Single-center comparison of outcomes between laparoscopic appendectomy and transumbilical laparoscopic assisted appendectomy

PurposeAppendectomy is the most common pediatric emergency surgery performed to date. This study compared outcomes between laparoscopic appendectomy (LA) and transumbilical laparoscopic assisted appendectomy (TULAA) for 1154 uncomplicated patients across 5 years at a single institution. Primary outcomes include length of stay (LOS), post-operative complications, pain score, and operating room (OR) time.MethodsDemographic and clinical data was collected for 1154 eligible patients treated for uncomplicated appendicitis between August 2014–October 2019, with 830 patients in the LA group, and 324 in the TULAA group. Mixed effects modeling procedure using logistic and linear regression examined the effect of surgery type on the four primary outcomes after adjustment for potential clustering effect of surgeon and confounding factors.ResultsOf 1154 patients, 62.7% were male, and mean (SD) age was 10.9 (3.6) years. Median [IQR] LOS was 28.0 h [22.0, 36.0], mean (SD) OR time was 29.0 (10.0) minutes, and median [IQR] pain at maximum level was 5.5 (2.7). The complication rate overall was <5.0% and did not differ between TULAA and LA groups (p > 0.05). OR time was reduced by an average of 5.2 min in the TULAA group (p < 0.001), pain did not differ between groups overall (p > 0.05), and patients were more likely to be discharged within 24 h in patients who underwent TULAA (OR = 5.3 [1.6, 17.4], p = 0.007).ConclusionRetrospective analysis of 1154 pediatric appendectomies, found no difference in complications between single- and three-incision laparoscopic procedures (TULAA vs. LA). Findings suggest TULAA is a safe procedure for acute appendicitis in pediatrics.Level of EvidenceIV.     

The impact of liver resection on survival for patients with metastatic breast cancer – A systematic review and meta-analysis

IntroductionThere is uncertainty surrounding the role of resection as an option for curative treatment of breast cancer with liver metastases (BCLM).AimTo perform a systematic review and meta-analysis evaluating the role of liver resection for BCLM.MethodsA systematic review was performed as per PRISMA guidelines. Hazard ratio (HR) for overall survival (OS) and standard error was obtained from each study and expressed using the generic inverse variance method, with a corresponding 95% confidence interval (CI). OS outcomes at 1- 3- and 5-years were expressed as dichotomous variables and pooled as odds ratios (OR) using the Mantel-Haenszel method.ResultsNine studies with 1732 patients were included. Of these, 24.5% underwent surgical resection of BCLM (424/1732) and 75.5% did not (1308/1732). Overall, OS was significantly better among those who underwent surgery versus controls (HR: 0.69, 95% CI: 0.59–0.80, P < 0.00001). Mortality rates were significantly reduced at 1-year (7.5% (10/134) vs 20.3% (79/390), OR: 0.25, 95% CI: 0.08–0.74, P = 0.010) and 5-years (54.0% (190/352) vs 75.3% (940/1249), OR: 0.46, 95% CI: 0.25–0.87, P = 0.020) respectively for those undergoing surgery versus controls. Mortality rates at 3 years after surgery were lower than the control group (19.1% (29/152) vs 53.0% (222/419)), however this failed to achieve statistical significance at meta-analysis (OR: 0.32, 95% CI: 0.09–1.12, P = 0.070).ConclusionLiver resection may be considered at multidisciplinary meetings for those with BCLM and offers a potentially curative option. However, judicious patient selection is crucial prior to making decisions in relation to resection of BCLM.     

Pediatric Pedestrian Injuries: Striking Too Close to Home

BackgroundPediatric pedestrian injuries (PPI) are a major public health concern. This study utilized geospatial analysis to characterize the risk and injury severity of PPI.MethodsA retrospective chart review of PPI patients (age < 18) from a level 1 trauma center was performed (2013–2020). A geographic information system geocoded injury location to home and other public landmarks. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association statistic tested for spatial clustering of injury rates per 10,000 children. Predictors for increased injury severity were assessed by logistic regression.ResultsPPI encompassed 6% (n = 188) of pediatric traumas. Most patients were black (54%), male (58%), >13 years (56%), and with Medicaid insurance (68%). Nine zip codes comprised a statistically significant cluster of PPI. Nearly half (40%) occurred within a quarter mile of home; 7% occurred at home. Most (65%) PPI occurred within 1 mile of a school, and 45% occurred within a quarter mile of a park. Nearly all (99%) PPI occurred within a quarter mile of a major intersection and/or roadway. Using admission to ICU as a marker for injury severity, farther distance from home (OR 1.060, 95% CI 1.001–1.121, p = 0.045) and age <13 years (3.662, 95% CI 1.854–7.231, p < 0.001) were independent predictors of injury severity.ConclusionsThere are significant sociodemographic disparities in PPI. Most injuries occur near patients’ homes and other public landmarks. Multidisciplinary injury prevention collaboration can help inform policymakers, direct local safety programs, and provide a model for PPI prevention at the national level.Level of EvidenceLevel IV.     

Obesity is not associated with increased resource utilization or morbidity in patients undergoing appendectomy

BackgroundObesity is a growing public health concern that places patients at risk of morbidity and mortality following surgery. We sought to determine whether obesity influences our resource utilization and postoperative outcomes for patients who present with appendicitis.MethodsCharts were reviewed for patients age 1–18 years identified from a prospective registry who presented with a diagnosis of appendicitis from 2017 to 2020. Patients who underwent appendectomy were eligible. Charts were reviewed for demographics, imaging studies, laboratory studies, length of stay, operative times and thirty-day postoperative adverse events defined as return to the emergency room, re-admission, postoperative abscess or return to the operating room. A multivariate logistic regression analysis was performed to identify differences in resource utilization and outcome.ResultsA total of 451 patients were identified. There were 126 obese patients (27.9%). Obese patients were not more likely to present with perforated appendicitis and were not more likely to undergo computed tomography scans. All patients underwent laparoscopic appendectomy. Although intraoperative times were significantly longer for Black patients and older patients, BMI did not influence length of surgery. Length of stay was significantly higher for younger patients (p = 0.019). Adverse events were seen in 38 patients (8.4%). There was no association between BMI and adverse events.ConclusionsWithin our standardized management pathway, obesity does not influence management or patient outcomes for the treatment of appendicitis. Furthermore, obese patients did not require additional resource utilization.Level of evidenceIII.     

Impact of left ventricular ejection fraction on the outcomes of open repair of descending thoracic and thoracoabdominal aneurysms

ObjectiveTo discern the impact of depressed left ventricular ejection fraction (LVEF) on the outcomes of open descending thoracic aneurysm (DTA) and thoracoabdominal aneurysms (TAAA) repair.MethodsRestricted cubic spline analysis was used to identify a threshold of LVEF, which corresponded to an increase in operative mortality and major adverse events (MAE: operative death, myocardial infarction, stroke, spinal cord injury, need for tracheostomy or dialysis). Logistic and Cox regression were performed to identify independent predictors of MAE, operative mortality, and survival.ResultsDTA/TAAA repair was performed in 833 patients between 1997 and 2018. Restricted cubic spline analysis showed that patients with LVEF <40% (n = 66) had an increased risk of MAE (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.22-3.87; P < .01) and operative mortality (OR, 2.72; 95% CI, 1.21-6.12; P = .02) compared with the group with LVEF ≥40% (n = 767). The group with LVEF <40% had a worse preoperative profile (eg, coronary revascularization, 48.5% vs 17.3% [P < .01]; valvular disease, 82.8% vs 49.39% [P < .01]; renal insufficiency, 45.5% vs 26.1% [P < .01]; respiratory insufficiency, 36.4% vs 21.2% [P = .01]) and worse long-term survival (35.5% vs 44.7% at 10 years; P = .01). Nonetheless, on multivariate regression, depressed LVEF was not an independent predictor of operative mortality, MAE, or survival.ConclusionsLVEF is not an independent predictor of adverse events in surgery for DTA.     

Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy

BackgroundLaparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database.MethodsWe queried the Pediatric Health Information System (PHIS) for patients ages 3–18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 – 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation.ResultsIn total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8–14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 – 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 – 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis.ConclusionSBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method.Level of evidenceLevel III.Study typeRetrospective Comparative Study.     

Impact of radiation dose on complications among women with breast cancer who underwent breast reconstruction and post-mastectomy radiotherapy: A multi-institutional validation study

PurposeEmerging data suggest that higher radiation doses in post-mastectomy radiotherapy may be associated with an increased risk of reconstruction complications. This study aimed to validate previous findings regarding the impact of radiation dose on complications among women with breast cancer using a multi-center dataset.MethodsFifteen institutions participated, and women with breast cancer who received radiotherapy after either autologous or prosthetic breast reconstruction were included. The primary endpoint was major post-radiation therapy complications requiring re-operation for explantation, flap failure, or bleeding control.ResultsIn total, 314 patients were included. Radiotherapy was performed using both conventional fractionation and hypofractionation in various schedules. The range of the radiation therapy dose in Equivalent Dose in 2 Gy fractions (EQD2; α/β = 3.5) varied from 43.4 to 71.0 Gy (median dose: 48.6 Gy). Boost radiation therapy was administered to 49 patients. Major post-radiation therapy complications were observed in 24 (7.6%) patients. In multivariate analysis, an increasing EQD2 per Gy (odds ratio [OR]: 1.58, 95% confidence interval [CI]: 1.26–1.98; p < 0.001), current smoking status (OR: 25.48, 95% CI: 1.56–415.65; p = 0.023), and prosthetic breast reconstruction (OR: 9.28, 95% CI: 1.84–46.70; p = 0.007) were independently associated with an increased risk of major complications.ConclusionA dose-response relationship between radiation dose and the risk of complications was validated in this multi-center dataset. In this context, we hypothesize that the use of hypofractionated radiotherapy (40 Gy in 15 fractions) may improve breast reconstruction outcomes. Our multi-center prospective observational study (NCT03523078) is underway to further validate this hypothesis.     

Stage 1 acute kidney injury is independently associated with infection following cardiac surgery

ObjectivesSevere acute kidney injury (AKI) is a known risk factor for infection and mortality. However, whether stage 1 AKI is a risk factor for infection has not been evaluated in adults. We hypothesized that stage 1 AKI following cardiac surgery would independently associate with infection and mortality.MethodsIn this retrospective propensity score–matched study, we evaluated 1620 adult patients who underwent nonemergent cardiac surgery at the University of Colorado Hospital from 2011 to 2017. Patients who developed stage 1 AKI by Kidney Disease Improving Global Outcomes creatinine criteria within 72 hours of surgery were matched to patients who did not develop AKI. The primary outcome was an infection, defined as a new surgical-site infection, positive blood or urine culture, or development of pneumonia. Secondary outcomes included in-hospital mortality, stroke, and intensive care unit (ICU) and hospital length of stay (LOS).ResultsStage 1 AKI occurred in 293 patients (18.3%). Infection occurred in 20.9% of patients with stage 1 AKI compared with 8.1% in the no-AKI group (P < .001). In propensity-score matched analysis, stage 1 AKI independently associated with increased infection (odds ratio [OR]; 2.24, 95% confidence interval [CI], 1.37-3.17), ICU LOS (OR, 2.38; 95% CI, 1.71–3.31), and hospital LOS (OR, 1.30; 95% CI, 1.17-1.45).ConclusionsStage 1 AKI is independently associated with postoperative infection, ICU LOS, and hospital LOS. Treatment strategies focused on prevention, early recognition, and optimal medical management of AKI may decrease significant postoperative morbidity.     

Bilevel positive airway pressure for gastroscopy with sedation in patients at risk of hypoxemia: A prospective randomized controlled study

Study objectiveHypoxemia is one of the most frequent adverse events during sedated gastroscopy, and there is still no effective means to prevent and cure it. Therefore, we conducted this randomized trial to confirm our hypothesis that, compared with the nasal cannula group, bilevel positive airway pressure (BPAP) would decrease the incidence of hypoxemia in patients with obstructive sleep apnea (OSA) or overweight status undergoing gastroscopy.DesignIn a single-center, prospective, randomized controlled clinical trial, 80 patients aged 18–65 years and with OSA or overweight status who underwent gastroscopy with sedation were randomly assigned to two groups: the nasal cannula and BPAP groups. The primary outcome was the incidence of hypoxemia (75% < peripheral oxygen saturation [SpO2] < 90% for >5 sand <60 s).Main resultsCompared to the nasal cannula group, BPAP therapy significantly decreased the incidence of hypoxemia from 40.0% to 2.5% (absolute risk difference [ARD], 37.5% [95% confidence interval (CI), 21.6 to 53.4], p < 0.001), decreased subclinical respiratory depression from 52.5% to 22.5% (ARD, 30.0% [95% CI, 9.8 to 50.2], p = 0.006), and decreased severe hypoxemia from 17.5% to 0% (ARD, 17.5% [95% CI, 5.7 to 29.3], p = 0.006). The BPAP intervention also decreased the total propofol dosage and operation time and improved anesthesiologist's satisfaction.ConclusionBPAP therapy significantly decreased the incidence of hypoxemia in patients with OSA or overweight status who underwent gastroscopy.     

Diagnostic performance of ultra-low dose versus standard dose CT for non-traumatic abdominal emergencies

PurposeThe purpose of this study was to compare the diagnostic performance of ultra-low dose (ULD) to that of standard (STD) computed tomography (CT) for the diagnosis of non-traumatic abdominal emergencies using clinical follow-up as reference standard.Materials and methodsAll consecutive patients requiring emergency abdomen-pelvic CT examination from March 2017 to September 2017 were prospectively included. ULD and STD CTs were acquired after intravenous administration iodinated contrast medium (portal phase). CT acquisitions were performed at 125 mAs for STD and 55 mAs for ULD. Diagnostic performance was retrospectively evaluated on ULD and STD CTs using clinical follow-up as a reference diagnosis.ResultsA total of 308 CT examinations from 308 patients (145 men; mean age 59.1 ± 20.7 (SD) years; age range: 18–96 years) were included; among which 241/308 (78.2%) showed abnormal findings. The effective dose was significantly lower with the ULD protocol (1.55 ± 1.03 [SD] mSv) than with the STD (3.67 ± 2.56 [SD] mSv) (P < 0.001). Sensitivity was significantly lower for the ULD protocol (85.5% [95%CI: 80.4–89.4]) than for the STD (93.4% [95%CI: 89.4–95.9], P < 0.001) whereas specificities were similar (94.0% [95%CI: 85.1–98.0] vs. 95.5% [95%CI: 87.0–98.9], respectively). ULD sensitivity was equivalent to STD for bowel obstruction and colitis/diverticulitis (96.4% [95%CI: 87.0–99.6] and 86.5% [95%CI: 74.3–93.5] for ULD vs. 96.4% [95%CI: 87.0–99.6] and 88.5% [95%CI: 76.5–94.9] for STD, respectively) but lower for appendicitis, pyelonephritis, abscesses and renal colic (75.0% [95%CI: 57.6–86.9]; 77.3% [95%CI: 56.0–90.1]; 90.5% [95%CI: 69.6–98.4] and 85% [95%CI: 62.9–95.4] for ULD vs. 93.8% [95%CI: 78.6–99.2]; 95.5% [95%CI: 76.2–100.0]; 100.0% [95%CI: 81.4–100.0] and 100.0% [95%CI: 80.6–100.0] for STD, respectively). Sensitivities were significantly different between the two protocols only for appendicitis (P = 0.041).ConclusionIn an emergency context, for patients with non-traumatic abdominal emergencies, ULD-CT showed inferior diagnostic performance compared to STD-CT for most abdominal conditions except for bowel obstruction and colitis/diverticulitis detection.     

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Atrioventricular septal defect in Fontan circulation: Right ventricular dominance,not valve surgery,adversely affects survival

ObjectiveThe effect of ventricular dominance and previous atrioventricular valve (AVV) surgery on patient outcomes after Fontan operation remains unclear. We sought to determine the effect of ventricular dominance and previous AVV surgery on transplantation-free survival and long-term AVV competency in patients with atrioventricular septal defect (AVSD) and Fontan circulation.MethodsWe conducted a retrospective study of 1703 patients in the Australia and New Zealand Fontan Registry, who survived Fontan operation between 1987 and 2021.ResultsOf 174 patients with AVSD, 60% (105/174) had right ventricular (RV) dominance and 40% (69/174) had left ventricular (LV) dominance. The cumulative incidence of moderate or greater AVV regurgitation at 25 years after Fontan operation in patients with LV dominance was 56% (95% CI, 35%-72%), compared with 54% (95% CI, 40%-67%) in patients with RV dominance (P = .6). Nonetheless, transplantation-free survival at 25 years in patients with LV dominance was 94% (95% CI, 86%-100%), compared with 67% (95% CI, 52%-87%) in patients with RV dominance (hazard ratio, 5.9; 95% CI, 1.4-25.4; P < .01). Of note, transplantation-free survival was not different in patients who underwent AVV surgery before or at Fontan completion compared with those who did not (15 years: 81% [95% CI, 62%-100%] vs 88% [95% CI, 81%-95%]; P = .3).ConclusionsIn patients with AVSD and Fontan circulation the rate of moderate or greater common AVV regurgitation is similar in those with LV and RV dominance. RV dominance, rather than previous AVV surgery, is a risk factor for death or transplantation.     

Liver Cirrhosis After the Fontan Procedure: Impact of Atrioventricular Valve Failure

BackgroundLiver cirrhosis is now well recognized as a potential complication after the Fontan procedure, although associated risk factors and optimal timing of liver screening remain unclear.MethodsAll patients who underwent an extracardiac conduit Fontan procedure at The Royal Children’s Hospital, Melbourne, were identified using the Australia and New Zealand Fontan Registry. Cirrhosis was diagnosed based on liver biopsy, or a combination of imaging findings and clinical evaluation by a hepatologist.ResultsBetween 1997 and 2020, 398 patients underwent an extracardiac conduit Fontan procedure at our center, and 276 had ongoing follow-up in Victoria. Ninety-five patients (34%) underwent liver assessment at a mean age of 18.2 ± 6.7 years (11.8 ± 5.5 years post-Fontan). Fifteen patients (16%) were diagnosed with cirrhosis at a mean age of 22.7 ± 5.9 years (14.0 ± 5.2 years post-Fontan). The need for prior or concomitant atrioventricular valve repair or replacement was associated with an increased risk of cirrhosis (univariable hazard ratio [HR] 7.09, 95% confidence interval [CI] 2.13-23.61, P = .001). By multivariable analysis, factors associated with development of cirrhosis were atrioventricular valve failure prior to Fontan (HR 3.27, 95% CI 1.15-9.31, P = .026) and older age at Fontan operation (HR 1.13 per year increase, 95% CI 1.01-1.26, P = .034). The proportion of patients alive, nontransplanted, and without cirrhosis at 10, 15, and 20 years was 93.4% (95% CI 88.4%-98.7%), 79.6% (95% CI 69.7%-90.8%), and 64.6% (95% CI 51.0%-81.9%), respectively.ConclusionsEarly commencement of liver screening should be considered for patients with a history of atrioventricular failure during Fontan palliation.     

Aortic growth and development of partial false lumen thrombosis are associated with late adverse events in type B aortic dissection

BackgroundPatients with medically treated type B aortic dissection (TBAD) remain at significant risk for late adverse events (LAEs). We hypothesize that not only initial morphological features, but also their change over time at follow-up are associated with LAEs.Materials and MethodsBaseline and 188 follow-up computed tomography (CT) scans with a median follow-up time of 4 years (range, 10 days to 12.7 years) of 47 patients with acute uncomplicated TBAD were retrospectively reviewed. Morphological features (n = 8) were quantified at baseline and each follow-up. Medical records were reviewed for LAEs, which were defined according to current guidelines. To assess the effects of changes of morphological features over time, the linear mixed effects models were combined with Cox proportional hazards regression for the time-to-event outcome using a joint modeling approach.ResultsLAEs occurred in 21 of 47 patients at a median of 6.6 years (95% confidence interval [CI], 5.1-11.2 years). Among the 8 investigated morphological features, the following 3 features showed strong association with LAEs: increase in partial false lumen thrombosis area (hazard ratio [HR], 1.39; 95% CI, 1.18-1.66 per cm² increase; P < .001), increase of major aortic diameter (HR, 1.24; 95% CI, 1.13-1.37 per mm increase; P < .001), and increase in the circumferential extent of false lumen (HR, 1.05; 95% CI, 1.01-1.10 per degree increase; P < .001).ConclusionsIn medically treated TBAD, increases in aortic diameter, new or increased partial false lumen thrombosis area, and increases of circumferential extent of the false lumen are strongly associated with LAEs.     

Screening for VACTERL Anomalies in Children with Anorectal Malformations: Outcomes of a Standardized Approach

PurposeThe majority of patients with an anorectal malformation (ARM) have associated congenital anomalies. It is well established that all patients diagnosed with an ARM should undergo systematic screening, including renal, spinal, and cardiac imaging. This study aimed to evaluate the findings and completeness of screening, following local implementation of standardized protocols.MethodsA retrospective cohort study was performed assessing all patients with an ARM managed at our tertiary pediatric surgical center, following a standardized protocol implementation for VACTERL screening (January 2016–December 2021). Cohort demographics, medical characteristics, and screening investigations were analyzed. Findings were compared with our previously published data (2000–2015), conducted prior to protocol implementation.ResultsOne hundred twenty-seven (64 male, 50.4%) children were eligible for inclusion. Complete screening was performed in 107/127 (84.3%) children. Of these, one or more associated anomalies were diagnosed in 85/107 (79.4%), whilst the VACTERL association was demonstrated in 57/107 (53.3%). The proportion of children that underwent complete screening increased significantly in comparison with those assessed prior to protocol implementation (RR 0.43 [CI 0.27–0.66]; p < 0.001). Children with less complex ARM types were significantly less likely to receive complete screening (p = 0.028). Neither presence of an associated anomaly, nor prevalence of the VACTERL association, differed significantly by ARM type complexity.ConclusionScreening for associated VACTERL anomalies in children with ARM was significantly improved following standardized protocol implementation. The prevalence of associated anomalies in our cohort supports the value of routine VACTERL screening in all children with ARM, regardless of malformation type.Level of EvidenceII.     

Impact of rectal dissection technique on primary-school-age outcomes for a British and Irish cohort of children with Hirschsprung disease

BackgroundThis prospective cohort study compared primary-school-aged outcomes between children with Hirschsprung disease (HD) following Soave, Duhamel or Swenson procedures.MethodsChildren with histologically proven HD were identified in British/Irish paediatric surgical centers (01/10/2010-30/09/2012). Parent/clinician outcomes were collected when children were 5–8 years old and combined with management/early outcomes data. Propensity score/covariate adjusted multiple-event-Cox and multivariable logistic regression analyses were used.Results277 (91%) of 305 children underwent a pull-through (53% Soave, 37% Duhamel, 9% Swenson). Based upon 259 children (94%) with complete operative data, unplanned reoperation rates (95% CI) per-person year of follow-up were 0.11 (0.08–0.13), 0.34 (0.29–0.40) and 1.06 (0.86–1.31) in the Soave/Duhamel/Swenson groups respectively. Adjusted Hazard Ratios for unplanned reoperation compared with the Soave were 1.50 (95% CI 0.66-3.44, p = 0.335) and 7.57 (95% CI 3.39-16.93, p < 0.001) for the Duhamel/Swenson respectively. Of 217 post-pull-through children with 5–8 year follow-up, 62%, 55%, and 62% in Soave/Duhamel/Swenson groups reported faecal incontinence. In comparison to Soave, Duhamel was associated with lower risk of faecal incontinence (aOR 0.34,95%CI 0.13-0.89,p = 0.028). Of 191 children without a stoma, 42%, 59% and 30% in Soave/Duhamel/Swenson groups required assistance to maintain bowel movements; compared to Soave, the Duhamel group were more likely to require assistance (aOR 2.61,95% CI 1.03–6.60,p = 0.043).ConclusionsCompared with Soave, Swenson was associated with increased risk of unplanned reoperation, whilst Duhamel was associated with reduced risk of faecal incontinence, but increased risk of constipation at 5–8 years of age. The risk profiles described can be used to inform consent discussions between surgeons and parents.Level of evidenceLevel II     

The Optimal Primary Treatment for Pediatric Perianal Abscess and Anal Fistula: A Systemic Review and Meta-Analysis

BackgroundPerianal abscesses and anal fistulas are common. The principle of intention-to-treat has not been considered in previous systemic reviews. Thus, the comparison between primary and post-recurrence management was confused, and the recommendation of primary treatment is obscure. The current study aims to identify the optimal initial treatment for pediatric patients.MethodsUsing PRISMA guidelines, studies were identified from MEDLINE, EMBASE, PubMed, Cochrane Library, and Google Scholar without any language or study design restriction. The inclusion criteria include original articles or articles with original data, studies of management for a perianal abscess with or without anal fistula, and patient age of <18 years. Patients with local malignancy, Crohn's disease, or other underlying predisposing conditions were excluded. Studies without analyzing recurrence, case series of <5, and irrelevant articles were excluded in the screening stage. Of the 124 screened articles, 14 articles had no full texts or detailed information. Articles written in a language other than English or Mandarin were translated by Google Translation first and confirmed with native speakers. After the eligibility process, studies that compared identified primary managements were then included in the qualitative synthesis.ResultsThirty-one studies involving 2507 pediatric patients met the inclusion criteria. The study design consisted of two prospective case series of 47 patients and retrospective cohort studies. No randomized control trials were identified. Meta-analyses for recurrence after initial management were performed with a random-effects model. Conservative treatment and drainage revealed no difference (Odds ratio [OR], 1.222; 95% Confidential interval [CI]: 0.615–2.427, p = 0.567). Conservative management had a higher risk of recurrence than surgery without statistical significance (OR 0.278, 95% CI: 0.109–0.707, p = 0.007). Compared with incision/drainage, surgery can prevent recurrence remarkably (OR 4.360, 95% CI: 1.761–10.792, p = 0.001). Subgroup analysis of different approaches within conservative treatment and operation was not performed for lacking information.ConclusionStrong recommendations cannot be made due to the lack of prospective or randomized controlled studies. However, the current study based on real primary management supports initial surgical intervention for pediatric patients with perianal abscesses and anal fistula to prevent recurrence.Level of evidenceType of study: Systemic review; Evidence level: Level II.     

Safety and Cost Savings Using Polymeric Clips in Appendectomies in the Pediatric Population: Single-Center Experience

IntroductionAlthough laparoscopic appendectomy is standard management for appendicitis, management of the appendiceal stump remains debated. Even though most surgeons can agree on the safety and effectiveness of various closure methods for the appendiceal stump, such as the surgical stapler (SS) or the Endoloop, the cost of these methods should also be considered. A relatively new alternative method, the polymeric clips (PC), has been gaining acceptance in the surgical community as it has repeatedly proven to be as safe as other methods, while being significantly cheaper.MethodsFor the period of January 2019 to December 2021, we performed a retrospective chart review of a single surgeon's laparoscopic appendectomies in children 18 years or younger for acute, non-complicated appendicitis and grouped the cases by appendiceal stump management (SS or PC). Demographics collected included gender, age, BMI percentile, race, and ASA score. Surgical variables included length of stay, surgical time, and anesthesia time. Outcomes were number of intra- and post-operative complications, reoperations, ER visits within 30 days, and total implant cost. Mann–Whitney U tests were performed to test for differences between SS and PC groups in surgical variables. Chi-square or Fisher's exact tests were performed to test differences in demographics and outcome variables.ResultsThere were 107 patients identified. The PC group represented 16% (n = 17) of our study population. The PC group was significantly younger than the SS group at 10 years (2.8) vs 12 years (3.5) p = 0.04. No differences were observed in length of stay and anesthesia time between the two groups. However, a significantly longer length of surgery was observed in the PC group at 33.5 min [30.0–43.3] when compared to the SS group at 28.0 min [23.0–36.0] (p = 0.003). No significant differences were seen in post-op complications, post-op ED visits and reoperations within 30 days. The median total implant cost of the PC closure method was significantly lower than the SS method ($35.36 vs. $375.67 p = <0.001).ConclusionThere were no significant differences in clinical outcomes. However, the significant difference in the implant cost between the 2 methods could favor the use of PC for selected cases. The increase in length of surgery can be attributed to the learning curve associated with a new device.Level of Evidence3.     

Dysphagia after cardiac surgery: Prevalence,risk factors,and associated outcomes

ObjectivesThe study objectives were to determine the prevalence of swallowing impairment in adults after cardiac surgery and examine associated risk factors and health-related outcomes.MethodsA prospective single-center study was conducted in postoperative adult cardiac surgery patients with no history of dysphagia. A standardized fiberoptic endoscopic evaluation of swallowing was performed within 72 hours of extubation. Blinded raters completed validated outcomes of swallowing safety and efficiency. Demographic, surgical, and postoperative health-related outcomes were collected. Univariate and multivariable regression analyses were performed with odds ratios (OR) and 95% confidence intervals (CIs).ResultsIn 182 patients examined, imaging confirmed inefficient swallowing (residue) in 52% of patients and unsafe swallowing in 94% (65% penetrators, 29% aspirators). Silent aspiration was observed in 53% of aspirators, and 32% did not clear aspirate material. Independent risk factors for aspiration included New York Heart Association III and IV (OR, 2.9; CI, 1.2-7.0); reoperation (OR, 2.0; CI, 0.7-5.5); transesophageal echocardiogram images greater than 110 (OR, 2.6; CI, 1.1-6.3); intubation greater than 27 hours (OR, 2.1; CI, 0.8-5.3); and endotracheal tube size 8.0 or greater (OR, 3.1; CI, 1.1-8.6). Patients with 3 or 4 identified risk factors had a 16.4 (CI, 3.2-148.4) and 22.4 (CI, 3.7-244.7) increased odds of aspiration, respectively. Compared with nonaspirators, aspirators waited an additional 85 hours to resume oral intake, incurred $49,372 increased costs, and experienced a 43% longer hospital stay (P < .05). Aspiration was associated with pneumonia (OR, 2.6; CI, 1.1-6.5), reintubation (OR, 5.7; CI, 2.1-14.0), and death (OR, 2.8; CI, 1.2-9.0).ConclusionsTracheal aspiration was prevalent, covert, and associated with increased morbidity and mortality.     

The Timing of Congenital Diaphragmatic Hernia Repair on Extracorporeal Membrane Oxygenation Impacts Surgical Bleeding Risk

BackgroundThe optimal timing of surgical repair for infants with congenital diaphragmatic hernia (CDH) treated with extracorporeal membrane oxygenation (ECMO) support remains controversial. The risk of surgical bleeding is considered by many centers as a primary factor in determining the preferred timing of CDH repair for infants requiring ECMO support. This study compares surgical bleeding following CDH repair on ECMO in early versus delayed fashion.MethodsA retrospective review of 146 infants who underwent CDH repair while on ECMO support from 1995 to 2021. Early repair occurred during the first 48 h after ECMO cannulation (ER) and delayed repair after 48 h (DR). Surgical bleeding was defined by the requirement of reoperative intervention for hemostasis or decompression.Results102 infants had ER and 44 infants DR. Surgical bleeding was more frequent in the DR group (36% vs 5%, p < 0.001) with an odds ratio of 11.7 (95% CI: 3.48–39.3, p < 0.001). Blood urea nitrogen level on the day of repair was significantly elevated among those who bled (median 63 mg/dL, IQR 20–85) vs. those who did not (median 9 mg/dL, IQR 7–13) (p < 0.0001). Duration of ECMO support was shorter in the ER group (median 13 vs 18 days, p = 0.005). Survival was not statistically different between the two groups (ER 60% vs. DR 57%, p = 0.737).ConclusionWe demonstrate a significantly lower incidence of bleeding and shorter duration of ECMO with early CDH repair. Azotemia was a strong risk factor for surgical bleeding associated with delayed CDH repair on ECMO.Level of evidenceLevel III cohort study.