Comparing pyloromyotomy outcomes across Canada

Geographic Differences in Pediatric Surgical Mortality in Canada: A Retrospective Cohort Study

OBJECTIVE

This study describes differences in postoperative mortality for pediatric patients in rural communities compared to urban communities.

BACKGROUND

Canada has the second largest land mass in the world, with a population density of 4 people per km2. There are 18 children's hospitals in Canada offering pediatric surgical services, all in urban centres, yet nearly one-fifth of the population lives in rural or remote communities. Children who live in rural settings may have worse surgical outcomes, including mortality rates, compared with urban populations.

METHODS

Pediatric patients, from birth to 18 years old, who had surgery from January 1, 2011, to December 31, 2021, at a single Children's Hospital were included in the study. Data was obtained from the provincial Operating Room Information System (ORIS) database. Postal code, rural and urban status, distance to children's hospital (0-50 km, 51-100 km, 101-150 km, 151-200 km, and >200 km), and procedure urgency were collected. 30-day mortality for all procedures was collected.

RESULTS

85,998 surgical procedures were performed at ACH between 2011 and 2021. 17,773 (20.7%) of patients lived >50 km or more from the hospital - 5,329 (6.2%) 51- 100 km, 4,053 (4.7%) 101-150 km, n=2,323 (2.7%) 151-200 km, and 6,070 (7.1%) >200 km. Rural patients had higher 30-day mortality rates than urban patients, with an odds ratio of mortality (rural vs urban) of 2.30 (95% CI, 0.95 to 5.60). When stratified by distance, patients living closer to the hospital (0-50 km) had lower odds of mortality.

CONCLUSIONS

Canadian Rural patients have higher operative mortality risks than urban patients. This study identifies a vulnerable group of patients who do not have equal access to care and may experience worse outcomes.

A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis

INTRODUCTION

In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes.

METHODS

The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach.

RESULTS

9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%).

CONCLUSIONS

In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.

Nationwide trends of laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis in Germany: A slow path forward

Since its introduction, laparoscopic pyloromyotomy (LP), has become increasingly popular in many countries. We have noticed an attenuated trend in Germany. The aim of this study was to analyse the distribution of open and LP in Germany. The national database of administrative claims data of the Institute for the Remuneration System in Hospitals (InEK) was analysed regarding numbers of patients with pyloromyotomy in the years 2019-2021. The German quality reports of the hospitals of 2019 and 2020 were analyzed regarding the number of procedures performed per hospital and pediatric surgical department. A total of 2050 patients underwent pyloromyotomy. The incidence of hypertrophic pylorus stenosis (HPS) was 699 and 657 patients in 2019 and 2021, respectively. Regarding age, 31.1% were admitted before 28 days of age. LP gradually increased from 216 patients (30.9%) in 2019 to 239 patients (36.4%) in 2021. Thirty-three laparoscopic operations (4.8%) were converted to an open approach. In 24 of all patients, there was an injury to the stomach, in 20 patients to the duodenum, needing repair with sutures. Analysis of the quality reports indicated that 44% of pediatric surgical departments performed LP. Although LP has became more prevalent in Germany recently, about two thirds of patients still undergo an open procedure.

Neonates undergoing pyloric stenosis repair are at increased risk of difficult airway management: secondary analysis of the NEonate and Children audiT of Anaesthesia pRactice IN Europe

BACKGROUND

Hypertrophic pyloric stenosis in otherwise healthy neonates frequently requires urgent surgical procedure but anaesthesia care may result in respiratory complications, such as hypoxaemia, pulmonary aspiration of gastric contents, and postoperative apnoea. The primary aim was to study whether or not the incidence of difficult airway management and of hypoxaemia in neonates undergoing pyloric stenosis repair was higher than that in neonates undergoing other surgeries.

METHODS

Data on neonates and infants undergoing anaesthesia and surgery for pyloric stenosis were extracted from the NEonate and Children audiT of Anesthesia pRactice In Europe (NECTARINE) database, for secondary analysis.

RESULTS

We identified 310 infants who had anaesthesia for surgery for pyloric stenosis. Difficult airway management (more than two attempts at laryngoscopy) was higher in children with pyloric stenosis when compared with the entire NECTARINE cohort (7.9% [95% confidence interval {CI}, 5.22-11.53] vs 4.4% [95% CI, 1.99-6.58]; relative risk [RR]=1.81 [95% CI, 1.21-2.69]; P=0.004), whereas transient hypoxaemia with oxygen saturation <90% was comparable between the two cohorts. Postoperative complications occurred in 16 children (5.6%) within the 30-day follow-up. No mortality was reported at 30 and 90 days.

CONCLUSIONS

Children undergoing surgery for pyloric stenosis had a higher incidence of difficult intubation compared with the entire NECTARINE cohort.

CLINICAL TRIAL REGISTRATION

NCT02350348.

From far and wide: Geographic distance to pediatric surgical care across Canada

PURPOSE

Canada is the second largest country in the world, with most of the population located in the southern-most portion of its geography. We sought to define the relative distribution of pediatric surgeons to potential pediatric patients using data from the Canadian census.

METHODS

The 2011 Canadian Census and a convenience sample of current Canadian pediatric surgeons were used to calculate straight-line distances between pediatric surgeon postal code centroids and census dissemination block centroids.

RESULTS

Currently, there are 74 practicing pediatric surgeons in Canada; 493,345 populated census blocks were identified, and 7,752,075 children were enumerated. The median (IQR) kilometers to the closest pediatric surgeon was 27.99 (11.35, 85.47) kilometers, and 22.7% of Canadian children lived more than 100 km from care. Nearly 13% of children lived greater than 200 km from the nearest pediatric surgeon.

CONCLUSION

More than 1.7 million Canadian children, nearly one quarter of all Canadian children, live greater than 100 km from the closest pediatric surgeon. This identifies a disparate group of patients who do not have an equal access-to-care as compared to others in the country.

LEVEL OF EVIDENCE

Level IV.

Trends and surgical outcomes of laparoscopic versus open pyloromyotomy

BACKGROUND

Hypertrophic pyloric stenosis (HPS) is one of the most common pediatric illnesses necessitating surgical intervention. Controversy remains over the optimal surgical approach between laparoscopic pyloromyotomy (LP) and open pyloromyotomy (OP). LP has gained acceptance for management of HPS in an era of expanding minimal access surgical approaches to pediatric conditions. Several studies suggest advantages of LP over OP; however, selection bias and small sample sizes remain a concern. This study compares the outcomes of LP versus OP using propensity score methods.

METHODS

The 2013-2015 ACS NSQIP Pediatric PUF was queried for all infants undergoing pyloromyotomy. The trend in the proportion of infants undergoing LP was described and perioperative outcomes between the OP and LP cohorts were compared using propensity score weighted regression models.

RESULTS

4847 infants were identified to have undergone surgical pyloromyotomy. The proportion of LP performed increased significantly from 59% in 2013 to 65.5% in 2015 (p < 0.001). LP was associated with lower overall complications (1.4% vs 2.9%) (OR_adj 0.52, 95% CI 0.34-0.80), surgical site-related complications (1.1% vs 2.1%) (OR_adj 0.52, 95% CI 0.32-0.84), and post-operative length of stay (1.5 days vs 1.9 days) (OR_adj 0.89, 95% CI 0.81-0.98) without significant differences in related re-operation (0.9% vs 0.9%) (OR_adj 1.01, 95% CI 0.52-1.93) or readmissions (1.4% vs 2.1%) (OR_adj 0.73, 95% CI 0.46-1.17).

CONCLUSIONS

Our study demonstrates that LP is increasingly utilized for management of hypertrophic pyloric stenosis and is associated with shorter length of stay, and lower odds of surgical site-specific and overall complications without differences in related re-operations. This study supports LP as a safe and effective method for management of HPS.