Li Ern Chen

Risk-Adjusted Hospital Outcomes for Children’s Surgery

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children’s surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. METHODS: Participating institutions included children’s units within general hospitals and free-standing children’s hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. RESULTS: In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. CONCLUSIONS: The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children’s surgery performance indicator. Programmatic improvements have resulted in actionable data.

Asymptomatic malrotation: Diagnosis and surgical management An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review

OBJECTIVE Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. METHODS Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. RESULTS There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. CONCLUSIONS There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patients caregivers can help guide a watchful waiting management plan in individual cases.

Trauma stat and trauma minor: are we making the call appropriately?

Objectives: Trauma accounts for a significant number of pediatric emergency room visits and is the leading cause of death in pediatric patients over 1 year of age. To provide quality care, protocols are used to mobilize personnel to treat injured patients. We reviewed our experience at a level 1 pediatric trauma center, where a 2-tiered trauma activation protocol is used in treating children with significant injuries. Methods: We analyzed data in our trauma registry from 1994 to 1999 of patients with Injury Severity Score ≥ 9 in whom trauma activations were called. Data reflected demographics, severity of injury, hospital course and outcome. Trauma activations were based on standard protocols that took physiologic status, anatomic area of injury, and mechanism of injury into account. Nineteen personnel were notified in a Trauma Stat Activation, and 8 were notified in a Trauma Minor Activation. Results: There were 470 trauma activations: Trauma Stat = 220 and Trauma Minor = 250. As a group, Trauma Stat patients were more hemodynamically unstable, had a lower GCS and a higher Injury Severity Score than Trauma Minor patients. Patients in the Trauma Stat group were also more likely to require intensive care and have a prolonged hospitalization. The Trauma Stat group had a mortality rate of 20%. There were no deaths in the Trauma Minor group. Conclusions: Trauma activations result in heavy resource utilization and must be appropriate. The 2 trauma activation levels were associated with differences in injury severity, medical resource utilization, and outcome. With no deaths in the Trauma Minor group and a 20% mortality rate in the Trauma Stat group, we conclude that the protocol used was neither too conservative, nor too liberal.

Pediatric surgery on YouTube™: Is the truth out there?

BACKGROUND/PURPOSE In 2000, we described the variability of pediatric surgical information on the Internet. Since then, online videos have become an increasingly popular medium for education and personal expression. The purpose of this study was to examine the content and quality of videos related to pediatric surgical diagnoses on the Internet. METHODS YouTube™ was searched for videos on gastroschisis, congenital diaphragmatic hernia, pediatric inguinal hernia, and pectus excavatum. The first 40 English language videos for each diagnosis were reviewed for owner and audience characteristics, content and quality. RESULTS A small majority of videos were made by medical professionals (50.63%, vs. 41.25% by lay persons and 8.13% by fundraising organizations). Eighty percent of videos were intended for a lay audience. Videos by medical professionals were more accurate and complete than those posted by lay persons. CONCLUSIONS The YouTube™ videos varied significantly in content and quality. Videos by lay persons often focused on the emotional aspect of the diagnosis and clinical course. Videos by members of the medical profession tended to be more complete and accurate. These findings underscore the continued need for high quality pediatric surgical information on the Internet for patients and their families.

Laparoscopic versus Open Surgery for Malrotation Without Volvulus

Purpose: We wished to determine the risks and benefits of laparoscopic surgery when compared to the standard open approach in the management of children with malrotation without volvulus. Patients and Methods: Eighteen children undergoing laparoscopic surgery were compared to 20 similar children having open surgery during the same time period (1994-1999). Results: Three laparoscopic cases were converted. Six (33%) laparoscopic patients were found to have a broad-based mesentery at laparoscopy, and underwent appendectomy alone. The rest went on to a Ladd procedure. Eight (40%) open patients were found intraoperatively to have a broad-based mesentery. The laparoscopic group required less narcotic, was faster to full feeds, and had a shorter mean postoperative stay. On followup, there were no late complications in the laparoscopic group, but 2 (10%) open surgery patients developed adhesive small bowel obstruction. There were no cases of late volvulus following either laparoscopic or open surgery. Conclusion:...

Pediatric surgeons’ attitudes toward regionalization of neonatal surgical care

BACKGROUND/PURPOSE Research has suggested that high-risk pediatric surgical patients have better outcomes when treated in resource-rich childrens environments. Surgical neonates are a particularly high-risk population and some suggest that regionalization might be a strategy to improve clinical outcomes in neonatal surgical patients. We conducted a national survey of pediatric surgeons in the United States to explore their attitudes toward regionalization of neonatal surgical care. METHODS Members of the American Pediatric Surgical Association were asked to participate in an anonymous online survey to assess both attitudes toward regionalization, as well as perceptions of the importance of various resources in providing optimal care for surgical neonates. RESULTS Overall, 56.2% of participants favored regionalization. Surgeons whose practice was part of a training program tended to favor regionalization more, as did those from larger group practices and those who practiced at free-standing childrens hospital. In addition, surgeons from larger groups and those involved with training programs more strongly favored the premise that a higher level of resource commitment should be available to treat surgical neonates. CONCLUSIONS The impact of any national strategy to improve neonatal surgical outcomes will be large and multi-faceted. While the majority of pediatric surgeons favor regionalization, our findings demonstrate variation in this view and highlight the necessity for surgeon involvement and education that will be critical in this effort.

Prevention of infectious complications after elective colorectal surgery in children: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee comprehensive review

OBJECTIVE This goal of this review was to examine the clinical evidence in support of commonly utilized measures intended to reduce complications following elective colorectal surgery. DATA SOURCE Literature searches were performed to identify relevant studies from Medline, PubMed, and Cochrane databases. STUDY SELECTION The American Pediatric Surgery Association Outcomes and Clinical Trials Committee selected eight questions to address this topic systematically in the context of three management areas: 1) appropriate utilization of systemic antibiotics for colorectal procedures, 2) reduction of stool burden through mechanical bowel preparation, and 3) intraluminal gut decontamination through use of enteral nonabsorbable antibiotics. Primary outcomes of interest included the occurrence of infectious and mechanical complications related to stool burden and intraluminal bacterial concentration (incisional surgical site infection, anastomotic leakage, and intraabdominal abscess). RESULTS The evidence in support of each management category was systematically reviewed, graded, and summarized in the context of the reviews primary outcomes. Practice recommendations were made as deemed appropriate by the committee. CONCLUSIONS Clinical evidence in support of interventions to reduce infectious complications following colorectal surgery is derived almost exclusively from the adult literature. High-quality evidence to guide clinical practice in children is sorely needed, as the available data may have only limited relevance to pediatric colorectal diseases.

An analysis of pediatric gunshot wounds treated at a Level I pediatric trauma center

BACKGROUND We reviewed the incidence and injury severity of children with gunshot wounds (GSWs) at our hospital. METHODS We compared trauma registry, emergency unit (EU), and admissions data from January 1993 to June 1996 (period I) and July 1996 to December 1999 (period II). Outcome measures included EU disposition (death, immediate operation, pediatric intensive care unit, ward), injury severity, mortality, and injury cause (accidental, intentional). RESULTS We treated 437 children for GSWs in the EU, with 238 (54%) admissions and 199 discharges. Comparing period I versus period II, patients treated declined from 288 to 149 (-52%, p < 0.001), and admissions decreased from 159 to 79 (-50%, p < 0.001). Injury severity increased from 35% to 57% (p < 0.001). Patients requiring immediate operations increased from 20% to 42% (p < 0.001). Direct ward admissions declined from 65% to 43% (p < 0.001). Deaths occurred in 3% of patients in both time periods. Accidental and intentional GSWs were evenly divided. CONCLUSION An alarming number of children, an average of 62 children annually, were treated for GSWs at our hospital. Despite a 52% reduction in GSWs, the percentage of severely injured patients increased by 63%. These data emphasize the importance of prevention, education, early assessment, and operative treatment.

Retrograde jejunoduodenal intussusception: a rare cause of acute pancreatitis after surgery for duodenal atresia

Duodenojejunostomy is a surgical treatment option in the repair of duodenal atresia. This case describes the heretofore unreported phenomenon of retrograde jejunoduodenal intussusception causing acute pancreatitis in a patient who underwent duodenojejunostomy in infancy.

Subspecialization within pediatric surgical groups in North America

PURPOSE The purpose of this study was to assess the current status of subspecialization in North American pediatric surgical practices and to evaluate factors associated with subspecialization. METHODS A survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44 operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1. everyone does the operation; 2. group policy--only some surgeons do the operation; 3. group policy--anyone can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it. Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with p<0.05 considered significant. RESULTS Response rate was 70%. There was significant variability in subspecialization among groups. Factors found to be significantly associated with increased subspecialization included free-standing childrens hospitals, pediatric surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases. CONCLUSIONS There is wide variation in the degree of subspecialization among North American pediatric surgery practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing pediatric surgical care and patient outcomes in the future.