Keith A. Kuenzler

Early recurrence of congenital diaphragmatic hernia is higher after thoracoscopic than open repair: a single institutional study.

INTRODUCTION Experience in thoracoscopic congenital diaphragmatic hernia (CDH) repair has expanded, yet efficacy equal to that of open repair has not been demonstrated. In spite of reports suggesting higher recurrent hernia rates after thoracoscopic repair, this approach has widely been adopted into practice. We report a large, single institutional experience with thoracoscopic CDH repair with special attention to recurrent hernia rates. METHODS We reviewed the records of neonates with unilateral CDH repaired between January 2006 and February 2010 at Morgan Stanley Childrens Hospital. Completely thoracoscopic repairs were compared to open repairs of the same period. In addition, successful thoracoscopic repairs were compared with thoracoscopic repairs that developed recurrence. Data were analyzed by Mann-Whitney U and Fisher exact tests. RESULTS Thirty-five neonates underwent attempted thoracoscopic repair, with 26 completed. Concurrently, 19 initially open CDH repairs were performed. Preoperatively, patients in the open repair group required more ventilatory support than the thoracoscopic group. Recurrence was higher after thoracoscopic repair (23% vs 0%; P = .032). In comparing successful thoracoscopic repairs to those with recurrence, none of the factors analyzed were predictive of recurrence. CONCLUSIONS Early recurrence of hernia is higher in thoracoscopic CDH repairs than in open repairs. Technical factors and a steep learning curve for thoracoscopy may account for the higher recurrence rates, but not patient severity of illness. In an already-tenuous patient population, performing the repair thoracoscopically with a higher risk of recurrence may not be advantageous.

Thoracoscopic Lobectomy in Infants Less Than 10 kg with Prenatally Diagnosed Cystic Lung Disease

PURPOSE Thoracoscopic lobectomy for congenital cystic lung lesions is an accepted technique in pediatric surgery. Since an increasing number of these lesions are detected prenatally, the safety and efficacy of infant resections have been questioned. We reviewed our experience over a 10-year period to evaluate early resection of these lesions. METHODS From January 2001 to August 2009, 75 patients under 1 year of age and weighing <10 kg underwent thoracoscopic lobectomy at two institutions. Patients carried the following diagnoses: 52 had congenital cystic adenomatoid malformation, 20 had bronchopulmonary sequestration, and 3 had congenital lobar emphysema. All lesions were confirmed after birth by computed tomography scan. Patient age at operation ranged from 4 days to 11 months and patient weight from 3.1 to 10 kg. RESULTS Seventy-four of 75 lobectomies were thoracoscopically completed. There were 16 upper lobectomies, 1 middle lobectomy, and 55 lower lobectomies. Operative time ranged from 45 to 225 minutes. Hospital length of stay ranged from 1 to 5 days. A subset of 26 patients had surgery younger than 3 months of age and <5 kg, despite being asymptomatic. Their operative time averaged 90 minutes, and mean length of hospital stay was 1.5 days. CONCLUSION Thoracoscopic lobectomy is safe for infants <10 kg and avoids the morbidity associated with thoracotomy. Operating early on younger patients may avoid the inflammatory changes associated with both clinically apparent and subclinical infections, even in patients weighing <5 kg. This may make the procedures less technically challenging and may result in lower complication and conversion rates.

Managing radiation exposure in children—reexamining the role of ultrasound in the diagnosis of appendicitis

PURPOSE To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children. METHODS A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate. RESULTS Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%). CONCLUSIONS US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.

Factors associated with failure of nonoperative treatment of complicated appendicitis in children

UNLABELLED Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively. METHODS Records of all children admitted with the diagnosis of perforated appendicitis to NYU Langone Medical Center and Bellevue Hospital Center from January 1, 2003 to December 31, 2013 were reviewed. The diagnosis was made with ultrasound and/or computed tomography scan. Those with abscesses amenable to drainage underwent aspiration and drain placement by an interventional radiologist. Broad spectrum intravenous (IV) antibiotics were given until the patient became afebrile, pain free and tolerating a regular diet. Oral antibiotics were continued for an additional week and interval appendectomy was done eight weeks later. The primary outcome measure was treatment response with failure defined as those who did not improve or required readmission for additional IV antibiotics and/or early appendectomy. Multiple patient and treatment related variables, including those previously reported as predicting failure in nonoperative therapy, were studied. Continuous variables were reported as means ± standard error and compared using 2-tailed unpaired t tests; nonparametric variables were analyzed by Mann-Whitney U tests. Categorical variables were reported as medians ± interquartile ranges and compared using Chi-square testing. Statistical significance was accepted for p<.05. RESULTS Sixty-four patients were identified as undergoing initial nonoperative therapy. Fifty-two (81%) were categorized as treatment successes being treated nonoperatively and 12 (19%) were failures. Variables showing no significance in predicting treatment failures included duration of symptoms, presence of appendicolith, presence of phlegmon, presence of abscess, initial white blood cell count, and SIRS (Systemic Inflammatory Response Syndrome) positive. The variables that predicted failure of nonoperative therapy vs. successes were presence of bandemia (75% vs. 40%, p=0.052) and small bowel obstruction on imaging (42% vs. 15%, p=0.052) and presence of bandemia ≥15% which was highly predictive of failure (67% vs. 4%, p<0.01). CONCLUSIONS Predicting which patients with complicated perforated appendicitis will respond well to nonoperative therapy may allow us to more effectively treat patients with complicated perforated appendicitis. In our study the presence of small bowel obstruction and bandemia, especially ≥15% correlated with treatment failure; this suggests that these select patients may need a modified treatment strategy.

Increased capture of pediatric surgical complications utilizing a novel case-log web application to enhance quality improvement

PURPOSE Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications. METHODS We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application. RESULTS 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events). CONCLUSIONS This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI. TYPE OF STUDY Diagnostic study/Retrospective study. LEVEL OF EVIDENCE Level III - case control study.

Imperforate Anus with Jejunal Atresia Complicated by Intestinal Volvulus: A Case Report

Anorectal malformations (ARMs) commonly co-occur with other congenital anomalies, particularly VACTERL (vertebral, anorectal, cardiac, tracheal, esophageal, renal, limb, and duodenal) associations. However, this collection of associations is not comprehensive, and other concurrent anomalies may exist that can be missed during the standard work-up of patients with ARMs. We present a rare case of a neonate with a low ARM with concurrent jejuno-ileal atresia that was diagnosed after the correction of the ARM when the patient developed segmental volvulus. This case illustrates the importance of having a high index of suspicion when deviation from a classic presentation occurs.

A novel approach to leveraging electronic health record data to enhance pediatric surgical quality improvement bundle process compliance

PURPOSE Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.

Epidural air in child with spontaneous pneumomediastinum.

A 3-year-old boy was seen in the emergency room after his mother noted neck swelling, drooling, and dysphonia. This occurred after a brief coughing episode and one episode of vomiting. Although hewas never diagnosed with asthma, the patient had a history of severe paroxysms of coughing. On examination, he had palpable subcutaneous emphysema of the neck, upper chest, and upper back. There were bilateral rhonchi (low pitched, snore-like sounds) on lung examination. He had no neurologic deficits. A chest X-ray showed significant subcutaneous emphysema of the soft tissues of the neck and chest. A neck and chest computed tomography (CT) scan (►Figs. 1 and 2) showed severe pneumomediastinum with extensive subcutaneous emphysema tracking along the fascial planes of the neck, supraclavicular regions, right upper extremity, anterior chest wall, and epidural space. He underwent an esophagram which was negative for perforation. He was observed in the hospital for a day and discharged to home the next day. During this hospitalization he was diagnosed with asthma and is currently being treated for such.

Diseases of the Pleural Space

Air, blood, chyle, or infected fluid may inappropriately accumulate in the pleural space, resulting in acute or chronic clinical manifestations of varying severity.