Steven Stylianos

Evidence-based guidelines for resource utilization in children with isolated spleen or liver injury

Abstract Purpose: This study is intended to resolve the disparity and reach consensus on issues regarding the treatment of children with isolated spleen or liver injuries. To maximize patient safety and assure efficient, cost-effective utilization of resources, it was essential to determine current practice. Methods: Data from the case records of 856 children with isolated spleen or liver injury treated at 32 pediatric surgical centers from July 1995 to June 1997 were collected. The severity of injury was classified by computed tomography (CT) grade and the data analyzed for intensive care unit (ICU) stay, length of hospital stay, transfusion requirement, need for operation, pre- and postdischarge imaging, and restriction of physical activity. Patients with grade V injuries (2.8%) were excluded leaving 832 patients for detailed review. These data and available literature were analyzed for consensus by the 1998 APSA Trauma Committee. Results: Resource utilization increased with injury severity (see Table 2). Based on the data analysis, literature search, and consensus conference, the authors propose guidelines (see Table 3) for the safe and optimal utilization of resources in routine cases. It is important to emphasize that no recommendation falls outside the 25th percentile of current practice at participating centers. Conclusions: Diversity of treatment, with attendant variation in resource utilization in children with isolated spleen and liver injury of comparable severity is confirmed. This analysis has stimulated a prospective outcomes study with the objective of validating the evidence-based guidelines proposed. This evidence-based study design can bring order and conformity to patient management resulting in optimal utilization of resources while maximizing patient safety. J Pediatr Surg 35:164-169. Copyright

Evidence-based practice in pediatric surgery

BACKGROUND/PURPOSEnThe current medical environment demands the provision of quality healthcare at an affordable cost. Both payors and regulators are committed to lowering cost through initiation of best practice strategies that include practice guidelines, clinical pathways, and standards of care. The only practical way to join this debate is through the use of objective, unbiased clinical data. This study was undertaken to review the current state of the pediatric surgery literature and its value in determining best clinical practice.nnnMETHODSnThe National Library of Medicine Medline database was accessed using the Ovid Internet client software. All references, abstracts, and keyword indexes from the core pediatric surgery literature, the Journal of Pediatric Surgery, the European Journal of Pediatric Surgery, Pediatric Surgery International, Zeitschrift fur Kinderchirurgie, and Seminars in Pediatric Surgery were downloaded and reviewed. Search criteria were defined to identify prospective, randomized, controlled studies. References were then categorized as case reports; retrospective case series; prospective case series; randomized, controlled studies; laboratory studies; review articles; or miscellaneous studies.nnnRESULTSnAs of March 1, 1998, there are 9,373 references, excluding citations of letters or comments, contained in the core pediatric surgery literature, as provided through Medline. Of these, 485 were identified as studies for review, possible prospective case series or prospective, randomized, controlled studies. After review, 34 studies (0.3%) were classified as prospective, randomized, controlled studies, whereas 139 (1.48%) were classified as prospective studies. There were 3,241 (34.6%) case reports, 5,619 (59.9%) retrospective case series, 1,109 (11.8%) laboratory studies, 195 (2.1%) review articles, and 36 (0.3%) miscellaneous studies that did not fit into other categories. When analyzed by decade of publication, prospective studies and prospective, randomized, controlled studies (n = 173) numbered 103 in the 1990s, 63 in the 1980s, and seven in the 1970s.nnnCONCLUSIONSnThere is a paucity of scientifically rigorous data on which to base clinical practice in pediatric surgery. The increasing numbers of prospective, case-controlled studies or the more sound prospective, randomized, controlled trials in the 1990s suggests that pediatric surgeons are aware of the need to generate unbiased data to support current clinical practice and the development of practice guidelines. Limitations exist in conducting prospective, randomized, controlled trials because of the rare nature of many pediatric surgical conditions and the lack of clinical equipoise over available treatment options. The authors encourage the use of multiinstitutional trials and the prospective, randomized, controlled study methodology to develop data that can be used to guide clinical practice in our evolving healthcare environment.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis

BACKGROUND/PURPOSEnThis study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery.nnnMETHODSnAfter institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis.nnnRESULTSnLaparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%).nnnCONCLUSIONnRoutine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

Laparoscopy for Diagnosis and Treatment of Recurrent Abdominal Pain in Children

Extensive radiographic evaluation of children with recurrent abdominal pain (RAP) is rarely diagnostic or cost-effective. The authors sought to define the role of laparoscopy in the evaluation of children with RAP. Fifteen children underwent laparoscopy for RAP in a 2-year period. Their mean age was 12 years (range, 6 to 16 years), 13 (87%) were female, and the mean duration of symptoms was 11 months (range, 2 to 60 months). Thirty-eight imaging studies (excluding plain films) had been obtained before laparoscopy, including 19 abdominal sonograms, 9 upper gastrointestinal series, four abdominal computed tomography scans, 3 barium enemas, 2 isotope scans, and 1 magnetic resonance examination of the head. Only two (5%) of these studies provided an accurate diagnosis. Eleven of the 15 children (73%) had positive findings diagnosed and treated laparoscopically. These included eight appendiceal abnormalities (in six patients), three Meckels diverticula, one inguinal hernia, one urachal cyst, one para-fallopian tube cyst, and one adhesion to an appendectomy stump. Eight of 11 (73%) children with positive findings had immediate resolution of symptoms after laparoscopic treatment. Three children with pathological findings at the time of laparoscopy had persistent symptoms, which resolved completely within 4 months of the laparoscopy. Laparoscopy is an accurate technique for the evaluation and treatment of children with RAP. Its early application could provide economic benefit by eliminating many low-yield imaging studies and minimizing lost time from school.

The “all-in-one” appendectomy: quick, scarless, and less costly

BACKGROUNDnA technique for laparoscopic appendectomy (LAP APPY) that involves brief surgeon and operating room times, results in no appreciable scar, and requires few disposable supplies would be desirable.nnnMETHODSnDuring 2009, 508 children underwent LAP APPY at our institution including 398 (78%) for acute, non-perforated appendicitis. Our all-in-one operative procedure involves use of a single instrument through a side-arm viewing operative laparoscope which is inserted through a single, trans-umbilical port. Successful procedure completion rates and operative times (cut-to-close) were determined. Our data for surgeon-directed, disposable supply costs per procedure were collated by Child Health Corporation of America and compared with 2009 LAP APPY data (n = 5692) from 17 other childrens hospitals in the United States.nnnRESULTSnWe successfully completed 359 (90.2%) LAP APPY procedures using the all-in-one technique resulting in no appreciable scar. Additional ports were used in 9.8% and there were no conversions to open procedures. Median operative time for the all-in-one technique was 24 minutes (5-66 min). Our median surgeon-directed, disposable supply cost was the lowest in the study group and significantly less than the other 17 childrens hospitals (

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

166 vs

Disaster response in a pediatric field hospital: lessons learned in Haiti

748, P < .001). Median variation of supply costs among surgeons within each institution was

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy

448 (

Outcomes in pediatric trauma care

3-

Primary button gastrostomy: a simplified percutaneous, open, laparoscopy-guided technique.

870). Aggregate savings of nearly