Outcomes of Abdominal Firearm Injury and Damage Control Laparotomy in the Pediatric Population

INTRODUCTION

Firearm injuries (GSW) in the pediatric population is a public health crisis. Little is known about the outcomes of damage control laparotomy (DCL) following abdominal GSW. This study aims to evaluate outcomes from abdominal GSWs in the pediatric population.

METHODS

The trauma registry from an urban Level 1 trauma was queried for pediatric (0-18 y) GSW was queried from September 2013 to June 2020. Demographics, clinical variables, outcomes, readmissions, and recidivism were analyzed.

RESULTS

Abdominal GSW were identified in 83 patients (17% of all GSW). The median age was 16 [15-17], 84% were male and 86% Black. Violent intent accounted for 90% of GSW. The injury severity score was 16 [9-26] and 80% went directly from the resuscitation bay to the operating room. Laparotomy was required in 87% of patients, and surgery was not required in any patient initially managed nonoperatively. The most common complications were intraabdominal infection (20%), other infections (13%), and small bowel obstruction (8%). DCL with temporary abdominal closure was performed in 16% of laparotomies and was associated with a longer length of stay, more infections, but similar rates of readmission and mortality. Overall mortality was 13%, with all but one patient expiring in the resuscitation bay or the operating room. All patients who underwent DCL survived to discharge.

CONCLUSIONS

Abdominal firearm injuries have high morbidity and mortality in the pediatric population. Damage control operations for abdominal GSWs are a valuable surgical option with similar outcomes to primary abdominal closure after initial injury survival.

Radical Resection of Pediatric Fibrosarcoma Is Not Associated With Survival Benefit: A Nationwide Database Analysis

INTRODUCTION

Fibrosarcoma is one of the most common nonrhabdomyosarcoma soft tissue sarcomas in the pediatric population. Surgical resection is the cornerstone of treatment; however, optimal factors regarding the extent of fibrosarcoma resection in localized versus regional disease is poorly understood.

METHODS

The Surveillance, Epidemiology, and End Results database was queried for patients who are 19 y old or younger with a diagnosis of fibrosarcoma from 1975 to 2016. Kaplan-Meier analyses were performed for disease-specific survival on clinical and pathologic variables. Multivariate analysis was performed based on significant predictors of disease-specific survival.

RESULTS

There were 1290 patients (median age 13 [7-17] y) identified with fibrosarcoma. The overall survival rate at 20 y was 93%. Radical resection was performed on 22%, 40%, and 52% of patients with localized, regional, and distant Surveillance, Epidemiology, and End Results disease stage, respectively. Chemotherapy (P < 0.001), radiation (P < 0.001), histology (P < 0.001), and stage (P = 0.004) were significant predictors of increased mortality using univariate Kaplan-Meier analysis. Most patients (86%) with localized or regional stage who underwent radiation had fibrosarcomas of nondermatofibrosarcoma histology (P < 0.001). Dermatofibrosarcoma subtype comprised most radical resections (41%). Excluding distant stage, nondermatofibroma histology (hazard ratio 16.94, 95% confidence interval 3.77-76.01) and regional stage (hazard ratio 8.15, 95% confidence interval 2.93-22.69) were independent prognostic factors of mortality (both P < 0.001). Radical resection was not a significant independent prognostic indicator of survival.

CONCLUSIONS

Nondermatofibrosarcoma subtype is independently associated with increased mortality. Although surgery remains the mainstay of treatment, the extent of resection is not a predictor of survival for patients with the localized and regional stage of disease.

Does surgical approach matter in the treatment of pediatric ulcerative colitis?

BACKGROUND

This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.

MATERIALS AND METHODS

The 2010-2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.

RESULTS

There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings.

CONCLUSIONS

In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.

Analyzing pediatric bicycle injuries using geo-demographic data

PURPOSE

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.

METHODS

From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.

RESULTS

Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (<1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).

CONCLUSION

Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

National burden of pediatric abusive injuries: patterns vary by age

PURPOSE

Child abuse is often unrecognized by healthcare practitioners. This study sought to characterize pediatric abuse injury patterns and associated mortality rates in a nationwide cohort.

METHODS

The Kids' Inpatient Database (1997-2012) was queried for patients < 18 years old with a diagnosis of child abuse (utilizing ICD-9 codes for abusive head trauma [AHT], neglect, physical, emotional, sexual, and other abuse). Demographic factors, mortality, and injury patterns were compared with demographic factors using standard statistical tests.

RESULTS

 > 39,000 children were hospitalized for abuse from 1997 to 2012. The majority were Caucasian (36%), male (51%) and < 4 years old (70%). Most sustained physical abuse (53%), followed by AHT (14%), sexual (9%) and emotional abuse (2%). Multiple injuries were sustained by 44% of patients. Mortality was 4% (n = 1476). Burns (2%) and intrathoracic (2%) injuries had the highest mortality compared to other injuries (21% and 19%, respectively; both P < 0.001). Emotional abuse (5%) and neglect (1%) were highest in those ≥ 13 years old (both P  = 0.001).

CONCLUSION

Physical injuries are less common in adolescents (13-18 years) hospitalized for abuse. However, they are more likely to report emotional abuse and neglect, which has not been compared in previous studies. Intrathoracic injuries and AHT are associated with significant mortality.

Comparing fatal child abuse involving biological and surrogate parents

BACKGROUND

Nearly half of pediatric homicides younger than 5 years are attributable to child abuse. Parents are most commonly the perpetrators, but less is known about incidents involving biological versus surrogate parents. We sought to evaluate the characteristics of fatal child abuse involving biological and surrogate parents using the Georgia National Violent Death Reporting System, which we believe may differ in demographics and incident characteristics.

METHODS

This database was used to examine all homicides of children younger than 18 years from 2011 to 2017. Demographics and incident characteristics were analyzed using the existing National Violent Death Reporting System variables and incident narratives. Nonparametric and χ2 tests were used to compare fatal child abuse incidents involving biological and surrogate parents (e.g., adoptive, foster, step-parents, intimate partners of biological parent).

RESULTS

There were 452 pediatric homicides and 219 cases of fatal child abuse. Of all cases of fatal child abuse, 60% involved biological and 29% involved surrogate parents. Compared with children killed by biological parents, children killed by surrogate parents were older (4 vs. 3 years), more often male (71% vs. 51%), more likely to survive the initial injury and present to the emergency department before death (96% vs. 69%), and less likely to have a medical comorbidity (2% vs. 11%; all p < 0.05). Surrogate parents were more likely to be male (90% vs. 48%) and use a firearm (20% vs. 13%) to inflict the injury, both p < 0.05. The race/ethnicity of the child was not associated with the parent's relationship.

CONCLUSION

Child abuse accounts for half of all pediatric homicides. Parents are the most common perpetrators of fatal child abuse, but surrogate parent perpetrators are almost exclusively male and more likely to use firearms. Most children have a history of abuse, leaving an opportunity to intervene on potentially preventable deaths if abuse is identified in a timely fashion.

LEVEL OF EVIDENCE

Prognostic and Epidemiologic, Level III.

Improper Restraint Use in Pediatric Patients Involved in Motor Vehicle Collisions

BACKGROUND

Motor vehicle collisions (MVCs) are the leading cause of unintentional death among children and adolescents; however, public awareness and use of appropriate restraint recommendations are perceived as deficient. We aimed to investigate the use of child safety restraints and examine outcomes in our community.

METHODS

We retrospectively queried a level 1 trauma registry for pediatric (0-18 y) MVC patients from October 2013 to December 2018. Demographic and clinical variables were recorded. Data regarding appropriate restraint use by age group were examined.

RESULTS

Four hundred thirty-four cases of pediatric MVC were identified. Overall, 53% were improperly restrained or unrestrained. Sixty-two percent of car seat age and 51% of booster age children were improperly restrained or unrestrained altogether. Fifty-nine percent of back seat riding, seatbelt age were improperly restrained/unrestrained, with 26% riding in the front. Fifty-one percent of seatbelt-only adolescents were not belted. Black, non-Hispanic children were more often improperly restrained/unrestrained compared to Hispanics (63% versus 48%, P = 0.001). Improperly restrained/unrestrained children had higher injury severity (10% versus 4% Injury Severity Score > 25, P = 0.021), require operative/interventional radiology (33% versus 19%, P = 0.001), and be discharged to rehabilitation or skilled nursing facility (5.2% versus 1.5%, P = 0.033). Mortality in adolescents was higher among those unrestrained (5.2% versus 0.8%, P = 0.034).

CONCLUSIONS

Although efforts to improve adherence to restraint regulations have greatly increased in the last decade, more than half of children in MVC are still improperly restrained. Injury prevention services and community outreach is essential to educate the most vulnerable populations, especially those with infants and toddlers, on adequate motor vehicle safety measures in our community.

Outcomes for Ladd's procedure: Does approach matter?

BACKGROUND

Laparoscopic Ladd's procedure has been proven safe and effective for the treatment of malrotation. However, the nationwide utilization and outcomes of elective Ladd's procedure are largely unknown.

METHODS

The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients 0-18 years (excluding newborns) with malrotation who underwent elective Ladd's procedure. Demographics, hospital factors, and outcomes were compared by approach (laparoscopic vs. open) using standard statistical tests and propensity score (PS) matched analysis. Results were weighted for national estimates.

RESULTS

1343 patients (44% male) underwent elective Ladd's procedure via laparoscopic (22%) or open (78%) approach. Laparoscopic approach was more common in large hospitals (26% vs. 16%), patients >13 years (30% vs. 20%), and those with higher income (29% vs. 16%), all p < 0.001. Following PS matching, compared to the laparoscopic approach, open Ladd's was associated with index hospital length of stay > 7 days (20% vs. 8%), more post-operative gastrointestinal dysfunction (12% vs. < 1%), and more nausea, vomiting, and/or diarrhea (16% vs. 6%), all p < 0.001. The overall readmission rates within 30 days and the year of index operation were 8% and 15%, respectively. In the matched cohort, those undergoing laparoscopic Ladd's were less likely to be readmitted than those with the open approach (7% vs. 16%, p < 0.001) and experienced less gastrointestinal issues on readmission (5% vs. 15%, p = 0.002). There were similar rates of post-operative small bowel obstruction (< 3% vs. < 3%, p = 0.840) and volvulus (0% vs. < 1%, p = 0.136). Redo Ladd's procedure was performed in less than 4% of readmissions and all occurred within 5 days of initial hospital discharge.

CONCLUSION

The majority of Ladd's procedures in the U.S. are being performed open, despite comparable outcomes following a laparoscopic approach. Readmission rates are similar with either approach, and the rate of redo Ladd's procedure is lower than previously reported.

LEVEL OF EVIDENCE

Level III.

Liquid Nitrogen Applied at Point of Sale: A New Presentation of Gastric Perforation in Children

ABSTRACT

The August 30, 2018, US Food and Drug Administration advisory warned consumers to avoid eating, drinking, or handling food products prepared with liquid nitrogen (LN) (US FDA. Safety Alerts & Advisories: FDA Advises Consumers to Avoid Eating, Drinking, or Handling Food Products Prepared with Liquid Nitrogen at the Point of Sale. US Food and Drug Administration). We report on the case of a pediatric patient sustaining gastric perforation after ingestion of LN applied to food at the point of sale in the United States. "Dragon's Breath" is a popular snack of cereal puffs coated in LN giving the allusion of breathing smoke on ingestion. Instructions provided by vendors include avoidance of touching or drinking the liquid in the bottom of the cup. We report on a case of a 9-year-old girl presenting with peritonitis and gross pneumoperitoneum after consumption of Dragon's Breath with injury conferred secondary to LN ingestion. Intraoperative finding of a large perforation along the lesser curvature of the stomach was repaired primarily with an omental overlay. Her postoperative course was complicated by pneumonia and a surgical site infection. She was discharged 13 days after admission. A review of the literature of previous case reports of LN ingestion by intentional or accidental means is provided. This case report and review of the literature bring awareness of the dangers posed to pediatric patients exposed to LN applied at the point of sale.

Nationwide Outcomes and Readmission After Pediatric Laparoscopic and Open Fundoplication

Purpose: Fundoplications are a common operation in the pediatric population. This study aims to explore outcomes comparing laparoscopic versus open operative techniques. Methods: From 2010 to 2014 the Nationwide Readmissions Database was used to identify patients aged 0-18 years who underwent a fundoplication. Propensity score matched analysis was performed based on 87 covariates. Demographics, hospital factors, readmissions, and complications were compared by surgical technique (laparoscopic versus open). Results: There were 4411 patients (47% female) who underwent fundoplication via laparoscopic (69%) versus open (31%) technique. Gastrostomy tubes were placed in 75% of patients also undergoing fundoplication. Newborn made up 64% of the cohort, with 47% of newborns having cardiac anomalies and 96% being premature. Open fundoplications were more likely to be performed in newborns (72% versus 61%) and those in the lowest income quartile compared to laparoscopic (41% versus 31% P < .001), both P < .001. The readmission rate was 20% within 30 days and 38% within the year, with 15% admitted to a different hospital. Only 14% of readmissions were elective. Open fundoplication was associated with more unplanned readmissions (94% versus 84%), conversion to gastrojejunostomy tube (11% versus 5%) along with major (5% versus 3%) and minor (8% versus 2%) complications compared to the laparoscopic approach, all P < 0.001. Conclusion: The majority of fundoplications are being performed in newborns and are being done laparoscopically, which are associated with lower complication and postoperative readmission rates compared to open fundoplications.

Ovarian Preservation and Recurrent Torsion in Children: Both Less Common Than We Thought

PURPOSE

Surgical management of pediatric ovarian torsion includes total oophorectomy (TO) or ovarian preservation surgery (OPS). This study sought to identify factors contributing to surgical management and readmission outcomes for ovarian torsion.

METHODS

The Nationwide Readmission Database from 2010-2014 was used to identify patients < 18 years admitted with ovarian torsion. Patient factors, hospital characteristics, and readmission outcomes were compared by TO and OPS. Standard statistical analysis was performed and results were weighted for national estimates.

RESULTS

There were 6028 patients (age 13 ± 4 years) identified with ovarian torsion who underwent either TO (50%) or OPS (50%). Patients had secondary pathology of ovarian cyst (41%), benign mass (19%), and malignant mass (0.4%). OPS was more common in teaching hospitals (84% vs. 74% TO, P<0.001), patients < 13 years of age (41% vs. 37% TO, P = 0.001), and those from high-income households (51% vs. 41% TO, P<0.001). The overall readmission rate was 4%, with no difference between surgical approach (4.3% OPS vs. 4.4% TO, P = 0.882). Of those readmitted (n = 265), readmission diagnoses were cyst (10%), malignant mass (9%), benign mass (7%), and torsion (5%). The overall rate of recurrent torsion was 0.2%, with no difference between OPS and TO (< 0.3% vs. < 0.2%, P = 0.282).

CONCLUSION

Half of pediatric patients are undergoing TO for ovarian torsion in the U.S. and disparities exist with the utilization of OPS. There is no difference in rate of readmission or recurrent torsion between surgical approaches, and the overall rate of retorsion is lower than previously reported.

Pediatric Gastrostomy Tube Placement: Less Complications Associated with Laparoscopic Approach

Background: There are few nationwide studies comparing outcomes of open, laparoscopic (LAP), and percutaneous endoscopic (PEG) gastrostomy tube (GT) placement in the pediatric population. Materials and Methods: The Nationwide Readmissions Database from 2010 to 2014 was used to identify patients ≤18 years (excluding newborns) who underwent GT placement. Demographics, hospital characteristics, and outcomes were compared by the GT approach. Results: There were 3278 patients (41% female, age 3 ± 5 years) identified who underwent GT placement (40% open versus 32% PEG versus 28% LAP). Following an open approach, there were higher rates of GT-related complications (10% versus 4% LAP versus 3% PEG) and postoperative gastrointestinal issues (24% versus 12% LAP versus 9% PEG) on index hospitalization, both P < .001. Readmission within 30 days and 1 year were 18% and 43%, respectively. Overall readmission rates were not affected by the GT approach (44% open versus 44% LAP versus 43% PEG, P = .773). However, readmission for GT-related complications was the lowest following the LAP approach (<0.3% versus 2% open versus 2% PEG, P < .001). When those who also underwent fundoplication were excluded, conversion to gastrojejunostomy or jejunostomy (GJ/J) on readmission was higher following open and PEG approaches (4% open versus 2% PEG versus 0% LAP, P = .039). Conclusions: Compared with PEG gastrostomy and open gastrostomy, LAP GT placement appears to have lower index complications and reoperation rates, and at least comparable readmission outcomes. Despite these advantages, LAP GT placement remains underutilized.

Prophylactic colectomy for children with familial adenomatous polyposis: resource utilization and outcomes for open and laparoscopic surgery

Background

Laparoscopic approach for the surgical management of familial adenomatous polyposis (FAP) has become increasingly common for pediatric patients. The purpose of this study was to compare short-term outcomes and resource utilization between open and laparoscopic surgery for prophylactic colectomy in children with FAP.

Methods

The Kids' Inpatient Database (2009 and 2012) was analyzed for children (age ≤20 years) with FAP that underwent prophylactic total colectomy or proctocolectomy. Patient demographics, treating hospital characteristics, hospital charges, and short-term outcomes were compared according to the surgical technique utilized (open versus laparoscopic).

Results

Overall, we identified 216 patients with FAP that underwent elective total colectomy, of which 95 cases were performed by open surgery and 121 were done laparoscopically. The majority of patients were treated at large, not-for-profit, urban teaching hospitals, and the median age was equal (16 years) in both groups. Complications that were more common for open procedures included accidental perforation or hemorrhage (4% vs. 0%, P=0.023), reopening of surgical site (3% vs. 0%, P=0.049), and pneumonia (3% vs. 0%, P=0.049). Simultaneous proctectomy was performed more commonly in the open cohort (91% vs. 71%, P<0.001) as well as ileostomy creation (74% vs. 49%, P<0.001). The median length of stay was similar in the open and laparoscopic groups (7 vs. 6 days, P=0.712). Median total hospital charges were also similar ($67,334 vs. $68,717, P=0.080).

Conclusions

A laparoscopic approach for prophylactic colectomy can be safely performed in children with FAP, and total hospital charges are equivalent compared to open surgery. However, simultaneous proctectomy was performed less often with laparoscopic surgery.

A retrospective comparison of outcomes for open vs. laparoscopic surgical techniques in pediatric ulcerative colitis

Background

Ulcerative colitis (UC) is an aggressive disease in the pediatric population and a cause of significant, lifelong morbidity. The aim of this study is to compare surgical complications in pediatric patients undergoing laparoscopic vs. open surgical treatment for UC.

Methods

We queried the Kids' Inpatient Database (KID) for all cases of UC undergoing surgical treatment in 2009 and 2012. We identified patients who received total colectomy without proctectomy (n=413) or total proctocolectomy (n=196) and performed univariate and multivariate analyses comparing laparoscopic vs. open procedures.

Results

In pediatric UC patients undergoing total colectomy without proctectomy, open procedures were associated with more complications than laparoscopic, including fluid and electrolyte disorders (40% vs. 28%), surgical wound dehiscence (6% vs. 2%), septicemia (18% vs. 2%), and gastrointestinal disorders (16% vs. 7%) among others, all P<0.05. Likewise, in patients with UC undergoing total proctocolectomy, there were more complications in open vs. laparoscopic technique, including increased transfusion requirements (25% vs. 7%, P=0.001) and significantly more gastrointestinal upset, including nausea, vomiting, and diarrhea (11% vs. 1%, P=0.003). In multivariate analysis, patients who underwent total colectomy with or without proctectomy had an increased risk of experiencing any complication when their procedure was performed in an open or non-elective fashion (all odds ratio >2.4; all P<0.001).

Conclusions

The laparoscopic approach was associated with significantly lower rates of surgical complications in pediatric patients undergoing total colectomy with or without proctectomy for UC. These findings demonstrate that laparoscopic technique compares favorably, and may be preferable, to the open approach in selected pediatric patients with UC.

Predictive Factors and Outcomes for Successful Thoracoscopic Lung Resection in Pediatric Patients

BACKGROUND

Less than 50% of children with congenital lung lesions are treated thoracoscopically. There are variable data regarding the benefits and limited information on factors contributing to successful thoracoscopic lobectomies in pediatric patients. We sought to identify predictive factors leading to safe and efficient thoracoscopic lung resection.

STUDY DESIGN

We performed a single-center, retrospective chart review of patients (age <18 y) who underwent lung resection between June 2009 and July 2020. Pulmonary wedge resection was excluded. Data collected included demographics, perioperative findings, such as symptoms or infection, and postoperative outcomes. Univariate, multivariate, and sensitivity analyses were performed.

RESULTS

Ninety-six patients were identified. Sixty-nine patients (72%) underwent initial thoracoscopy, with 15 (22%) converting to open thoracotomy (CTO). Forty-one (43%) patients had preoperative symptoms and 15 (15.6%) had an active infection. Among symptomatic patients, 18 (43.9%) underwent thoracotomy and 23 (56%) were attempted thoracoscopically, 13 (31%) of whom were completed thoracoscopically. On univariate analysis, age >1 year, infection, preoperative symptoms, and intraoperative adhesions were associated with CTO. Older age (odds ratio [OR] = 1.041) and estimated blood loss (EBL) (OR = 2.398) were significant prognostic factors of CTO on logistic regression. Thoracoscopy was significantly associated with decreased length of stay, opioid use, chest tube duration, blood loss and need for blood transfusion. There was no difference in operative time, 30-day readmission, or mortality.

CONCLUSIONS

Thoracoscopy has become a standard approach for pediatric lung resection. Our findings indicate that age < 1 year and the absence of active respiratory infection and preoperative symptoms may be predictive of successful completion of the thoracoscopic approach. Thoracoscopy offers significant advantages over the traditional open thoracotomy with regard to blood loss and opioid requirements, LOS, and chest tube duration.

Complications while awaiting elective inguinal hernia repair in infants: Not as common as you thought

BACKGROUND

The dogma of early inguinal hernia repair in infants, especially those born prematurely, has dominated clinical practice owing to reports of a high frequency of incarceration and significant complications associated with untreated inguinal hernias. We aim to evaluate the frequency of complications after discharge with delayed surgery for inguinal hernia repair.

METHODS

The Nationwide Readmissions Database (2010-2014) was queried to identify infants diagnosed with inguinal hernia. We compared the frequency and characteristics of inguinal hernia repair performed during the index admission, discharge from the index admission without hernia repair, and unplanned readmissions.

RESULTS

We identified 33,530 infants (16,624 preterm and 16,906 full-term) diagnosed with an inguinal hernia during an index admission. For those infants diagnosed with an inguinal hernia at birth, inguinal hernia repair was performed during the birth admission for only a minority of both preterm (35%) and full-term infants (18%; P < .001). Of the infants discharged without hernia repair, 15% required nonelective readmission up to 1 year later, but only 2% of preterm and 1% of full-term infants actually underwent inguinal hernia repair during these unplanned readmissions. None of the readmitted infants underwent additional procedures suggestive of a strangulated hernia.

CONCLUSION

Complications among infants awaiting inguinal hernia repair may be substantially less common than previously reported, and the occurrence of significant associated morbidity is quite rare.

The limited role of ultrasound in the surgical assessment of solid pediatric breast lesions

INTRODUCTION

Ultrasound (US) is an adjunct to history and clinical exam (CE) in the assessment of pediatric breast lesions. We sought to investigate the reliability of US and CE to predict final pathologic diameter (P).

METHODS

A single institutional retrospective analysis of patients aged ≤18 years who underwent breast mass resection was performed. Data was collected and analyzed using SPSS.

RESULTS

88 patients met inclusion criteria with an average age at surgery of 16 ± 1.5 years. No malignancies were encountered. The largest mean diameter measured by final pathology (MPØ) for all lesions was 4.1 ± 2.6 cm. Pathology encountered were fibroadenoma (83%, MPØ 3.7 ± 1.7 cm), juvenile fibroadenoma (10%, MPØ 7.0 ± 5.4 cm), and low-grade phyllodes tumor (3%, MPØ 6.2 ± 3.8 cm). 67 patients had documented CE measurement with a mean diameter of 3.4 ± 1.8 cm. 62 patients underwent US with a mean diameter of 3.3 ± 1.6 cm. US and CE were accurate in determining P by Cronbach Alpha reliability testing.

CONCLUSION

US and CE are reliable measurements of P. The surgical utility of US when considering pediatric breast lesions is limited and should be individualized following pediatric surgical evaluation and CE.

Geodemographic analysis of pediatric firearm injuries in Miami, FL

PURPOSE

Firearm injuries (GSW) are a growing public health concern and leading cause of morbidity and mortality among children, yet predictors of injury remain understudied. This study examines the correlates of pediatric GSW within our county.

METHODS

We retrospectively queried an urban Level 1 trauma center registry for pediatric (0-18 years) GSW from September 2013 to January 2019, examining demographic, clinical, and injury information. We used a geographic information system to map GSW rates and perform spatial and spatiotemporal cluster analysis to identify zip code "hot spots."

RESULTS

393 cases were identified. The cohort was 877% male, 87% African American, 10% Hispanic, and 22% Caucasian/Other. Injuries were 92% violence-related and 4% accidental, with 63% occurring outside school hours. Mortality was 12%, with 53% of deaths occurring in the resuscitation unit. Zip-level GSW rates ranged from 0 to 9 (per 1000 < 18 years) by incident address and 0-6 by home address. Statistically significant hot spots were in predominantly underserved African American and Hispanic neighborhoods.

CONCLUSIONS

Geodemographic analysis of pediatric GSW injuries can be utilized to identify at-risk neighborhoods. This methodology is applicable to other metropolitan areas where targeted interventions can reduce the burden of gun violence among children.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level III.

Utility of routine intraoperative cholangiogram during cholecystectomy in children: A nationwide analysis of outcomes and readmissions

PURPOSE

This study aims to determine postoperative outcomes and readmissions in pediatric cholecystectomy with routine intraoperative cholangiogram (IOC) utilization.

METHODS

The Nationwide Readmissions Database 2010-2014 was queried for all pediatric cholecystectomies. A propensity score-matched analysis (PSMA) with over 30 covariates was performed between cholecystectomy alone (CCY) versus those with routine IOC (CCY + IOC, no biliary obstruction, dilatation, or pancreatitis). χ² analysis or Mann-Whitney U were used for statistical analysis with p < 0.05 set as significant.

RESULTS

34,390 cholecystectomies were performed: 92% were laparoscopic, most were teenage females (75%, 15 years [13-17]) and did not undergo IOC (75%). Postoperative mortality rate was 0.1%. The PSMA cohort comprised of 1412 CCY and 1453 CCY + IOC. Patients with CCY alone had higher rates of 30-day (7% vs 5%), 1-year readmissions (13% vs 11%) and had higher rates of overall complications (22% vs 12%) compared with CCY + IOC, all p < 0.05. Although uncommon, bile duct injuries were more prevalent in CCY (2% vs 0%, p < 0.001), while there was no difference in readmissions for retained stones. Resource utilization was increased in CCY patients, likely due to increased complication rates.

CONCLUSION

This nationwide PSMA suggests pediatric CCY with routine IOC is associated with decreased readmissions, overall resource utilization, complications, and bile duct injuries.

TYPE OF STUDY

Retrospective Comparative Study.

LEVEL OF EVIDENCE

Level III.

Identifying Abuse and Neglect in Hospitalized Children With Burn Injuries

BACKGROUND

The purpose of this study was to identify the pattern of injuries that relates to abuse and neglect in children with burn injuries.

METHODS

The Nationwide Readmissions Database for 2010-2014 was queried for all patients aged less than 18 y admitted with burn injuries. The primary outcome was child maltreatment identified at the index admission. The secondary outcome was readmission for maltreatment. A subgroup analysis was performed on patients without a diagnosis of maltreatment during the index admission. Multivariable logistic regression was performed for each outcome.

RESULTS

There were 57,939 admissions identified and 1960 (3.4%) involved maltreatment at the index admission. Maltreatment was associated with total body surface area burned >20% (odds ratio (OR) 2.79, P < 0.001) and burn of the lower limbs (OR 1.37, P < 0.001). Readmission for maltreatment was found in 120 (0.2%), and the strongest risk factor was maltreatment identified at the index admission (OR 5.11, P < 0.001). After excluding the patients with maltreatment identified at the index admission, 96 (0.17%) children were found to have a readmission for maltreatment that may have been present on the index admission and subsequently missed. The strongest risk factor was burn of the eye or ocular adnexa (OR 3.79, P = 0.001).

CONCLUSIONS

This study demonstrates that a portion of admissions for burn injuries in children could involve maltreatment that was undiagnosed. Identifying these at-risk individuals is critical to prevention efforts.