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

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

Hepatobiliary cystadenoma: a rare pediatric tumor.

Hepatobiliary cystadenoma is a rare hepatic neoplasm that has been reported only 10 times in the pediatric population. Although considered a benign cystic tumor of the liver, hepatobiliary cystadenoma has a high risk of recurrence with incomplete excision and a potential risk for malignant degeneration. Complete tumor excision with negative margins is the mainstay in treatment. Unfortunately, due to the paucity of cases and its vague presentation, hepatobiliary cystadenoma is rarely diagnosed preoperatively. Therefore, in patients with hepatic cystic masses without a clear diagnosis, total resection of the lesion with negative margins is indicated to adequately evaluate for malignant potential and limit the risk of recurrence. We describe a 2-year-old girl with an asymptomatic abdominal mass that was found to be hepatobiliary cystadenoma. In addition, the pathogenic, histopathologic and clinical features of hepatobiliary cystadenoma are reviewed

Pediatric Gastrostomy Tube Placement: Lessons Learned from High-performing Institutions through Structured Interviews.

Introduction: Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children\u27s hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions. Methods: Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis. Results: Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes. Conclusions: We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality

Case Volume and Revisits in Children Undergoing Gastrostomy Tube Placement.

OBJECTIVES: Emergency department (ED) visits and hospital readmissions are common after gastrostomy tube (GT) placement in children. We sought to characterize interhospital variation in revisit rates and explore the association between this outcome and hospital-specific GT case volume. PATIENTS AND METHODS: We conducted a retrospective cohort study from 38 hospitals using the Pediatric Health Information System database. Patients younger than 18 years who had a GT placed in 2010 to 2012 were assessed for a GT-related (mechanical or infectious) ED visit or inpatient readmission at 30 and 90 days after discharge from GT placement. Risk-adjusted rates were calculated using generalized linear mixed-effects models accounting for hospital clustering and relevant demographic and clinical attributes, then compared across hospitals. RESULTS: A total of 15,642 patients were included. A median of 468 GTs were placed in all the 38 hospitals during 3 years (range: 83-891), with a median of 11.4 GT placed per 1000 discharges (range: 2.4-16.7). Median ED visit for each hospital at 30 days after discharge was 8.2% (range: 3.7%-17.2%) and 14.8% at 90 days (range: 6.3%-26.1%). Median inpatient readmissions for each hospital at 30 days after discharge was 3.5% (range: 0.5%-10.5%) and 5.9% at 90 days (range: 1.0%-18.5%). Hospital-specific GT placement per 1000 discharges (rate of GT placement) was inversely correlated with ED visit rates at 30 (P = 0.007) and 90 days (P = 0.020). The adjusted 30- and 90-day readmission rate and the adjusted 30- and 90-day ED return rates decreased with increasing GT insertion rate (P \u3c 0.001). CONCLUSION: Higher hospital GT insertion rates are associated with lower ED revisit rates but not inpatient readmissions

Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement.

OBJECTIVES: To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children\u27s Hospitals. STUDY DESIGN: This retrospective cohort study evaluated patientscourse. RESULTS: Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. CONCLUSIONS: GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations