Postoperative intussusception in 10-year-old presenting as decreased intestinal motility

Postoperative intussusception is a rare surgical complication. It typically presents as bilious emesis with abdominal pain following a symptom-free period within two weeks of either intra or extra-abdominal surgery. We present the case of a 10-year-old boy who had undergone uncomplicated open appendectomy. He developed abdominal pain, bilious vomiting and tenesmus at one week post-operatively, and postoperative intussusception was suspected. At laparotomy, he was noted to have an ileal–ileal intussusception

Limitations of Online Information on Abdominal Aortic Aneurysm

Background. Patients with AAA face a complex decision, and knowledge of the risks and benefits of each treatment option is essential to informed decision-making. Here we assess the current information on the internet accessible to patients regarding the management of AAA. Study Design. We performed a search on Google using the keywords “abdominal aortic aneurysm” and reviewed the top 50 web sites. We focused on information related to treatment options and alternatives to treatment and the risks of each option. Results. Twenty-seven websites were included in the study. Nearly 30% of websites discussed the risk of mortality and myocardial infarction after open surgery, compared to only 7.4% for both risks after EVAR. Other complications were listed by fewer websites. Fifty-five percent of websites reported that patients had a faster recovery following EVAR, but only 18.5% mentioned the risk of reintervention after EVAR or the need for long-term surveillance with CT scans. Conclusions. While most websites included descriptive information on AAA and mentioned the potential treatment options available to patients, the discussion of the risks of open surgery and EVAR was inadequate. These results suggest that websites frequently accessed by patients lack important information regarding surgical risk

Characterization of initial North American pediatric surgical response to the COVID-19 pandemic

INTRODUCTION: The impact of COVID-19 pandemic on pediatric surgical care systems is unknown. We present an initial evaluation of self-reported pediatric surgical policy changes from hospitals across North America. METHODS: On March 30, 2020, an online open access, data gathering spreadsheet was made available to pediatric surgeons through the American Pediatric Surgical Association (APSA) website, which captured information surrounding COVID-19 related policy changes. Responses from the first month of the pandemic were collected. Open-ended responses were evaluated and categorized into themes and descriptive statistics were performed to identify areas of consensus. RESULTS: Responses from 38 hospitals were evaluated. Policy changes relating to three domains of program structure and care processes were identified: internal structure, clinical workflow, and COVID-19 safety/prevention. Interhospital consensus was high for reducing in-hospital staffing, limiting clinical fellow exposure, implementing telehealth for conducting outpatient clinical visits, and using universal precautions for trauma. Heterogeneity in practices existed for scheduling procedures, implementing testing protocols, and regulating use of personal protective equipment. CONCLUSIONS: The COVID-19 pandemic has induced significant upheaval in the usual processes of pediatric surgical care. While policies evolve, additional research is needed to determine the effect of these changes on patient and healthcare delivery outcomes. LEVEL OF EVIDENCE: III

Perfect storm? COVID-19, area deprivation, and their association with pediatric trauma

Introduction: Social determinants of health (SDOH) affect pediatric injury patterns as vulnerable populations are likely to experience more frequent or severe injuries. This study evaluates the association of COVID-19 and area deprivation with pediatric traumatic injuries. Methods: We retrospectively evaluated institutional level I pediatric trauma encounters from 1/2018-8/2022. Patients were assessed relative to the U.S. pandemic declaration date (3/11/2020): pre-COVID (\u3c3/11/2020), early post-COVID (3/11/2020-3/11/2021), and late post-COVID (\u3e3/11/2021). The Area Deprivation Index (ADI) measured SDH-related risk at a census block tract group level. Associations between ADI and COVID-19 and injury mechanism and outcomes (intensive care unit [ICU]/ventilator duration, hospital length of stay, and mortality) were assessed using chi-square for categorical and Spearman’s rank correlation for continuous variables. Results: 4,055 patients were included in the study. There was variability in injury patterns relative to the level of deprivation and the timing of COVID-19. MVCs (12.7% pre vs. 14.3% early post vs. 18.6% late post, p\u3c0.0001) and GSWs (1.2% pre vs. 2.6% early post vs. 2.0% late post, p=0.018) were more common after COVID-19 and more frequently experienced by children with higher deprivation indices. Higher ADI was also associated with worse outcomes (ICU days, r=0.049, p=0.006; ventilator days, r=0.035, p=0.047). Discussion: Children with vulnerable SDOH status appear to have been disproportionately affected by pediatric traumatic injuries following COVID-19. National-level stressors (COVID-19) impact behaviors on a population level and shift exposure risk to different injury mechanisms. Multi-level public health initiatives are needed to address disparate injury patterns based on SDOH exposure

Association of operative approach with postoperative outcomes in neonates undergoing surgical repair of esophageal atresia and tracheoesophageal fistula

Introduction: Minimally invasive surgery (MIS) is gaining traction as a first-line approach to repair congenital anomalies. This study aims to evaluate outcomes for neonates undergoing open versus MIS repairs for esophageal atresia/tracheoesophageal fistula (EA/TEF). Methods: Neonates undergoing EA/TEF repair from 2013-2020 were identified using the National Surgical Quality Improvement Program-Pediatric database. Proportions of operative approach (open vs. MIS) over time were analyzed. A propensity score-matched analysis using preoperative characteristics was performed and outcomes were compared including composite morbidity and reintervention rates (overall, major [thoracoscopy, thoracotomy], and minor [chest/feeding tube placement, endoscopy]) between operative approaches. Pearson’s chi-square or Fisher’s exact test were used as appropriate. Results: We identified 1738 neonates who underwent EA/TEF repair. MIS utilization increased over time (p=0.019). Pre-match, neonates undergoing open repair were more likely premature, lower weight, and higher ASA class. Post-match, the groups were similar and included 183 neonates per group. MIS repair was associated with longer median operative time (206 vs. 180 minutes, p\u3c0.001), increased overall reintervention rates (MIS 9.8% vs. open 3.3%, p=0.011), and increased minor reintervention rates (MIS 7.7% vs. open 2.2%, p=0.016). There were no differences in composite morbidity (MIS 20.2% vs. open 26.8%, p=0.14) or major reinterventions (MIS 2.2% vs. open 1.1%, p=0.41). Discussion: MIS is gaining traction as a first-line approach for neonates with EA/TEF but appears to be associated with a higher rate of reinterventions. Further studies evaluating MIS approaches for the repair of EA/TEF are needed to better define short and long-term outcomes to optimize patient selection

Minimally Invasive Surgery in Neonates with Congenital Anomalies: Experience from the NSQIP-P

Background: Congenital diaphragmatic hernias (CDH) and tracheoesophageal fistulas (TEF) are managed with minimally invasive surgery (MIS) or open surgery. Little is known about the patient populations and outcomes for those treated by each approach. Hypothesis/Specific Aims: We expect that there will be fewer complications, better outcomes, and longer operative times for the MIS group versus the open group. Methods: National Surgical Quality Improvement Program-Pediatric Participant Use Files (NSQIP-P PUFs) from 2012-2015 were used to identify neonates (up to 30 days old) who underwent CDH and TEF repair. The patient characteristics, post-operative complications, and 30-day mortality were analyzed using multivariable logistic regression to determine morbidity associated with each. Data/Results: We identified 1,142 neonates who underwent CDH (n=577) and TEF (n=565) repair. Neonates who underwent open repair were sicker than those who underwent MIS and had slightly worse select outcomes. Median operative time was longer for both CDH and TEF with the MIS approach. However, multivariable logistic regression analysis adjusting for patient comorbidities showed that open versus MIS surgical approach was not associated with increased morbidity. Discussion: Neonates who underwent MIS repair had fewer co-morbidities and better outcomes. This surgical approach was not associated with any adverse 30-day outcomes in the multivariable models. This suggests that MIS repair of CDH and TEF can be safely performed in a subset of patients, but further research is needed to understand whether surgical approach affects the incidence of longer-term complications such as CDH recurrence or esophageal stricture

Generalized phantom energy

We examine cosmological models with generalized phantom energy (GPE). Generalized phantom energy satisfies the supernegative equation of state, but its evolution with the scale factor is generally independent, i.e. not determined by its equation of state. The requirement of general covariance makes the gravitational constant time-dependent. It is found that a large class of distinct GPE models with different evolution of generalized phantom energy density and gravitational constant, but the same equation of state of GPE have the same evolution of the scale factor of the universe in the distant future. The time dependence of the equation of state parameter determines whether the universe will end in a de Sitter-like phase or diverge in finite time with the accompanying "Big Rip" effect on the bound structures.Comment: v1: 9 pages. v2: version to appear in Phys. Lett.

A Standardized Diagnostic Pathway for Suspected Appendicitis in Children Reduces Unnecessary Imaging

Introduction: Ultrasound (US) for the diagnosis of acute appendicitis is often nondiagnostic, and additional imaging is required. A standardized approach may reduce unnecessary imaging. Methods: We retrospectively analyzed all patients who had imaging for appendicitis in our emergency department in 2017 and evaluated patient characteristics associated with nondiagnostic US. Using these results, we developed a pediatric appendicitis score (PAS)-based imaging pathway and compared imaging trends prepathway and postpathway implementation. Results: A total of 971 patients received imaging for suspected appendicitis prepathway in 2017. Female sex, obesity, and low/intermediate PAS were significantly associated with nondiagnostic US, but not magnetic resonance imaging (MRI) (P \u3c 0.0001). Nearly one-third of patients received multiple imaging studies (US followed by MRI/computed tomography). As low/intermediate PAS was most strongly associated with a nondiagnostic US on multivariate analysis, we developed a PAS-based imaging stewardship pathway to eliminate imaging in low-PAS patients and reduce the number of patients with an intermediate PAS who received multiple imaging studies by obtaining an MRI as the first-line study. After implementation, only 22 low-PAS patients received imaging (compared with 238 preimplementation), and the proportion of intermediate-PAS patients receiving multiple imaging studies decreased from 31.4% to 13% (P \u3c 0.0001). The cost of imaging per 100 patients increased from $24,255 to$31,082. Conclusion: A PAS-based imaging stewardship pathway reduces unnecessary imaging for suspected appendicitis

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents.

BACKGROUND: Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion. METHODS: We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models. RESULTS: Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P \u3c .01). Vomiting was significantly associated with torsion for all patients (P \u3c .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion. CONCLUSIONS: Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II