Moritz M. Ziegler

Pediatric American College of Surgeons National Surgical Quality Improvement Program: feasibility of a novel, prospective assessment of surgical outcomes

PURPOSEnThe American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) provides validated assessment of surgical outcomes. This study reports initiation of an ACS NSQIP Pediatric at 4 childrens hospitals.nnnMETHODSnFrom October 2008 to June 2009, 121 data variables were prospectively collected for 3315 patients, including 30-day outcomes and tailoring the ACS NSQIP methodology to childrens surgical specialties.nnnRESULTSnThree hundred seven postoperative complications/occurrences were detected in 231 patients representing 7.0% of the study population. Of the patients with complications, 175 (75.7%) had 1, 39 (16.9%) had 2, and 17 (7.4%) had 3 or more complications. There were 13 deaths (0.39%) and 14 intraoperative occurrences (0.42%) detected. The most common complications were infection, 105 (34%) (SSI, 54; sepsis, 31; pneumonia, 13; urinary tract infection, 7); airway/respiratory events, 27 (9%); wound disruption, 18 (6%); neurologic events, 8 (3%) (nerve injury, 4; stroke/vascular event, 2; hemorrhage, 2); deep vein thrombosis, 3 (<1%); renal failure, 3 (<1%); and cardiac events, 3 (<1%). Current sampling captures 17.5% of cases across institutions with unadjusted complication rates ranging from 6.8% to 10.2%. Completeness of data collection for all variables exceeded 95% with 98% interrater reliability and 87% of patients having full 30-day follow-up.nnnCONCLUSIONnThese data represent the first multiinstitutional prospective assessment of specialty-specific surgical outcomes in children. The ACS NSQIP Pediatric is poised for institutional expansion and future development of risk-adjusted models.

American College of Surgeons National Surgical Quality Improvement Program Pediatric: A Phase 1 Report

BACKGROUNDnThere has been a long-standing desire to implement a multi-institutional, multispecialty program to address surgical quality improvement for children. This report documents results of the initial phase of the American College of Surgeons National Surgical Quality Improvement Program Pediatric.nnnSTUDY DESIGNnFrom October 2008 to December 2009, patients from 4 pediatric referral centers were sampled using American College of Surgeons National Surgical Quality Improvement Program methodology tailored to children.nnnRESULTSnA total of 7,287 patients were sampled, representing general/thoracic surgery (n = 2,237; 30.7%), otolaryngology (n = 1,687; 23.2%), orthopaedic surgery (n = 1,367; 18.8%), urology (n = 893; 12.3%), neurosurgery (n = 697; 9.6%), and plastic surgery (n = 406; 5.6%). Overall mortality rate detected was 0.3% and 287 (3.9%) patients had postoperative occurrences. After accounting for demographic, preoperative, and operative factors, occurrences were 4 times more likely in those undergoing inpatient versus outpatient procedures (odds ratio [OR] = 4.71; 95% CI, 3.01-7.35). Other factors associated with higher likelihood of postoperative occurrences included nutritional/immune history, such as preoperative weight loss/chronic steroid use (OR = 1.49; 95% CI, 1.03-2.15), as well as physiologic compromise, such as sepsis/inotrope use before surgery (OR = 1.68; 95% CI, 1.10-1.95). Operative factors associated with occurrences included multiple procedures under the same anesthetic (OR = 1.58; 95% CI, 1.21-2.06) and American Society of Anesthesiologists classification category 4/5 versus 1 (OR = 5.74; 95% CI, 2.94-11.24). Specialty complication rates varied from 1.5% for otolaryngology to 9.0% for neurosurgery (p < 0.001), with specific procedural groupings within each specialty accounting for the majority of complications. Although infectious complications were the predominant outcomes identified across all specialties, distribution of complications varied by specialty.nnnCONCLUSIONSnBased on this initial phase of development, the highly anticipated American College of Surgeons National Surgical Quality Improvement Program Pediatric has the potential to identify outcomes of childrens surgical care that can be targeted for quality improvement efforts.

Developing a NSQIP module to measure outcomes in children’s surgical care: opportunity and challenge

Under the guidance of the American College of Surgeons (ACS) and in partnership with the US Department of Veterans Affairs (VA), the National Surgical Quality Improvement Program (NSQIP) has been developed to improve the quality of surgical care in adults on a national level. Its purpose is to provide reliable, risk-adjusted outcomes data so that surgical quality can be assessed and compared between institutions. Data analysis consists of reporting observed to expected ratios (O/E) for 30-day postoperative mortality and morbidity measurements. A surgical clinical nurse reviewer is assigned at each medical center to collect information on 97 variables, including preoperative, operative, and postoperative factors for patients undergoing major operations in the specialties of general and vascular surgery. Eligible operations are entered into the database on a structured 8-day cycle to ensure representative sampling of cases. Since the introduction of the program into the VA system, there has been a 47% reduction in 30-day postoperative mortality and a 42% reduction in 30-day postoperative morbidity. Over 160 institutions have enrolled with the ACS in its adult NSQIP. In 2005, a planning committee was formed by the ACS and the American Pediatric Surgical Association to explore the development of a childrens surgery NSQIP module. In conjunction with the Colorado Health Outcomes Program at the University of Colorado, a program potentially applicable to all childrens surgical specialties has been designed. This manuscript describes the development of that Childrens ACS-NSQIP module.

American College of Surgeons National Surgical Quality Improvement Program Pediatric: A beta phase report

PURPOSEnThe American College of Surgeons (ACS) National Surgical Quality Improvement Program Pediatric (NSQIP-P) expanded to beta phase testing with the enrollment of 29 institutions. Data collection and analysis were aimed at program refinement and development of risk-adjusted models for inter-institutional comparisons.nnnMETHODSnData from the first full year of beta-phase NSQIP-P were analyzed. Patient accrual used ACS-NSQIP methodology tailored to pediatric specialties. Preliminary risk adjusted modeling for all pediatric and neonatal operations and pediatric (excluding neonatal) abdominal operations was performed for all cause morbidity (other than death) and surgical site infections (SSI) using hierarchical logistic regression methodology and eight predictor variables. Results were expressed as odds ratios with 95% confidence intervals.nnnRESULTSnDuring calendar year 2010, 29 institutions enrolled 37,141 patients. 1644 total CPT codes were entered, of which 456 accounted for 90% of the cases. 450 codes were entered only once (1.2% of cases). For all cases, overall mortality was 0.25%, overall morbidity 7.9%, and the SSI rate 1.8%. For neonatal cases, mortality was 2.39%, morbidity 18.7%, and the SSI rate 3%. For the all operations model, risk-adjusted morbidity institutional odds ratios ranged 0.48-2.63, with 9/29 hospitals categorized as low outliers and 9/29 high outliers, while risk-adjusted SSI institutional odds ratios ranged 0.36-2.04, with 2/29 hospitals low outliers and 7/29 high outliers.nnnCONCLUSIONnThis report represents the first risk-adjusted hospital-level comparison of surgical outcomes in infants and children using NSQIP-P data. Programmatic and analytic modifications will improve the impact of this program as it moves into full implementation. These results indicate that NSQIP-P has the potential to serve as a model for determining risk-adjusted outcomes in the neonatal and pediatric population with the goal of developing quality improvement initiatives for the surgical care of children.

Mechanisms and prevention of port-site tumor recurrence after laparoscopy in a murine model

BACKGROUND/PURPOSEnAlthough minimally invasive surgery (MIS) has been broadly applied in patients with cancer of the gastrointestinal tract, the etiology of port-site tumor recurrence (PSR) after laparoscopic cancer surgery remains unclear. The authors report here an analysis of PSR in a model of murine neuroblastoma after laparoscopic tumor biopsy and propose a mechanism for this complication as well as a potential treatment.nnnMETHODSnImmature 5- to 7-week old male A/J mice (18-23 g) were subcutaneously inoculated with the minimally immunogenic TBJ-neuroblastoma (TBJ-NB) in the left flank and divided into three treatment groups. The following operations were performed 14 days after tumor inoculation: group 1, additional intraperitoneal or intravenous injection of TBJ-NB during CO2 pneumoperitoneum; group 2, simulated transperitoneal tumor biopsy using MIS techniques during either CO2 pneumoperitoneum or gasless suspension; Group 3, intraperitoneal (IP) or intravenous (IV) administration of cyclophosphamide on postoperative days 0 and 3 to prevent PSR after simulated tumor biopsy during CO2 pneumoperitoneum.nnnRESULTSnIn group 1, the incidence of PSR was 0% in the intravenously injected mice versus 63% in mice injected intraperitoneally with TBJ-NB. In group 2, no significant difference in the incidence of PSR was seen between simulated tumor biopsy (89%) animals with CO2 pneumoperitoneum versus animals with gasless suspension (81%). In group 3, mice that did not receive any chemotherapy had an 89% incidence of PSR. Administration of cyclophosphamide via either the IP or IV route effectively prevented PSR, although there was no difference in the incidence of PSR between the two routes (IP 12% versus IV 13%).nnnCONCLUSIONSnThe data suggest that PSR in tumor-bearing hosts may be caused by direct seeding of exfoliated tumor cell, and not by hematogenous metastases. Contrary to the other reports, CO2 pneumoperitoneum was not found to be essential for the development of PSR. Furthermore, the authors conclude that postoperative chemotherapy may be useful in preventing PSR after MIS in patients bearing chemotherapy-sensitive tumors such as neuroblastoma.

Frequency and Variety of Inpatient Pediatric Surgical Procedures in the United States

OBJECTIVE: Pediatric surgical procedures are being performed in a variety of hospitals with large differences in surgical volume. We examined the frequency and variety of inpatient pediatric surgical procedures in the United States by hospital type and geographic region using a nationally representative sample. METHODS: The 2009 Kids’ Inpatient Database for patients <18 years old was used to calculate surgical frequencies by using International Classification of Diseases, Ninth Revision, Clinical Modification, (ICD-9-CM) codes. We performed stratified analysis by hospital type (free-standing children’s hospital, children’s unit within an adult hospital, and general hospital) and geographic region (South, West, Midwest, Northeast) to compare frequencies of surgical procedures. RESULTS: A total of 216u2009081 procedures were projected for 2009 with the top 20 procedures accounting for >90% of cases. As many as 40% of all pediatric inpatient surgical procedures are being performed in adult general hospitals. Infrequent complex low-volume neonatal surgical procedures (pullthrough for Hirschsprung disease, surgery for malrotation, esophageal atresia repair, and diaphragmatic hernia repair) were 6.8 to 16 times more likely to occur in a childrens hospital. Significant regional variation in procedure frequency rates occurred for appendectomy and cholecystectomy. CONCLUSIONS: This report is the first to characterize pediatric surgical inpatient volume in the United States. Such data may influence the distribution of pediatric surgeons, number of trainees, and training curricula for pediatric surgeons, pediatricians, general surgeons and other surgical specialists who might operate on children. In addition, it raises the question of whether complex pediatric surgical procedures should preferably be performed at dedicated high volume childrens hospitals.

Management of the Short Bowel Syndrome in the Pediatric Population

The short bowel syndrome in the pediatric population most commonly results from neonatal necrotizing enterocolitis. Multiple remedial surgical procedures have been developed to manage the rapid intestinal transit, decreased mucosal surface area, ineffective peristalsis, and short intestinal length in these patients. Despite significant morbidity, the overall outcome is favorable and warrants aggressive nutritional support, medical management, and surgical intervention in selected patients.

A comparative review of the immunobiology of murine neuroblastoma and human neuroblastoma

The prognosis for children with neuroblastoma (NB) remains dismal, in part because of extent of disease at diagnosis as well as resistance of tumors to conventional therapies. However, human NB exhibits many favorable traits, including the capability to mature into a more benign form or to regress spontaneously. A murine model of disease that could permit eventual genetic manipulation, so that such beneficial traits could be identified or even augmented, would be most useful.

Surgical outcomes research: a progression from performance audits, to assessment of administrative databases, to prospective risk-adjusted analysis – how far have we come?

Purpose of review This review focuses on how the assessment of surgical quality and safety has evolved from individual performance audits and morbidity and mortality reviews, to assessment of large administrative databases, to the current practice of prospective risk-adjusted analysis by a National Surgical Quality Improvement Program for childrens surgical care. This evolution follows the natural availability of surgical outcome data and a national call for improved hospital care safety and quality. Recent findings Two new advances in childrens surgical care include the comparative use of national health record data compiled in administrative datasets and the use of a risk-adjusted assessment of childrens surgical morbidity and mortality as assessed by a newly developed National Surgical Quality Improvement Program for childrens operative care. The value and application of these two datasets are presented. Summary The evolution of the assessment of surgical quality and safety will equip the surgeon with an optimal array of outcome assessment tools to assure the best in surgical quality and safety for the pediatric patient.

Anti-reflux gastrointestinal surgery in the neurologically handicapped child

The frequent requirement for gastrointestinal feeding tubes in the mental-motor retarded (MMR) child has become a relative indication for concomitant anti-reflux surgery in many pediatric surgical centers. The need for the addition of this relatively morbid procedure to simple feeding tube placement remains controversial. To analyze the role of anti-reflux surgery in the MMR child, we reviewed our experience with enteral feeding access procedures and anti-reflux procedures. A total of 76 feeding access procedures (71 gastrostomies) and 98 anti-reflux procedures were performed. All patients were thoroughly evaluated for the presence of reflux preoperatively. The presence of asymptomatic reflux prior to feeding tube placement was not predictive of subsequent need for fundoplication. Only 3 of 71 patients with gastrostomies (4.2%) ultimately required fundoplication. Of 106 MMR children in this series, 48 had an anti-reflux operation with their feeding gastrostomy while 58 had a primary feeding tube alone, 2 of which were jejunostomies. Although 2 children in the gastrostomy group later required fundoplication for uncontrolled GER, the other 54 were managed without an anti-reflux procedure. Our experience does not support the routine performance of concomitant anti-reflux surgery with feeding tube placement in the MMR child and argues for a conservative approach to feeding access. Fundoplication should be reserved for those children with a clinical indication for an anti-reflux operation.