Deriving literature-based benchmarks for pediatric appendectomy and cholecystectomy complications from national databases in high-income countries: A systematic review and meta-analysis

BackgroundHealth systems must identify preventable adverse outcomes to improve surgical safety. We conducted a systematic review to determine national rates of postoperative complications associated with two common pediatric surgery operations in High-Income Countries (HICs).MethodsNational database studies of complication rates associated with pediatric appendectomies and cholecystectomies (2000–2016) in Canada, the US, and the UK were included. Outcomes included mortality, length of hospital stay (LOS), and other surgical complications. Outcome data were extracted and comparisons made between countries and databases.ResultsThirty-three papers met inclusion criteria (1 Canadian, 1 UK, and 4 US Databases). Mean LOS was 3.00 (± 1.42) days and 3.44 (± 1.55) days for appendectomy and cholecystectomy, respectively. Mortality was 0.06% after appendectomy and 0.24% after cholecystectomy. Readmission and reoperation rates were 6.79% and 0.32% for appendectomy, and 1.37% and 0.71% for cholecystectomy. For appendectomies, LOS was shorter in Canadian and UK studies compared to US studies, and mortality and readmission rates were lower (OR 0.46 95%CI 0.23 to 0.93, OR 3.63 to 3.77 95%CI) in UK studies compared to US studies.ConclusionsOutcomes after pediatric appendectomy and cholecystectomy are good but vary between HICs. Understanding national outcomes and intercountry differences is essential in developing health system approaches to pediatric surgical safety.Level of evidenceII     

Comparative effectiveness of imaging modalities for preoperative assessment of anorectal malformation in the pediatric population

ObjectiveThe aim of this study was to compare the accuracy of MRI, colostography/fistulography, and X-ray imaging modalities for preoperative diagnosis of anorectal malformations (ARMs) in pediatric patients.MethodsThis retrospective analysis included a total of 84 pediatric patients with ARMs. Preoperative imaging findings were assessed by 2 radiologists and compared to surgical findings.ResultsMRI identified anomalies of the spine in 25 of 84 patients (29.8%), anomalies of the genital system in 7 of 84 patients (8.3%), anomalies of the urinary system in 22 of 84 patients (26.2%), and underdeveloped sphincter muscle complex in 34 of 84 patients (40.5%). In the 44 subjects receiving both MRI and X-ray, MRI was more sensitive in detecting anomalies of spine (18/44 vs. 8/44; P = 0.002), and both correctly identified the distal end of the rectum in 77.3% (34/44) of the cases. In the 24 subjects receiving both MRI and colostography/fistulography, MRI was more accurate in identifying Pena's classification (22/24 vs. 15/24; P = 0.039). Distal end of the rectum was correctly identified in 75.0% (18/24) and 58.3% (14/24) of the cases (P = 0.125).ConclusionsMRI could clearly reveal fistula anatomy and associated anomalies of ARMs and should be routinely used for preoperative evaluation of ARMs.Type of studyStudy of diagnostic test.Level of evidenceLevel II.     

Assessment of pulmonary wedge resection for the treatment of lung metastases.

Wedge resection for pulmonary metastases was performed on 18 children suffering from a variety of malignant tumors. The overall survival rate was 39%. However, tumor recurred at or near the site of resection in half the patients. A more extensive resection, such as lobectomy, should be considered for most patients. Wedge resection should be reserved for tumor involving many lobes or for neoplasms having a demonstrated sensitivity to chemotherapy and irradiation.     

Incidence of hallux valgus primary surgical treatment. Finnish nationwide data from 1997 to 2014

BackgroundMany surgical procedures have been described for hallux valgus. Evidence provided by the current literature on the different procedures is, however, poor. The purpose of this study was to assess the incidence of HV surgery in Finland between 1997 and 2014 and to find out whether changes in operation techniques of HV have occurred during the study period.MethodsThe study included all adult patients (≥18 years) who underwent primary HV operation. Patients were included into study if they had been operated with a diagnosis of HV (ICD-10 code M20.1). The data were collected by the Finnish National Hospital Discharge Register (NHDR).ResultsThe total incidence of primary HV operations was 66.7 per 100,000 person-years in 1997 and 41.4 per 100,000 person-years in 2014. The incidence of arthroplasty operations of the MTP-1 joint decreased while at the same time the incidence of the MTP-1 joint arthrodesis and TMT-1 arthrodesis increased. The gender difference (13% men, 87% women) is consistent with previous studies.ConclusionThis study shows a significant decreasing trend of HV operations in Finland between 1997 and 2014. During the study period, the incidence of MTP I joint arthroplasty decreased, and since 2005 the incidence of MT-1-osteotomies has almost halved. At the same time, the incidence of MTP-1 joint arthrodesis increased by over 1000% and TMT-1 joint arthrodesis by nearly 2000%.     

Sclerotherapy for rectal prolapse in children: A systematic review and meta-analysis

BackgroundSclerotherapy is a commonly utilized treatment for rectal prolapse in children. This study systematically evaluates the effectiveness and complications of various sclerosing agents in treating pediatric rectal prolapse.MethodsAfter protocol registration (CRD-42018088980), multiple databases were searched. Studies describing injection sclerotherapy for treatment of pediatric rectal prolapse were included, with screening and data abstraction duplicated. The methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score.ResultsNineteen studies were identified, published between 1970 and 2017. Most studies were single institution case series, with median “N” 57 +/?88.9 and mean MINORS score of 0.51 +/?0.17 (perfect score = 1). 1510 patients with a mean age of 4.5 years were accounted for: 36.2% female, most without comorbidities. Mean follow up length was 30 months. The most common sclerosing agent described was ethanol (45%), followed by phenol (33%). The mean number of treatments per patient was 1.1 +/?0.34. The overall success rate after a single sclerotherapy treatment was 76.9%+/?8.8%. The overall complication rate was 14.4%+/?2%.ConclusionsInjection sclerotherapy appears effective and low-risk in the treatment of pediatric rectal prolapse and should be considered before more invasive surgical options. The available evidence is of relatively poor quality, and prospective comparative investigations are warranted.Level of evidence3 (meta-analysis of level 3 studies).     

Long-term impact of saliva control surgery in children with disability

Sialorrhea is a common problem in children with disability, often negatively affecting socialization, self-esteem, and burden of care. Saliva control surgery is an available option to manage this problem, particularly when other conservative methods have failed. As little is known about the long-term impact of surgery, we followed up 62 patients who had combined bilateral submandibular duct translocation and bilateral sublingual gland excision at our pediatric hospital between 1994 and 2014. Eligible individuals were identified through a search of ICD procedure codes. When families of patients were contacted successfully, they were invited to complete a 14-item questionnaire designed specifically for this study. The results indicated that long-term outcomes of surgery were very good; 13/62 (21%) individuals no longer had a drooling problem and another 30 (48%) experienced only mild to moderate drooling. Although 84% families reported some or major improvement in drooling, 9 families reported that they would not go through the experience again because of a difficult recovery period, lack of effectiveness of the intervention, changes in saliva consistency that caused coughing and gagging, and dental decay. None of the collected variables were predictive of good or poor outcome. The study indicated that surgical intervention is effective in the long term in the majority of cases and can be recommended to other families who attend our saliva control clinic.     

Evaluation of Lung Injury in Infants with Congenital Diaphragmatic Hernia

Background/PurposeThe presence of lung injury and the factors that contribute to it in infants with congenital diaphragmatic hernia (CDH) have not been objectively measured during their clinical course. In adults with acute respiratory distress syndrome, higher serum levels of surfactant protein D (SP-D) are linked to lung injury and worse outcomes. We hypothesized that serum SP-D levels would be elevated in CDH infants and that the levels would correlate to the amount of lung injury present.MethodsIn this retrospective cohort study, serum SP-D levels were analyzed in 37 CDH infants and 5 control infants using a commercially available enzyme-linked immunosorbent assay kit.ResultsInfants with more severe CDH had a statistically significant increase (p < 0.001) in serum SP-D over their first month of life. SP-D levels in CDH infants were similar to control infants while on extracorporeal membrane oxygenation (ECMO) but were 2.5-fold higher (p = 0.03) than controls following ECMO termination. SP-D levels increased 1.6-fold following surgical repair of the diaphragm and were significantly higher in the second week following surgery when compared to pre-operative levels (p < 0.03).ConclusionsThese results demonstrate that CDH infants experience lung injury during the first week of life, around the time of surgery, and at the time of ECMO termination.Level II prognosis study.     

Posteromedial release combined with arthrodesis of the talocalcaneal and calcaneocuboid joints for equinovarus associated with myelodysplasia: Clinical outcomes assessment preliminary report

Background

Whether arthrodesis is necessary to correct equinovarus associated with myelodysplasia in children, possibly preventing its recurrence, is controversial. At our hospital, patients >4 years of age with equinovarus associated with myelodysplasia are treated with posteromedial release combined with arthrodesis of the talocalcaneal and calcaneocuboid joints. This retrospective study aimed to reinvestigate the postoperative outcomes of this surgery.

Early glucose abnormalities are associated with pulmonary inflammation in young children with cystic fibrosis

BackgroundChildren with CF are insulin deficient from infancy but very little is known about the impact of glucose abnormalities in early life. We aimed to identify and describe interstitial glucose levels in CF children <6 years and to evaluate the association with pulmonary infection and inflammation.MethodsWe assessed 18 children (5 females) with median age of 3.2 years (range 0·9–5.5) with Continuous Glucose Monitoring for 3 days. Bronchoalveolar lavage (BAL) fluid was cultured for known pathogenic microbial agents and assessed for total white blood cells, percentage of neutrophils and IL-8 level.ResultsPeak sensor glucose (SG) was >11.1 mmol/L in 39% of participants. The percentage neutrophil count on BAL was positively correlated with elevated SG (peak SG r_s = 0.48, p = .044) and with glucose variability (SG standard deviation r = 0.62, β = 38.5, p = .006). BAL IL-8 level was significantly correlated with all measures of CGM hyperglycemia including % time > 7.8 mmol/L (p = .008) and standard deviation (p < .001). Participants with a history of Pseudomonas aeruginosa had a higher % time > 7.8 mmol/L glucose (16% versus 3%, p = .015).ConclusionChildren with CF frequently demonstrate elevated SG levels before age 6 years, which are associated with increased pulmonary inflammation and Pseudomonas aeruginosa infection. Transient SG elevations into the diabetic range (≥11.1 mmol/L) were identified in children from 1 year of age.     

Anomalous origin of the left coronary artery from the pulmonary artery. Definitive surgical treatment by saphenous vein interposition in a 17-month-old child.

A 17-month-old child underwent successful operative correction of anomalous origin of the left coronary artery from the pulmonary artery by saphenous vein interposition. The clinical, hemodynamic, and angiographic features of the anomaly are presented. Three months after the operation, cardiac catheterization and angiography revealed a patent graft with good antegrade flow and improvement in left ventricular function.     

Early respiratory viral infections in infants with cystic fibrosis

BackgroundViral infections contribute to morbidity in cystic fibrosis (CF), but the impact of respiratory viruses on the development of airway disease is poorly understood.MethodsInfants with CF identified by newborn screening were enrolled prior to 4 months of age to participate in a prospective observational study at 4 centers. Clinical data were collected at clinic visits and weekly phone calls. Multiplex PCR assays were performed on nasopharyngeal swabs to detect respiratory viruses during routine visits and when symptomatic. Participants underwent bronchoscopy with bronchoalveolar lavage (BAL) and a subset underwent pulmonary function testing. We present findings through 8.5 months of life.ResultsSeventy infants were enrolled, mean age 3.1 ± 0.8 months. Rhinovirus was the most prevalent virus (66%), followed by parainfluenza (19%), and coronavirus (16%). Participants had a median of 1.5 viral positive swabs (range 0–10). Past viral infection was associated with elevated neutrophil concentrations and bacterial isolates in BAL fluid, including recovery of classic CF bacterial pathogens. When antibiotics were prescribed for respiratory-related indications, viruses were identified in 52% of those instances.ConclusionsEarly viral infections were associated with greater neutrophilic inflammation and bacterial pathogens. Early viral infections appear to contribute to initiation of lower airway inflammation in infants with CF. Antibiotics were commonly prescribed in the setting of a viral infection. Future investigations examining longitudinal relationships between viral infections, airway microbiome, and antibiotic use will allow us to elucidate the interplay between these factors in young children with CF.     

Surgical wound care: A survey of parental knowledge and expectations

BackgroundParents play an integral role in postoperative wound care. Existing parental knowledge is potentially variable. Our aim was to evaluate for any gaps or misconceptions in the parental knowledge base to determine the need for targeted educational programs.MethodsParents of children presenting to a tertiary pediatric center were surveyed in the preoperative stage. This consisted of 26 questions relating to wound healing, complications, and postoperative care. Participants were asked to complete the questionnaire for a same-day, clean abdominal procedure with a 2 cm incision to standardize responses. Expert responses from pediatric surgeons were utilized as a benchmark for nominating concordant answers.Results200 parents were surveyed. 129 parents (64.5%) had previous experience with surgical wound care. Only 64.5% of parents recognized the most concerning features of wound infection, with 65% of parents correctly identifying when infection is most likely to occur. Parents misjudged the time required before return to school (73.5%) and physical activity (51%). More than half of parents (51.5%) expected postoperative antibiotics to be given. Contrary to our routine surgical practice, 80% and 46% of parents respectively felt that regular dressing changes and application of antiseptics to the wound were necessary postoperatively.ConclusionsThere is a deficit of parental knowledge concerning wound healing in children. Therefore, there is a requirement for standardization of advice provided to parents with regards to wound and dressing care, development of wound complications, antibiotic and antiseptic use, and the timing of return to regular activities.Type of studySurvey.Level of evidenceIII