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.

Antibiotics and appendicitis in the pediatric population: an American Pediatric Surgical Association Outcomes and Clinical Trials Committee systematic review

Objective

The aim of the study was to review evidence-based data regarding the use of antibiotics for the treatment of appendicitis in children.

Data Source

Data were obtained from PubMed, MEDLINE, and citation review.

Study Selection

We conducted a literature search using “appendicitis” combined with “antibiotics” with children as the target patient population. Studies were selected based on relevance for the following questions:

(1)

What perioperative antibiotics should be used for pediatric patients with nonperforated appendicitis?

(2)

For patients with perforated appendicitis treated with appendectomy:

a.

What perioperative intravenous antibiotics should be used?

b.

How long should perioperative intravenous antibiotics be used?

c.

Should oral antibiotics be used?

(3)

For patients with perforated appendicitis treated with initial nonoperative management, what antibiotics should be used in the initial management?

Results

Children with nonperforated appendicitis should receive preoperative, broad-spectrum antibiotics. In children with perforated appendicitis who had undergone appendectomy, intravenous antibiotic duration should be based on clinical criteria. Furthermore, broad-spectrum, single, or double agent therapy is as equally efficacious as but is more cost-effective than triple agent therapy. If intravenous antibiotics are administered for less than 5 days, oral antibiotics should be administered for a total antibiotic course of 7 days. For children with perforated appendicitis who did not initially undergo an appendectomy, the duration of broad-spectrum, intravenous antibiotics should be based on clinical symptoms.

Conclusions

Current evidence supports the use of guidelines as described above for antibiotic therapy in children with acute and perforated appendicitis.     

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review

PurposeManagement of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children.MethodsA comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020.ResultsA total of 825 articles were identified in the initial search, and 260 were included in the final review.ConclusionsPre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.     

Natural history of nonoperative management for grade 4 and 5 liver and spleen injuries in children

Purpose

Nonoperative management is standard treatment of blunt liver or spleen injuries. However, there are few reports outlining the natural history and outcomes of severe blunt hepatic and splenic trauma. Therefore, we reviewed our experience with nonoperative management of grade 4 or 5 liver and spleen injuries.

Methods

A retrospective analysis was performed on patients with grade 4 or 5 (high-grade) blunt liver and/or spleen injuries from April 1997 to July 2007 at our children's hospital. Demographics, hospital course data, and follow-up data were analyzed.

Results

There were 74 high-grade injuries in 72 patients. There were 30 high-grade liver and 44 high-grade spleen injuries. Two patients had both a liver and splenic injury. High-grade liver injuries had a significantly longer length of intensive care and hospital stay compared to high-grade spleen injuries. There were also a significantly higher number of transfusions, radiographs, and total charges in the high-grade liver injuries when compared to the high-grade splenic injuries. The only mortality from solid organ injury was a grade 4 liver injury with portal vein disruption. In contrast, there was only one complication from a high-grade splenic injury—a pleural effusion treated with thoracentesis. There were 5 patients with complications from their liver injury requiring 18 therapeutic procedures. Three patients (10%) with liver injury required readmission as follows: one 5 times, one 3 times, and another one time.

Conclusions

Patients with high-grade liver injuries have a longer recovery, more complications, and greater use of resources than in patients with similar injuries to the spleen.     

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.     

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.     

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.     

Recombinant factor VIIa as an adjunct in nonoperative management of solid organ injuries in children

Background

Ongoing bleeding after blunt solid organ injury in children may require invasive therapy in the form of either angiographic or operative control. We report our experience in the use of a procoagulant, recombinant activated factor VII (rFVIIa), for controlling persistent bleeding in blunt abdominal trauma in children.

Methods

After institutional review board approval, the records of 8 children with blunt abdominal trauma, persistent bleeding, and managed nonoperatively with rFVIIa were reviewed.

Results

All 8 patients presented to our institution after sustaining blunt abdominal trauma and solid organ injury. All children had evidence of persistent bleeding with a drop in hematocrit and elevation in heart rate. Patients received a single dose of rFVIIa at 75 to 90 μg/kg (1 patient had 24 μg/kg) and had successful control of their bleeding without any further therapeutic intervention. Only 3 patients required a blood transfusion after rFVIIa administration—2 who had subarachnoid hemorrhages and the third during pelvic fixation. There were no cases of thromboembolic events after treatment with rFVIIa.

Conclusions

Recombinant factor VIIa is a useful adjunctive therapy in pediatric patients with evidence of ongoing hemorrhage from blunt abdominal injury and may reduce the need for invasive therapeutic procedures and transfusions.     

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.     

Throwing out the "grade" book: management of isolated spleen and liver injury based on hemodynamic status

Purpose

Current organizational guidelines for the management of isolated spleen and liver injuries are based on injury grade. We propose that management based on hemodynamic status is safe in children and results in decreased length of stay (LOS) and resource use compared to current grade-based guidelines.

Methods

Patients with spleen or liver injuries for a 5-year period were identified using our institutional trauma registry. All patients were managed using a pathway based on hemodynamic status. Charts were reviewed for demographics, mechanism, hematrocrit values, transfusion requirement, imaging, injury grade, LOS, and outcome. Exclusion criteria included penetrating mechanism, associated injuries altering LOS or ambulation status, combined spleen/liver injury, initial operative management or death. Statistical comparison was performed using Student's t test; P < .05 is significant.

Results

One hundred one patients (50 spleen, 51 liver) meeting inclusion criteria were identified. Average actual LOS for all patients was 1.9 days vs 3.2 projected days based on American Pediatric Surgical Association guidelines (P < .0001). Actual vs projected LOS for grades III to V was 2.5 vs 4.3 days (P < .0001). All patients returned to full activity without complication.

Conclusions

Isolated blunt spleen and liver injuries, regardless of grade, can be safely managed using a pathway based on hemodynamic status, resulting in decreased LOS and resource use compared to current guidelines.     

Correlation of rib fracture patterns with abdominal solid organ injury: A retrospective observational cohort study

PurposeRib fractures are one of the most common causes of morbidity and mortality and are associated with abdominal solid organ injury (ASOI). The purpose of this study was to investigate the correlation of ASOI with the number, location, and involved segments of rib fracture(s) in blunt chest trauma.MethodsThis retrospective cohort study was conducted on patients with blunt chest trauma over the age of 15 years, who were hospitalized with the diagnosis of rib fractures from July 2015 to September 2020. After ethic committee approval, a retrospective chart review was designed and patients with a diagnosis of rib fractures were selected. Patients who had chest and abdominopelvic CT scan were included in the study and additional data including age, gender, injury severity score, trauma mechanism, number and sides of the fractured ribs (left/right/bilateral), rib fracture segments (upper, middle, lower zone) and results of chest and abdominal spiral CT scan were recorded. The correlation between ASOI and the sides, segments and number of rib fracture(s) was assessed by Pearson's correlation coefficient.ResultsAltogether 1056 patients with rib fracture(s) were included. The mean age was (42.76 ± 13.35) years and 85.4% were male. The most common mechanism of trauma was car accident (34.6%). Most fractures occurred in the middle rib zone (60.44%) and the most commonly involved ribs were the 6th and 7th ones (15.7% and 16.4%, respectively). Concurrent abdominal injuries were observed in 103 patients (34.91%) and were significantly associated with middle zone rib fractures.ConclusionThere is a significant relationship between middle zone rib fractures and ASOI. Intra-abdominal injuries are not restricted to fractures of the lower ribs and thus should always be kept in mind during management of blunt trauma patients with rib fractures.     

Reduction of resource utilization in children with blunt solid organ injury

Background/purpose

Nonoperative management of blunt solid organ injuries continues to progress and improve cost-effective utilization of resources while maximizing patient safety. The purpose of this study is to compare resource utilization and patient outcomes after changing admission criteria from a grade-based protocol to one based on hemodynamic stability.

Prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children

Purpose

The aim of this study was to validate the safety, and quantify the impact of, an abbreviated protocol for blunt spleen/liver injury (BSLI), we instituted a prospective study with early ambulation.

Methods

Following institutional review board approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to 1 night for grade I and II injuries and 2 nights for grade III or higher.

Results

A total of 131 patients with BSLI were enrolled. Injuries included isolated spleen in 72 (55%), liver only in 55 (42%), and both in 4 (3%). One splenectomy was required for a grade 5 injury. Transfusions were used in 24 patients, with 18 patients undergoing transfusion because of injured solid organ. Bedrest was applicable to 110 patients (84%), for which the mean grade of injury was 2.6 and mean bedrest was 1.6 days. The need for bedrest was the limiting factor for length of stay in 86 patients (66%). There were 2 deaths, and no patients were readmitted.

Conclusions

An abbreviated protocol of 1 night of bedrest for grade I and II injuries and 2 nights for grade III or higher can be safely used, resulting in dramatic decreases in hospitalization compared with the current American Pediatric Surgical Association recommendations.     

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.     

Surgical correction of equinus deformity in children with cerebral palsy: a systematic review

Purpose  

Equinus is the most common deformity in cerebral palsy. However, despite the large volume of published studies, there are poor levels of evidence to support surgical intervention. This study was undertaken to examine the current evidence base for the surgical management of equinus deformity in cerebral palsy.     

Treatment and outcome of traumatic biliary injuries in children

Background/Purpose

Traumatic biliary tract injuries in children are rare but may result in significant morbidity. The objective of this study was to review the occurrence of traumatic biliary tract injuries in children, management strategies, and outcome.

Methods

We conducted a retrospective review of patients with biliary tract injury using the trauma registry at our level 1 pediatric trauma center from 2002–2012.

Results

Twelve out of 13,582 trauma patients were identified, representing 0.09% of all trauma patients. All were secondary to blunt trauma. Mean age was 9.7 years [range 4–15], and mean Injury Severity Score was 31 ± 14, with overall survival of 92%. Biliary injuries included major ductal injury (6), minor ductal injury with biloma (4), gallbladder injury (2), and intrahepatic ductal injury (1). Major ductal injuries were managed by endoscopic retrograde cholangiopancreatography (ERCP) and biliary stent (5) and Roux-en-Y hepaticojejunostomy (1). Associated gallbladder injury was managed by cholecystectomy. In addition, the associated biloma was managed with percutaneous drainage (7), laparoscopic drainage (2), or during laparotomy (3). Two patients with ductal injuries developed late strictures after initial management with ERCP and stent placement. One of the two patients ultimately required a left hepatectomy, and the other has been managed conservatively without evidence of cholangitis. Two patients required placement of additional drains and prolonged antibiotics for superinfection following biloma drainage.

Conclusion

Biliary tract injuries are rare in children, and many are amenable to adjunctive therapy, including ERCP and biliary stent placement with or without placement of a peritoneal drain. Patients with a discrete ductal injury are at higher risk for stricture and require close follow up. Hepaticojejunostomy remains the definitive repair for large extrahepatic biliary tract injuries or transections.     

Surgical management of anal fistulae: a systematic review

Objective  The anal fistula has been a common surgical ailment reported since the time of Hippocrates but little systematic evidence exists on its management. We aimed to systematically review the available studies relating to the surgical management of anal fistulas. Method  Studies were identified from PubMED, EMBASE, Cochrane Controlled Trials Register, ClinicalTrials.Gov and Current Controlled Trials. All uncontrolled, nonrandomized, retrospective studies, duplications or those unrelated to the surgical management of anal fistulas were excluded. Results  The search strategy revealed 443 trials. After exclusions 21 randomized controlled trials remained evaluating: fistulotomy vs fistulectomy (n = 2), seton treatment (n = 3), marsupialization (n = 2), glue therapy (n = 3), anal flaps (n = 3), radiosurgical approaches (n = 2), fistulotomy/fistulectomy at time of abscess incision (n = 5) and intra‐operative anal retractors (n = 1). Two meta‐analyses evaluating incision and drainage alone vs incision + fistulotomy were obtained. Conclusion  Marsupialization after fistulotomy reduces bleeding and allows for faster healing. Results from small trials suggest flap repair may be no worse than fistulotomy in terms of healing rates but this requires confirmation. Flap repair combined with fibrin glue treatment of fistulae may increase failure rates. Radiofrequency fistulotomy produces less pain on the first postoperative day and may allow for speedier healing. Major gaps remain in our understanding of anal fistula surgery.     

A systematic review of management options in pediatric rectal prolapse

PurposeRectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children.MethodsWe searched Pubmed, Medline, and Scopus with the terms “rectal prolapse” and “children” for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated.ResultsTwenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%–100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable.ConclusionThough many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates.Level of EvidenceIV.     

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.