Trends and outcomes of total and partial nephrectomy in children: A statewide analysis

ObjectiveTo report trends in surgical approach and associations with outcomes in children undergoing extirpative renal surgery in the state of Maryland over a 12-year period.MethodsThe Maryland Health Services Cost Review Commission (HSCRC) database was queried to identify children undergoing total or partial nephrectomy between 2000 and 2011. Demographic, clinical, hospital, and charge data were compared between children undergoing open and minimally invasive renal surgery. Multivariable logistic regression analysis was performed to identify independent predictors of prolonged length of hospital stay and 30-day readmission. Multivariable linear regression was performed to identify independent predictors of increased hospital charges.ResultsOf the 346 children undergoing extirpative renal surgery, 289 (83.5%) underwent total nephrectomy and 48 (13.9%) underwent minimally invasive surgery. Utilization of minimally invasive surgery for congenital urinary anomalies has steadily increased from 15% to 35% over the past decade. Children undergoing minimally invasive total nephrectomy were healthier, had shorter hospital stay, and were more likely to have surgery at a high-volume institution. No such differences were noted in patients undergoing open and minimally invasive partial nephrectomy. On multivariable regression analyses, high patient complexity was the main predictor of increased length of stay (OR 16.02, 95% CI 7.06–36.31), 30-day readmission (OR 3.04, 95% CI 1.38–6.70), and total hospital charge (p < 0.001).ConclusionIn Maryland hospitals, most extirpative renal surgeries in children are total nephrectomies performed using an open technique by high-volume surgeons. Although the overall proportion of minimally invasive surgeries has not increased over time, the utilization of MIS in congenital anomaly cases has. Patient complexity and not operative approach dictates postoperative morbidity and hospital charges.     

Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome

OBJECTIVES: To analyze recent nationwide trends in the use of adolescent bariatric surgery and to compare early postoperative outcomes of adolescents and adults undergoing these procedures. DESIGN: Analysis of national administrative data by using survey analysis techniques. SETTING: Data obtained from the Nationwide Inpatient Sample from 1996 to 2003. PARTICIPANTS: Adolescents (aged <20 years) and adults undergoing bariatric surgery. Intervention Bariatric surgery. MAIN OUTCOME MEASURES: Population-based case rates, major postoperative complications, length of hospital stay, hospital charges, and mortality. RESULTS: The population-based annual adolescent bariatric case volume varied little between 1996 and 2000 but more than tripled from 2000 to 2003. Despite this trend, only 771 bariatric procedures were performed in adolescents in 2003, representing fewer than 0.7% of bariatric procedures performed nationwide. Univariate comparison with data from 2003 showed a similar in-hospital complication rate in adolescents and adults but a significantly shorter length of stay among adolescents. Although in-hospital mortality was observed in 0.2% of adults, no in-hospital deaths were observed in any adolescents. CONCLUSIONS: Although procedure rates have increased recently, bariatric surgery in adolescents remains an uncommonly performed procedure. These data support efforts to align bariatric surgery programs for adolescents initially with higher volume programs for adults and to develop multicenter collaborative studies directed at defining the short- and long-term effect of bariatric surgery in morbidly obese adolescents.     

Laparoscopic and conventional appendicectomy in children: outcomes in English hospitals between 1996 and 2006

Background  Laparoscopic appendicectomy is increasingly used in children. This national retrospective study compared outcomes of paediatric open and laparoscopic appendicectomy. Methods  Length of stay, readmission rates and mortality in children undergoing open and laparoscopic appendicectomy in English NHS Trusts between 1 April 1996 and 31 March 2006 were compared. Procedures coded as emergency excision of appendix (OPCS-4 H01) on the Hospital Episode Statistics (HES) database in patients less than 15 years of age were included. Multivariate analysis was used to identify independent predictors of length of hospital stay and mortality. Results  Eighty-nine thousand, four-hundred and ninety-seven (89,497) appendicectomies were studied; of which, 2,689 (3%) were performed laparoscopically. The percentage of laparoscopic cases rose from 0.6 to 8.4% between 1996 and 2006 (Pearson’s r = 0.954, P < 0.001). Length of stay (median 3, interquartile range 2 days, P = 0.068) and 28-day readmission rates were similar (6.3 vs. 7.2%, respectively; P = 0.072) between groups. No independent hospital stay advantage for laparoscopy was observed (P = 0.121). No difference in 30-day mortality (P = 0.986) or 365-day mortality (P = 0.598) was demonstrated. Conclusion  Hospital stay, readmission rates and mortality are similar following laparoscopic and open appendicectomy in children.     

Frequency and Indications for Tracheostomy and Gastrostomy After Congenital Heart Surgery

Patients undergoing congenital heart surgery may occasionally require additional surgical procedures in the form of tracheostomy and gastrostomy. These procedures are often performed in an attempt to diminish hospital morbidity and length of stay. We reviewed the Web-based medical records of all patients undergoing congenital heart surgery at Miami Children’s Hospital from February 2002 through August 2007. Patients who were deemed preterm and had undergone closure of a patent ductus arteriosis were eliminated. The records of all other patients were queried for the terms gastrostomy, g-tube, Nissan, fundal plication, tracheostomy, or tracheotomy. Patients’ medical records in which these terms appeared in any portion were completely reviewed. There were 1660 congenital heart operations performed in the study period. There were 592 operations performed on patients whose age ranged from 1 month to 1 year and 441 neonatal operations. Mortality was 2%. Median postoperative stay was 8 days (range, 1–191 days), 12 days for neonates (range, 3–142 days), and 19 days for neonates undergoing RACHS-1 category 6 operations (range, 4–142 days). Tracheostomies were performed in four patients (0.2%). Gastrostomies were performed on eight patients (0.4%), representing 0.8% of patients <1 year of age, 1.4% of neonates, and 2.4% of patients undergoing RACHS-1 category 6 operations. The rate of patients undergoing either tracheostomy or gastrostomy after congenital heart surgery at our institution was quite low. Avoidance of either of these two procedures was achieved without increased morbidity or length of stay. The rate at which these procedures need to be performed may reflect the magnitude of the patients’ lifetime trauma related to their underlying condition and acute and total surgical experiences.     

Robotic-assisted laparoscopic extravesical ureteral reimplantation: an initial experience

ObjectiveThere are many emerging techniques using robotic-assisted laparoscopy (RAL) in pediatrics. We performed a retrospective review of our first patients who underwent RAL extravesical ureteral reimplantation.Materials/MethodsBetween October 2007 and May 2010, a single surgeon performed RAL extravesical ureteral reimplantation in 17 patients. Six patients underwent bilateral reimplantation, resulting in a total of 23 ureters repaired. There were 16 females and 1 male (mean age 6.23 years). Four patients had prior Deflux injection. Postoperative reflux status was assessed by voiding cystourethrogram.Results16 patients (22 ureters) were compliant with follow up. Mean follow up was 11.5 months. Mean anesthetic time was 3 h, 57 min for unilateral and 4 h, 45 min for bilateral repair. Complete vesicoureteral reflux resolution was seen in 20 ureters (90.9%), downgrading in one ureter, and unchanged persistent reflux in one ureter. Average hospital stay was 1.3 days. No patients required postoperative catheterization at discharge.ConclusionsOutcomes for new procedures can be variable and unpredictable as the technique evolves. Given the high success rates of open reimplantation, a minimally invasive technique must show comparable results if it is to play a continuing role. Our initial results are encouraging, but prospective analyses are required to outline the future role of RAL ureteral reimplantation.     

腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常21例报告

目的 探讨腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常的临床疗效.方法 回顾性分析我院2014年10月至2016年1月用腹腔镜膀胱外输尿管膀胱再植术治疗21例输尿管膀胱连接部异常患儿的临床资料.其中输尿管膀胱连接部狭窄14例,输尿管膀胱连接部反流3例,输尿管异位开口4例.术前检查包括泌尿系统超声检查、泌尿系统CT三维重建成像检查、排泄性膀胱尿道造影和肾图检查.所有患儿术前检查均提示输尿管全程扩张,有反复尿路感染史14例,伴发肾积水9例,输尿管全程扩张达20 mm以上者6例,术前肾图结果提示异常者10例.结果 21例均经腹腔镜完成手术,无中转开放.手术时间120～170 min.术后4例出现轻度肉眼血尿,1d后消失.术后平均住院时间为8d,所有患儿术后无尿潴留发生,无吻合口漏发生.术后随访3～12个月,有2例发生尿路感染(9.5％),1例予口服抗生素及多饮水后缓解,1例抗感染治疗无效后,膀胱镜下取出双J管后缓解.术前肾图11例正常,10例患侧异常,术后3个月异常者有8例复查肾图,较术前有改善,失访2例.术后3～6个月超声复查输尿管直径均小于6mm.结论 腹腔镜下膀胱外输尿管膀胱再植术治疗儿童输尿管膀胱连接部异常疾病安全有效,术中用时合理、出血少,膀胱创伤小,肾功能有明显改善,临床疗效确切,且具有微创优势.     

Comparison of Maximum Vasoactive Inotropic Score and Low Cardiac Output Syndrome As Markers of Early Postoperative Outcomes After Neonatal Cardiac Surgery

Low cardiac output syndrome (LCOS) and maximum vasoactive inotropic score (VIS) have been used as surrogate markers for early postoperative outcomes in pediatric cardiac surgery. The objective of this study was to determine the associations between LCOS and maximum VIS with clinical outcomes in neonatal cardiac surgery. This was a secondary retrospective analysis of a prospective randomized trial, and the setting was a pediatric cardiac intensive care unit in a tertiary care children’s hospital. Neonates (n = 76) undergoing corrective or palliative cardiac operations requiring cardiopulmonary bypass were prospectively enrolled. LCOS was defined by a standardized clinical criteria. VIS values were calculated by a standard formula during the first 36 postoperative hours, and the maximum score was recorded. Postoperative outcomes included hospital mortality, duration of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay (LOS), as well as total hospital charges. At surgery, the median age was 7 days and weight was 3.2 kg. LCOS occurred in 32 of 76 (42%) subjects. Median maximum VIS was 15 (range 5–33). LCOS was not associated with duration of mechanical ventilation, ICU LOS, hospital LOS, and hospital charges. Greater VIS was moderately associated with a longer duration of mechanical ventilation (p = 0.001, r = 0.36), longer ICU LOS (p = 0.02, r = 0.27), and greater total hospital costs (p = 0.05, r = 0.22) but not hospital LOS (p = 0.52). LCOS was not associated with early postoperative outcomes. Maximum VIS has only modest correlation with duration of mechanical ventilation, ICU LOS, and total hospital charges.     

Impact of the Viral Respiratory Season on Postoperative Outcomes in Children Undergoing Cardiac Surgery

To compare postoperative outcomes in children undergoing cardiac surgery during the viral respiratory season and nonviral season at our institution. This was a retrospective cohort study and secondary matched case–control analysis. The setting was an urban academic tertiary-care children’s hospital. The study was comprised of all patients <18 years of age who underwent cardiac surgery at Johns Hopkins Hospital from October 2002 through September 2007. Patients were stratified by season of surgery, complexity of cardiac disease, and presence or absence of viral respiratory infection. Measurements included patient characteristics and postoperative outcomes. The primary outcome was postoperative length of stay (LOS). A total of 744 patients were included in the analysis. There was no difference in baseline characteristics or outcomes, specifically, no difference in postoperative LOS, intensive care unit (ICU) LOS, and mortality, among patients by seasons of surgery. Patients with viral respiratory illness were more likely to have longer postoperative LOS (p < 0.01) and ICU LOS (p < 0.01) compared with matched controls. We identified no difference in postoperative outcomes based on season in patients undergoing cardiac surgery. Children with viral respiratory infection have significantly worse outcomes than matched controls, strengthening the call for universal administration of influenza vaccination and palivizumab to appropriate groups. Preoperative testing for respiratory viruses should be considered during the winter months for children undergoing elective cardiac surgery.     

Management of vesicoureteral reflux secondary to neurogenic bladder

The authors encountered 108 cases of vesicoureteral reflex (VUR) in 231 cases of neurogenic bladder complicating spina bifida. Bladder compliance and percent volume (% vol.) were measured pre- and postoperatively and the patients were divided into four groups retrospectively according to the treatment. Ninety-five percent of low-grade VUR (grades I and II) disappeared spontaneously with conservative therapy or after augmentation cystoplasty without antireflux surgery; 92% of high-grade VUR (grade III or more) required ureteral reimplantation with or without bladder augmentation. Reflux did not recur in any case of ureteral reimplantation with bladder augmentation, however, it did recur in 20.4% of the cases of simple ureteral reimplantation without bladder augmentation. Percent volume and bladder compliance in cases of recurrence following simple ureteral reimplantation were significantly lower than in the successful cases. This study suggests that low-grade VUR can resolve spontaneously with conservative therapy or with a suitable maneuver to improve bladder compliance. High-grade reflux in cases of preserved bladder volume (% vol.>75%) and compliance (>7 ml/cmH₂O) can be treated successfully with simple ureteral reimplantation, however, in cases of low volume (% vol.<60%) and low compliance (<4 ml/cmH₂O), reimplantation with bladder augmentation is recommended. Accepted: 6 January 1998     

Effect of surgical subspecialty training on patent ductus arteriosus ligation outcomes

Purpose

Surgical outcomes data for patent ductus arteriosus (PDA) ligation come primarily from single institution case series. The purpose of this study was to evaluate national PDA ligation trends, and to compare outcomes between pediatric general (GEN) and pediatric cardiothoracic (CT) surgeons.

Methods

The Pediatric Health Information System database was queried to identify neonates who underwent PDA ligation from 2006 through 2009. Outcomes evaluated included surgical morbidity, in-hospital mortality, length of stay, and total charges. Outcomes were compared between pediatric general and pediatric cardiothoracic surgeons.

Results

The records of 1,482 neonates who underwent PDA ligation were identified and analyzed. Overall mean gestational age was 26 ± 3 weeks and birth weight was 888 ± 428 g. The majority of patients among both surgeons had birth weights of ≤1,000 g (77.2 %) and were born at ≤27-week gestation (81.5 %). Most of the PDA ligations were performed by pediatric CT surgeons (n = 1,196, 80.7 %). The mortality rate did not differ by surgeon subspecialty training (GEN = 5.2 %, CT 7.9 %, p = 0.16). Neonates in the cardiothoracic surgeon cohort showed lower length of stay (p < 0.001–0.05) and total hospital charges (p < 0.05) among patients with birth weight ≤1,200 g. Proxy measures of surgical morbidity—gastrostomy, fundoplication, and tracheostomy—showed no significant differences between the two surgical subspecialists overall or across birth weight subgroups (p > 0.05).

Conclusion

These data provide a contemporary snapshot of PDA ligation outcomes at American children’s hospitals. Pediatric general surgeons achieve comparable outcomes performing PDA ligation compared to pediatric cardiothoracic surgeons.     

Dorsal lumbotomy incision for pediatric pyeloplasty – a good alternative

This study reviews the value and benefits of the dorsal lumbotomy incision (DL) for exposure of the pelviureteric junction (PUJ) in infantile and paediatric pyeloplasty. Ninety-one children underwent pyeloplasty for confirmed PUJ obstruction between January 1993 and December 1997. The conventional loin incision (CL) (n = 60) was used as the standard, to which DL (n = 31) was compared. Information on the duration of surgery, length of hospital stay, length of time to return to full oral intake, and complications was obtained retrospectively from the hospital chart. The results were analysed using a non-parametrical statistical analysis. Follow-up was between 6 months and 5 years (median 2.4 years). The median age at surgery was 1.5 years (1 month–14 years). The median operating time was similar in both groups (95 min). The median length of stay was 3 days for the DL group compared to 7 days for the CL group (P < 0.001). The length of hospital stay had no correlation to the patient's age at surgery or the type of postoperative analgesia used. The median time to return to full oral intake and unrestricted activity in the DL group was 43 h compared to 83 h for the CL group (P < 0.001). The surgeons found that there was better exposure of the PUJ in infants in the DL group compared to the DL incision. There were no operative complications related to the DL itself. At the time of last follow-up 3 children required re-operation for a failed pyeloplasty, 2 in the DL group. The results suggest that DL is a safe and reasonable alternative to CL in paediatric pyeloplasty and probably the incision of choice in infantile pyeloplasty. Accepted: 1 March 1999     

Results of surgery for vesicoureteral reflux in children: 6 years' experience in an Asian country

From January 1990 to December 1995, a total of 181 patients underwent reimplantation of 318 ureters for primary vesicoureteral reflux (VUR); 87.8% received bilateral reimplantation. Surgical indications included breakthrough infection (35%), high-grade (≥IV) reflux (33%), or both (29%). The operative success rate was 99.4% at 3 months postoperatively and 100% ultimately. The complications included: contralateral sequential reflux in 3.9%, postoperative bladder diverticula in 1.1%, postoperative urinary infection in 1.1%, residual reflux in 0.3%, postoperative vesicoureteral stenosis in 0.3%, and slippage of the drainage tube in 0.3% of cases. Two patients had renal failure due to VUR that was proven by renal biopsy (one 4-year-old and one 8-year-old). The incidence of associated anomalies was higher than in the normal population. The average number of hospital admission days was 7.9 (3–63). After 1992, no ureteral stent was left in postoperatively. All patients received prophylactic antibiotics for 3 months postoperatively until the VUR disappeared. The surgical results were satisfactory in this series. Accepted: 4 February 1997     

Critical incidents in paediatric critical care: who is at risk?

We evaluated the characteristics of children for whom critical incidents (CIs) were reported by performing prospective collection of patient data and retrospective review of reported CIs in a multidisciplinary neonatal–paediatric intensive care unit of a tertiary care university children’s hospital. A period of 1 year was analysed (January to December 2007; 1,251 admissions). CIs comprised adverse events (actual patient injury), as well as near-misses. The report form of critical incidents was web-based and reporting was voluntary, anonymous and non-punitive. The severity of all CIs was divided into minor, moderate and major. Patients with and without CIs were compared regarding the following characteristics: Paediatric Index of Mortality (PIM2), duration of mechanical ventilation, length of stay in the intensive care, admission mode (surgery, cardiopulmonary bypass, cardiac/non-cardiac unit), age and sex. There were 360 CI reports (83 per 1,000 patient days; 13% major, 26% moderate, 61% minor severity). Of these, 310 CIs could be assigned to 198 specific patients. In the univariate analysis, patient-related risk factors for CIs were higher PIM2 score (p < 0.0001), increased length of stay (p < 0.0001), mechanical ventilation (p < 0.0001), increased ventilator days (p < 0.0001), male gender (p = 0.022) and young age (p < 0.0001). Using a logistic regression model, mechanical ventilation (p < 0.0001), male gender (p = 0.034) and length of stay (p < 0.0001) continued to be associated with the occurrence of CIs. Conclusion CIs often occur in paediatric intensive care. Among the patient-related factors, male gender, mechanical ventilation, and length of stay are independently associated with CIs. Already known at admission to intensive care are male gender and, usually, requirement for mechanical ventilation. Improved knowledge of the risk factors for CIs could help to minimize their frequency and thus improve quality of care.     

Hospital stay and short-term follow-up of children of drug-abusing mothers born in an urban community hospital – a retrospective review

In order to assess the current use of medical and social services of children of drug-abusing mothers in regard to their short term outcome in a Swiss urban community hospital, we compared hospital, private paediatricians and home nursing records of 37 of these children with 37 matched control children from birth to 18 months of age. Children of drug-abusing mothers (CDAM) experienced a longer neonatal hospital stay than control children with a median (25%–75%) of 26 days (10.5–52.5 days) versus 5 (5–6) days (P < 0.001), a substantial part of which, 8 days (3.5–26 days) versus 0 days (0–1 day) (P < 0.001) was not motivated by any specific medical treatment or nursing care. Before discharge, CDAM were referred to out of hospital nursing and social services for further management, but only 13% were effectively followed. More than 50% were lost to follow-up by their initial paediatrician after 1 year of life. Conclusion New ways to ensure better co-ordination between paediatricians and the social services (inside and outside the hospital) should be developed to shorten the neonatal hospitalisation period and improve the quality of follow-up. Received: 14 September 1999 and in revised form: 19 January, 25 February and 16 March 2000 Accepted: 24 March 2000     

机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流

目的探讨机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流的可行性、安全性和手术技巧。方法回顾性分析2014年5月至2019年2月上海市儿童医院收治的11例原发性膀胱输尿管反流患儿临床资料,其中男童10例,女童1例,均应用达芬奇系统辅助腹腔镜行Lich-Greqoir输尿管再植手术。患儿平均年龄9.4岁(3.2~18岁)。其中双侧4例,单侧7例。反流程度Ⅱ~Ⅳ级(Ⅱ级2侧,Ⅲ级3侧,Ⅳ级10侧)。结果患儿均采用Lich-Gregoir术式,术中患侧输尿管平均直径9 mm(5~15 mm),平均黏膜下隧道长度4.4 cm(3~6 cm)。术中无中转开放手术,单侧输尿管手术平均时间152 min(132~175 min),双侧输尿管手术平均时间257 min(249~264 min),术后平均住院时间4.5 d(3~6 d),1例双侧VUR患儿术后出现短期尿潴留,延长留置导尿管2周后痊愈。患儿平均随访时间2.5年(6个月至5.3年),所有病例均无发热性尿路感染,B超均未见患侧输尿管肾盂积水加重。术后完成VCUG 9例(其中双侧4例,单侧5例),其中1例双侧病例术后发现左侧反流Ⅰ级。结论机器人辅助腹腔镜下Lich-Greqoir手术治疗儿童原发性膀胱输尿管反流安全、有效,可以应用于3岁以上儿童的治疗。     

The prognostic importance of trauma scoring systems in pediatric patients

Purpose  Traumas are among important causes of morbidity and mortality in the pediatric group. Our aim was to evaluate the predicting effects of general trauma scores on mortality and morbidity rates. Methods  The files of 74 patients, who were admitted to our hospital with trauma between the years 2006 and 2008, were retrospectively investigated. Patients’ ages, sex, types of trauma, the time between the trauma and entrance to the hospital, vital and laboratory findings, length of hospital stay, length of intensive care unit (ICU) stay, surgical interventions, the organs affected by the trauma, morbidity, and mortality rates were recorded., glasgow coma scale (GCS), abbreviated injury scale (AIS), trauma score—injury severity score (TRISS), revised trauma score (RTS), injury severity score (ISS), pediatric trauma score (PTS), specific trauma scores for lung, liver, and spleen were calculated using the data in the files. Results  The mean age of patients was 7.0 ± 4.34 (1–16) years and 50% of them were men. The types of the trauma were blunt in 66 (89.2%) patients, penetrating in 5 (6.8%) patients and injury due to gun shot in 3 (4.1%) patients. The mean time between the trauma and entrance to the emergency service was 80.40 ± 36.67 (10–120) min. Emergency operation and elective surgery was performed in 13 (17%) and 20 (27%) patients, respectively. The mean length of hospitalization was 4.50 ± 7.93 (1–35) days.Seven (9.5%) patients needed ICU. The morbidity and mortality rates were 60.8% (n = 45) and 2.7% (n = 2), respectively. AIS, ISS, TRISS and PTS were independent predictors of morbidity (p < 0.05). AIS and ISS were independent predictors of the length of hospital stay (p < 0.05). RTS, TRISS, ISS and PTS were independent predictors of the need for ICU (p < 0.05). Among laboratory findings, blood glucose, AST and ALT were found to be independent predictors of liver trauma. Conclusion  ISS was found to be more valuable than other trauma scoring systems for prognostic evaluation of pediatric trauma patients. On the other hand, blood glucose, AST, and ALT are easily available, cheap, and valuable alternative laboratory findings in prognostic evaluation.     

The effectiveness of single and multiple applications of triple dye on umbilical cord separation time

The effectiveness of single and multiple applications of triple dye for umbilical cord care in the umbilical cord separation time (UCST) was evaluated in 180 neonates. Seven neonates were excluded, three where the cord stump separation time was uncertain and four to whom contact was lost. The participating neonates were randomly assigned to two groups. Group 1, 101 neonates, were treated with a regimen of a single application of triple dye. Group 2, 79 neonates, were treated with multiple applications of triple dye. Complete information was obtained from 97 neonates (96.2%) in group 1 and 76 (96%) in group 2. The UCST was 12.6 ± 0.45 (mean ± SE) days in group 1 and 16.68 ± 0.65 days in group 2 (P < 0.0001) and showed no significant association with infants' gender, mode of delivery, gravidity, gestational age, birth weight, or hospital stay. Conclusion A single application of triple dye may be a more favourable regimen with a similarly antimicrobial effect, a shorter UCST and may be more cost effective than multiple applications of triple dye in umbilical cord care. Received: 4 September 1997 / Accepted in revised form: 8 April 1998     

Relation Between Red Cell Distribution Width and Clinical Outcome After Surgery for Congenital Heart Disease in Children

Recent studies have reported a strong association between increased red cell distribution width (RDW) and the risk of adverse outcomes for adults with heart failure. This study investigated the association between preoperative RDW and postoperative clinical outcomes for children with cardiac disease. The relation between preoperative RDW and the length of postoperative stay was tested with 688 consecutive children undergoing surgery for congenital heart disease (CHD). The RDW was significantly higher in patients who died during the postoperative hospital stay (mean, 18.34?±?4.69 vs 16.12?±?2.84; p?=?0.004). The risk of postoperative death was five times higher for patients with an RDW of 16% or more. In the general study population, RDW correlated with the intensive care unit (ICU) stay (p?<?0.0001) and with the total hospital stay in the local population (p?<?0.0001). The correlation between RDW and ICU stay was stronger for patients with acyanotic CHD (p?<?0.0001) than for those with cyanotic CHD (p?=?0.0007), and for the subpopulation of patients with acyanotic CHD and normal hemoglobin level (p?<?0.0001) than for anemic patients with acyanotic CHD (p?=?0.025). Preoperative RDW is a strong predictor of an adverse outcome in children undergoing surgery for CHD, especially in nonanemic patients, for whom it reflects an underlying inflammatory stress.     

Cost-Effectiveness Analysis of Stents,Balloon Angioplasty,and Surgery for the Treatment of Branch Pulmonary Artery Stenosis

Branch pulmonary artery stenosis is a common problem in pediatric cardiology. Treatment has included surgery, balloon angioplasty, and balloon expandable stent placement. It was the purpose of this investigation to demonstrate the cost-effectiveness of each of these modes of treatment. From 1983 to 1994 there were 30 patients admitted for treatment of branch pulmonary artery stenosis only. Data included age at procedure, sex, primary diagnosis, acute and intermediate term success, and complications. Acute success was defined by results at the end of the procedure where intermediate term (IT) success was defined by results at follow-up. Success of a procedure was defined by at least one of the following: an increase in vessel diameter by ≥50% of predilation diameter, a decrease in right ventricular to left ventricular or aortic systolic pressure ratio by ≥20%, or a decrease in peak to peak pressure gradient by ≥50%. The procedure was considered a failure if the previously mentioned criteria were not met or if the patient required a second procedure for the same stenosis. The expense of the procedure (estimated by using the patient charges) were collected from the time of the procedure until December 1994. Because of differing lengths of follow-up, the patients were analyzed separately for procedures and outpatient charges. The total charges were corrected to 1994 dollars using the Medical Consumer Price Index. Thirty patients had 46 separate procedures (12 patients had >1 procedure and 3 had >2 procedures). There were 13 surgeries, 13 balloon angioplasties, and 20 stents. Stents were the most successful (90% acute and 85% IT), but were not statistically superior to surgery (62% acute and IT). Balloon angioplasty was significantly less successful as compared with stents (31% acute and 23% IT), and was not statistically different from surgery over the acute and intermediate term. The charge data showed balloon angioplasty was the least expensive followed by stents and then by surgery. The average total charges per procedure, including outpatient charges, were: surgery $58,068 ± $4372 (standard error), balloon $21,893 ± $5019, stents $33,809 ± $3533 (p < 0.001); excluding outpatient charges: surgery $52,989 ± $3649, balloon $15,653 ± $1691, and stents $29,531 ± $2241 (p < 0.001). Average total charges per patient, including all procedure types and grouped by initial procedure, were: surgery $53,707 ± $6388, balloon $50,040 ± $8412, and stent $34,346 ± $3488 (p= 0.047). Stents were at least as effective as surgery and were more effective than balloon angioplasty in both acute and intermediate term follow-up. Balloon angioplasty was least expensive per procedure but was also least effective. Therefore, intravascular balloon expandable stents are the most cost-effective means available in the treatment of branch pulmonary artery stenosis.     

Neonatal duodenal obstruction: a review of 30 consecutive cases

Delayed return of normal duodenal function necessitating a prolonged hospital stay may often follow operative treatment of neonatal duodenal obstruction (NDO). Previously suggested ways to improve the operative result include variations in the anastomic technique, duodenal tapering, and the omission of gastrostomy. We have analysed the experience at the Prince of Wales Children's Hospital of 30 consecutive cases of NDO treated over a 7-year period (1984–1990) in order to define factors in the treatment that might influence the establishment of oral feeding and duration of hospital stay. There were 19 males and 11 females, with duodenal atresia occurring in 10 and extrinsic or intrinsic causes of duodenal stenosis in the remaining 20. Two patients died without operation. Corrective procedures included 17 duodenoduodenostomies, 9 duodenoplasties, and 2 patients had lysis of Ladd's bands that produced duodenal obstruction from the time of birth. Only 1 patient underwent duodenal tapering. There were 20 gastrostomies performed according to the preferences of the primary-care surgeons. It was shown that the duration of establishing oral feeding and hospital stay were not influenced by the type of corrective procedure, although Ladd's bands duodenal obstruction was associated with the shortest hospital stay. The use of a gastrostomy was related to higher morbidity, a longer period to establish oral feeding, and a prolonged hospital stay. Prenatal diagnosis has also emerged as an important influencing factor. It is concluded that gastrostomy should be omitted in the treatment of NDO. The various types of corrective procedures were similar in final outcome in terms of morbidity and total hospitalisation time.Presented at the 7th Asian Congress of Paediatrics, Perth, 1991. Correspondence to: E. Shi