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

Use of biobehavioral interventions in children undergoing surgery and associated patient-reported outcomes

Background: Biobehavioral interventions including relaxation, distraction, and mindfulness meditation exercises have been shown to decrease perioperative stress, anxiety, and pain. Our aims were to 1) quantify pediatric surgical patient-reported pre-operative exposure to and post-operative use of biobehavioral interventions; 2) understand barriers and facilitators to incorporation of biobehavioral interventions into clinical practice; and 3) evaluate associated patient-reported outcomes. Methods: We conducted an embedded mixed-methods study with a quantitative focus. Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial for children, ages 10–18 years, undergoing elective gastrointestinal surgery. Patients/caregivers were surveyed about preoperative exposure to and postoperative use of biobehavioral interventions. Four semi-structured group interviews with 20 pediatric surgery providers were conducted. Outcomes included pain-related functional disability, health-related quality of life (HRQoL), and perioperative nervousness. Results: 41 % (n = 67) of 164 enrolled patients/caregivers reported preoperative exposure to and 71 % (n = 117) reported postoperative use of a biobehavioral intervention(s). Barriers to incorporation of biobehavioral interventions included lack of standardized workflows, clinician knowledge, and resources. Potential facilitators included media and peer-counseling. After adjusting for individual and hospital characteristics, those who reported using a biobehavioral intervention(s) were 70 % less likely to report worsened postoperative nervousness (95 % CI 0.10–0.91; p = 0.03). Reported use of a biobehavioral intervention(s) was not found to be associated with pain-related functional disability or HRQoL. Conclusions: Use of a biobehavioral intervention(s) may stabilize postoperative nervousness of children undergoing surgery. There is a need for redesign of clinical workflows and clinician training to facilitate integration of biobehavioral interventions.</p

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&mdash;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

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

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