Sandra M. Farach

Operative Findings Are a Better Predictor of Resource Utilization in Pediatric Appendicitis.

PURPOSE Post-operative management following appendectomy is dependent upon intraoperative assessment. We determined concordance between surgical and histopathologic diagnosis to better predict resource utilization in pediatric patients undergoing appendectomy. METHODS A retrospective analysis of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Based on operative findings, patients were classified as simple appendicitis (SA) or complex appendicitis (CA). RESULTS The SA group included 194 (59.5%) patients while the CA group included 132 (40.5%) patients. There were significant differences in WBC, CRP, operative time, length of stay, and 30-day complications. Seventy percent of patients with intra-operative findings of SA were found to have complex pathology while 10.6% with intra-operative findings of CA were found to have simple pathology. There is poor agreement between intra-operative findings and histopathologic findings (κ=0.173). Although 70% of patients with intra-operative findings of SA were labeled as complex pathology, 86% followed a fast track protocol (same day discharge) with a low complication rate (1.7%). CONCLUSIONS Pathology findings that overestimate the severity of disease correlate poorly with the post-operative outcomes for appendicitis. We conclude that operative findings are more predictive of clinical course than histopathologic results. This can have an impact on resource utilization planning.

Diagnostic Laparoscopy for Intraabdominal Evaluation and Ventriculoperitoneal Shunt Placement in Children: A Means to Avoid Ventriculoatrial Shunting

BACKGROUND Laparoscopic assistance for the placement of a ventriculoperitoneal shunt (VPS) has been shown to be a safe, effective, and minimally invasive approach for distal peritoneal shunt placement. The purpose of our study was to review our experience with laparoscopy for VPS placement in patients with a potential hostile abdomen. MATERIALS AND METHODS After institutional review board approval, a retrospective analysis of all patients who underwent diagnostic laparoscopy for VPS placement from March 2009 to March 2013 was performed. Patient demographics and outcomes were analyzed. RESULTS Twenty-seven patients underwent diagnostic laparoscopy for VPS placement at a mean age of 7.7 ± 6.8 years. Twenty-five patients had previous shunts placed in the peritoneum, whereas 2 underwent initial placement. Sixteen patients (59%) had undergone previous non-shunt abdominal operations. Twenty-three patients (85%) had successful peritoneal shunt placement. Distal peritoneal shunt placement was unsuccessful at the time of laparoscopy in 4 patients (15%) secondary to adhesions. Of the 23 patients who had successful peritoneal shunt placement, 57% did not require further shunt intervention, 22% underwent conversion to a ventriculoatrial shunt, 17% underwent re-externalization, and 4% required distal shunt revision. Of the 4 patients who required externalization, 3 underwent a second laparoscopic procedure with successful peritoneal shunt placement. CONCLUSIONS Diagnostic laparoscopy eliminated the need for ventriculoatrial shunt placement in 85% of patients with a potentially hostile abdomen. Sixty percent required no further shunt revision. Laparoscopic-assisted peritoneal shunt insertion is a safe, minimally invasive technique in children with the added benefit of allowing full exploration and adhesiolysis.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

BACKGROUND Regional anesthesia is commonly used in children. Our hypothesis was that percutaneous ultrasound-guided (PERC) rectus sheath blocks would result in lower postoperative pain scores compared to intraoperative (IO) rectus sheath blocks following umbilical hernia repair. METHODS A single-institution randomized blinded trial was conducted in pediatric patients undergoing elective umbilical hernia repair. The primary outcome was mean postoperative Wong-Baker pain score. Secondary outcomes included narcotic requirements and length of postoperative stay. RESULTS Fifty-eight patients were included: 28 PERC and 30 IO. Operating room time was significantly longer in the PERC group (41 vs. 35min, p<0.01). Mean postoperative pain scores (PERC-2.6 vs. IO-3.3, p=0.11), morphine equivalents intraoperatively (PERC-0 vs. IO-0.04mg/kg, p=0.29) and postoperatively (PERC-0.04 vs. IO-0.09mg/kg, p=0.17), time to first postoperative narcotic dose (PERC-30 vs. IO-22min, p=0.33, log-rank test), and postoperative length of stay (PERC-76 vs. IO-80min, p=0.44) were similar. CONCLUSION Following umbilical hernia repair in children, percutaneous ultrasound-guided and intraoperative rectus sheath blocks resulted in similar mean postoperative pain scores. There were no differences in secondary outcomes such as time to first narcotic, narcotic requirements, and length of stay. The additional resources required to complete a percutaneous ultrasound-guided rectus sheath block may not be warranted. TYPE OF STUDY Randomized controlled trial. LEVEL OF EVIDENCE Level I.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children.

BACKGROUND Single-incision laparoscopic appendectomy (SILA) is an effective treatment for appendicitis in children. We report our experience with SILA, focusing on how surgeon experience may impact quality outcomes. METHODS A retrospective review of patients who underwent SILA from August 2009 to November 2013 was performed. Patients were grouped by early experience, late experience without surgical trainees, and late experience with trainees and further stratified into simple and complex appendicitis. RESULTS SILA was performed on 703 patients with a mean age of 11.8±3.9years. Four hundred eleven (58.5%) patients were diagnosed with simple and 292 (41.5%) with complex appendicitis. There was a significant decrease in operative time between early and late groups for both simple and complex appendicitis. Following the introduction of surgical trainees, there was a significant increase in operative time compared to the late group for simple appendicitis. There were no significant differences in complication rates between any of the groups. CONCLUSION The adoption of SILA requires a significant learning curve even for the experienced laparoscopist with the potential for decreased operative times with experience. While there may be an increase in operative time with the introduction of trainees, this does not impact quality outcomes.

The modified percent depth: Another step toward quantifying severity of pectus excavatum without cross-sectional imaging

INTRODUCTION Current approaches to quantifying the severity of pectus excavatum require internal measurements based on cross-sectional imaging. This study evaluated the modified percent depth (MPD), a novel index of severity that can be obtained with external measurements, potentially avoiding the need for cross-sectional imaging. METHODS Patients undergoing surgical repair of pectus excavatum (pectus group), and those undergoing cross-sectional imaging for unrelated reasons (control group), between 2010 and 2016 were included. The MPD of the deformity was calculated using external (i.e. skin surface to skin surface) measurements from the radiographic images. The same external measurements were taken using chest calipers on a subset of these patients in the outpatient clinic. The optimal threshold for MPD that defined severe pectus deformity was derived from receiver-operator characteristic (ROC) analysis. Sensitivity and specificity of the MPD was compared with that of the Haller Index (HI) and Correction Index (CI). RESULTS There were 92 children (49 pectus, 43 controls) included. The median MPD was 20.2% and 4.2% for pectus and control patients, respectively (p<0.0001). An MPD cutoff of 10% optimally discriminated between severe pectus patients and controls by ROC analysis. An MPD of >10% had 98% sensitivity and 98% specificity for severe pectus deformity. Sensitivity and specificity were respectively 93% and 93% for HI >3.25, and 100% and 79% for CI >10. CONCLUSION An MPD >10% performs slightly better than the HI and CI in distinguishing patients with severe pectus deformities. This novel measurement approach offers distinct advantages over existing indices, in that it does not require cross-sectional imaging and can be done using chest calipers in the office setting. Further studies with larger sample size are needed to verify reproducibility of the technique. LEVEL OF EVIDENCE Level II, Study of Diagnostic Test.

Admission patterns in pediatric trauma patients with isolated injuries

BACKGROUND Pediatric trauma patients presenting with stable, isolated injuries are often admitted to the trauma service for initial management. The purpose of this study was to evaluate admission patterns in trauma patients with isolated injuries and compare outcomes based on admitting service. METHODS The institutional trauma registry was retrospectively reviewed for patients presenting from January 2007-December 2012. A total of 3417 patients were admitted to a surgical service and further reviewed. Patients with isolated injuries were further stratified by admission to the general trauma service (GTS, n = 738) versus admission to the subspecialty surgical trauma service (STS, n = 2251). RESULTS When compared to patients admitted to GTS, patients admitted to STS with isolated injuries were significantly younger, were more likely to present with injury severity scores ranging from 9-14, Glasgow coma scale ≥ 13, had shorter emergency room length of stay, were more likely to undergo surgery within 24 h, and had fewer computed tomography scans performed. There were no missed injuries in patients with isolated injuries admitted to STS (with 5% having a GTS consult) compared with one missed injury in those admitted to GTS. Patients with isolated injuries admitted to an STS were found to have significantly lower complication rates (0.6% versus 2.2%, P < 0.01). CONCLUSIONS Pediatric trauma patients presenting with stable, isolated injuries may be efficiently and safely managed by nontrauma services without an increase in missed injuries or complications.

Helicopter Transport From the Scene of Injury: Are There Improved Outcomes for Pediatric Trauma Patients?

Background There is conflicting data to support the routine use of helicopter transport (HT) for the transfer of trauma patients. The purpose of this study was to evaluate outcomes for trauma patients transported via helicopter from the scene of injury to a regional pediatric trauma center. Methods The institutional trauma registry was queried for trauma patients presenting from January 2000 through March 2012. Of 9119 patients, 1709 patients who presented from the scene were selected for further evaluation. This cohort was stratified into HT and ground transport (GT) for analysis. Associations between mode of transport and outcomes were estimated using odds ratios and 95% confidence intervals from multivariable logistic regression models. Results Seven hundred twenty-five patients (42.4%) presented via HT, whereas 984 (57.6%) presented via GT. Patients arriving by HT had a higher Injury Severity Score, lower Glasgow Coma Scale, were less likely to undergo surgery within 3 hours, more likely to present after motorized trauma, and had longer intensive care unit (ICU) and hospital length of stay (LOS). Multivariate analysis controlling for Injury Severity Score, Glasgow Coma Scale, mechanism of injury, scene distance, and time to arrive to the hospital revealed that patients arriving by HT were more likely to have longer hospital LOS compared with those arriving by GT (odds ratios = 2.3, 95% confidence interval = 1.00–5.28, P = 0.049). However, no statistically significant association was observed for prehospital intubation, surgery within 3 hours, ICU admissions, or ICU LOS. Conclusions Although patients arriving by helicopter are more severely injured and arrive from greater distances, when controlling for injuries, scene distance, and time to hospital arrival, only hospital LOS was significantly affected by HT.

Pediatric patients transferred for operative management of appendicitis: are they at a disadvantage?

PURPOSE Many pediatric patients are initially diagnosed with appendicitis at referring hospitals and are subsequently transferred to pediatric facilities. We aimed to compare outcomes of patients transferred to a pediatric referral center to those who present primarily for operative management of appendicitis. METHODS A retrospective review of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Demographic data, clinical parameters, and outcomes were analyzed. RESULTS Transferred (n=222, 68%) and primary patients (n=104, 32%) were similar except for mean age (primary 12.4 vs. transferred 11.2 years, p<0.01). Computed tomography scans were performed in 80% of transferred compared to 40% of primary patients. Primary patients were more likely to present between the hours of 09:00 and 17:59 (52%), while transferred arrived equally across all hours. Both groups were more likely to present with acute appendicitis (primary 56% vs. transfer 61%, p=NS). There was no difference in time of diagnosis to time of appendectomy, length of hospital stay, or 30 day complications (primary 8.6% vs. transfer 5.8%, p=NS). CONCLUSIONS Patients transferred for definitive care of appendicitis are not found to have more advanced disease or have increased complications; however, they are exposed to significantly more ionizing radiation during evaluation for appendicitis.