Parenteral nutrition-associated cholestasis: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

ObjectiveThe aim of this study was to review evidence-based data addressing key clinical questions regarding parenteral nutrition–associated cholestasis (PNAC) and parenteral nutrition–associated liver disease (PNALD) in children.Data SourceData were obtained from PubMed, Medicine databases of the English literature (up to October 2010), and the Cochrane Database of Systematic Reviews.Study SelectionThe review of PNAC/PNALD has been divided into 4 areas to simplify one's understanding of the current knowledge regarding the pathogenesis and treatment of this disease: (1) nonnutrient risk factors associated with PNAC, (2) PNAC and lipid emulsions, (3) nutritional (nonlipid) considerations in the prevention of PNAC, and (4) supplemental medications in the prevention and treatment of PNAC.ResultsThe data for each topic area relevant to the clinical practice of pediatric surgery were reviewed, evaluated, graded, and summarized.ConclusionsAlthough the conditions of PNAC and PNALD have been well recognized for more than 30 years, only a few concrete associations and treatment protocols have been established.     

Strategies for the prevention of central venous catheter infections: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Purpose

The aim of this study is to review the current evidence-based data regarding strategies for prevention of central venous catheter (CVC) infections at the time of catheter insertion and as a part of routine care.

Methods

We conducted a PubMed search from January 1990 to November 2010 using the following keywords: central venous catheter, clinical trials, pediatric, infection, prevention, antibiotic, chlorhexidine, dressing, antiseptic impregnated catheters, ethanol lock, impregnated cuff, insertion site infection, and Cochrane systematic review. Seven questions, selected by the American Pediatric Surgical Association Outcomes and Clinical Trials Committee, were addressed.

Results

Thirty-six studies were selected for detailed review based on the strength of their study design and relevance to our 7 questions. These studies provide evidence that (1) chlorhexidine skin prep and chlorhexidine-impregnated dressing can decrease CVC colonization and bloodstream infection, (2) use of heparin and antibiotic-impregnated CVCs can decrease CVC colonization and bloodstream infection, and (3) ethanol and vancomycin lock therapy can reduce the incidence of catheter-associated bloodstream infections.

Conclusion

Grade A and B recommendations can be made based on available evidence in adult and limited pediatric studies for multiple components of proper CVC insertion practices and subsequent management. These strategies can minimize the risk of CVC infections in pediatric patients.     

Research interests and funding of members of the American Pediatric Surgical Association: report from 2010 American Pediatric Surgical Association Outcomes and Clinical Trials Committee

Objective

There is lack of data relating to the research interests and funding of pediatric surgeons within the United States and Canada. These data may be helpful in promoting basic and clinical research among pediatric surgeons.

Methods

The American Pediatric Surgical Association (APSA) Outcomes and Clinical Trials Committee developed and administered an online survey via e-mail to the APSA membership to help characterize research activities and funding. The survey was available for completion during December of 2009. The survey contained 10 items with a drop-down menu for multiple choice answers and required 5 to 10 minutes to complete. Results based on research interests as well as funding sources were compiled and analyzed.

Results

A total of 275 members, which comprises 27.4% of the APSA membership, completed the survey. Of the respondents, 177 (64%) described being in an academic practice, 44 (16%) in an academically associated private practice, 9 (3.3%) in a private solo practice, 17 (6.2%) in private group practice, and 3 (1%) in the military. A total of 189 (68.7%) respondents stated that they participated in formal research. Respondents also categorized their research interests, and the following were the most common subjects of study (decreasing order of frequency): appendicitis, trauma and critical care, outcomes, minimally invasive surgery, and congenital diaphragmatic hernia. Of those participating in research, 64.5% stated that they have no formal financial support. Of those supported through the National Institutes of Health, funding grants achieved were as follows: R01 (n = 29), K08 (n = 9), K23 (n = 2), and U01 (n = 8).

Conclusions

Research activities are common among APSA members and encompass a wide range of pediatric surgery topics. Strikingly, the overall financial support of these efforts is limited, predominantly supported by the surgeons themselves. Funded respondents attained grants through Public Health Service grants, departmental grants, or private institutions.     

Pediatric appendicitis rupture rate: disparities despite universal health care

Background/Purpose

Significant socioeconomic disparities have been observed in the rates of perforated appendicitis among children in private health care. We seek to explore if, in the Canadian system of public, universal health care access, pediatric appendicitis rupture rates are an indicator of health disparities.

Methods

Using the Population Health Research Data Repository housed at Manitoba Centre for Health Policy, a retrospective analysis over a 20-year period (1983-2003) examined all patients aged less than 18 years with International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic and procedural codes for appendicitis (N = 7475). Multivariate logistic regression analysis was used to calculate odds ratios in the association between appendiceal rupture rates and the patient's socioeconomic status (SES) based upon average household income of the census area adjusted for age, sex, area of residence, and treating hospital.

Results

The overall appendiceal rupture rate was 28.8%. Significant positive predictors of appendiceal rupture were lower rural SES, lower urban SES, younger age, northern area of residence, and receiving treatment at the province's only pediatric tertiary care hospital.

Conclusion

Despite free, universal access health care, children from lower SES areas have increased appendiceal rupture rates. Seeking and accessing medical attention can be complicated by social, behavioral, and geographical problems.     

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review

Background

The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy.

Non-operative management of solid organ injuries in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee systematic review

PurposeThe American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children.MethodsA comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016.ResultsLOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries.ConclusionBased upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage.Type of StudySystematic Review.Levels of EvidenceLevels 2–4.     

Comparison of pediatric appendicitis outcomes between teaching and nonteaching hospitals

Purpose

The aim of the study was to determine the outcomes of pediatric appendicitis between a teaching and nonteaching institution.

Methods

A retrospective review of all patients younger than 18 years treated for appendicitis between 1998 and 2007 was performed. The teaching institution has its own general surgery residency program, and the nonteaching institution has no surgical resident involvement. Both hospitals are part of a larger system and were similar except for resident involvement. Study outcomes included postoperative morbidity and length of hospitalization (LOH). Patients with perforated appendicitis treated nonoperatively were excluded. Data were analyzed using Wilcoxon rank sum test and χ² analysis with P < .01 considered significant.

Results

Seven hundred ninety-two patients were treated at the teaching institution (mean age, 10.9 years; 62% male) and 1670 at the nonteaching institution (mean age, 11 years; 61% male). The perforated appendicitis rate was 31% at the teaching institution and 26% at the nonteaching institution (P = .008). Forty-five patients at the teaching institution and 14 at the nonteaching institution with perforated appendicitis were treated nonoperatively and excluded. For nonperforated appendicitis, despite similar rates of postoperative wound infection, abscess drainage, and readmission within 30 days between the 2 institutions, LOH was shorter in the teaching institution (1.4 ± 1.0 vs 1.8 ± 1.4 days; P < .0001). For perforated appendicitis, LOH and rates of wound infection, abscess drainage, and readmission within 30 days were similar between the 2 institutions.

Conclusions

Children with nonperforated appendicitis cared for at a teaching institution had similar postoperative morbidity and shorter LOH compared to a nonteaching institution. In patients with perforated appendicitis, postoperative morbidity and LOH were similar between teaching and nonteaching institutions. Overall, the presence of surgical trainees did not adversely impact on the quality of care for children with appendicitis.     

Nationwide management of perforated pediatric appendicitis: Interval versus same-admission appendectomy

PurposeAlthough conservative management followed by readmission for interval appendectomy is commonly used to manage perforated appendicitis, many studies are limited to individual or noncompeting pediatric hospitals. This study sought to compare national outcomes following interval or same-admission appendectomy in children with perforated appendicitis.MethodsThe Nationwide Readmission Database was queried (2010–2014) for patients <18 years old with perforated appendicitis who underwent appendectomy using ICD9-CM Diagnosis codes. A propensity score-matched analysis (PSMA) utilizing 33 covariates between those with (Interval Appendectomy) and without a prior admission (Same-Admission Appendectomy) was performed to examine postoperative outcomes.ResultsThere were 63,627 pediatric patients with perforated appendicitis. 1014 (1%) had a prior admission for perforated appendicitis within one calendar year undergoing interval appendectomy compared to 62,613 (99%) Same-Admission appendectomy patients. The Interval Appendectomy group was more likely to receive a laparoscopic (87% vs. 78% same-admission) than open (13% vs. 22% same-admission; p < 0.001) operation. Patients receiving interval appendectomy were more likely to have their laparoscopic procedure converted to open (5% vs. 3%) and receive more concomitant procedures. PSMA demonstrated a higher rate of small bowel obstruction in those receiving Same-Admission appendectomy while all other complications were similar. Although those receiving Interval Appendectomy had a shorter index length of stay (LOS) and lower admission costs, they incurred an additional $8044 [$5341-$13,190] from their prior admission.ConclusionPatients treated with interval appendectomy experienced more concomitant procedures and incurred higher combined hospitalization costs while still having a similar postoperative complication profile compared to those receiving same-admission appendectomy for perforated appendicitis.Level of evidenceIII.Type of studyRetrospective Comparative Study.     

Optimizing resources for the surgical care of children: An American Pediatric Surgical Association Outcomes and Clinical Trials Committee Consensus Statement

The United States’ healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.     

Complicated appendicitis in children: a clear role for drainage and delayed appendectomy

INTRODUCTION: Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. METHODS: A retrospective review of all children undergoing appendectomy over a 5-year period was performed. RESULTS: We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy. CONCLUSION: In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.     

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

Background/PurposeAppendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system.MethodsUsing administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression.ResultsOver the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those > 125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31–4. 02, p = 0.001; and OR 2.55, 95%CI 1.35–4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates.ConclusionsIn this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada.Level of evidencePrognosis study, level II.     

Outcomes of perforated appendicitis in obese and nonobese children

Introduction

Despite abundant data on the impact of obesity in adults, little data exist that examine the impact of obesity on surgical outcomes in children. Therefore, we analyzed the impact of obesity on children with perforated appendicitis.

Methods

We analyzed data from 3 prospective trials on perforated appendicitis between 2005 and 2009. Perforation was defined as a hole in the appendix or fecalith in the abdomen. There was no difference in abscess rate in the 6 arms of these trials. Body mass index (BMI) was calculated, and BMI percentile was identified according to sex and age. The obese group was defined as BMI greater than 95th percentile. Data were compared between nonobese and obese patients.

Results

There were 220 patients, of which 37 patients were obese. The obese group was older with no other differences in presentation. Mean length of stay was 7.9 days in the obese patients compared with 5.8 days for the nonobese (P < .001). Mean operative time was 55.2 minutes in obese patients compared with 43.6 for nonobese (P = .003). Abscess rate was 35% in obese patients compared with 15% for nonobese (P = .01).

Conclusions

Obese children undergoing laparoscopic appendectomy for perforated appendicitis experience longer operative times and suffer worse outcomes.     

Failure in the nonoperative management of pediatric ruptured appendicitis: predictors and consequences

Introduction

The initial nonoperative management of perforated appendicitis fails in 15% to 25% of children. These children have complications and increased hospitalization. The purpose of this study was to identify predictors of failure.

Methods

Children with perforated appendicitis treated with antibiotics and intent for nonoperative management over a 4-year period were reviewed. Seventy-five children were identified and included in the study. Failure was defined as undergoing appendectomy before the initially planned interval.

Results

Nine (12%) of the patients required appendectomy sooner than initially planned. Age, presenting symptoms, physical examination findings, and white blood cell (WBC) count were similar in both success and failure groups. Absence of abscess and presence of appendicolith were both predictors of failure in a multivariate analysis, which included the presence of small bowel obstruction. The failed group had a longer median total length of stay (18 days [range, 4-67] vs 8 days [range, 4-31]; P = .002) and underwent 3 times as many computed tomography scans as successes (3 [range, 2-7] vs 1 [range, 0-5]; P < .001).

Conclusion

Lack of abscess and presence of an appendicolith predict failure of nonoperative management of perforated appendicitis in children even when the effect of small bowel obstruction is accounted for. Children with these characteristics may benefit from alternative management strategies.     

Accounting for early job turnover in recent pediatric surgery fellowship graduates: An American Pediatric Surgical Association Membership and Credentials Committee study

Purpose

Employment opportunities for graduating pediatric surgeons vary from year to year. Significant turnover among new employees indicates fellowship graduates may be unsophisticated in choosing job opportunities which will ultimately be satisfactory for themselves and their families. The purpose of this study was to assess what career, life, and social factors contributed to the turnover rates among pediatric surgeons in their first employment position.

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

Background

The purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC).

Methods

Patients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness.

Results

We included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71).

Conclusions

After accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.     

Post-colonoscopy appendicitis: A case report and systematic review

Colonoscopy is a widely used diagnostic and therapeutic modality with a relatively low morbidity.However,given the large volume of procedures performed,awareness of the infrequent complications is essential.Perforation is an established complication of colonoscopy,and can range from 0.2%-3%depending on the series,population and modality of colonoscopy.Acute appendicitis after colonoscopy is an extremely rare event,and a cause-effect relationship between the colonoscopy and the appendicitis is not well documented.In addition,awareness of this condition can aid in prompt diagnosis.Relatively mild symptoms and exclusion of bowel perforation by contrast studies do not exclude appendicitis from the differential diagnosis for post-colonoscopy pain.In addition to the difficult diagnosis inherent to postcolonoscopy appendicitis,treatment strategies have varied greatly.This paper reviews these approaches.We also expand upon prior articles by giving guidance for the role of nonoperative management in these patients.This case and review of the literature will help to create awareness about this complication,and guide optimal treatment of pericolonoscopy appendicitis.     

The management of pediatric appendicitis: a survey of North American Pediatric Surgeons

Background/purpose

Variation exists among pediatric surgeons in the management of pediatric appendicitis. The goal of this study was to determine current practice patterns and provide a foundation for evidence-based outcome studies that would standardize patient care.

Methods

Members of the American Pediatric Surgical Association (APSA) were surveyed. Data included preference of imaging, timing of operation, and opinions on interval appendectomy. Intraoperative principles surveyed included use of cultures, antibiotic irrigation, transperitoneal drains, and method of wound closure. Spectrum and duration of antibiotic coverage were assessed, as were discharge criteria.

Results

Survey response was 70%. A majority prefers computerized tomographic (CT) imaging and favors interval appendectomy in appropriate candidates. Seventy percent indicate a stable child with suspected appendicitis would be operated on in a semiurgent manner rather than emergently in their practice. Discrepancy exists in the type and duration of antibiotic coverage, impact of clinical parameters on antibiotic use, and utility of discharge criteria.

Conclusions

This study consolidates current opinions on appropriate management of pediatric appendicitis, providing a foundation for evidence-based outcome studies capable of bringing conformity to the management of this surgical disease. Such studies would establish clinical practice guidelines that optimize resource utilization while maintaining quality care.     

Post operative pediatric appendicitis nurse-driven discharge: Patient outcomes and nursing perspectives

BackgroundNurse-driven discharge pathways following pediatric appendectomies have proven effective in children’s hospitals; studies in general hospital settings are lacking. Additionally, despite the central role of nursing in such pathways, nursing perspectives aren’t investigated in the literature.MethodsData from all pediatric acute uncomplicated appendicitis patients who underwent laparoscopic appendectomy in the 12 months following institution of a nurse-driven discharge pathway (intervention, n = 67) were compared to those treated in the preceding year (control, n = 64). Surveys on the pathway were distributed to pediatric ward nurses.ResultsPostoperative length of stay (POLOS) decreased by 37% in the intervention group, about 6 h, (0.44 days ± 0.22 vs 0.7 days ± 0.27, p-value 0.0001), without a significant increase in related readmissions. Same day discharges increased from 10.9% to 46.3%, (P-value 0.0001). Nurse surveys revealed a high approval of the pathway (7–10/10) and yielded valuable feedback.ConclusionA nurse-driven discharge pathway decreased POLOS without increasing readmission following pediatric laparoscopic appendectomy in a general hospital setting. Valuable insight into nursing perspectives on this pathway was acquired.     

Research publication in pediatric surgery: a cross-sectional study of papers presented at the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association

Introduction

Several studies have examined predictors of publication of research presented in scientific meetings in different disciplines. A tendency toward publishing studies with positive results has been described as “publication bias.” Our objective was to determine the proportion of the studies that were published, time to publication, and factors that could predict publication in pediatric surgery.

Methods

The abstract books of the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association meetings for 2001 to 2002 were reviewed. Data were gathered regarding the methodology and characteristics of each study. Case reports and editorials were excluded. A Medline search was then conducted to determine the publication status. Analysis using univariate and multivariate techniques was undertaken, comparing the difference between published and unpublished studies.

Results

Two hundred seven abstracts were reviewed. Of the 183 abstracts included, 118 (64.5%) were published. Most studies were published 1 year after presentation (93.2%). Presentation in the American Pediatric Surgery Association meeting and research originating from North America and reporting statistically significant results were significantly associated with subsequent publication on univariate analysis. The presence of statistically significant results was the only factor associated with successful publication on multivariate analysis (odds ratio, 3.3; confidence interval, 1.5-7.7).

Conclusion

The strong association between successful publication and the presence of statistically significant results point to the strong possibility of publication bias affecting decisions made about publishing research in the pediatric surgery.     

Firearm injuries and children: Position statement of the American Pediatric Surgical Association

Firearm injuries are the second most common cause of death in children who come to a trauma center, and pediatric surgeons provide crucial care for these patients. The American Pediatric Surgical Association (APSA) is committed to comprehensive pediatric trauma readiness, including firearm injury prevention. APSA supports a public health approach to firearm injury, and it supports availability of quality mental health services. APSA endorses policies for universal background checks, restrictions on assault weapons and high capacity magazines, strong child access protection laws, and a minimum purchase age of 21 years. APSA opposes efforts to keep physicians from counseling children and families about firearms. APSA promotes research to address this problem, including increased federal research support and research into the second victim phenomenon. APSA supports school safety and readiness, including bleeding control training. While it may be daunting to try to reduce firearm deaths in children, the U.S. has seen success in reducing motor vehicle deaths through a multidimensional approach – prevention, design, policy, behavior, trauma care. APSA believes that a similar public health approach can succeed to save children from death and injury from firearms. APSA is committed to building partnerships to accomplish this.Type of StudyAPSA Position Statement.Level of EvidenceLevel V, Expert Opinion.