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Background/Purpose
The purpose of this study was to review the management of obstructive symptoms and enterocolitis (HAEC) following pull-through for Hirschsprung's disease.Methods
A systematic review and meta-analysis (1992–2017) was performed. Included studies were: randomized controlled trials (RCT), retrospective/prospective case–control (C-C), case-series (C-S). Random-effect model was used to produce risk ratio (RR) [95% CI]. P?<?0.05 was considered significant.Results
Twenty-nine studies were identified. Routine postoperative dilatations (5 C-S, 2 C-C; 405 patients): no effect on stricture incidence (RR 0.3 [0.02–5.7]; p?=?0.4). Routine postoperative rectal irrigations (2 C-C; 172 patients): reduced HAEC incidence (RR 0.2 [0.1–0.5]; p?=?0.001). Posterior myotomy/myectomy (4 C-S; 53 patients): resolved obstructive symptoms in 79% [60.6–93.5] and HAEC in 80% [64.1–92.1]. Botulinum toxin injection (9 C-S; 166 patients): short-term response in 77.3% [68.2–85.2], long-term response in 43.0% [26.9–59.9]. Topical nitric oxide (3 C-S; 13 patients): improvement in 100% of patients. Probiotic prophylaxis (3 RCT; 160 patients): no reduction in HAEC (RR 0.6 [0.2–1.7]; p?=?0.3). Anti-inflammatory drugs (1 C-S, sodium cromoglycate; 8 patients): improvement of HAEC in 75% of patients.Conclusions
Several strategies with variable results are available in patients with obstructive symptoms and HAEC. Routine postoperative dilatations and prophylactic probiotics have no role in reducing the incidence of postoperative obstructive symptoms and HAEC.Type of study
Systematic review and meta-analysis.Level of evidence
Level II. 相似文献3.
Ira L. Leeds Mitchell R. Ladd Margaret H. Sundel Melissa L. Fannon Jessica A. George Emily F. Boss Eric B. Jelin 《Journal of pediatric surgery》2018,53(11):2266-2272
Background/purpose
The role of process measures used to predict quality in pediatric colorectal surgery enhanced recovery protocols has not been described. The purpose of this study was to demonstrate the feasibility of abstracting and monitoring process measures over protocol improvement iteration.Methods
Patients enrolled in the Pediatric Colorectal Enhanced Recovery After Surgery pathway at our institution were grouped by stage of implementation. We used a quality improvement database to compare multistage enhanced recovery process measures and 30-day patient outcomes.Results
We identified 58 surgical patients with 28(48%) cases enrolled in the pathway. There was increased use of regional anesthesia techniques in pathway patients (83% versus 20%, p?<?0.001). All preoperative process measures clinically improved between early and full implementation. Improvements included a dramatic increase in formal preoperative education (56% versus 0%, p?=?0.004) and administration of preoperative medication (p?=?0.025). Overall, 12 (21%) patients experienced postoperative complications, which were similarly distributed between implementation groups. Readmissions were highest during the early implementation phase (40%, p?=?0.029). Children in the late implementation group experienced fewer complications, which clinically correlated with process measure adherence.Conclusions
Process measures complement outcome measures in assessing quality and effectiveness of a pediatric colorectal recovery protocol. Adherence to processes may reduce complications.Level of evidence
Treatment study, Level III. 相似文献4.
Mitchell R. Ladd Alejandro V. Garcia Ira L. Leeds Courtney Haney Maria M. Oliva-Hemker Samuel Alaish Emily Boss Daniel S. Rhee 《Journal of pediatric surgery》2018,53(11):2336-2345
Background
Pediatric patients with Crohn disease (CD) are frequently malnourished, yet how this affects surgical outcomes has not been evaluated. This study aims to determine the effects of malnourishment in children with CD on 30-day outcomes after surgery.Study design
The ACS NSQIP-Pediatric database from 2012 to 2015 was used to select children aged 5–18 with CD who underwent bowel surgery. BMI-for-age Z-scores were calculated based on CDC growth charts and 2015 guidelines of pediatric malnutrition were applied to categorize severity of malnutrition into none, mild, moderate, or severe. Malnutrition's effects on 30-day complications. Propensity weighted multivariable regression was used to determine the effect of malnutrition on complications were evaluated.Results
516 patients were included: 349 (67.6%) without malnutrition, 97 (18.8%) with mild, 49 (9.5%) with moderate, and 21 (4.1%) with severe malnutrition. There were no differences in demographics, ASA class, or elective/urgent case type. Overall complication rate was 13.6% with malnutrition correlating to higher rates: none 9.7%, mild 18.6%, moderate 20.4%, and severe 28.6% (p?<?0.01). In propensity-matched, multivariable analysis, malnutrition corresponded with increased odds of complications in mild and severely malnourished patients (mild OR?=?2.1 [p?=?0.04], severe OR 3.26 [p?=?0.03]).Conclusion
Worsening degrees of malnutrition directly correlate with increasing risk of 30-day complications in children with CD undergoing major bowel surgery. These findings support BMI for-age z scores as an important screening tool for preoperatively identifying pediatric CD patients at increased risk for postoperative complications. Moreover, these scores can guide nutritional optimization efforts prior to elective surgery.Level of Evidence
IV. 相似文献5.
Emily F. Midura Andrew D. Jung Dennis J. Hanseman Vikrom Dhar Shimul A. Shah Janice F. Rafferty Bradley R. Davis Ian M. Paquette 《Surgery》2018,163(3):528-534
Background
Before elective colectomy, many advocate mechanical bowel preparation with oral antibiotics, whereas enhanced recovery pathways avoid mechanical bowel preparations. The optimal preparation for right versus left colectomy is also unclear. We sought to determine which strategy for bowel preparation decreases surgical site infection (SSI) and anastomotic leak (AL).Methods
Elective colectomies from the National Surgical Quality Improvement Program colectomy database (2012–2015) were divided by (1) type of bowel preparation: no preparation (NP), mechanical preparation (MP), oral antibiotics (PO), or mechanical and oral antibiotics (PO/MP); and (2) type of colonic resection: right, left, or segmental colectomy. Univariate and multivariate analyses identified predictors of SSI and AL, and their risk-adjusted incidence was determined by logistic regression.Results
When analyzed as the odds ratio compared with NP, the PO and PO/MP groups were associated with a decrease in SSI (PO?=?0.70 [0.55–0.88] and PO/MP?=?0.47 [0.42–0.53]; P?<?.01). Use of PO/MP was associated with a decrease in SSI across all types of resections (right colectomy?=?0.40 [0.33–0.50], left colectomy?=?0.57 [0.47–0.68], and segmental colectomy?=?0.43 (0.34–0.54); P?<?.01). Similarly, use of PO/MP was associated with a decrease in AL in left colectomy?=?0.50 ([0.37–0.69]; P?<?.01) and segmental colectomy?=?0.53 ([0.36–0.80]; P?<?.01).Conclusion
Mechanical bowel preparation with oral antibiotics is the preferred preoperative preparation strategy in elective colectomy because of decreased incidence of SSI and AL. 相似文献6.
William Bonadio Syeda Shahid Lior Vardi Carly Buckingham Allison Kornblatt Chloe Free Peter Homel 《Journal of pediatric surgery》2018,53(3):441-445
Importance
Appendicitis is a common, potentially serious pediatric disease. An important factor in determining management strategy [whether/when to perform appendectomy, duration of antibiotic therapy/hospitalization, etc.] and predicting outcome is distinguishing whether perforation is present.Objective
The objective was to determine efficacy of commonly assessed pre-operative variables in stratifying perforation risk in children with appendicitis.Design
A retrospective analysis of consecutive cases was performed.Setting
The setting was a large urban hospital pediatric emergency department.Participants
Four hundred forty-eight consecutive cases of CT [computerized tomography]-confirmed pediatric appendicitis during a 6-year period in an urban pediatric ED [emergency department]: 162 with perforation and 286 non-perforated.Main outcome(s) and measure(s)
To determine efficacy of clinical and laboratory variables with distinguishing perforation outcome in children with appendicitis.Results
Regression analysis identified 3 independently significant variables associated with perforation outcome – and determined their ideal threshold values: duration of symptoms > 1 day; ED-measured fever [body temperature > 38.0 °C]; CBC WBC absolute neutrophil count > 13,000/mm3. The resulting multivariate ROC [receiver operating characteristic] curve after applying these threshold values gave an AUC [area under curve] of 89% for perforation outcome [p < 0.001]. Risk for perforation was additive with each additional predictive variable exceeding its threshold value, linearly increasing from 7% with no variable present to 85% when all 3 variables are present.Conclusions
A pre-operative scoring system comprised of 3 commonly assessed clinical/laboratory variables is useful in stratifying perforation risk in children with appendicitis.Physicians can utilize these factors to gauge pre-operative risk for perforation in children with appendicitis, which can potentially aid in planning subsequent management strategy.Level of evidence
III. 相似文献7.
Suk Kyun Hong Nam-Joon Yi Hak Chang Sung-Woo Ahn Hyo-Sin Kim Kyung Chul Yoon Hyeyoung Kim Seong Oh Park Ung Sik Jin Kyung Won Minn Kwang-Woong Lee Kyung-Suk Suh 《Journal of pediatric surgery》2018,53(8):1516-1522
Background
Liver transplantation (LT) is an excellent treatment option for patients with biliary atresia (BA) who fail portoenterostomy surgery. LT is also increasingly performed in patients with metabolic liver diseases. This study compared the outcomes in pediatric patients who underwent LT for metabolic liver diseases and BA.Basic procedures
Data from 237 pediatric patients who underwent primary LT at Seoul National University Hospital from 1988 to 2015, including 33 with metabolic liver diseases and 135 with BA, were retrospectively analyzed.Main findings
Compared with children with BA, children with metabolic liver diseases were significantly older at the time of LT (121.3 vs. 37.3?months; P?<?0.001), and had lower Child–Pugh (7.1 vs. 8.4; P?=?0.010) and Pediatric End-stage Liver Disease (6.5 vs. 12.8; P?=?0.042) scores. Overall survival rates were similar (87.8% vs. 90.8%; P?=?0.402), but hepatic artery (HA) complications were significantly more frequent in children with metabolic liver diseases (12.1% vs. 1.5%; P?=?0.014).Principal conclusion
Despite similar overall survival, children with metabolic liver diseases had a higher rate of HA complications.Type of submission
Original article, Case control study, Retrospective.Evidence level
III. 相似文献8.
Benjamin J. Booth Stephen M. Bowman Mauricio A. Escobar Sam R. Sharar 《Journal of pediatric surgery》2018,53(11):2209-2213
Background
Initial results of Washington State's quality improvement initiative addressing the management of blunt traumatic pediatric spleen injuries were published in 2008. In this update, we evaluated whether these effects were sustained over time.Methods
Data from the Washington Trauma Registry for years 1999–2001 (pre-intervention), 2003–2005 (post-intervention), and 2012–2014 (follow-up) were used in a retrospective cohort study. Children between ages 0 to 14?years who were hospitalized with a traumatic blunt spleen injury were included. Multivariable logistic regression was used to account for patient, injury, and hospital characteristics.Results
Overall, splenectomies continued to be less common with 8.3% of pediatric patients receiving splenectomies in the follow-up period compared with 14.3% and 7.2% in the preintervention and post-intervention periods (p?=?0.034). After adjustment, splenectomies remained less likely to be performed in both post-intervention (OR?=?0.37; 95% CI?=?0.16–0.90) and follow-up periods (OR?=?0.29; 95% CI?=?0.12–0.70) compared to pre-intervention. Children were much more likely to be cared for at pediatric trauma hospitals in the follow-up period (OR?=?5.13; 95% CI?=?2.79–9.43) after adjustment.Conclusions
Evaluation of this statewide quality improvement initiative showed that positive changes in management practices persist. This evidence suggests that statewide quality improvement initiatives can be sustainable with minimal ongoing effort.Level of evidence
Level III. 相似文献9.
Loren Berman Jordan Jackson Kristen Miller Rebecca Kowalski Paul Kolm Francois I. Luks 《Journal of pediatric surgery》2018,53(8):1592-1599
Background
Pediatric surgeons frequently offer prenatal consultation for congenital pulmonary airway malformation (CPAM) and congenital diaphragmatic hernia (CDH); however, there is no evidence-based consensus to guide prenatal decision making and counseling for these conditions. Eliciting feedback from experts is integral to defining best practice regarding prenatal counseling and intervention.Methods
A Delphi consensus process was undertaken using a panel of pediatric surgeons identified as experts in fetal therapy to address current limitations. Areas of discrepancy in the literature on CPAM and CDH were identified and used to generate a list of content and intervention questions. Experts were invited to participate in an online Delphi survey. Items that did not reach first-round consensus were broken down into additional questions, and consensus was achieved in the second round.Results
Fifty-four surgeons (69%) responded to at least one of the two survey rounds. During round one, consensus was reached on 54 of 89 survey questions (61%), and 45 new questions were developed. During round two, consensus was reached on 53 of 60 survey questions (88%).Conclusions
We determined expert consensus to establish guidelines regarding perinatal management of CPAM and CDH. Our results can help educate pediatric surgeons participating in perinatal care of these patients.Level of Evidence
V. 相似文献10.
Marilyn W. Butler Sandy Zarosinski Dagmar Rockstroh 《Journal of pediatric surgery》2018,53(12):2378-2382
Background
Inaccurate assignment of surgical wound class (SWC) remains a challenge in perioperative documentation. The purpose of our intervention was to increase the accuracy of SWC through a targeted training program directed toward pediatric surgeons and nurses.Methods
A retrospective electronic medical record (EMR) chart review of 400 operations was performed according to NSQIP criteria during specified periods in 2014 and 2017, assessing SWC errors before and after a training program and posting of reference materials in operating rooms at a 165-bed children's hospital. After each operation, nurses confirmed SWC with the surgeon before recording the value in the EMR. Differences in proportions of misclassified SWC were evaluated with a chi-square test.Results
Following the educational program, misclassified SWC improved from 70/200 (35.0%) to 18/200 (9.0%), p?<?0.001. Misclassified SWC for appendectomies improved from 46/95 (48.4%) to 12/108 (11.1%), p?<?0.001.Conclusions
Accurate SWC assignment in the EMR was improved by an educational program and posting of materials to aid assignment, as well as enhanced communication between surgeons and nurses at the conclusion of each operation. We present the first known attempt to list all pediatric surgery procedures according to SWC. Accurate SWC allows stratification of risks and more effective targeted interventions.Level of evidence
Level III. 相似文献11.
Jamie E. Anderson Laura A. Galganski Yvonne Cheng Rebecca A. Stark Payam Saadai Jacob T. Stephenson Shinjiro Hirose 《Journal of pediatric surgery》2018,53(12):2399-2403
Background
Although the incidence of gastroschisis is increasing, risk factors are not clearly identified.Methods
Using the Linked Birth Database from the California Office of Statewide Health Planning and Development from 1995 to 2012, patients with gastroschisis were identified by ICD-9 diagnosis/procedure code or birth certificate designation. Logistic regressions examined demographics, birth factors, and maternal exposures on risk of gastroschisis.Results
The prevalence of gastroschisis was 2.7 cases per 10,000 live births. Patients with gastroschisis had no difference in fetal exposure to alcohol (p?=?0.609), narcotics (p?=?0.072), hallucinogenics (p?=?0.239), or cocaine (p?=?0.777), but had higher exposure to unspecified/other noxious substances (OR 3.27, p?=?0.040; OR 2.02, p?=?0.002). Gastroschisis was associated with low/very low birthweight (OR 5.08–16.21, p?<?0.001) and preterm birth (OR 3.26–10.0, p?<?0.001). Multivariable analysis showed lower risk in black (OR 0.44, p?<?0.001), Asian/Pacific Islander (OR 0.76, p?=?0.003), and Hispanic patients (OR 0.72, p?<?0.001) compared to white patients. Risk was higher in rural areas (OR 1.24–1.76, p?=?0.001). Compared to women age?<?20, risk decreased with advancing maternal age (OR 0.49-OR 0.03, p?<?0.001). Patients with gastroschisis had increased total charges ($336,270 vs. $9012, p?<?0.001) and length of stay (38.1 vs. 2.9?days, p?<?0.001). Mortality was 4.6%.Conclusions
This is the largest population-based study summarizing current epidemiology of gastroschisis in California.Type of study
Retrospective comparative cohort study.Level of evidence
III. 相似文献12.
Dor Yoeli Ruth L Ackah Rohini R Sigireddi Michael L Kueht N Thao N Galvan Ronald T Cotton Abbas Rana Christine A O&#x;Mahony John A Goss 《Journal of pediatric surgery》2018,53(11):2240-2244
Background
The aim of this study is to describe the incidence and impact of reoperation following pediatric liver transplantation, as well as the indications and risk factors for these complications.Methods
All primary pediatric liver transplants performed at our institution between January 2012 and September 2016 were reviewed. A reoperative complication was defined as a complication requiring return to the operating room within 30?days or the same hospital admission as the transplant operation, excluding retransplantation.Results
Among the 144 pediatric liver transplants performed during the study period, 9% of the recipients required reoperation. The most common indications for reoperation were bleeding and bowel complications. There was no significant difference in the graft survival of patients with a reoperation and those without a reoperation (p?=?0.780), but patients with a reoperation had a significantly longer hospital length of stay (median of 39?days vs. 11?days, p?=?0.001). Variant donor arterial anatomy, transplant operative time, intraoperative blood loss, transfusion volume of packed red blood cells or cell saver per weight, and transfusion with fresh frozen plasma, platelets, or cryoprecipitate were significantly associated with reoperation upon univariable logistic regression, but none of these risk factors remained statistically significant upon multivariable regression.Conclusion
At our institution, reoperation did not significantly impact graft survival. We identified variant donor arterial anatomy, transplant operative time, intraoperative blood loss, transfusion volume of packed red blood cells or cell saver per weight, and transfusion with fresh frozen plasma, platelets, or cryoprecipitate as risk factors for reoperation, although none of these risk factors demonstrated independent association with reoperation in a multivariable model.Type of study
Prognosis Study.Level of evidence
Level III. 相似文献13.
Jake D Foster Nigel J Hall S Charles Keys David M Burge 《Journal of pediatric surgery》2018,53(11):2331-2335
Background
Many pediatric surgeons have limited experience of esophageal replacement. This study reports outcomes of esophageal replacement by gastric transposition performed by a single UK-based pediatric surgeon.Methods
Consecutive patients were identified who underwent esophageal replacement by gastric transposition over a 28?year period. Clinical and demographic data were collected. Weight-for-age Z-scores were calculated for esophageal atresia patients.Results
Nineteen patients were identified. Indication in the majority was long-gap esophageal atresia (n?=?17; 10 with tracheoesophageal fistula). At surgery, median age was 8.5?months (range 2–55); median weight was 7.4?kg (range 4.0–17.4?kg). A right-sided thoracotomy or transhiatal approach was used. Median postoperative length of stay was 17.5?days (range 7–130); median intensive care stay was three days (range 1–63). There were no deaths. Anastomotic leak rate at 30?days was 10.5% (n?=?2). One patient required early stricture dilatation. Median weight-for-age Z-score increased from ? 2.17 at one year of age to ? 1.86, ? 1.70 and ? 1.93 at 5, 10 and 15?years.Conclusions
Esophageal replacement by gastric transposition offers a potentially life-changing treatment; however, it is associated with significant morbidity. The majority of patients eventually achieve full oral feeding and maintenance of weight gain trajectory. A right-sided approach to the esophagus is feasible.Type of Study
Treatment Study.Level of Evidence
IV. 相似文献14.
Punam P. Parikh Jun Tashiro Amy E. Wagenaar Miosotys Curbelo Eduardo A. Perez Holly L. Neville Anthony R. Hogan Juan E. Sola 《Journal of pediatric surgery》2018,53(4):616-619
Background
Appendiceal ligation during pediatric laparoscopic appendectomy (LA) may be performed using looped suture versus stapler. Controversy regarding the utility of either method exists. Clinical outcomes and cost analysis of LA with both methods were compared.Methods
All pediatric LA were performed from fiscal years 2013 and 2014 by two pediatric surgeons. While one surgeon used looped suture, the other used stapler exclusively. chi-Square tests were performed to analyze associations.Results
Two hundred thirty-eight cases were analyzed where looped suture versus stapler LA was performed in 46% and 54% of patients, respectively. Operating room costs were $317.10 and $707.12/person for looped suture and stapler LA, respectively (P < 0.0001). Difference in cost of $390.02/person was attributed solely to ligation type. On bivariate analysis, rate of in-hospital complications, length of stay, return-to-ER and readmission within 30 days did not significantly differ between groups.Conclusion
A comparative analysis of looped suture versus stapler device during LA for pediatric appendicitis revealed that postoperative complications, length of stay, ER visits and readmissions were not significantly different. Looped suture LA was significantly more cost efficient than stapler LA. In pediatric appendicitis, appendiceal ligation during LA may be performed safely and cost effectively with looped suture versus stapler.Type of study
Cost effectivenessLevel of evidence
III. 相似文献15.
Heather L. Short Natalie Taylor Kaitlin Piper Mehul V. Raval 《Journal of pediatric surgery》2018,53(4):592-598
Purpose
Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures.Methods
A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children. The 16-member multidisciplinary expert panel included surgeons, gastroenterologists, anesthesiologists, nursing, and patient/family representatives.Results
Building upon a national survey of surgeons in which 14 of 21 adult ERAS elements were considered acceptable for use in children, the 7 more contentious elements were investigated using the modified Delphi process. In final ranking, 5 of the 7 controversial elements were deemed appropriate for inclusion in a pediatric ERAS protocol. Routine use of insulin to treat hyperglycemia and avoidance of mechanical bowel preparation were not included in the final recommendations.Conclusions
Using a modified Delphi process, we have defined an appropriate ERAS protocol comprised of 19 elements for use in adolescents undergoing elective intestinal surgery. Prospective validation studies of ERAS protocols in children are needed.Level of evidence
Level V, Expert opinion. 相似文献16.
Patrick Ho Yu Chung Paul Kwong Hang Tam Kenneth Kak Yuen Wong 《Journal of pediatric surgery》2018,53(12):2409-2411
Purpose
This study compared the bacteriology and clinical outcomes between simple (SC) and intractable cholangitis (IC) after Kasai operation.Methods
Post-Kasai patients (n?=?192) from 1980 to 2015 were retrospectively reviewed. The results of blood culture and clinical outcomes between the patients with SC and IC were compared.Main results
A total of 102 cholangitic episodes in 68 patients were analyzed (SC vs IC?=?76 vs 26). There were more IC episodes within the first year of Kasai operation (SC vs IC?=?36.8% vs 61.5%, p?=?0.022). The most common bacteria identified in SC and IC groups were Escherichia Coli and Staphylococcus aureus. Until the latest follow up, the native liver survival rates in patients with SC and IC were 75.0% and 50.0% (p?=?0.89). Among the patients with IC, the native liver survival rate was significantly better in those with a positive culture (100% vs 20%, p?=?0.001).Conclusion
Intractable cholangitis is a common complication within the first year of Kasai operation and may be caused by a different spectrum of organisms. The identification of the bacteria by blood culturing may result in a better treatment outcome.Level of evidence
Level III. 相似文献17.
Jamie R. Robinson Nicholas H. Carter Corinne Gibson Adam S. Brinkman Kyle Van Arendonk Karen E. Speck Melissa E. Danko Gretchen P. Jackson Harold N. Lovvorn Martin L. Blakely 《Journal of pediatric surgery》2018,53(6):1181-1186
Purpose
Standardized care via a unified surgeon preference card for pediatric appendectomy can result in significant cost reduction. The purpose of this study was to evaluate the impact of cost and outcome feedback to surgeons on value of care in an environment reluctant to adopt a standardized surgeon preference card.Methods
Prospective observational study comparing operating room (OR) supply costs and patient outcomes for appendectomy in children with 6-month observation periods both before and after intervention. The intervention was real-time feedback of OR supply cost data to individual surgeons via automated dashboards and monthly reports.Results
Two hundred sixteen children underwent laparoscopic appendectomy for non-perforated appendicitis (110 pre-intervention and 106 post-intervention). Median supply cost significantly decreased after intervention: $884 (IQR $705–$1025) to $388 (IQR $182–$776), p < 0.001. No significant change was detected in median OR duration (47 min [IQR 36–63] to 50 min [IQR 38–64], p = 0.520) or adverse events (1 [0.9%] to 6 [4.7%], p = 0.062). OR supply costs for individual surgeons significantly decreased during the intervention period for 6 of 8 surgeons (87.5%).Conclusion
Approaching value measurement with a surgeon-specific (rather than group-wide) approach can reduce OR supply costs while maintaining excellent clinical outcomes.Level of Evidence
Level II. 相似文献18.
Olivia J. Bono Gregory W. Poorman Norah Foster Cyrus M. Jalai Samantha R. Horn Jonathan Oren Alexandra Soroceanu Subaraman Ramachandran Taylor E. Purvis Deeptee Jain Shaleen Vira Bassel G. Diebo Breton Line Daniel M. Sciubba Themistocles S. Protopsaltis Aaron J. Buckland Thomas J. Errico Virginie Lafage Peter G. Passias 《The spine journal》2018,18(7):1204-1210
Background Context
Obesity as a comorbidity in spine pathology may increase the risk of complications following surgical treatment. The body mass index (BMI) threshold at which obesity becomes clinically relevant, and the exact nature of that effect, remains poorly understood.Purpose
Identify the BMI that independently predicts risk of postoperative complications following lumbar spine surgery.Study Design/Setting
Retrospective review of the National Surgery Quality Improvement Program (NSQIP) years 2011–2013.Patient Sample
A total of 31,763 patients were undergoing arthrodesis, discectomy, laminectomy, laminoplasty, corpectomy, or osteotomy of the lumbar spine.Outcome Measures
Complication rates.Methods
The patient sample was categorized preoperatively by BMI according to the World Health Organization stratification: underweight (BMI <18.5), normal overweight (BMI 20.0–29.9), obesity class 1 (BMI 30.0–34.9), 2 (BMI 35.0–39.9), and 3 (BMI≥40). Patients were dichotomized based on their position above or below the 75th surgical invasiveness index (SII) percentile cutoff into low-SII and high-SII. Differences in complication rates in BMI groups were analyzed by Bonferroni analysis of variance (ANOVA) method. Multivariate binary logistic regression evaluated relationship between BMI and complication categories in all patients and in high-SII and low-SII surgeries.Results
Controlling for baseline difference in SII, Charlson Comorbidity Index (CCI) score, diabetes, hypertension, and smoking, complications significantly increased at a BMI of 35?kg/m2. The odds ratios for any complication (odds ratio [OR] [95% confidence interval {CI}]; obesity 2: 1.218 [1.020–1.455]; obesity 3: 1.742 [1.439–2.110]), infection (obesity 2: 1.335 [1.110–1.605]; obesity 3: 1.685 [1.372–2.069]), and surgical complication (obesity 2: 1.622 [1.250–2.104]; obesity 3: 2.798 [2.154–3.634]) were significantly higher in obesity classes 2 and 3 relative to the normal-overweight cohort (all p<.05).Conclusion
There is a significant increase in complications, specifically infection and surgical complications, in patients with BMI≥35 following lumbar spine surgery, with that rate further increasing with BMI≥40. 相似文献19.
Yangyang R. Yu Richard Sola Somala Mohammed Joshua T. Lackey Sheena John Eric Rosenfeld Wei Zhang Shawn D. St. Peter Sohail R. Shah 《Journal of pediatric surgery》2018,53(10):2032-2035
Background
Patient-controlled analgesia (PCA) is often used in children with perforated appendicitis. To prevent urinary retention, some providers also routinely place Foley catheters.This study examines the necessity of this practice.Methods
We retrospectively reviewed all children (≤ 18?years old) with perforated appendicitis and postoperative PCA from 7/2015 to 6/2016 at two academic children's hospitals. Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley catheter.Results
Of 313 patients who underwent appendectomy for perforated appendicitis (Hospital 1: 175, Hospital 2: 138), 129 patients received an intraoperative Foley (Hospital 1: 22 [13%], Hospital 2: 107 [78%], p?<?0.001). Age, gender, and BMI were similar between those with an intraoperative Foley and those without. There were no urinary tract infections in either group.Urinary retention rate in patients with an intraoperative Foley following removal on the inpatient unit (n?=?3, 2%) and patients without an intraoperative Foley (n?=?10, 5%) did not reach significance (p?=?0.25). On univariate analysis, demographics, intraoperative findings, PCA specifics, postoperative abscess formation, and postoperative length of stay, were not significant risk factors for urinary retention.Conclusions
The risk of urinary retention in this population is low despite the use of PCA. Children with perforated appendicitis do not require routine Foley catheter placement to prevent urinary retention.Level of evidence
II 相似文献20.
Yuenshan Sammi Wong Yuk Him Tam Kristine Kit Yi Pang Ho Chung Yau 《Journal of pediatric surgery》2018,53(12):2498-2501