Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was ...to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.
A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.
Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (
= .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (
= .02), preoperative suspicion for malignancy (
< .0001), larger lesion size (
< .0001), and presence of solid components (
< .0001). Preoperative findings independently associated with malignancy included increasing size (
< .0001), solid components (
= .003), and age (
< .0001).
The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.
Abstract Purpose Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based ...guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF. Methods The Midwest Pediatric Surgery Consortium conducted a multi-center, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009–2014), with a minimum one-year follow up, across 11 centers. Results 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p = 0.005). Post-operative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n = 127; 43%); anastomotic leak (n = 54; 18%); recurrent fistula (n = 15; 5%); vocal cord paralysis/paresis (n = 14; 5%); and esophageal dehiscence (n = 5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p = 0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p > 0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p < 0.001), but no difference in the incidence of recurrent fistula (p = 0.3). Empiric postoperative antibiotics for > 24 h was used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤ 24 h (all p > 0.3). Hospital volume was not associated with post-operative complication rates (p > 0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7. Conclusion Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24 h and empiric acid suppression may not prevent complications. Use of a trans-anastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine post-operative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds. Study type: Treatment study. Level III evidence.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the ...association of outpatient BT injections for early obstructive symptoms on the development of HAEC.
A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 – July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections.
Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode.
Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Gastrostomy tube (GT) dislodgement is a common reason for emergency department (ED) visits. We aim to assess the efficacy of our institution's algorithm in reducing surgical consultation and GT ...contrast studies for replacement of dislodged GT and to examine the need for operation before and after algorithm implementation.
A retrospective review was performed between March 2017-February 2018 (prealgorithm) and March 2018-December 2018 (postalgorithm) for patients <18 years presenting to the ED with GT dislodgement. Demographics and outcomes were analyzed.
A total of 433 visits among 279 patients were included, 200 (46.2%) pre and 233 (53.8%) postalgorithm implementation. Median ED LOS was 2.1 h (IQR 1.4, 3.0). Surgery was consulted in 92 visits (21.3%) and a contrast study obtained in 287 (66.3%). The GT was replaced by ED providers in 363 visits (83.8%) and by surgery in 70 (16.2%). Surgical consultation increased postalgorithm (16.5% vs. 25.3%; p = 0.03). Six (1.4%) patients required reoperation, with 5 occurring postalgorithm, p = 0.22. For GTs placed < 8 weeks prior to the dislodgment, there were no differences in surgical consultations, contrast studies performed, or need for reoperation pre and postalgorithm.
An algorithm for replacement of dislodged GT is usable, effective, and increased surgical team involvement without significant changes in patient outcomes.
Treatment Study.
Level III.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Background
The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the ...different surgical approaches and types of anastomoses for duodenal atresia repair.
Methods
Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis.
Results
A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach.
Conclusion
The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.
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NUK, OILJ, SAZU, UKNU, UL, UM, UPUK
The thoracoscopic repair of esophageal atresia with tracheoesophageal fistula is a complex neonatal minimally invasive procedure. The thoracoscopic approach is now nearing its third decade of ...experience and but is overall still not widely utilized, only in skilled centers and by experienced surgeons. This article will summarize the recent advancements in technique and knowledge in the thoracoscopic approach to this challenging neonatal congenital abnormality.
The impact of the COVID-19 pandemic on pediatric injury, particularly relative to a community's vulnerability, is unknown. The objective of this study was to describe the change in pediatric injury ...during the first 6 months of the COVID-19 pandemic compared with prior years, focusing on intentional injury relative to the social vulnerability index (SVI).
All patients younger than 18 years meeting inclusion criteria for the National Trauma Data Bank between January 1, 2016, and September 30, 2020, at nine Level I pediatric trauma centers were included. The COVID cohort (children injured in the first 6 months of the pandemic) was compared with an averaged historical cohort (corresponding dates, 2016-2019). Demographic and injury characteristics and hospital-based outcomes were compared. Multivariable logistic regression was used to estimate the adjusted odds of intentional injury associated with SVI, moderated by exposure to the pandemic. Interrupted time series analysis with autoregressive integrated moving average modeling was used to predict expected injury patterns. Volume trends and observed versus expected rates of injury were analyzed.
There were 47,385 patients that met inclusion criteria, with 8,991 treated in 2020 and 38,394 treated in 2016 to 2019. The COVID cohort included 7,068 patients and the averaged historical cohort included 5,891 patients (SD, 472), indicating a 20% increase in pediatric injury ( p = 0.031). Penetrating injuries increased (722 10.2% COVID vs. 421 8.0% historical; p < 0.001), specifically firearm injuries (163 2.3% COVID vs. 105 1.8% historical; p = 0.043). Bicycle collisions (505 26.3% COVID vs. 261 18.2% historical; p < 0.001) and collisions on other land transportation (e.g., all-terrain vehicles) (525 27.3% COVID vs. 280 19.5% historical; p < 0.001) also increased. Overall, SVI was associated with intentional injury (odds ratio, 7.9; 95% confidence interval, 6.5-9.8), a relationship which increased during the pandemic.
Pediatric injury increased during the pandemic across multiple sites and states. The relationship between increased vulnerability and intentional injury increased during the pandemic.
Prognostic and Epidemiological; Level III.
Abstract Purpose Identify injuries and outcomes from Recreational/Off-Highway Vehicles (RV/OHV) accidents at a pediatric trauma center. Methods Retrospective review of a prospective pediatric trauma ...registry was performed to identify patients sustaining injuries from a RV/OHV between January 2007 and July 2015. Vehicles included: all-terrain vehicles (ATV), dirt bikes, utility-terrain vehicles (UTV), golf carts, go-karts, and dune buggies. Results Five hundred twenty-eight patients were injured while on a RV/OHV: 269 ATV, 135 dirt bike, 42 UTV, 38 golf cart, 34 go-kart, and 10 dune buggy. The majority (n = 381, 72%) had at least one injury with an Abbreviated Injury Scale ≥ 2; 39% (n = 204) had orthopedic injuries and 22% (n = 116) had central neurologic injuries. Over three-fourths (n = 412, 78%) were admitted. For the 48% (n = 253) of patients requiring surgery, 654 surgical procedures were performed. Median hospital charge was $27,565 (IQR: $15,553–$44,935). Excluding golf carts, helmet use was 49% (n = 231); 16% (n = 76) wore protective clothing. Only 22% (n = 26) wore a restraining belt. Conclusion Severe injuries occur in children who ride RV/OHV often warranting admission and surgical intervention. Improved understanding of RV/OHV injuries may guide caregivers in decision-making about pediatric RV/OHV use and encourage use of protective gear. Level of Evidence Level II, Prognosis Study
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Purpose
COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at ...our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI).
Methods
A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded.
Results
Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation.
Conclusion
Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
We report a prospective randomized trial comparing primary closure (PC) to bedside silo and delayed closure (DC) for babies with gastroschisis.
Patients were randomized to PC versus DC. We excluded ...those with atresia/necrosis, <34 weeks' gestation, or congenital anomalies. The primary outcome was length of stay (LOS).
A total of 38 patients were included from August 2011 to August 2016; 18 patients underwent DC and 20 PC. There were no differences in gestational age or birth weight. Fifty percent of PC patients were successfully closed with the rest closed at a median of 4 days (interquartile range IQR: 2-4 days). DC patients were closed at a median of 4 days after silo placement (IQR: 2-5.8 days). None of the patients in this series developed abdominal compartment syndrome after closure. Median LOS, median time to enteral tolerance, and median time on ventilation were not statistically different. Two patients (one DC and one PC) had bowel ischemia and necrosis following silo placement requiring reoperation. Four patients (two DC and two PC) were noted to have small umbilical defects; none have yet required operative correction.
There were no differences seen between PC and DC in LOS, time to enteral feeds, or ventilator times.
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