Robert S. Sawin

Early recognition of neonatal abdominal wall necrotizing fasciitis

Necrotizing fasciitis (NF) of the abdominal wall occurring in newborns is associated with a 50% mortality rate. Improved survival requires early diagnosis followed by aggressive surgical débridement. During a 10-year period, we treated 7 infants who developed NF. During the same period, 32 infants were admitted with omphalitis that did not progress to NF. The patients with omphalitis and those with NF were compared. Tachycardia, abnormal white blood cell counts, induration, and violaceous skin discoloration were seen exclusively in the NF patients. Polymicrobial infections were documented in 28% of the omphalitis patients and 86% of the NF patients. All omphalitis patients survived, whereas 5 of 7 (71%) NF patients died. Adjuvant hyperbaric oxygen therapy was used for 4 infants with NF, 2 of whom survived (50%). NF is a highly morbid disease, that can be distinguished from other infant abdominal wall infections by the skin changes, white blood cell counts, heart rate, and microbiologic results. Prompt diagnosis of NF improves survival when combined with aggressive surgical débridement.

Minimally invasive surgery and clinical decision-making for pediatric malignancy.

AbstractBackground: Minimally invasive surgery (MIS) is an ideal way to obtain biopsy specimens in children with cancer. We examined the safety, reliability and outcome of decisions made based on tissue obtained using MIS. Methods: Fifty-nine oncology patients underwent 62 MIS procedures between January 1994 and July 1998. Complications, biopsy results, and outcomes were reviewed. Results: The study population comprised 32 boys and 27 girls, with an average age of 8.8 years. There were 47 thoracoscopic and 15 laparoscopic operations. Laparoscopic procedures included initial biopsy, determination of resectability, and second-look exam. Thoracoscopic procedures included 40 lung biopsies and seven biopsies/resections of mediastinal masses. Diagnostic accuracy was 100% in all cases. No patient was found retrospectively to have been inadequately treated based on decisions made from tissue obtained by MIS. Conclusion: MIS is a safe and accurate means of obtaining tissue in pediatric oncology patients. Treatment decisions can be made accurately and with confidence using these techniques.

Do antireflux operations decrease the rate of reflux-related hospitalizations in children?

OBJECTIVE. Gastroesophageal reflux disease is extremely common in the pediatric population, and antireflux procedures are performed with increasing frequency. The objective of this study was to determine whether pediatric antireflux procedures are associated with a decreased rate of reflux-related hospitalizations. METHODS. A study was conducted of pediatric patients who were undergoing antireflux procedures using data that were derived from the Washington State Comprehensive Hospital Abstract Reporting System and Vital Records. Patients were identified by a search of all records (1987–2001) for procedure codes that pertained to antireflux procedures in patients who were younger than 19 years. The number of hospitalizations for and rates of reflux-related events per patient-year before and after an antireflux procedure was calculated, and factors that were associated with higher antireflux procedure rates were examined. RESULTS. A total of 1142 patients underwent antireflux procedures. The rate of reflux-related events declined sharply with age both before and after an antireflux procedure. The cohort was divided into 3 groups on the basis of age at first antireflux procedure (<1 year, 1–3 years, or 4–19 years), and the calculations of incidence rate ratios before to after an antireflux procedure were done within the same age strata. Results suggest an overall benefit of antireflux procedures in young children. For antireflux procedures that were performed in children who were older than 4 years, the benefit is less clear. Developmental delay was significantly associated with higher rates of reflux-related events among patients who underwent an antireflux procedure after age 4. CONCLUSIONS. The rate of reflux-related events was lower after an antireflux operation for children who underwent an antireflux procedure before age 4. Older children, however, were hospitalized at equal rates before and after an antireflux procedure, and older children with developmental delay were hospitalized at greater rates after an antireflux procedure. These findings highlight the need to clarify the subjective and objective indications for antireflux procedures in infants and children.

Necrotizing enterocolitis in term neonates.

Necrotizing enterocolitis (NEC) is usually a disease of premature infants, but occasionally it affects the term neonate. A 5-year review of NEC at Childrens Hospital and Medical Center identified the unique features of this disease in the term neonate. Eighty-one patients with NEC were treated between January 1984 and May 1989. Ten full-term neonates with gestational age greater than 38 weeks were identified for study. Charts were reviewed for recognized risk factors, clinical course, surgical intervention, and outcome. Ninety percent had a birth weight greater than or equal to 2.7 kg, and all were above 2.1 kg. NEC developed early in this group, with onset of disease in the first 48 hours of life in 50% of the group and within the first 4 days of life in 90%. The recognized risk factors of asphyxia, hypoglycemia, polycythemia, and respiratory distress were absent in 60%. Seven of 10 patients required exploratory laparotomy, whereas 3 of 10 required only medical treatment. Indications for operation were perforation in three patients, peritonitis in three patients, and mass in one patient. All patients requiring operations had severe colonic disease, with perforation of the colon in five of seven and full-thickness necrosis without perforation in two of seven. Two patients required total abdominal colectomy. Only one patient with perforated meconium ileus and associated NEC had small bowel involvement. This patient was the only mortality of the group. Subsequent intestinal continuity was restored in all surviving patients with no late complications. Two patients required resection of additional NEC strictures prior to reanastomosis. Of the three medically treated patients, none required subsequent operation for colonic stricture. Our experience indicates that the presentation, clinical course, and operative findings in full-term neonates with NEC differ from those encountered in the premature infant with NEC.

Application of lean methods improves surgical clinic experience

BACKGROUND A quality visit in high volume surgery clinics is challenging. There is variability in numbers of patients seen and care provider behavior. Documentation, regulatory and compliance issues and computerization of patient care systems may decrease clinic efficiency and throughput. We tried to reduce variability and improve patient experience. METHODS Baseline data included: patients seen, time in exam rooms, and spent with providers, and patient satisfaction surveys. Two Rapid Process Improvement Workshops (RPIWs) were conducted to apply lean methods. 5S techniques helped standardize exam rooms. Similar data were collected at 30 days, 60 days, and 1 year. Satisfaction surveys were followed at 6 months and 1 year. RESULTS Median pre-RPIW room time was 49 minutes. Post-RPIW times were 33 minutes at 30 days, 41 minutes at 60 days, and 42 minutes at 1 year. Face to face provider-patient time increased 30% to 61% at 30 days, 58% at 60 days, and 59% at 1 year. The median number of patients in a 4-hour clinic increased from 10 to 12. Satisfaction survey Problem Scores improved and were sustained. CONCLUSIONS Lean methodology may be used to improve clinic efficiency as well as patient and staffs experience.

Improved long-term outcome for patients with jejunoileal apple peel atresia

BACKGROUND/PURPOSE Although apple peel intestinal atresia is a rare lesion associated with significant morbidity and high mortality, the authors have seen no deaths since 1983. Similar success has rarely been reported, and there are no reports of long-term follow-up. This study examines the short-term and long-term complications and outcome for these children, critiques our evolution in care, and gives current recommendations for therapy. METHODS A retrospective review of 12 patients over 11 years was conducted. Perinatal history and operative and perioperative management were examined and end results and complications using different management plans compared. Long-term outcome was determined through clinic follow-up. RESULTS Mean follow-up was 5.1 years. Children had a mean 61.4 cm of total small bowel. Seven patients underwent a primary anastomosis and five had enterostomies. The proximal jejunum was tapered, plicated, resected or left intact. Eleven children required gastrostomy tubes. All children required total parenteral nutrition. Full enteral feeding was achieved in all children, but three required gastrostomy supplementation. Three patients who had enterostomies suffered bowel obstruction, two with dilated, dysmotile proximal jejunum required subsequent tapering. Eight children maintained a growth curve between the 5th and 50th percentile. None have short bowel physiology, and all have achieved acceptable bowel function. CONCLUSIONS (1) Total parenteral nutrition is essential for initial nutritional management. (2) Use of an enterostomy leads to an increased incidence of complications. (3) The dilated proximal bowel should be resected, tapered, or plicated, and a primary anastomosis should be performed. (4) Gastrostomy tubes are necessary for initial management. (5) Early morbidity is common, though excellent long-term outcome and normal growth and development are expected.

Needle localization for thoracoscopic resection of small pulmonary nodules in children

BACKGROUND Children who have malignant disease and pulmonary nodules frequently need a tissue diagnosis to direct therapy. Computed tomography (CT)-guided needle localization and methylene blue marking allow thoracoscopic resection of nonvisible nodules. METHODS Malignant disease was diagnosed in three patients aged 2, 2.5, and 11 years. Pulmonary nodules seen on chest CT, representing either metastatic disease or infection developed in each patient. All lesions were 1 to 2 cm deep to the pleural surface, precluding thoracoscopic visualization. A Homer mammographic needle was placed near the lesion using CT guidance under general anesthesia. The pleura overlying the lesion was also marked with methylene blue. Under the same anesthetic, patients went to the operating room where the lesions were thoracoscopically resected. RESULTS Needle localization and methylene blue staining accurately localized the lesion in all cases. Thoracoscopic resection provided a diagnosis of metastatic disease or infection in all cases. There were no complications. CONCLUSION CT-guided needle localization of pulmonary lesions deep to the pleural surface, is a safe, accurate method for allowing thoracoscopic resection in these children who would otherwise need open thoracotomy for diagnosis.

Adrenocortical insufficiency in infants with congenital diaphragmatic hernia: A pilot study

BACKGROUND/PURPOSE Prior reports have documented that premature infants do not have normal serum levels of cortisol. In contrast, full-term infants usually have adequate cortisol levels. The stress response in critically ill infants may be vital to their recovery. The purpose of this pilot study was to determine whether critically ill full-term infants with congenital diaphragmatic hernia (CDH) show a subnormal adrenal stress response. METHODS Random serum cortisol levels in infants with CDH (n = 10) were measured using fluorescent polarization immunoassay. In addition, serum cortisol levels were measured after exogenous adrenocorticotropic hormone stimulation (Cosyntropin stimulation test). RESULTS Six of the 10 infants studied died. Most (79%) of the cortisol levels were subnormal (<7 microgm/dL). Although no significant differences in mean cortisol levels from terminally ill infants compared with surviving infants were detected, survivors tended to have higher cortisol levels. Cosyntropin stimulation resulted in inappropriately low cortisol levels in 2 of the 4 fatally ill patients tested (<30 microgm/dL) and normal responses in the 2 survivors tested. CONCLUSIONS Infants born with CDH may have an inadequate adrenal stress response despite a life-threatening anomaly. A large-scale prospective study may be warranted to confirm this apparent association. Corticosteroid therapy may be beneficial in this population of patients.

Thoracoscopic repair of congenital diaphragmatic hernia in infancy.

BACKGROUND Minimally invasive surgical techniques, specifically the thoracoscopic approach, have been applied to congenital diaphragmatic hernia (CDH) with varying outcomes from selected centers. The aim of our study was to examine the rate of successful completion and compare outcomes between open and thoracoscopic approaches in CDH repair. METHODS We performed a retrospective analysis of infants with CDH repair (From February 2004 to January 2008). Patients were divided into thoracoscopic and open groups, based on operative approach. We analyzed demographic, clinical, and hospitalization characteristics to compare the completion rate and outcomes in these two groups. RESULTS Analysis of 31 infants with CDH (14 thorascocopic and 17 open) demonstrated no differences in sex (P = 0.132), age (P = 0.807), birthweight (P = 0.256), weight at operation (P = 0.647), pulmonary hypertension (P = 0.067), preoperative intensive care unit (ICU) days (P = 0.673), ventilator days (P = 0.944), or use of a patch (P = 0.999) between the groups. Seventy-nine percent of thoracoscopic operative approaches were completed successfully. There was a significant difference between the open and thoracoscopic groups with respect to estimated gestational age (39 versus 36.5 weeks; P = 0.006) and operating room time (70 versus 145 minutes; P = 0.004). The total (P = 0.662), ICU (P = 0.889), and postoperative (P = 0.619) length of stay and days on ventilator (P = 0.705), as well as days until initial enteral feeds (P = 0.092), were not significantly different between groups. There were no deaths and no evidence of recurrence, with a mean follow-up of 346 days. CONCLUSIONS In our early experience, the thoracoscopic approach for congenital diaphragmatic hernia repair was completed in 80% of our patient population with minimal exclusion criteria. Further study, with larger sample sizes, is needed to ascertain differences in outcomes, such as length of stay and initiation of enteral feeding.

Standardization of operative equipment reduces cost

BACKGROUND We hypothesize that standardizing operative equipment, and reducing variability can safely achieve cost reduction. METHODS We retrospectively measured supply costs, operative time, intra-operative complications, and length of stay in a cohort of 145 patients at a childrens hospital who underwent a laparoscopic appendectomy. A standardized preference card for laparoscopic appendectomy was developed and implemented. Data were prospectively collected on 101 consecutive patients and compared to the retrospective cohort using multiple linear regression. A survey assessing the perception of surgeons, nurses and scrub technologists of the impact of standardization on patient safety, patient care, OR efficiency, and cost was conducted. Wilcoxon rank sum test was used to evaluate associations between clinical role and years of experience with the total level of agreement on the survey. RESULTS A 20% average reduction was achieved in supply cost per case, with no significant change in operative time (p=0.14), total time in OR (p=0.15), or length of stay (p=0.60). No intra-operative complications were identified in either group. Survey participants agreed that standardization improves cost and safety. Nurses tended to have greater agreement that standardization improved efficiency and patient care compared to other roles (p=0.06). CONCLUSIONS Standardization of operative equipment can result in a significant cost reduction without impacting quality or delivery of care. Based on average case number per year, a total annual cost savings of >