J. Ruben Rodriguez

Correlating surgical and pathological diagnoses in pediatric appendicitis

BACKGROUND The stratification of appendicitis into simple and complex variants has far-reaching implications. While the operative diagnosis made by the surgeon dictates clinical management, the pathologic diagnosis often differs and is frequently used for coding and reimbursement. The purpose of this study was to examine discrepancies between the operative and pathologic diagnoses with subsequent correlation to clinical outcomes. METHODS Patients with acute appendicitis from July 2011 to July 2012 were identified. Diagnoses included simple (normal, acute, and suppurative) and complex (gangrenous and perforated). We evaluated the inter-rater reliability between pathologic and operative diagnoses in the five appendicitis categories. Clinical outcomes of deep and superficial surgical site infections were evaluated according to the pathologic and surgical diagnosis. RESULTS During the study period, we identified 1166 patients with acute appendicitis. The surgeon and pathologist agreed on the specific diagnosis (acute, suppurative, gangrenous, perforated, normal) in 48% of patients (kappa 0.289, 95% CI 0.259-0.324, p=0.001). Agreement on disease severity (simple vs. complex) improved to 82%. The operative diagnosis more accurately predicted infectious complications than the pathologic diagnoses. CONCLUSION Significant discordance exists between surgical and pathologic diagnoses. While the relevance of this discordance to clinical outcomes is still not clear, a potential for incorrect hospital coding and subsequent reimbursement exists. Future quality improvement projects should focus on standardizing the surgical and pathologic diagnoses.

Risk factors for surgery in pediatric intussusception in the era of pneumatic reduction

INTRODUCTION Surgical treatment is still necessary for intussusception management in a subgroup of patients, despite advances in enema reduction techniques. Early identification of these patients should improve outcomes. METHODS The medical records of patients treated for intussusception at our institution from 2006 to 2011 were reviewed. Univariate and multivariate analyses, including stepwise logistic regression, were performed. RESULTS Overall, 379 patients were treated for intussusception, and 101 (26%) patients required operative management, with 34 undergoing intestinal resection. The post-operative complication rate was 8%. On multivariate analysis, failure of initial reduction (OR 9.9,p=0.001 95% CI, 4.6-21.2), a lead point (OR 18.5,p=0.001 95% CI, 6.6-51.8) or free/interloop fluid (OR 3.3,p=0.001 95% CI, 1.6-6.7) or bowel wall thickening on ultrasound (OR 3.3,p=0.001 95% CI, 1.1-10.1), age <1 year at reduction (OR 2.7,p=0.004, 95% CI, 1.4-5.9), and abdominal symptoms>2 days (OR 2.9,p=0.003, 95% CI, 1.4-5.9) were significantly associated with a requirement for surgery. Similarly, a lead point (OR 14.5, p=0.005 95% CI, 2.3-90.9) or free/interloop fluid on ultrasound (OR 19.8, p=0.001 95% CI, 3.4-117) and fever (OR 7.2, p=0.023 95% CI, 1.1-46) were significantly associated with the need for intestinal resection. CONCLUSION Abdominal symptoms>2 days, age<1 year, multiple ultrasound findings, and failure of initial enema reduction are significant predictors of operative treatment for intussusception. Patients with these findings should be considered for early surgical consultation or transfer to a hospital with pediatric surgical capabilities.

Modification of an evidence-based protocol for advanced appendicitis in children

INTRODUCTION We previously developed an evidence-based clinical pathway for children with advanced appendicitis. The pathway standardized the choice and duration of antibiotic therapy and established discharge criteria. Initially, the pathway led to a 50% decrease in the rate of superficial and deep surgical site infections and a significant decrease in hospital length of stay. Four years after implementation, we noted an increase in the infectious complication rate and the emergence of resistant bacteria to commonly used antibiotics. In this study, we prospectively collected peritoneal fluid cultures at the time of appendectomy in an effort to optimize our antibiotic therapy and decrease complication rates. METHODS Microbiology analysis of peritoneal fluid cultures obtained at the time of appendectomy was performed in patients with an intraoperative diagnosis of advanced appendicitis. Clinical information, including demographics, laboratory data, and postoperative outcomes were collected and compared to the historic cohort. X(2), Students t-test, and Fisher exact test were used where appropriate. RESULTS The historic and prospective cohorts were similar with respect to clinical and demographic data. The postoperative intra-abdominal abscess rate remained unchanged (28% from 24%, P = 0.603). Escherichia coli and Pseudomonas aeruginosa were the most commonly isolated aerobic bacteria from peritoneal fluid in the prospective cohort. Thirty-two percent of these patients had Pseudomonas spp., and 12% had Enterococcus spp. or Escherichia coli resistant to cefoxitin in their peritoneal fluid cultures. DISCUSSION A significant proportion (40%) of children with advanced appendicitis had organisms either not susceptible or resistant to our first line antibiotic in their peritoneal fluid cultures. Our clinical pathway now recommends piperacillin-tazobactam as the most effective empiric therapy for advanced appendicitis in children. Microbiologic analysis of peritoneal fluid at appendectomy may be used to tailor antibiotic therapy in advanced appendicitis.

Increased complication rates associated with Port-a-Cath placement in pediatric patients: Location matters

INTRODUCTION Port-a-Caths (PACs) are commonly placed below the clavicle or below the inframammary line for cosmesis. We hypothesized that inframammary placement is associated with increased catheter-related complications due to redundant catheter length. METHODS A review of pediatric patients with PAC placement from 2007 to 2009 was performed. Port placement was identified as subclavicular (SC) or inframammary by x-ray (below the fifth-intercostal space). Inframammary ports were stratified by the midclavicular line: medial inframammary (MIM) and lateral inframammary (LIM). Early complications (<30 days) and late complications were analyzed. RESULTS We identified 167 SC, 46 MIM, and 166 LIM patients. LIM placement was independently associated with increased total complication rate (p<0.001), migration rate (p<0.001), and operative exchange (p=0.017) compared to the SC group. The catheter survival time was decreased in the LIM vs. SC group (1021 ± 55 vs. 1396 ± 48 days, p=0.005). Additionally, LIM placement was independently associated with increased odds of catheter removal (p=0.006). MIM patients demonstrated fewer complications compared to the LIM group (17.4% vs. 44.6%, p=0.001) and were similar to the SC group (17.4% vs. 20.4%, p=0.835). CONCLUSIONS Lateral inframammary chest wall placement of PACs is independently associated with increased total complication rates, migration rates, and need for operative exchange. We recommend subclavicular or medial inframammary PAC placement in children.

Cytogenetic Analysis in the Diagnosis and Management of Lipoblastomas: Results From a Single-Institution

BACKGROUND Lipoblastomas are rare, benign, soft tissue tumors that occur primarily in young children. Treatment includes complete excision and surveillance for recurrence. Lipoblastomas can be indistinguishable from other benign lipomatous tumors and liposarcomas. Cytogenetic analysis can provide the definitive diagnosis in questionable cases, because benign and malignant lipomatous tumors exhibit specific nonrandom cytogenetic abnormalities. The purpose of the present study was to discuss the disease management and outcomes in a large contemporary group of patients with lipoblastoma. MATERIALS AND METHODS A retrospective chart review of patients diagnosed with lipoblastoma presenting from 2000-2011 was conducted. The data from these patients were compared with data from a previously published historical group of patients (1985-1999) from the same childrens hospital. RESULTS We identified 37 patients in the contemporary cohort group and compared them with 25 patients from the historical group. The tumor involvement sites were similar. The current cohort group had a lower recurrence rate, although this might have been underestimated owing to a shorter follow-up period (median 1.4 y, range 2 wk to 11.0 y). Preoperative imaging findings led to an incorrect diagnosis in 62% of the patients. Cytogenetic analysis was used to help determine the final diagnosis in 50% of the cases. In 39% of cases, translocations involved the long arm of chromosome 8, the most common anomaly in lipoblastoma. CONCLUSIONS Lipoblastomas are rare tumors in young children that can be misclassified as other malignant or benign lipomatous tumors with markedly different outcomes and treatments. We recommend that cytogenetic analysis be routinely used for all pediatric lipomatous tumors to provide an accurate diagnosis and guide appropriate therapy and follow-up.

Resource utilization after gastrostomy tube placement: Defining areas of improvement for future quality improvement projects

BACKGROUND Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care childrens hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. METHODS We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30-365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. RESULTS During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months-22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31-365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). CONCLUSIONS Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.

Evaluating the impact of infliximab use on surgical outcomes in pediatric Crohn's disease.

BACKGROUND The impact of infliximab (IFX) on surgical outcomes is poorly defined in pediatric Crohns disease (CD). We evaluated our institutions experience with IFX on postoperative complications and surgical recurrence. METHODS A retrospective review of children who underwent intestinal resection with primary anastomosis for CD from 1/2002 to 10/2014 was performed. Data collected included IFX use and surgical outcomes. Preoperative IFX use was within 3months of surgery. RESULTS Seventy-three patients were included with median age 15years (range: 9-18). The most frequent indications for operation were obstruction (n=26) and fistulae (n=19). Nine patients (13%) had a surgical recurrence at a median of 2.3years (IQR 0.7-3.5). Twenty-two patients received preoperative IFX at median of 26days (IQR 14-46). There were 7 postoperative complications: 2 bowel obstructions, and 5 superficial wound infections. Outcomes of patients stratified by IFX were not different. When stratified by indication, refractory disease was associated with higher preoperative IFX use (IFX use 55% vs. no IFX use 28%, p=0.027). No specific indication was associated with increased reoperation rates. CONCLUSION Pediatric CD patients treated with preoperative IFX undergo intestinal resection with primary anastomosis with acceptable morbidity. The heterogeneous approach to medical management underscores the need for guidelines to direct treatment.

Evaluating the effect of time process measures on appendectomy clinical outcomes

BACKGROUND With varied reports on the impact of time to appendectomy on clinical outcomes, we examined the effects of pre-operative delays in pediatric acute appendicitis. METHODS Children with acute appendicitis (January 2013-June 2014) were identified from a prospective database. Univariate analyses compared time metrics, patient characteristics, and disease severity with postoperative complications (POC) and organ space surgical site infection (OSSI), and multivariate logistic regression determined predictors of POC and OSSI. RESULTS 1211 patients underwent appendectomy. Median age was 10.4years (IQR 7.8-13years). 537 patients (45%) had complex appendicitis. Overall, POC was 11% (n=133), and OSSI was 9% (n=105). Neither time from presentation to appendectomy nor diagnosis to appendectomy increased POCs. On univariate analyses, operative time (OT) was longer in patients with POC (57min (IQR 49-75) vs. 46min (IQR 36-57), p<0.001 and OSSI (60min (IQR 51-80) vs. 46min (IQR 37-57), p<0.001. However, after adjusting for confounding factors, disease severity remained the most significant predictor of POC (OR 6.5, 95% CI 2.79-15.23) and OSSI (OR 76.6, 95% CI 7.87-745.65). CONCLUSION Pre-operative delays were not associated with increased POC or OSSI. The strongest predictor of POC or OSSI was disease severity, for which operative time may represent a surrogate.

Congenital Left Paraduodenal Hernia Causing Chronic Abdominal Pain and Abdominal Catastrophe

Paraduodenal hernias are the most common type of congenital internal hernia. Because of its overall rare incidence, this entity is often overlooked during initial assessment of the patient. Lack of specific diagnostic criteria also makes diagnosis exceedingly difficult, and the resulting diagnostic delays can lead to tragic outcomes for patients. Despite these perceived barriers to timely diagnosis, there may be specific radiographic findings that, when combined with the appropriate constellation of clinical symptoms, would aid in diagnosis. This patient first presented at 8 years of age with vague symptoms of postprandial emesis, chronic abdominal pain, nausea, and syncope. Over the span of 6 years he was evaluated 2 to 3 times a year with similar complaints, all of which quickly resolved spontaneously. He underwent multiple laboratory, imaging, and endoscopic studies, which were nondiagnostic. It was not until he developed signs of a high-grade obstruction and extremis that he was found to have a large left paraduodenal hernia that had volvulized around the superior mesenteric axis. This resulted in the loss of the entire superior mesenteric axis distribution of the small and large intestine and necrosis of the duodenum. In cases of chronic intermittent obstruction without clear etiology, careful attention and consideration should be given to the constellation of symptoms, imaging studies, and potential use of diagnostic laparoscopy. Increased vigilance by primary care and consulting physicians is necessary to detect this rare but readily correctable condition.

Characteristics and outcomes of children with ductal-dependent congenital heart disease and esophageal atresia/tracheoesophageal fistula: A multi-institutional analysis

Background. Extracardiac birth defects are associated with worse outcomes in congenital heart disease (CHD). The impact of esophageal atresia/trachea‐esophageal fistula (EA/TEF) on outcomes after surgery for ductal‐dependent CHD is unknown. Methods. Retrospective matched cohort study using the Pediatric Health Information System database from 07/2004 to 06/2015. Hospitalizations with ductal‐dependent CHD and EA/TEF, undergoing CHD surgery were included as cases. Admissions with ductal‐dependent CHD without EA/TEF were matched 3:1 for age at admission and Risk Adjustment for Congenital Heart Surgery‐1 classification. Comparisons were performed using generalized estimating equations. Results. There were 124 cases and 372 controls. Cases included 32 (25.8%) low‐risk, 86 (69.3%) intermediate‐risk, and 6 (4.8%) high‐risk patients. Cases had more females compared to controls (53.2% vs 41.1%, P = .022). Cases were more likely to be premature (28.2% vs 13.7%, P = .001) and low birth weight (29.8% vs 11.8%, P < .001). Cases had a similar frequency of Down syndrome, and DiGeorge/Velocardiofacial syndrome, but a higher frequency of anorectal malformations (4.3% vs 2.4%, P < .001) and renal anomalies (27.4% vs 9.9%, P < .001) than controls. Cases had a higher mortality on univariate (22.0% vs 8.4%, P < .001) and multivariable analysis (odds ratio 2.45, 95%, confidence interval 1.34 – 4.49). Prematurity also was significantly associated with mortality on multivariable analysis. Cases had a longer duration of mechanical ventilation, longer hospital duration of stay, and higher total cost than controls (all P < .001). Conclusion. In children with ductal‐dependent CHD, EA/TEF is associated with increased morbidity, mortality and resource utilization. A majority of patients undergo EA/TEF repair prior to congenital heart disease surgery. (Surgery 2017;160:XXX‐XXX.)