for infectious risk assessment, perioperative protocol development, and surgical decision-making. The wound classification system categorizes all surgeries into: clean, clean/contaminated, contaminated, and dirty, with estimated postoperative rates of surgical site infection (SSI) being 1%-5%, 3%-11%, 10%-17%, and over 27%, respectively. The present study evaluates the associated rates of the SSI by wound classification using a large risk adjusted surgical patient database. METHODS A cross-sectional study was performed using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset between 2005 and 2008. All surgical cases that specified a wound class were included in our analysis. Patient demographics, hospital length of stay, preoperative risk factors, co-morbidities, and complication rates were compared across the different wound class categories. Surgical site infection rates for superficial, deep incisional, and organ/space infections were analyzed among the four wound classifications using multivariate logistic regression. RESULTS A total of 634,426 cases were analyzed. From this sample, 49.7% were classified as clean, 35.0% clean/contaminated, 8.56% contaminated, and 6.7% dirty. When stratifying by wound classification, the clean, clean/contaminated, contaminated, and dirty wound classifications had superficial SSI rates of 1.76%, 3.94%, 4.75%, and 5.16%, respectively. The rates of deep incisional infections were 0.54%, 0.86%, 1.31%, and 2.1%. The rates for organ/space infection were 0.28%, 1.87%, 2.55%, and 4.54%. CONCLUSION Using ACS-NSQIP data, the present study demonstrates substantially lower rates of surgical site infections in the contaminated and dirty wound classifications than previously reported in the literature.

Low-cost mesh for inguinal hernia repair in resource-limited settings

IntroductionHernia repair is one of the most frequently performed surgical procedures worldwide, yet more than half of hernias may be untreated in African countries that lack adequate and affordable surgical care. Although this disease burden can be effectively reduced by surgical repair, public health efforts to promote repair have been sparse because of the presumed high cost of surgery.ObjectiveTo review the epidemiology and treatment of hernias in African countries and to assess the efficacy and safety of using low-cost mesh for repair in resource-limited settings.MethodsAn extensive literature search was performed using PubMed and the Cochrane Library to locate pertinent background information and studies that used low-cost alternatives to commercial mesh.ResultsMost hernia repairs in Africa are performed as high-risk emergency procedures. When treatment is provided, fewer than 5% are repaired using implanted mesh because of its high cost, despite the demonstrated improvement in clinical outcomes with tension-free repair. A total of four studies using low-cost mesh were reviewed. Three of the studies compared postoperative outcomes for repairs using sterile mosquito nets with those using commercial surgical mesh. The fourth study randomized patients to receive either an indigenous bilayer device or the Prolene Hernia System. No significant differences in recurrence or in incidence of wound complications between repairs using low-cost and commercial mesh were observed. The price of low-cost mesh was generally less than 1/1,000 the price of commercial mesh.ConclusionsThere were no significant differences in outcomes between repairs using low-cost and commercial mesh. While the size of the study populations and the limited time for follow-up preclude conclusive measures of effectiveness, recurrence, and long-term complications, these studies demonstrate that providing an improved standard of surgical care need not be prohibitively expensive.

Outcomes research in pediatric surgery part 2: how to structure a research question☆

Innovative treatments and procedures are essential to the advancement of surgery. Outcomes research provides the mechanism to analyze these new treatments as they enter clinical practice and evaluate them against established therapies. Information gained through this methodology is essential because new techniques and innovations often gain rapid acceptance before clinical trials can be conducted to assess them. Increasing national emphasis is placed on comparative effectiveness as health care costs rise. Surgeons must take the lead in surgical outcomes and comparative effectiveness research, with the goal of identifying the most efficient and effective treatment for our patients. The authors show how to structure and design a research project involving pediatric surgical outcomes. The model consists of the following 3 phases: (1) study design, (2) data preparation, and (3) data analysis. The model we present provides the reader with a basic format and research structure to serve as a guide to performing high-quality surgical outcomes research.

Analysis of risk factors for morbidity in children undergoing the Kasai procedure for biliary atresia

ObjectiveTo evaluate the perioperative risk factors for 30-day complications of the Kasai procedure in a large, cross-institutional, modern dataset.Study designThe 2012–2015 National Surgical Quality Improvement Program Pediatric database was used to identify patients undergoing the Kasai procedure. Patients’ characteristics were compared by perioperative blood transfusions and 30-day outcomes, including complications, reoperations, and readmissions. Multivariable logistic regression was used to identify risk factors predictive of outcomes. Propensity matching was performed for perioperative blood transfusions to evaluate its effect on outcomes.Results190 children were included with average age of 62 days. Major cardiac risk factors were seen in 6.3%. Perioperative blood transfusions occurred in 32.1%. The 30-day post-operative complication rate was 15.8%, reoperation 6.8%, and readmission 15.3%. After multivariate analysis, perioperative blood transfusions (OR 3.94; p < 0.01) and major cardiac risk factors (OR 7.82; p < 0.01) were found to increase the risk of a complication. Perioperative blood transfusion (OR 4.71; p = 0.01) was associated with an increased risk of reoperation. Readmission risk was increased by prematurity (OR 3.88; p = 0.04) and 30-day complication event (OR 4.09; p = 0.01). After propensity matching, perioperative blood transfusion was associated with an increase in complications (p < 0.01) and length of stay (p < 0.01).ConclusionMajor cardiac risk factors and perioperative blood transfusions increase the risk of post-operative complications in children undergoing the Kasai procedure. Further research is warranted in the perioperative use of blood transfusions in this population.Level of evidenceIV.

Bronchoscopy for Pediatric Airway Foreign Body: Thirty-Day Adverse Outcomes in the ACS NSQIP-P

Objectives (1) Describe outcomes of bronchoscopy with foreign body removal among children on the basis of a large standardized multi-institutional data set. (2) Identify factors associated with 30-day adverse events. Study Design Cross-sectional analysis of a US national database. Setting Public data set from the ACS NSQIP-P (American College of Surgeons National Surgical Quality Improvement Program–Pediatric) from 2012 to 2015. Subjects and Methods Children <18 years old who underwent bronchoscopy with removal of foreign body were identified. Patient demographics, comorbidities, hospitalization factors, surgical characteristics, and 30-day postoperative adverse events, including complication and readmission, were analyzed. Multivariate logistic regression identified predictive factors for postoperative complications and prolonged length of stay. Results A total of 275 children underwent bronchoscopic foreign body removal (n = 165 male, 60%; n = 75 nonwhite and/or Hispanic, 27%; mean age, 3.5 years [range, 0.63-17.9; median, 2.0]). Adverse events occurred among 10 children (4%). Seven had pulmonary-related complications, and 1 patient died. Three patients were readmitted; there were no reoperations. On multivariate analysis, preoperative pulmonary disease or need for pulmonary support (odds ratio [OR], 6.42; P = .04) predicted postoperative complications. Preoperative pulmonary compromise (OR, 8.10; P < .01), American Society of Anesthesiologists class 3 or 4 (OR, 4.13; P < .01), and prolonged operative time (OR, 3.05; P = .01) were associated with prolonged hospital stay. Conclusion Bronchoscopy for retrieval of foreign body among children has an overall low incidence of 30-day adverse events. Children with preoperative pulmonary compromise have a significantly higher risk of postoperative complications. These findings may be applied to optimize perioperative care and counsel parents and families.

Summary article: Update on Wilms tumor

This article reviews of the current evidence-based treatment standards for children with Wilms tumor. In this article, a summary of recently completed clinical trials by the Childrens Oncology Group is provided, the current diagnostic evaluation and surgical standards are discussed, and the surgical impact on current risk stratification for patients with Wilms tumor is highlighted. LEVEL OF EVIDENCE: This is a review article of previously published and referenced LEVEL 1 studies, but also includes expert opinion LEVEL V, represented by the American Pediatric Surgical Association Cancer Committee.

Optimal timing for elective resection of asymptomatic congenital pulmonary airway malformations

PURPOSE We sought to determine optimal timing for CPAM resection within the first year of life. METHODS We queried the National Surgical Quality Improvement Program pediatric database from 2012 to 2015 for elective CPAM resections on patients less than 1year of age. Patients were divided by age in months: 1-3 (n=57), 4-6 (n=135), and 6-12 (n=214). Patient operative variables and 30-day postoperative outcomes were compared. RESULTS A total of 406 patients were included with no differences in demographics or comorbidities. Median operative time increased with each older age category (115min, 152min, 163min, respectively; p<0.01). Thoracoscopic approach was less utilized in 1-3months (40.4%) compared to the older two age categories (65.9% and 69.6%, respectively; p<0.01). There were no differences by age in major complications, conversion to open, or readmissions. On multivariate analysis, ASA class≥3 (p<0.01) and prolonged operative time (p<0.01) were associated with a major complication. Furthermore, operations on patients aged 6-12months were associated with increased operative time (p<0.01) regardless of operative approach. CONCLUSION Elective CPAM resections are equally safe in patients 1-12months of age. Earlier resection including both open and thoracoscopic resection is associated with decreased operative time. LEVEL OF EVIDENCE IIc, Outcomes Research.

Update on neuroblastoma

Neuroblastoma is an embryonic cancer arising from neural crest stem cells. This cancer is the most common malignancy in infants and the most common extracranial solid tumor in children. The clinical course may be highly variable with the possibility of spontaneous regression in the youngest patients and increased risk of aggressive disease in older children. Clinical heterogeneity is a consequence of the diverse biologic characteristics that determine patient risk and survival. This review will focus on current progress in neuroblastoma staging, risk stratification, and treatment strategies based on advancing knowledge in tumor biology and genetic characterization. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level II.

Minimally invasive repair of pectus excavatum: Analysis of the NSQIP database and the use of thoracoscopy

BACKGROUND The minimally invasive repair of pectus excavatum (MIRPE) has been widely accepted and has become a viable alternative to the open Ravitch technique. MIRPE has evolved over time with some advocating that a safe repair can be accomplished without direct visualization utilizing thoracoscopy. The MIRPE with and without a thoracoscopic approach has not been previously analyzed from a nationwide database to determine differences in safety and short-term outcomes. METHODS The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2012-2015 database was used in identifying patients that had MIRPE using Current Procedural Terminology (CPT) codes and ICD-9CM/ICD-10CM postoperative diagnosis codes. Outcomes of interest were readmissions, reoperations, complications, cardiothoracic injury, operative time, and duration of hospital stay after surgery for MIRPE with and without thoracoscopy. Descriptive statistics, simple and multivariable logistic regressions, Fishers exact, and Wilcoxon rank sum test were used to determine any differences in 30-day postoperative outcomes. RESULTS There were 1569 MIRPE cases included. 15.9% (N=249) of MIRPE were done without thoracoscopy. There were no significant differences with the use of thoracoscopy compared to without thoracoscopy in the rate of readmissions (2.5 vs 4.8%; p=0.06), reoperations (1.4 vs 2.0%; p=0.57), postoperative complications (2.6% vs 3.2%; p=0.52), and cardiothoracic injuries (0.2% vs 0.0%; p=1.00). Unadjusted odds ratios (ORs) for readmission and reoperation comparing MIRPE with thoracoscopy to MIRPE without thoracoscopy were 0.51 (p<0.05) and 0.71 (p=0.50), respectively. Adjusted ORs were 0.49 (p=0.04) and 0.71 (p=0.50), respectively. There were no reported deaths, but two cardiothoracic injuries were recorded in the group with thoracoscopy. MIRPE with thoracoscopy was associated with longer operative time (mean 13.0min; p=0.00) and longer hospital stay (mean 0.37days; p<0.01) compared to MIRPE without thoracoscopy. No data were available for the severity of the pectus defect. CONCLUSION MIRPE has a low adverse event rate with no difference in reoperations, postoperative complications, and cardiothoracic injuries with or without the use of thoracoscopy. There may be a higher rate of readmissions in the nonthoracoscopic group. While the technique used remains the surgeons decision, the use of thoracoscopy may be unnecessary and is at an added cost. TYPE OF STUDY Treatment study (retrospective comparative study). LEVEL OF EVIDENCE Level III.

Malnutrition increases the risk of 30-day complications after surgery in pediatric patients with Crohn disease

BACKGROUND Pediatric patients with Crohn disease (CD) are frequently malnourished, yet how this affects surgical outcomes has not been evaluated. This study aims to determine the effects of malnourishment in children with CD on 30-day outcomes after surgery. STUDY DESIGN The ACS NSQIP-Pediatric database from 2012 to 2015 was used to select children aged 5-18 with CD who underwent bowel surgery. BMI-for-age Z-scores were calculated based on CDC growth charts and 2015 guidelines of pediatric malnutrition were applied to categorize severity of malnutrition into none, mild, moderate, or severe. Malnutritions effects on 30-day complications. Propensity weighted multivariable regression was used to determine the effect of malnutrition on complications were evaluated. RESULTS 516 patients were included: 349 (67.6%) without malnutrition, 97 (18.8%) with mild, 49 (9.5%) with moderate, and 21 (4.1%) with severe malnutrition. There were no differences in demographics, ASA class, or elective/urgent case type. Overall complication rate was 13.6% with malnutrition correlating to higher rates: none 9.7%, mild 18.6%, moderate 20.4%, and severe 28.6% (p < 0.01). In propensity-matched, multivariable analysis, malnutrition corresponded with increased odds of complications in mild and severely malnourished patients (mild OR = 2.1 [p = 0.04], severe OR 3.26 [p = 0.03]). CONCLUSION Worsening degrees of malnutrition directly correlate with increasing risk of 30-day complications in children with CD undergoing major bowel surgery. These findings support BMI for-age z scores as an important screening tool for preoperatively identifying pediatric CD patients at increased risk for postoperative complications. Moreover, these scores can guide nutritional optimization efforts prior to elective surgery. LEVEL OF EVIDENCE IV.