Richard Sola

Can ultrasound reliably identify complicated appendicitis in children

BACKGROUNDnThe ability of ultrasound to identify specific features relevant to nonoperative management of pediatric appendicitis, such as the presence of complicated appendicitis (CA) or an appendicolith, is unknown. Our objective was to determine the reliability of ultrasound in identifying these features.nnnMETHODSnWe performed a retrospective study of children who underwent appendectomy after an ultrasound at four childrens hospitals. Imaging, operative, and pathology reports were reviewed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ultrasound for identifying CA based on pathology and intraoperative findings and an appendicolith based on pathology were calculated. CA was defined as a perforation of the appendix. Equivocal ultrasounds were considered as not indicating CA.nnnRESULTSnOf 1027 patients, 77.5% had simple appendicitis, 16.2% had CA, 5.4% had no evidence of appendicitis, and 15.6% had an appendicolith. Sensitivity and specificity of ultrasound for detecting CA based on pathology were 42.2% and 90.4%; the PPV and NPV were 45.8% and 89.0%, respectively. Sensitivity and specificity of ultrasound for detecting CA based on intraoperative findings were 37.3% and 92.7%; the PPV and NPV were 63.4% and 81.4%, respectively. Sensitivity and specificity of ultrasound for detecting an appendicolith based on pathology were 58.1% and 78.3%; the PPV and NPV were 33.1% and 91.0%, respectively. Results were similar when equivocal ultrasound and negative appendectomies were excluded.nnnCONCLUSIONSnThe high specificity and NPV suggest that ultrasound is a reliable test to exclude CA and an appendicolith in patients being considered for nonoperative management of simple appendicitis.

Standardized reporting of appendicitis-related findings improves reliability of ultrasound in diagnosing appendicitis in children

PURPOSEnOur objective was to increase ultrasound reliability for diagnosing appendicitis in an academic childrens hospital emergency department (ED) through a multidisciplinary quality improvement initiative.nnnMETHODSnA retrospective review of ultrasound use in patients diagnosed with appendicitis in our ED from 1/1/2011 to 6/30/2014 established a baseline cohort. From 8/1/2014 to 7/31/2015 a diagnostic algorithm that prioritized ultrasound over CT was used in our ED, and a standardized template was implemented for the reporting of appendicitis-related ultrasound findings by our radiologists.nnnRESULTSnOf 627 patients diagnosed with appendicitis in the ED during the retrospective review, 46.1% (n=289) had an ultrasound. After implementation of the diagnostic algorithm and standardized ultrasound report, 88.4% (n=236) of 267 patients diagnosed with appendicitis had an ultrasound (p<0.01). The frequency of indeterminate results decreased from 44.3% to 13.1%, and positive results increased from 46.4% to 66.1% in patients with appendicitis (p<0.01). The sensitivity of ultrasound (indeterminate counted as negative) increased from 50.6% to 69.2% (p<0.01).nnnCONCLUSIONSnUltrasound reliability for the diagnosis of appendicitis in children can be improved through standardized results reporting. However, these changes should be made as part of a multidisciplinary quality improvement initiative to account for the initial learning curve necessary to increase experience.nnnLEVEL OF EVIDENCEnLevel II, Study of Diagnostic Test.

Magnet foreign body ingestion: rare occurrence but big consequences

PURPOSEnTo review the outcomes of magnet ingestions from two childrens hospitals and develop a clinical management pathway.nnnMETHODSnChildren <18years old who ingested a magnet were reviewed from 1/2011 to 6/2016 from two tertiary center childrens hospitals. Demographics, symptoms, management and outcomes were analyzed.nnnRESULTSnFrom 2011 to 2016, there were 89 magnet ingestions (50 from hospital 1 and 39 from hospital 2); 50 (56%) were males. Median age was 7.9 (4.0-12.0) years; 60 (67%) presented with multiple magnets or a magnet and a second metallic co-ingestion. Suspected locations found on imaging were: stomach (53%), small bowel (38%), colon (23%) and esophagus (3%). Only 35 patients (39%) presented with symptoms and the most common symptom was abdominal pain (33%). 42 (47%) patients underwent an intervention, in which 20 (23%) had an abdominal operation. For those undergoing abdominal surgery, an exact logistic regression model identified multiple magnets or a magnet and a second metallic object co-ingestion (OR 12.9; 95% CI, 2.4 - Infinity) and abdominal pain (OR 13.0; 95% CI, 3.2-67.8) as independent risk factors.nnnCONCLUSIONnMagnets have a high risk of requiring surgical intervention for removal. Therefore, we developed a management algorithm for magnet ingestion.nnnLEVEL OF EVIDENCEnLevel III.

Are Foley catheters needed after minimally invasive repair of pectus excavatum

Background. High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice. Materials and Methods. We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic childrens hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI). Results. Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient‐controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter. Conclusion. Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement.

Outcomes of circumcision in children with single ventricle physiology

PurposeChildren with single ventricle physiology (SVP) have been shown to have a high morbidity and mortality after non-cardiac surgical procedures. Elective circumcision is one of the most common pediatric operations with low morbidity and mortality. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine peri-operative course and outcomes.MethodsWe performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with non-single ventricle physiology or children undergoing circumcision in combination with another case were excluded. Demographics, surgical characteristics, and outcomes were analyzed. Descriptive statistics were performed, all medians were reported with interquartile range.Results15 males underwent elective circumcision with a median age at the time of surgery of 1.13 (1.03, 1.38) years. Eighty-four percent underwent their circumcision after their 2nd stage cardiac operation. Most common operative indication was uncomplicated phimosis. Median operative time was 20 (16, 27)xa0mins. Median total length of stay was 229 (185, 242)xa0mins with no admissions. Post-operative complications included two (16%) hematomas with one requiring surgical intervention. There were no deaths.ConclusionChildren with SVP who undergo elective circumcision may have a higher risk of bleeding.

Battery ingestions in children: Variations in care and development of a clinical algorithm

PURPOSEnTo review current management and outcomes of ingested batteries and develop a clinical management algorithm.nnnMETHODSnChildren <18years old who ingested a battery between 1/2011 and 9/2016 at two tertiary care childrens hospitals were reviewed. Demographics, imaging, management and outcomes were analyzed using descriptive statistics, Chi-square and Wilcoxon Rank-sum tests.nnnRESULTSnThere were 180 battery ingestions. The median age was 3.9 (range 0.7-18) years, with 78 (43%) males. The most common symptoms were abdominal pain (17%) and nausea/vomiting (14%). Diagnosis was confirmed with plain radiographs in 170 (94%) patients. Locations on imaging were: stomach (37%), small bowel (24%), esophagus (18%), colon (11%), and non-specific location past the gastroesophageal junction (9%). Treatment was dictated by five different subspecialties including surgery (35%), gastroenterology (25%), emergency medicine (19%), primary care/emergency with a consulting service (13%), and otolaryngology (8%). All esophageal batteries (n=33) had an intervention. Interventions included fluoroscopic balloon extraction (6 attempted, 33% retrieval rate), rigid esophagoscopy (26 attempted, 96% retrieval rate), and EGD (6 attempted, 83% retrieval rate). For batteries distal to the gastroesophageal junction 16 (11%) patients had an intervention. Interventions included EGD (13 patients, 69% retrieval), colonoscopy (1 patient, successful retrieval), and abdominal surgery in two patients.nnnCONCLUSIONnIsolated batteries that pass the gastroesophageal junction rarely require intervention and can be managed conservatively. Given the variability in managing these patients, we developed an evidence based algorithm.nnnLEVEL OF EVIDENCEnLevel 2.nnnSTUDY TYPEnRetrospective Study.

Foley catheters are not routinely necessary in children treated with patient-controlled analgesia following perforated appendicitis

BACKGROUNDnPatient-controlled analgesia (PCA) is often used in children with perforated appendicitis. To prevent urinary retention, some providers also routinely place Foley catheters. This study examines the necessity of this practice.nnnMETHODSnWe retrospectively reviewed all children (≤18u202fyears old) with perforated appendicitis and postoperative PCA from 7/2015 to 6/2016 at two academic childrens hospitals. Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley catheter.nnnRESULTSnOf 313 patients who underwent appendectomy for perforated appendicitis (Hospital 1: 175, Hospital 2: 138), 129 patients received an intraoperative Foley (Hospital 1: 22 [13%], Hospital 2: 107 [78%], pu202f<u202f0.001). Age, gender, and BMI were similar between those with an intraoperative Foley and those without. There were no urinary tract infections in either group. Urinary retention rate in patients with an intraoperative Foley following removal on the inpatient unit (nu202f=u202f3, 2%) and patients without an intraoperative Foley (nu202f=u202f10, 5%) did not reach significance (pu202f=u202f0.25). On univariate analysis, demographics, intraoperative findings, PCA specifics, postoperative abscess formation, and postoperative length of stay, were not significant risk factors for urinary retention.nnnCONCLUSIONSnThe risk of urinary retention in this population is low despite the use of PCA. Children with perforated appendicitis do not require routine Foley catheter placement to prevent urinary retention.nnnLEVEL OF EVIDENCEnII.

Transabdominal Versus Subcuticular Sutures to Secure a Laparoscopic Gastrostomy

PURPOSEnTraditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques.nnnMETHODSnA retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications.nnnRESULTSnA total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, Pu2009<u2009.05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, Pu2009<u2009.05) and abscess (0.8% versus 7.6%, Pu2009<u2009.05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (Pu2009<u2009.05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups.nnnCONCLUSIONnWhile both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

Abdominal Exploration in Neonates Using Transumbilical Exposure Compared with Transverse Laparotomies

INTRODUCTIONnThe vertical transumbilical incision (TU) technique during neonatal abdominal exploration involves dissection and ligation of umbilical vessels, which allow access to all quadrants of the abdomen and complete bowel evisceration with minimal violation to the anterior abdominal wall. We compared patient characteristics and outcomes for neonates undergoing TU with standard transverse exploration.nnnMATERIALS AND METHODSnA single-center retrospective review of neonates who underwent abdominal exploration between January 2010 and September 2015 was conducted after obtaining Institutional Review Board approval. Data included patient demographics, indication for operative intervention, operative details, complications, including incisional hernias, and long-term outcomes.nnnRESULTSnThere were 88 neonates under 4 months of age who underwent abdominal exploration, with a median age of 5.5u2009±u200917 days and a median gestational age of 32.8u2009±u200916 weeks. Exploration was emergent in 38 patients (43%) and 49 (56%) required ostomy formation. A transverse incision (TV) was used in 30 patients and a TU in 58 patients. Both groups had similar postoperative complication rates; 27 (47%) in the TU group and 11 (36%) in the TV group, Pu2009=u2009.51. Median length of follow-up in the TU group was 5.1u2009±u200918 months and 6.2u2009±u200916 months in the TV group, Pu2009=u2009.48. The TU group had 4 incisional/umbilical hernias (7%), none have required repair.nnnCONCLUSIONnTUs for abdominal explorations in neonates have similar outcomes as the standard TV while preserving the integrity of the anterior abdominal wall.

Non-Accidental Trauma: A National Survey on Management

INTRODUCTIONnNon-accidental trauma (NAT) has significant societal and health care implications. Standardized care has been shown to improve outcomes. The purpose of our study was to survey trauma centers and elucidate the continued variable management of NAT.nnnMETHODSnAfter institutional review board approval, an email survey was sent to Level 1 and 2 ACS verified trauma centers along with general and pediatric surgery training programs. Trauma hospital characteristics and NAT management were analyzed.nnnRESULTSnA total of 493 emails were sent and 91 responses (18%) were received. There were 74 (81%) pediatric surgeons who responded and 15(17%) adult general surgeons. The most common location of respondents were childrens hospitals within academic/community hospitals (58%) followed by stand-alone children hospitals (42%), and adult only hospitals (9%). 51 (57%) providers reported using a screening tool; most commonly used by the emergency department (52%). 75% of providers reported utilizing management protocols in which 71% were initiated by trauma surgery. The most common consulting and admitting service for NAT was trauma surgery (86% and 84%). When comparing stand-alone and affiliated children hospitals, there was no difference in the use of a screening tool (54% vs. 59%; pu202f=u202f0.84), and management protocol (70% vs. 85%; pu202f=u202f0.19). However, those providers from pediatric trauma centers used a management protocol more often than providers from adult trauma centers (78% vs. 38%; pu202f=u202f0.04). No providers from adult trauma centers had intentions to initiate a management protocol in the future.nnnCONCLUSIONnScreening and management of non-accidental trauma continues to vary across the country. Future studies focusing on standardization and outreach/education to adult trauma centers is warranted.