Laura A. Boomer

Reducing computed tomography scans for appendicitis by introduction of a standardized and validated ultrasonography report template.

PURPOSEnComputed tomography (CT) for the diagnosis of appendicitis is associated with radiation exposure and increased cost. In an effort to reduce the diagnostic use of CT scans, we implemented a standardized ultrasound report template based on validated secondary signs of appendicitis.nnnMETHODSnIn September 2012, as part of a quality improvement project, we developed and introduced a four category standardized ultrasound report template for limited right lower quadrant abdominal ultrasounds. Outcomes for patients undergoing ultrasound or CT scan for appendicitis between 9/10/2012 and 12/31/2013 (Period 2, n=2033) were compared to the three months prior to implementation (Period 1, n=304).nnnRESULTSnIn Period 1, 78 of 304 (25.7%) patients had appendicitis versus 385 of 2033 (18.9%) in Period 2 (p=0.006). Non-diagnostic exams decreased from 48% to 0.1% (p<0.001). Ultrasound sensitivity improved from 66.67% to 92.2% (p<0.001). Specificity did not significantly change (96.9% to 97.69%, p=0.46). CT utilization for appendicitis decreased from 44.3% in Period 1 to 14.5% at the end of Period 2 (p<0.001).nnnCONCLUSIONSnImplementation of a standardized ultrasound report template based on validated secondary signs of appendicitis nearly eliminated non-diagnostic exams, improved diagnostic accuracy, and resulted in a striking decrease in CT utilization.

Enteric nervous system abnormalities are present in human necrotizing enterocolitis: potential neurotransplantation therapy

IntroductionIntestinal dysmotility following human necrotizing enterocolitis suggests that the enteric nervous system is injured during the disease. We examined human intestinal specimens to characterize the enteric nervous system injury that occurs in necrotizing enterocolitis, and then used an animal model of experimental necrotizing enterocolitis to determine whether transplantation of neural stem cells can protect the enteric nervous system from injury.MethodsHuman intestinal specimens resected from patients with necrotizing enterocolitis (nu2009=u200918), from control patients with bowel atresia (nu2009=u20098), and from necrotizing enterocolitis and control patients undergoing stoma closure several months later (nu2009=u200914 and nu2009=u20096 respectively) were subjected to histologic examination, immunohistochemistry, and real-time reverse-transcription polymerase chain reaction to examine the myenteric plexus structure and neurotransmitter expression. In addition, experimental necrotizing enterocolitis was induced in newborn rat pups and neurotransplantation was performed by administration of fluorescently labeled neural stem cells, with subsequent visualization of transplanted cells and determination of intestinal integrity and intestinal motility.ResultsThere was significant enteric nervous system damage with increased enteric nervous system apoptosis, and decreased neuronal nitric oxide synthase expression in myenteric ganglia from human intestine resected for necrotizing enterocolitis compared with control intestine. Structural and functional abnormalities persisted months later at the time of stoma closure. Similar abnormalities were identified in rat pups exposed to experimental necrotizing enterocolitis. Pups receiving neural stem cell transplantation had improved enteric nervous system and intestinal integrity, differentiation of transplanted neural stem cells into functional neurons, significantly improved intestinal transit, and significantly decreased mortality compared with control pups.ConclusionsSignificant injury to the enteric nervous system occurs in both human and experimental necrotizing enterocolitis. Neural stem cell transplantation may represent a novel future therapy for patients with necrotizing enterocolitis.

Does delay in appendectomy affect surgical site infection in children with appendicitis

PURPOSEnThe purpose of this study was to investigate the association between time from diagnosis to operation and surgical site infection (SSI) in children undergoing appendectomy.nnnMETHODSnPediatric patients undergoing appendectomy in 2010-2012 were included. We collected data on patient demographics; length of symptoms; times of presentation, admission and surgery; antibiotic administration; operative findings; and occurrence of SSI.nnnRESULTSn1388 patients were analyzed. SSI occurred in 5.1% of all patients, 1.4% of simple appendicitis (SA) patients, and 12.4% of complex appendicitis (CA) patients. SSI did not increase significantly as the length of time between ED triage and operation increased (all patients, p=0.51; SA patients, p=0.91; CA patients, p=0.44) or with increased time from admission to operation (all patients, p=0.997; SA patients, p=0.69; CA patients, p=0.96). However, greater length of symptoms was associated with an increased risk of SSI (p<0.05 for all, SA and CA patients). In univariable analysis, obesity, and increased admission WBC count were each associated with significantly increased SSI. In multivariable analysis, only CA was a significant risk factor for SSI (p<0.0001).nnnCONCLUSIONnWe found no significant increase in the risk of SSI related to delay in appendectomy. A future multi-institutional study is planned to confirm these results.

Scaffolding for challenging environments: Materials selection for tissue engineered intestine

Novel therapies are crucially needed for short bowel syndrome. One potential therapy is the production of tissue engineered intestine (TEI). The intestinal environment presents significant challenges to the selection of appropriate material for tissue engineering scaffolds. Our goal was to characterize different scaffold materials to downselect to that best suited for TEI production. To investigate this, various tubular scaffolds were implanted into the peritoneal cavity of adult rats and harvested at multiple time-points. Harvested scaffolds were examined histologically and subjected to degradation studies and mechanical evaluation. We found that poly(glycolic acid) (PGA)-nanofiber and PGA-macrofiber scaffolds exhibited early robust tissue infiltration. Poly(ɛ-caprolactone) (PCL)-nanofiber, poly(l-lactic acid) (PLLA)-nanofiber, poly(d-lactic acid-co-glycolic acid) (PDLGA)-nanofiber and polyurethane (PU)-nanofiber experienced slower tissue infiltration. Poly(ɛ-caprolactone-co-lactic acid) (PLC) nanofiber had poor tissue infiltration. Significant weight loss was observed in PGA-nanofiber (92.2%), PGA-macrofiber (67.6%), and PDLGA-nanofiber (76.9%) scaffolds. Individual fibers were no longer seen by scanning electron microscopy in PLC-nanofiber and PGA-nanofiber scaffolds after 1 week, PGA-macrofiber scaffolds after 2 weeks, and PDLGA-nanofiber scaffolds after 4 weeks. In conclusion, PGA-macrofiber and PDLGA appear to be the most appropriate materials choices as TEI scaffolds due to their biocompatibility and degradation. Future experiments will confirm these results by analyzing cell-seeded scaffolds in vitro and in vivo.

Nonoperative management of esophageal perforations in the newborn

BACKGROUNDnEsophageal perforation in neonates occurs most often in cases of extreme prematurity and is commonly due to iatrogenic causes. Treatment over recent decades has become more conservative. The purpose of this study was to review cases of esophageal perforation in neonates and to describe the presentation, management, and outcomes.nnnMATERIALS AND METHODSnA retrospective chart review was performed for patients with International Classification of Diseases, Ninth Revision code for esophageal perforation treated at our institution between the years 2009 and 2015. Data collected included demographic information, etiology of perforation (specifically focusing on cases secondary to orogastric tube placement), treatment course, time to resumption of enteral feeds, length of antibiotic use, time to subsequent radiographic resolution, and mortality.nnnRESULTSnTwenty-five patients met study criteria. The average post-conceptual age at time of diagnosis was 26.5xa0±xa02.3xa0wk. All 25 patients were managed nonoperatively with bowel rest, parenteral nutrition, and broad-spectrum antibiotics. Enteral feeds were resumed after a median of 8xa0d (interquartile range [IQR]: 7-11), the median antibiotic duration was 7xa0d (IQR: 7-10), and the median time to follow-up esophagram was 7xa0d (IQR: 7-10). Overall, 24 of 25 patients (96%) demonstrated radiological resolution of perforation on initial follow-up esophagram. Four patients died during the study period, but no deaths were related to the diagnosis of esophageal perforation.nnnCONCLUSIONSnIn this largest reported sample of neonates treated for esophageal perforation, nonoperative management with bowel rest, parenteral nutrition, and antibiotics was successful.

Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections: A Multi-institutional Analysis of Children With Appendicitis.

Objectives: To investigate the association between time to appendectomy and the risk of surgical site infections (SSIs) in children with appendicitis across multiple NSQIP-Pediatrics institutions. Background: Several recently published single institution retrospective studies have reported conflicting relationships between delaying appendectomy and the risk of increasing surgical site infections (SSI) in both children and adults. This study combines data from NSQIP-Pediatrics with institutional data to perform a multi-institutional analysis to examine the effects of delaying appendectomy on surgical site infections. Methods: Data from NSQIP-Pediatrics between January 2010 and June 2012 for cases of appendectomy for appendicitis at 6 institutions (preoperative characteristics, time of operation, and postoperative occurrences) were combined with data from medical record review (length of symptoms; times of initial presentation, emergency department (ED) triage, and admission; and diagnosis as simple appendicitis (SA, acute) or complicated appendicitis (CA, gangrenous/ruptured)). Cochran-Armitage tests for trend and multivariable logistic regression models were used to evaluate associations between time to appendectomy and SSI. Results: Of the 1338 patients included, 70% had SA and 30% had CA. Postoperative SSIs were more common in CA (5.7% vs 1.2%, Pu200a<u200a0.001). SSI rates did not differ significantly across hospitals (Pu200a=u200a0.17). Compared with patients who did not develop an SSI, patients who developed an SSI had similar times between ED triage and appendectomy (median (interquartile range) 11.5u200ahours (6.4–14.7) versus 9.7u200ahours (5.8–15.6, Pu200a=u200a0.36), and similar times from admission to appendectomy (5.5u200ahours (1.9–10.2) versus 4.3u200ahours (1.4–9.9), Pu200a=u200a0.36). Independent risk factors for SSI were CA (Odds Ratio (95% CI): 3.46 (1.48–8.10), Pu200a=u200a0.004), longer symptom duration (OR for a 10-hour increase: 1.05 (1.01–1.10), Pu200a=u200a0.02), and presence of sepsis/septic shock (2.70 (1.17–6.28), Pu200a=u200a0.02). Conclusions: A 16-hour delay from ED presentation or a 12-hour delay from hospital admission to appendectomy was not associated with an increased risk for SSI.

An unusual case of foreign body pulmonary embolus: case report and review of penetrating trauma at a pediatric trauma center

PurposePenetrating thoracic trauma is relatively rare in the pediatric population. Embolization of foreign bodies from penetrating trauma is very uncommon. We present a case of a 6-year-old boy with a penetrating foreign body from a projectile dislodged from a lawn mower. Imaging demonstrated a foreign body that embolized to the left pulmonary artery, which was successfully treated non-operatively.MethodsWe reviewed the penetrating thoracic trauma patients in the trauma registry at our institution between 1/1/03 and 12/31/12. Data collected included demographic data, procedures performed, complications and outcome.ResultsSixty-five patients were identified with a diagnosis of penetrating thoracic trauma. Fourteen of the patients had low velocity penetrating trauma and 51 had high velocity injuries. Patients with high velocity injuries were more likely to be older and less likely to be Caucasian. There were no statistically significant differences between patients with low vs. high velocity injuries regarding severity scores or length of stay. There were no statistically significant differences in procedures required between patients with low and high velocity injuries.ConclusionsPenetrating thoracic trauma is rare in children. The case presented here represents the only report of cardiac foreign body embolus we could identify in a pediatric patient.

Managing moderately injured pediatric patients without immediate surgeon presence: 10 years later.

PURPOSEnBeginning in 2003, the pediatric emergency medicine (PEM) physician replaced the surgeon as the team leader for all level II trauma resuscitations at a busy pediatric trauma center. The purpose was to review the outcomes 10 years after implementing this practice change.nnnMETHODSnTrauma registry data for all level II activations requiring admission were extracted for the 21 months (April 1, 2001-December 31, 2002) prior to policy change (period 1, **n=627) and compared to the admitted patients from the 10 subsequent years (2003-2013; period 2, n=2694). Data included demographics, length of stay (LOS), injury severity score (ISS), readmissions, complications, and mortality.nnnRESULTSnMean ISS scores for admitted patients during period 1 (8.5) were higher than during period 2 (7.8). During period 1, 53.6% of patients underwent abdominal CT versus 41.8% in period 2 (p<.001), and the median ED LOS was 135 versus 191 minutes in period 2. From 2000 to 2003, 91% of patients seen as level II trauma alerts were admitted compared to 56.6% of patients in period 2 (p<0.001). There were no missed abdominal injuries identified, and readmission rate was low.nnnCONCLUSIONSnWe conclude that level II trauma resuscitations can be safely evaluated and managed without immediate surgeon presence. Although ED LOS increased, admission rate and CT scan usage decreased significantly without an increase in missed injuries.

Minimally Invasive Ileal Pouch-Anal Anastomosis with Rectal Eversion Allows for Equivalent Outcomes in Continence in Pediatric Patients

BACKGROUNDnDifferent techniques for ileal pouch-anal anastomosis (IPAA) following total proctocolectomy (TPC) have been described in patients with ulcerative colitis (UC), including rectal eversion (RE). RE allows for precise identification of the dentate line, but concerns have been raised regarding continence rates. No studies have specifically evaluated RE in the pediatric population. The purpose of this study was to evaluate the outcomes and continence rates for pediatric patients undergoing minimally invasive surgery (MIS) TPC and IPAA with RE for UC.nnnMATERIALS AND METHODSnAll patients who underwent TPC and IPAA were reviewed at our institution. Data collected included demographics, proctocolectomy technique (open without RE versus MIS with RE), operative time, postoperative data, and continence outcomes following ileostomy closure.nnnRESULTSnThirty-three patients were identified who underwent TPC and IPAA between July 2006 and October 2014. Thirty of these patients underwent ileostomy takedown and were evaluated for continence. Of these, 17 (56.7%) patients had a laparoscopic procedure, 5 (16.7%) had a robotic-assisted procedure, and 8 (26.7%) had an open procedure. There were no statistically significant differences in regard to demographics, operative time, or length of stay when comparing the two groups. There were no differences in the two groups as measured at 1, 6, and 12 months in terms of number of daily stools (Pu2009=u2009.93, .09, and .87, respectively), nighttime stooling (Pu2009=u2009.29, .10, and .25, respectively), soiling (Pu2009=u2009.43, .36, and .52, respectively), or stool-altering medication usage (Pu2009=u2009.26, 1.00, and .37, respectively).nnnCONCLUSIONSnThe RE technique can be used safely and effectively during MIS TPC and IPAA in children without altering continence rates.

Single-incision laparoscopic surgery (SILS) for children with Crohn’s disease

PurposeSingle-incision laparoscopic surgery (SILS) has been described in adults with Crohn’s disease, but its use in pediatric Crohn’s patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn’s disease.MethodsA retrospective review was performed for patients diagnosed with Crohn’s disease who underwent small bowel resection or ileocecectomy at a freestanding children’s hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes.ResultsAnalysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4xa0%) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7xa0% vs. OS 68.4xa0%, pxa0=xa00.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2xa0% vs. OS 100xa0% OS). Operative times were longer for SILS (135xa0±xa050 vs. 105xa0±xa037xa0min, pxa0=xa00.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3xa0±xa034.2 vs. OS 105xa0±xa036.5, pxa0=xa00.12). No difference was noted in postoperative length of stay (SILS 6.5xa0±xa02.2xa0days vs. OS 7.4xa0±xa02.2xa0days, pxa0=xa00.16) or overall complication rate (SILS 24.4xa0% vs. OS 26.3xa0%, pxa0=xa00.16).ConclusionSILS ileocecectomy is feasible in pediatric patients with Crohn’s disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.