Surgical Outcomes in Children According to Hospital Location and Designation: A National Study

Thesis (Master's)--University of Washington, 2013Introduction: The effects of hospital location and specialty designation on post-operative outcomes in children have not been extensively evaluated. We hypothesized that outcomes would be improved at urban centers, and that outcomes would differ at urban centers for children from rural versus urban counties. Methods: We conducted a retrospective cohort study of children undergoing non-incidental appendectomy (n=129,507) and pyloromyotomy (n=17,109) using the 2006 and 2009 Kid's Inpatient Database and 2007, 2008 and 2010 Nationwide Inpatient Sample. Hospitals were defined as non-children's, children's unit in a general hospital, or freestanding children's hospitals, and were classified as urban or rural based on census data. Patient County of residence was classified as urban or rural based on census data. Outcomes included post-operative complications defined by ICD-9 codes and total hospital length of stay. Multivariate logistic and linear regression models were used to adjust for confounding. Results: Among appendectomy patients, 12.1% were treated at rural hospitals, while 3.4% of pyloromyotomy patients received their operation at a rural hospital. For appendectomy patients, treatment at urban relative to rural hospitals was associated with a reduced odds of any post-operative complication (OR=0.82, 95% C.I. 0.73 - 0.92) and anesthesia-related complications (OR=0.75, 95% C.I. 0.59 - 0.96). This association was strongest in the youngest children (<5 years) and at freestanding children's hospitals, specifically. Among children receiving appendectomy at urban centers, adjusted length of stay was half a day shorter for urban children than for rural children (p<0.001). For pyloromyotomy patients, urban hospitals were associated with a reduced odds of any complication (OR=0.33, 95% C.I. 0.20 - 0.55), anesthesia-related complications (OR=0.12, 95% C.I. 0.05 - 0.29), and duodenal perforation (OR=0.36, 95% C.I. 0.16 - 0.82). These associations were strongest at freestanding children's hospitals. Conclusion: Post-operative outcomes are improved at urban specialty hospitals for certain common procedures in children, and this effect seems to be most important in younger children. The specific factors responsible for these improved outcomes must be identified in order to improve care for children treated in all practice settings

Cardiac injury following penetrating chest trauma: Delayed diagnosis and successful repair

Penetrating cardiac trauma is rare and often results in poor outcomes in the pediatric population. Clinical presentation may range from relative stability to cardiovascular collapse and arrest. We present a case of a cardiac gunshot injury in an 11 year old who was shot in the back, sustaining a through and through injury to left chest. The missile projectile penetrated the left ventricle with subsequent diaphragmatic and splenic injury. The cardiac injury was not identified on initial examination or intraoperative repair of diaphragmatic injury. After becoming unstable in the pediatric intensive care unit, a bedside thoracotomy was performed and the cardiac injury was successfully repaired. In the setting of penetrating thoracic trauma, a normal cardiac exam, echocardiography, or intraoperative findings should not eliminate the possibility of a cardiac injury. The key factor for patient survival is early diagnosis of injury and emergent intervention. Background: Penetrating cardiac trauma is rare and often results in poor outcomes in children. Clinical presentation may range from relative stability to cardiovascular collapse and arrest. Case report: We present a case of an 11-year old male who was shot in the back sustaining a through and through injury to left chest. A missile projectile penetrated the left ventricle with subsequent diaphragmatic and splenic injury. A cardiac injury was not identified during initial examination or laparoscopic repair of a diaphragmatic injury. Five hours after the initial presentation, the child became unstable in the pediatric intensive care unit, a bedside thoracotomy was performed and the cardiac injury was identified and successfully repaired. Conclusion: In the setting of penetrating thoracic trauma, a normal cardiac exam, echocardiography, or intraoperative findings should not eliminate the possibility of a cardiac injury. The key element for patient survival is early diagnosis of injury and emergent intervention

Cardiac injury following penetrating chest trauma: Delayed diagnosis and successful repair

© 2018 The Authors Penetrating cardiac trauma is rare and often results in poor outcomes in the pediatric population. Clinical presentation may range from relative stability to cardiovascular collapse and arrest. We present a case of a cardiac gunshot injury in an 11 year old who was shot in the back, sustaining a through and through injury to left chest. The missile projectile penetrated the left ventricle with subsequent diaphragmatic and splenic injury. The cardiac injury was not identified on initial examination or intraoperative repair of diaphragmatic injury. After becoming unstable in the pediatric intensive care unit, a bedside thoracotomy was performed and the cardiac injury was successfully repaired. In the setting of penetrating thoracic trauma, a normal cardiac exam, echocardiography, or intraoperative findings should not eliminate the possibility of a cardiac injury. The key factor for patient survival is early diagnosis of injury and emergent intervention. Background: Penetrating cardiac trauma is rare and often results in poor outcomes in children. Clinical presentation may range from relative stability to cardiovascular collapse and arrest. Case report: We present a case of an 11-year old male who was shot in the back sustaining a through and through injury to left chest. A missile projectile penetrated the left ventricle with subsequent diaphragmatic and splenic injury. A cardiac injury was not identified during initial examination or laparoscopic repair of a diaphragmatic injury. Five hours after the initial presentation, the child became unstable in the pediatric intensive care unit, a bedside thoracotomy was performed and the cardiac injury was identified and successfully repaired. Conclusion: In the setting of penetrating thoracic trauma, a normal cardiac exam, echocardiography, or intraoperative findings should not eliminate the possibility of a cardiac injury. The key element for patient survival is early diagnosis of injury and emergent intervention

Management of the undescended testis in children: An American pediatric surgical association outcomes and evidence based practice committee systematic review.

PURPOSE: Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS: A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS: A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS: Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy

Management of intussusception in children: A systematic review

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. Level 3–5 (mainly level 3–4) Systematic Review of level 1–4 studie

The effects of early anesthesia on neurodevelopment: A systematic review

There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms “general anesthesia and neurodevelopment” as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. Systematic review of level 1–4 studies. Level 1–4 (mainly level 3–4

Management and outcomes for long-segment Hirschsprung disease: A systematic review from the APSA outcomes and evidence based practice committee

Long-Segment Hirschsprung Disease (LSHD) differs clinically from short-segment disease. This review article critically appraises current literature on the definition, management, outcomes, and novel therapies for patients with LSHD. Four questions regarding the definition, management, and outcomes of patients with LSHD were generated. English-language articles published between 1990 and 2018 were compiled by searching PubMed, Scopus, Cochrane Central Register of Controlled Trials, Web of Science, and Google Scholar. A qualitative synthesis was performed. 66 manuscripts were included in this systematic review. Standardized nomenclature and preoperative evaluation for LSHD are recommended. Insufficient evidence exists to recommend a single method for the surgical repair of LSHD. Patients with LSHD may have increased long-term gastrointestinal symptoms, including Hirschsprung-associated enterocolitis (HAEC), but have a quality of life similar to matched controls. There are few surgical technical innovations focused on this disorder. A standardized definition of LSHD is recommended that emphasizes the precise anatomic location of aganglionosis. Prospective studies comparing operative options and long-term outcomes are needed. Translational approaches, such as stem cell therapy, may be promising in the future for the treatment of long-segment Hirschsprung disease