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

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS\u3csup\u3e®\u3c/sup\u3e) Society Recommendations

Background: Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery. Methods: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process. Results: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline. Discussion: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties

Key Strategies for Optimizing Pediatric Perioperative Nutrition—Insight from a Multidisciplinary Expert Panel

Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting

Bile duct injuries during pediatric laparoscopic cholecystectomy: a national perspective.

BACKGROUND: Though rare, bile duct injuries (BDI) during laparoscopic cholecystectomy (LC) represent a major potential complication with significant associated morbidity. The objectives of this study were to (1) assess the national use of LC and incidence of BDI over time in the pediatric surgical population, (2) measure the added resource utilization burden associated with BDI, and (3) identify patient and hospital factors associated with BDI. METHODS: All patients 0 to 20 years of age undergoing cholecystectomy were identified in the Kids\u27 Inpatients Database from 1997 to 2006. National rates of LC use and BDI as well as overall costs were assessed using weighted estimates. Factors associated with BDI were analyzed with a logistic regression model. RESULTS: Of 31,653 patients undergoing cholecystectomy, 28,243 (89.2%) underwent LC. Over time, the proportion of LC has risen from 81% in 1997 to 91% in 2006 (P \u3c .001). Of patients undergoing LC, 0.44% had BDI with no significant change of BDI rate over time. Length of stay was 6.1 days for patients with BDI compared to 3.3 days for those without injury (P \u3c .001). BDI patients had median costs of US $9550 as compared to US$6030 for non-BDI patients (P \u3c .001). After taking patient, hospital, and disease-specific factors into consideration, BDI was more common in patients 5 years of age or less, nonwhite patients, and in patients admitted under an elective setting (all P \u3c .01). CONCLUSIONS: With increasing LC use, BDI remains a rare yet resource intense complication in children. Age, race, and admission related factors are associated with BDI and may provide guidance toward improving outcomes

Margin status and multimodal therapy in infantile fibrosarcoma.

PURPOSE: The rarity of infantile fibrosarcoma (IF) has precluded comprehensive treatment evaluation. The purpose of this study was to better define the extent of surgical resection required and the role of chemotherapy. METHODS: Patients (0-2 years) with IF were evaluated from the National Cancer Data Base (1985-2007). Survival was estimated using the Kaplan-Meier method stratifying patients by margin status and treatment with or without chemotherapy. RESULTS: Of the 224 patients, 171 (76.3 %) were(28.6 %) with positive margins, 36 (56.3 %) had microscopic disease, 12 (18.8 %) had macroscopic disease, and 16 (25 %) had unknown margin status; none were found to have metastases. Most were managed with surgical resection (171, 76.4 %). The proportion treated with both surgery and chemotherapy increased over time (18-40 %, p = 0.025). Disease-free survival was 90.6 %. No significant survival difference was noted in this retrospective, non-randomized cohort based on margin status, nodal involvement, tumor size, or treatment modality. CONCLUSIONS: The use of multimodal therapy has increased over time. There was a small increase in survival associated with negative margins and the use of multimodal therapy, however, neither result reached significance. Future studies investigating tumor biology and chemosensitivity will likely determine the optimal management of IF

Dollars and sense of interval appendectomy in children: a cost analysis.

PURPOSE: Although initial nonoperative management of focal, perforated appendicitis in children is increasingly practiced, the need for subsequent interval appendectomy remains debated. We hypothesized that cost comparison would favor continued nonoperative management over routine interval appendectomy. METHODS: Decision tree analysis was used to compare continued nonoperative management with routine interval appendectomy after initial success with nonoperative management of perforated appendicitis. Outcome probabilities were obtained from literature review and cost estimates from the Kid\u27s Inpatient Database. Sensitivity analyses were performed on the 2 most influential variables in the model, the probability of successful nonoperative management and the costs associated with successful observation. Monte Carlo simulation was performed using the range of cost estimates. RESULTS: Costs for continued nonoperative observation were estimated at $3080.78 as compared to$5034.58 for the interval appendectomy. Sensitivity analysis confirms a cost savings for nonoperative management as long as the likelihood of successful observation exceeds 60%. As the cost of nonoperative management increased, the required probability for its success also increased. Using wide distributions for both probability estimates as well as costs, Monte Carlo simulation favored continued observation in 75% of scenarios. CONCLUSION: Continued nonoperative management has a cost advantage over routine interval appendectomy after initial success with conservative management in children with focal, perforated appendicitis

Evidence-based prevention and surgical treatment of necrotizing enterocolitis-a review of randomized controlled trials

Necrotizing enterocolitis remains a common cause of morbidity and mortality in the neonatal period. Despite many advances in the management of the critically ill neonate, the exact etiology, attempts at prevention and determining best treatment for NEC have been elusive. Unfortunately, the overall survival for this poorly understood and complex condition has not improved. NEC is a condition that can and should be studied with randomized prospective trials (RCTs). This chapter reviews the current evidence-based trials for this condition thus far performe

Laparoscopic splenectomy for metastatic squamous cell cancer of the neck

Squamous cell carcinoma (SCC) spreads through direct extension, lymphatic vessels, and, rarely, hematogenous routes. The most common malignancies to metastasize to the spleen include carcinomas of the breast, lung, and melanoma. We present an unusual case of SCC of the neck with splenic metastases. The patient presented with a primary solid tumor of the neck that extended into the surrounding soft tissues, including the internal jugular vein and regional lymph nodes. A metastatic work-up with a positron emission tomograph showed enhancement in the left upper quadrant. A computed tomograph (CT) was then performed. The CT revealed three distinct splenic lesions, the largest measuring 6 × 6.5 × 2.5 cm. Subsequently, the patient was scheduled for a splenectomy. At the time of operation, diagnostic laparoscopy revealed only the splenic lesions. A laparoscopic splenectomy was performed successfully and the patient was started on a regular diet on postoperative day 1. This paper describes the first documented case of SCC of the neck with splenic metastases. The lesion was diagnosed and treated laparoscopically. The case is described in detail along with the clinical implications of this rare finding. © Mary Ann Liebert, Inc

Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients.

IMPORTANCE: Appendectomy is the most common abdominal operation performed in pediatric patients in the United States. Studies in adults have suggested that same-day discharge (SDD) after appendectomy is safe and does not result in higher-than-expected hospital readmissions. OBJECTIVE: To evaluate the influence of SDD on 30-day readmission rates following appendectomy for acute appendicitis in pediatric patients. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among pediatric patients who underwent an appendectomy for acute, nonperforated appendicitis. The database provides high-quality surgical outcomes data from more than 80 participating US hospitals, including free-standing pediatric facilities, children\u27s hospitals, specialty centers, children\u27s units within adult hospitals, and general acute care hospitals with a pediatric wing. Patients selected for inclusion (n = 22 771) were between ages 0 and 17 years and underwent appendectomy for uncomplicated appendicitis between January 1, 2012, and December 31, 2015. Patients excluded were those discharged more than 2 days after surgery. EXPOSURES: Same-day discharge after appendectomy or discharge 1 or 2 days after surgery. MAIN OUTCOMES AND MEASURES: The primary outcome was 30-day readmission. Secondary outcomes included surgical-site infections and other wound complications. RESULTS: Of the 20 981 patients, 4662 (22.2%) had SDD and 16 319 (77.8%) were discharged within 1 or 2 days after surgery. The patient cohort included 12 860 boys (61.3%) and 8121 girls (38.7%), with a mean (SD) age of 11.0 (3.56) years. There was no difference in the odds of readmission for patients with SDD compared with those discharged within 2 days (adjusted odds ratio [aOR], 0.82; 95% CI, 0.51-1.04; P = .06; readmission rate, 1.89% vs 2.33%). There was no significant difference in reason for readmission on the basis of discharge timing. Likewise, there was no difference in wound complication rate between patients with SDD and those discharged 1 or 2 days after surgery (aOR 0.75; 95% CI, 0.56-1.01; P = .06). CONCLUSIONS AND RELEVANCE: In pediatric patients with acute appendicitis undergoing appendectomy, SDD is not associated with an increase in 30-day hospital readmission rates or wound complications when compared with discharge 1 or 2 days after surgery. Same-day discharge may be an applicable quality metric for the provision of safe and efficient care for pediatric patients with acute, nonperforated appendicitis

Total thyroidectomy for benign disease in the pediatric patient--feasible and safe.

PURPOSE: Total thyroidectomy (TT) is a safe and efficacious treatment of malignant thyroid disease in children. The role of TT in benign thyroid disease is less well-defined. The goal of this study was to compare the safety of TT performed for benign and malignant disease. METHODS: The medical records of 31 patients undergoing TT from January 2000 to June 2007 at a single center were reviewed. The benign cohort totaled 15 patients consisting of 12 with Graves\u27 disease, 2 with hyperthyroidism, and 1 with large and symptomatic multinodular goiter. The malignant cohort totaled 16 patients consisting of 9 with malignant disease, 4 with a nodule and history of cancer or radiation exposure, and 3 with RET proto-oncogene mutations. RESULTS: The most common complication was transient hypocalcemia observed in 7 (46%) of 15 patients with benign disease and 9 (56%) of 16 patients with malignancy (P = .72). Permanent hypocalcemia, defined as need for calcium supplement 6 months postprocedure, was observed in 1 patient with benign disease (6.67%) and 1 patient with malignancy (6.25%; P = 1.0). A single parathyroid gland was reimplanted in 2 patients with malignancy and 2 patients with benign disease (P = 1.0). One case of keloid scar was noted, and no cases of recurrent laryngeal nerve palsy, nerve paralysis, tracheal injury, tracheostomy, or wound infection were encountered in either cohort. There were no cases of relapse hyperthyroidism in the benign cohort. CONCLUSIONS: Similar rates of postoperative complications can be expected with TT for benign thyroid disease as compared to TT for malignant disease. Total thyroidectomy is a safe treatment option for benign thyroid disease in children