Use of Antipseudomonal Antibiotics is Not Associated With Lower Rates of Postoperative Drainage Procedures or More Favorable Culture Profiles in Children With Complicated Appendicitis: Results From a Multicenter Regional Research Consortium

OBJECTIVE

To compare rates of postoperative drainage and culture profiles in children with complicated appendicitis treated with the 2 most common antibiotic regimens with and without antipseudomonal activity [piperacillin-tazobactam (PT) and ceftriaxone with metronidazole (CM)].

BACKGROUND

Variation in the use of antipseudomonal antibiotics has been driven by a paucity of multicenter data reporting clinically relevant, culture-based outcomes.

METHODS

A retrospective cohort study of patients with complicated appendicitis (7/2015-6/2020) using NSQIP-Pediatric data from 15 hospitals participating in a regional research consortium. Operative report details, antibiotic utilization, and culture data were obtained through supplemental chart review. Rates of 30-day postoperative drainage and organism-specific culture positivity were compared between groups using mixed-effects regression to adjust for clustering after propensity matching on measures of disease severity.

RESULTS

In all, 1002 children met the criteria for matching (58.9% received CM and 41.1% received PT). In the matched sample of 778 patients, children treated with PT had similar rates of drainage overall [PT: 11.8%, CM: 12.1%; odds ratio (OR): 1.44 (OR: 0.71-2.94)] and higher rates of drainage associated with the growth of any organism [PT: 7.7%, CM: 4.6%; OR: 2.41 (95% CI: 1.08-5.39)] and Escherichia coli [PT: 4.6%, CM: 1.8%; OR: 3.42 (95% CI: 1.07-10.92)] compared to treatment with CM. Rates were similar between groups for drainage associated with multiple organisms [PT: 2.6%, CM: 1.5%; OR: 3.81 (95% CI: 0.96-15.08)] and Pseudomonas [PT: 1.0%, CM: 1.3%; OR: 3.42 (95% CI: 0.55-21.28)].

CONCLUSIONS AND RELEVANCE

The use of antipseudomonal antibiotics is not associated with lower rates of postoperative drainage procedures or more favorable culture profiles in children with complicated appendicitis.

Nissen Fundoplication in Infants With Severe Bronchopulmonary Dysplasia: A Propensity-Matched Analysis

INTRODUCTION

Bronchopulmonary dysplasia (BPD) is a common respiratory morbidity among premature infants. Nissen fundoplication may be performed on infants with BPD to protect the lungs from gastroesophageal reflux-related aspiration, but the indications and benefits associated with fundoplication are not well-defined. This study evaluated associations of Nissen with clinical outcomes in infants with severe BPD (sBPD), using propensity score matching to minimize bias and confounding.

METHODS

Infants ≤31 wk gestational age with sBPD (grade 2-3) admitted to a single neonatal intensive care unit (NICU) between January 2016 and October 2021 were included. Patients with sBPD who underwent Nissen fundoplication during initial NICU admission were propensity score-matched at a 1:2 ratio with control patients who did not undergo Nissen (no-Nissen). Outcomes were compared, including time to freedom from respiratory support (defined as ≤2 L nasal cannula), time to initial NICU discharge, and incidence of hospital readmission or death within 1 y postdischarge.

RESULTS

After propensity score matching, 18 Nissen infants were compared with 30 no-Nissen infants. The Nissen group trended toward longer time to freedom from respiratory support (median 105 versus 70 d, P = 0.09), and had longer initial hospital stays (188 versus 111 d, P = 0.002), more 1-y hospital readmissions (83% versus 50%, P = 0.04), and more tracheostomies (28% versus 0%, P = 0.005). Mortality during first-year postdischarge was similar (6% versus 10%, P = 1.0).

CONCLUSIONS

Despite adjustment for confounding variables, Nissen fundoplication was associated with prolonged support and greater resource utilization among infants with sBPD. Prospective studies are needed to clarify indications for fundoplication in this population.

Balanced resuscitation with whole blood versus component therapy in critically injured preadolescent children: Getting there faster with fewer exposures

PURPOSE

Balanced blood product resuscitation with red blood cells, plasma, and platelets can be achieved using whole blood (WB) or component therapy (CT). However, balanced resuscitation of younger children with severe traumatic hemorrhage may be complicated by delays in delivering all blood components and concerns regarding multiple product exposures. We hypothesized that WB achieves balanced resuscitation faster than CT, with fewer product exposures and improved clinical outcomes.

METHODS

Children younger than 12 years receiving balanced resuscitation within 4 hours of arrival were identified from the 2017 to 2019 Trauma Quality Improvement Program database. Time to balanced resuscitation was defined as the time of initiation of WB or all three components. Patient characteristics, resuscitation details, and outcomes were compared between WB and CT groups. Time to balanced resuscitation was compared using Kaplan-Meier analysis and Cox regression modeling to adjust for covariates. Additional multivariable regression models compared number of transfusion exposures, intensive care unit (ICU) length of stay, and mortality.

RESULTS

There were 390 patients (109 WB, 281 CT) with median age 7 years, 12% penetrating mechanism, 42% severe traumatic brain injury, and 49% in-hospital mortality. Time to balanced resuscitation was shorter for WB versus CT (median, 28 vs. 87 minutes; hazard ratio [HR], 2.93; 95% confidence interval [CI], 2.31-3.72; p < 0.0001). Whole blood patients received fewer transfusion exposures (mean, 3.2 vs. 3.9; adjusted incidence rate ratio, 0.82; 95% CI, 0.72-0.92; p = 0.001) and lower total product volumes (50 vs. 85 mL/kg; p = 0.01). Intensive care unit stays trended shorter for WB versus CT (median, 10 vs. 12 days; adjusted HR, 1.32; 95% CI, 0.93-1.86), while in-hospital mortality was similar (50% vs. 45%; adjusted odds ratio, 1.11; 95% CI, 0.65-1.88).

CONCLUSION

In critically injured preadolescent children receiving emergent transfusion, WB was associated with faster time to balanced resuscitation, fewer transfusion exposures, lower blood product volumes, and a trend toward shorter ICU stays than CT.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Postoperative Antibiotics, Outcomes, and Resource Use in Children With Gangrenous Appendicitis

Importance

Gangrenous, suppurative, and exudative (GSE) findings have been associated with increased surgical site infection (SSI) risk and resource use in children with nonperforated appendicitis. Establishing the role for postoperative antibiotics may have important implications for infection prevention and antimicrobial stewardship.

Objective

To compare SSI rates in children with nonperforated appendicitis with GSE findings who did and did not receive postoperative antibiotics.

Design, Setting, and Participants

This was a retrospective cohort study using American College of Surgeons' National Surgical Quality Improvement Program (NSQIP)-Pediatric Appendectomy Targeted data from 16 hospitals participating in a regional research consortium. NSQIP data were augmented with operative report and antibiotic use data obtained through supplemental medical record review. Children with nonperforated appendicitis with GSE findings who underwent appendectomy between July 1, 2015, and June 30, 2020, were identified using previously validated intraoperative criteria. Data were analyzed from October 2022 to July 2023.

Exposure

Continuation of antibiotics after appendectomy.

Main Outcomes and Measures

Rate of 30-day postoperative SSI including both incisional and organ space infections. Complementary hospital and patient-level analyses were conducted to explore the association between postoperative antibiotic use and severity-adjusted outcomes. The hospital-level analysis explored the correlation between postoperative antibiotic use and observed to expected (O/E) SSI rate ratios after adjusting for differences in disease severity (presence of gangrene and postoperative length of stay) among hospital populations. In the patient-level analysis, propensity score matching was used to balance groups on disease severity, and outcomes were compared using mixed-effects logistic regression to adjust for hospital-level clustering.

Results

A total of 958 children (mean [SD] age, 10.7 [3.7] years; 567 male [59.2%]) were included in the hospital-level analysis, of which 573 (59.8%) received postoperative antibiotics. No correlation was found between hospital-level SSI O/E ratios and postoperative antibiotic use when analyzed by either overall rate of use (hospital median, 53.6%; range, 31.6%-100%; Spearman ρ = -0.10; P = .71) or by postoperative antibiotic duration (hospital median, 1 day; range, 0-7 days; Spearman ρ = -0.07; P = .79). In the propensity-matched patient-level analysis including 404 patients, children who received postoperative antibiotics had similar rates of SSI compared with children who did not receive postoperative antibiotics (3 of 202 [1.5%] vs 4 of 202 [2.0%]; odds ratio, 0.75; 95% CI, 0.16-3.39; P = .70).

Conclusions and Relevance

Use of postoperative antibiotics did not improve outcomes in children with nonperforated appendicitis with gangrenous, suppurative, or exudative findings.

Effect of Early vs Late Inguinal Hernia Repair on Serious Adverse Event Rates in Preterm Infants: A Randomized Clinical Trial

Importance

Inguinal hernia repair in preterm infants is common and is associated with considerable morbidity. Whether the inguinal hernia should be repaired prior to or after discharge from the neonatal intensive care unit is controversial.

Objective

To evaluate the safety of early vs late surgical repair for preterm infants with an inguinal hernia.

Design, Setting, and Participants

A multicenter randomized clinical trial including preterm infants with inguinal hernia diagnosed during initial hospitalization was conducted between September 2013 and April 2021 at 39 US hospitals. Follow-up was completed on January 3, 2023.

Interventions

In the early repair strategy, infants underwent inguinal hernia repair before neonatal intensive care unit discharge. In the late repair strategy, hernia repair was planned after discharge from the neonatal intensive care unit and when the infants were older than 55 weeks' postmenstrual age.

Main Outcomes and Measures

The primary outcome was occurrence of any prespecified serious adverse event during the 10-month observation period (determined by a blinded adjudication committee). The secondary outcomes included the total number of days in the hospital during the 10-month observation period.

Results

Among the 338 randomized infants (172 in the early repair group and 166 in the late repair group), 320 underwent operative repair (86% were male; 2% were Asian, 30% were Black, 16% were Hispanic, 59% were White, and race and ethnicity were unknown in 9% and 4%, respectively; the mean gestational age at birth was 26.6 weeks [SD, 2.8 weeks]; the mean postnatal age at enrollment was 12 weeks [SD, 5 weeks]). Among 308 infants (91%) with complete data (159 in the early repair group and 149 in the late repair group), 44 (28%) in the early repair group vs 27 (18%) in the late repair group had at least 1 serious adverse event (risk difference, -7.9% [95% credible interval, -16.9% to 0%]; 97% bayesian posterior probability of benefit with late repair). The median number of days in the hospital during the 10-month observation period was 19.0 days (IQR, 9.8 to 35.0 days) in the early repair group vs 16.0 days (IQR, 7.0 to 38.0 days) in the late repair group (82% posterior probability of benefit with late repair). In the prespecified subgroup analyses, the probability that late repair reduced the number of infants with at least 1 serious adverse event was higher in infants with a gestational age younger than 28 weeks and in those with bronchopulmonary dysplasia (99% probability of benefit in each subgroup).

Conclusions and Relevance

Among preterm infants with inguinal hernia, the late repair strategy resulted in fewer infants having at least 1 serious adverse event. These findings support delaying inguinal hernia repair until after initial discharge from the neonatal intensive care unit.

Trial Registration

ClinicalTrials.gov Identifier: NCT01678638.

Utility of a Benchmarking Report for Balancing Infection Prevention and Antimicrobial Stewardship in Children with Complicated Appendicitis

OBJECTIVE

To develop a severity-adjusted, hospital-level benchmarking comparative performance report for postoperative organ space infection and antibiotic utilization in children with complicated appendicitis.

BACKGROUND

No benchmarking data exist to aid hospitals in identifying and prioritizing opportunities for infection prevention or antimicrobial stewardship in children with complicated appendicitis.

METHODS

This was a multicenter cohort study using NSQIP-Pediatric data from 16 hospitals participating in a regional research consortium, augmented with antibiotic utilization data obtained through supplemental chart review. Children with complicated appendicitis who underwent appendectomy from 07/01/2015 to 06/30/2020 were included. Thirty-day postoperative OSI rates and cumulative antibiotic utilization were compared between hospitals using observed-to-expected (O/E) ratios after adjusting for disease severity using mixed effects models. Hospitals were considered outliers if the 95% confidence interval for O/E ratios did not include 1.0.

RESULTS

1790 patients were included. Overall, the OSI rate was 15.6% (hospital range: 2.6-39.4%) and median cumulative antibiotic utilization was 9.0 days (range: 3.0-13.0). Across hospitals, adjusted O/E ratios ranged 5.7-fold for OSI (0.49-2.80, P=0.03) and 2.4-fold for antibiotic utilization (0.59-1.45, P<0.01). Three (19%) hospitals were outliers for OSI (1 high and 2 low performers), and eight (50%) were outliers for antibiotic utilization (5 high and 3 low utilizers). Ten (63%) hospitals were identified as outliers in one or both measures.

CONCLUSIONS

A comparative performance benchmarking report may help hospitals identify and prioritize quality improvement opportunities for infection prevention and antimicrobial stewardship, as well as identify exemplar performers for dissemination of best practices.

Risk of Injury-Related Readmission Varies by Initial Presenting-Hospital Type Among Children at High Risk for Physical Abuse

OBJECTIVES

Children experiencing physical abuse may initially present to hospitals with underappreciated minor injuries, only to experience more severe injuries in the future. The objectives of this study were to 1) describe young children presenting with high-risk diagnoses for physical abuse, 2) characterize the hospitals to which they initially presented, and 3) evaluate associations of initial presenting-hospital type with subsequent admission for injury.

METHODS

Patients aged younger than 6 years from the 2009-2014 Florida Agency for Healthcare Administration database with high-risk diagnoses (codes previously associated with >70% risk of child physical abuse) were included. Patients were categorized by the hospital type to which they initially presented: community hospital, adult/combined trauma center, or pediatric trauma center. Primary outcome was subsequent injury-related hospital admission within 1 year. Association of initial presenting-hospital type with outcome was evaluated with multivariable logistic regression, adjusting for demographics, socioeconomic status, preexisting comorbidities, and injury severity.

RESULTS

A total of 8626 high-risk children met inclusion criteria. Sixty-eight percent of high-risk children initially presented to community hospitals. At 1 year, 3% of high-risk children had experienced subsequent injury-related admission. On multivariable analysis, initial presentation to a community hospital was associated with higher risk of subsequent injury-related admission (odds ratio, 4.03 vs level 1/pediatric trauma center; 95% confidence interval, 1.83-8.86). Initial presentation to a level 2 adult or combined adult/pediatric trauma center was also associated with higher risk for subsequent injury-related admission (odds ratio, 3.19; 95% confidence interval, 1.40-7.27).

CONCLUSIONS

Most children at high risk for physical abuse initially present to community hospitals, not dedicated trauma centers. Children initially evaluated in high-level pediatric trauma centers had lower risk of subsequent injury-related admission. This unexplained variability suggests stronger collaboration is needed between community hospitals and regional pediatric trauma centers at the time of initial presentation to recognize and protect vulnerable children.

Language Differences by Race on Letters of Recommendation for the Pediatric Surgery Match

OBJECTIVE

This study aims to evaluate if there is any significant linguistic difference in LoR based on applicant's race/ethnicity.

DESIGN

Retrospective review of applications to pediatric surgery fellowship at a single institution (2016-2020). Race was self-reported by applicants. LoR were analyzed via the Linguistic Inquiry and Word Count (LIWC) software program.

SETTING

Johns Hopkins All Children's Hospital, St. Petersburg, Florida USA. A free-standing tertiary pediatric hospital.

PARTICIPANTS

Pediatric surgery fellowship applicants from 2016 to 2020.

RESULTS

A total of 1086 LoR from 280 applicants (52% female) were analyzed. Racial distribution was Caucasians 62.1%, Asian 12.1%, Hispanics 7.1%, multiracial 6.4% African Americans 5%, and other/unknown 7.1%. Letter writers were largely male (84%), pediatric surgeons (63%) and professors (57%). There was no difference in LoR word count across races. LoR for female multiracial candidates contained higher use of affiliation and negative emotion terms compared to Hispanic females (p = 0.002 and 0.048, respectively), and past focus terms when compared to Caucasian and Asian female applicants (p < 0.001 and p = 0.003, respectively). Religion terms were more common in LoR for Asian females when compared to Caucasian females (p < 0.001).

CONCLUSION

This study demonstrates linguistic differences in LoR for pediatric surgery training programs based on applicant race/ethnicity. While differences are present, these do not suggest overt bias based on applicants race or ethnicity.

Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study

Importance

There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients.

Objective

To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model.

Design, Setting, and Participants

This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022.

Exposure

Blunt trauma.

Main Outcomes and Measures

Primary outcome was CSI. The primary and secondary objectives were predetermined.

Results

The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915).

Conclusion and Relevance

This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.

Association Between Antibiotic Redosing Before Incision and Risk of Incisional Site Infection in Children With Appendicitis

OBJECTIVE

To evaluate whether redosing antibiotics within an hour of incision is associated with a reduction in incisional surgical site infection (iSSI) in children with appendicitis.

BACKGROUND

Existing data remain conflicting as to whether children with appendicitis receiving antibiotics at diagnosis benefit from antibiotic redosing before incision.

METHODS

This was a multicenter retrospective cohort study using data from the Pediatric National Surgical Quality Improvement Program augmented with antibiotic utilization and operative report data obtained though supplemental chart review. Children undergoing appendectomy at 14 hospitals participating in the Eastern Pediatric Surgery Network from July 2016 to June 2020 who received antibiotics upon diagnosis of appendicitis between 1 and 6 hours before incision were included. Multivariable logistic regression was used to compare odds of iSSI in those who were and were not redosed with antibiotics within 1 hour of incision, adjusting for patient demographics, disease severity, antibiotic agents, and hospital-level clustering of events.

RESULTS

A total of 3533 children from 14 hospitals were included. Overall, 46.5% were redosed (hospital range: 1.8%-94.4%, P <0.001) and iSSI rates were similar between groups [redosed: 1.2% vs non-redosed: 1.3%; odds ratio (OR) 0.84, (95%,CI, 0.39-1.83)]. In subgroup analyses, redosing was associated with lower iSSI rates when cefoxitin was used as the initial antibiotic (redosed: 1.0% vs nonredosed: 2.5%; OR: 0.38, (95% CI, 0.17-0.84)], but no benefit was found with other antibiotic regimens, longer periods between initial antibiotic administration and incision, or with increased disease severity.

CONCLUSIONS

Redosing of antibiotics within 1 hour of incision in children who received their initial dose within 6 hours of incision was not associated with reduction in risk of incisional site infection unless cefoxitin was used as the initial antibiotic.

Association of blood product ratios with early mortality in pediatric trauma resuscitation: A time-dependent analysis from the National Trauma Databank

BACKGROUND

Injured children with severe hemorrhage often receive blood product transfusions with ratios of plasma and platelets to packed red blood cells (PRBCs) approaching 1:1:1. Whether blood product ratios vary during pediatric resuscitation is unknown. This study (1) described precise timing of pediatric blood product administration, (2) characterized changes in blood product ratios over time, and (3) evaluated the association of blood products with early mortality while incorporating time-varying factors.

METHODS

Pediatric (younger than 18 years) trauma patients receiving high-volume transfusion (>40 mL/kg total products or >2 U PRBC or whole blood, during first 4 hours) were obtained from the 2017 to 2019 Trauma Quality Improvement Program database. The time of each individual product transfusion was recorded, along with demographics, injury details, and times of death. Patients were assigned to blood product groups at 15-minute intervals: high plasma/PRBC ratio (>1:1) with platelets, high plasma/PRBC ratio (>1:1) without platelets, low plasma/PRBC ratio (<1:1), PRBC only, and whole blood. Cox proportional hazards modeling for 24-hour mortality was performed, including blood product group as a time-varying variable and adjusting for relevant covariates.

RESULTS

Of 1,152 included patients (median age, 15 years; 32% penetrating, 28% severe traumatic brain injury [sTBI]), 18% died within 24 hours. During the resuscitation period, the number of patients in high-ratio groups increased over time, and patients switched blood product groups up to six times. There was no significant difference in mortality by blood product group. Among patients with sTBI, there was a strong trend toward lower mortality among high plasma/PRBC without platelets versus high plasma/PRBC with platelets (hazard ratio, 0.55; p = 0.07).

CONCLUSION

No significant association of high ratios or whole blood with mortality was seen when time-varying factors were incorporated. The impact of balanced resuscitation strategies, particularly platelet transfusion, may be greatest among patients with sTBI. Optimizing balanced resuscitation for children requires appropriately designed prospective studies.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Predictive Value of Routine WBC Count Obtained Before Discharge for Organ Space Infection in Children with Complicated Appendicitis: Results from the Eastern Pediatric Surgery Network

BACKGROUND

The objective of this study was to evaluate the clinical utility of a routine predischarge WBC count (RPD-WBC) for predicting postdischarge organ space infection (OSI) in children with complicated appendicitis.

STUDY DESIGN

This was a multicenter study using NSQIP-Pediatric data from 14 hospitals augmented with RPD-WBC data obtained through supplemental chart review. Children with fever or surgical site infection diagnosed during the index admission were excluded. The positive predictive value (PPV) for postdischarge OSI was calculated for RPD-WBC values of persistent leukocytosis (≥9.0 × 10 3 cells/μL), increasing leukocytosis (RPD-WBC > preoperative WBC), quartiles of absolute RPD-WBC, and quartiles of relative proportional change from preoperative WBC. Logistic regression was used to calculate predictive values adjusted for patient age, appendicitis severity, and use of postdischarge antibiotics.

RESULTS

A total of 1,264 children were included, of which 348 (27.5%) had a RPD-WBC obtained (hospital range: 0.8 to 100%, p < 0.01). The median RPD-WBC was similar between children who did and did not develop a postdischarge OSI (9.0 vs 8.9; p = 0.57), and leukocytosis was absent in 50% of children who developed a postdischarge OSI. The PPV of RPD-WBC was poor for both persistent and increasing leukocytosis (3.9% and 9.8%, respectively) and for thresholds based on the quartiles of highest RPD-WBC values (>11.1, PPV: 6.4%) and greatest proportional change (<32% decrease from preoperative WBC; PPV: 7.8%).

CONCLUSIONS

Routine predischarge WBC data have poor predictive value for identifying children at risk for postdischarge OSI after appendectomy for complicated appendicitis.

Examining Implicit Bias Differences in Pediatric Surgical Fellowship Letters of Recommendation Using Natural Language Processing

OBJECTIVE

We analyzed the prevalence and type of bias in letters of recommendation (LOR) for pediatric surgical fellowship applications from 2016-2021 using natural language processing (NLP) at a quaternary care academic hospital.

DESIGN

Demographics were extracted from submitted applications. The Valence Aware Dictionary for sEntiment Reasoning (VADER) model was used to calculate polarity scores. The National Research Council dataset was used for emotion and intensity analysis.  The Kruskal-Wallis H-test was used to determine statistical significance.  SETTING: This study took place at a single, academic, free standing quaternary care children's hospital with an ACGME accredited pediatric surgery fellowship.

PARTICIPANTS

Applicants to a single pediatric surgery fellowship were selected for this study from 2016 to 2021. A total of 182 individual applicants were included and 701 letters of recommendation were analyzed.

RESULTS

Black applicants had the highest mean polarity (most positive), while Hispanic applicants had the lowest.  Overall differences between polarity distributions were not statistically significant.   The intensity of emotions showed that differences in "anger" were statistically significant (p=0.03).  Mean polarity was higher for applicants that successfully matched in pediatric surgery.

DISCUSSION

This study identified differences in LORs based on racial and gender demographics submitted as part of pediatric surgical fellowship applications to a single training program. The presence of bias in letters of recommendation can lead to inequities in demographics to a given program. While difficult to detect for humans, natural language processing is able to detect bias as well as differences in polarity and emotional intensity. While the types of emotions identified in this study are highly similar among race and gender groups, the intensity of these emotions revealed differences, with "anger" being most significant.

CONCLUSION

From this work, it can be concluded that bias in LORs, as reflected as differences in polarity, which is likely a result of the intensity of the emotions being used and not the types of emotions being expressed.   Natural language processing shows promise in identification of subtle areas of bias that may influence an individual's likelihood of successful matching.

Pediatric intraoperative cardiopulmonary arrests: A survey to evaluate if Medical Emergency Teams are utilized in pediatric operating rooms

BACKGROUND

Studies have shown that standardized code teams may improve outcomes following cardiac arrests. Pediatric intra-operative cardiac arrests are rare events and are associated with a mortality rate of 18%. There is limited data available regarding use Medical Emergency Team (MET) response to pediatric intra-operative cardiac arrest. The purpose of this study was to identify the use of MET in response to pediatric intraoperative cardiac arrest as an exploratory step in establishing evidence-based standardized practice across the hospital for training and management of this rare event.

METHODS

An anonymous electronic survey was created and sent to two populations: The Pediatric Anesthesia Leadership Council, a section of the Society for Pediatric Anesthesia, and the Pediatric Resuscitation Quality Collaborative, a multinational collaborative group, which works to improve resuscitation care in children. Standard summary and descriptive statistics were used for survey responses.

RESULTS

The overall response rate was 41%. The majority of respondents worked in a university affiliated, free-standing children's hospital. Ninety-five percent of respondents had a dedicated pediatric MET at their hospital. In 60% of responses from Pediatric Resuscitation Quality Collaborative and 18% of Pediatric Anesthesia Leadership Council hospitals, the MET responds to pediatric intra-operative cardiac arrest; however, the majority of times MET involvement is requested rather than automatic. The MET was found to be activated intraoperatively for situations other than cardiac arrest such as, massive transfusion events, need for extra staff, and for specialty expertise. In 65% of institutions, simulation-based training for cardiac arrest is supported but lacking pediatric intra-operative focus.

CONCLUSIONS

This survey revealed heterogeneity in the composition and response of the medical response teams responding to pediatric intra-operative cardiac arrests. Improved collaboration and cross training among MET, anesthesia, and operating room nursing may improve outcomes of pediatric intra-operative code events.

Outcomes and resource utilization associated with use of routine pre-discharge white blood cell count for clinical decision-making in children with complicated appendicitis: A multi-center hospital-level analysis

BACKGROUND

The objective was to explore the hospital-level relationship between routine pre-discharge WBC utilization (RPD-WBC) and outcomes in children with complicated appendicitis.

METHODS

Multicenter analysis of NSQIP-Pediatric data from 14 consortium hospitals augmented with RPD-WBC data. WBC were considered routine if obtained within one day of discharge in children who did not develop an organ space infection (OSI) or fever during the index admission. Hospital-level observed-to-expected ratios (O/E) for 30-day outcomes (antibiotic days, imaging utilization, healthcare days, and OSI) were calculated after adjusting for appendicitis severity and patient characteristics. Spearman correlation was used to explore the relationship between hospital-level RPD-WBC utilization and O/E's for each outcome.

RESULTS

1528 children were included. Significant variation was found across hospitals in RPD-WBC use (range: 0.7-100%; p < 0.01) and all outcomes (mean antibiotic days: 9.9 [O/E range: 0.56-1.44, p < 0.01]; imaging: 21.9% [O/E range: 0.40-2.75, p < 0.01]; mean healthcare visit days: 5.7 [O/E 0.74-1.27, p < 0.01]); OSI: 14.1% [O/E range: 0.43-3.64, p < 0.01]). No correlation was found between RPD-WBC use and antibiotic days (r = +0.14, p = 0.64), imaging (r = -0.07, p = 0.82), healthcare days (r = +0.35, p = 0.23) or OSI (r = -0.13, p = 0.65).

CONCLUSIONS

Increased RPD-WBC utilization in pediatric complicated appendicitis did not correlate with improved outcomes or resource utilization at the hospital level.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Clinical Research.

Risk factors for prolonged hospitalization and readmission after total thyroidectomy in children: Associations with surgical subspecialty

BACKGROUND

Total thyroidectomy (TT) in children is performed by pediatric general surgeons (P-GS), pediatric otolaryngologists (P-ENT), or adult GS/ENT. This study evaluated short-term pediatric TT outcomes, focusing on surgical subspecialties.

METHODS

Pediatric (<18 years) TT with/without central limited lymph node dissection (CLND) between 2015 and 2020 were obtained from the National Surgical Quality Improvement Program-Pediatric database. Risk factors for prolonged hospitalization (PH,>2 days) and 30-day readmission were investigated with multivariate logistic regression.

RESULTS

Of 1535 patients, 14% had PH and 2% were readmitted. PH rates for P-ENT vs. P-GS vs. adult were 21% vs. 11% vs. 10%, respectively. Adjusted risk of PH was higher for P-ENT (OR 1.70, p = 0.003) but similar for P-GS/adult. There was no difference for risk of readmission by subspecialty.

CONCLUSION

PH is more likely after pediatric TT performed by P-ENT, as compared to P-GS or adult surgeons. While TT may be performed safely by individual subspecialties, collaboration across specialties may further optimize outcomes.

Postoperative respiratory complications in SARS-CoV-2 positive pediatric patients across 20 United States hospitals: A Cohort Study

INTRODUCTION

Data examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.

METHODS

This retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.

RESULTS

Of 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n = 214, 80.5%). The most common procedures were appendectomies (n = 78, 29.3%) and fracture repairs (n = 40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p = 0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.

CONCLUSIONS

Postoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.

LEVEL OF EVIDENCE

Iii, Respiratory complications.

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis

Importance

The clinical significance of gangrenous, suppurative, or exudative (GSE) findings is poorly characterized in children with nonperforated appendicitis.

Objective

To evaluate whether GSE findings in children with nonperforated appendicitis are associated with increased risk of surgical site infections and resource utilization.

Design, Setting, and Participants

This multicenter cohort study used data from the Appendectomy Targeted Database of the American College of Surgeons Pediatric National Surgical Quality Improvement Program, which were augmented with operative report data obtained by supplemental medical record review. Data were obtained from 15 hospitals participating in the Eastern Pediatric Surgery Network (EPSN) research consortium. The study cohort comprised children (aged ≤18 years) with nonperforated appendicitis who underwent appendectomy from July 1, 2015, to June 30, 2020.

Exposures

The presence of GSE findings was established through standardized, keyword-based audits of operative reports by EPSN surgeons. Interrater agreement for the presence or absence of GSE findings was evaluated in a random sample of 900 operative reports.

Main Outcomes and Measures

The primary outcome was 30-day postoperative surgical site infections (incisional and organ space infections). Secondary outcomes included rates of hospital revisits, postoperative abdominal imaging, and postoperative length of stay. Multivariable mixed-effects regression was used to adjust measures of association for patient characteristics and clustering within hospitals.

Results

Among 6133 children with nonperforated appendicitis, 867 (14.1%) had GSE findings identified from operative report review (hospital range, 4.2%-30.2%; P < .001). Reviewers agreed on presence or absence of GSE findings in 93.3% of cases (weighted κ, 0.89; 95% CI, 0.86-0.92). In multivariable analysis, GSE findings were associated with increased odds of any surgical site infection (4.3% vs 2.2%; odds ratio [OR], 1.91; 95% CI, 1.35-2.71; P < .001), organ space infection (2.8% vs 1.1%; OR, 2.18; 95% CI, 1.30-3.67; P = .003), postoperative imaging (5.8% vs 3.7%; OR, 1.70; 95% CI, 1.23-2.36; P = .002), and prolonged mean postoperative length of stay (1.6 vs 0.9 days; rate ratio, 1.43; 95% CI, 1.32-1.54; P < .001).

Conclusions and Relevance

In children with nonperforated appendicitis, findings of gangrene, suppuration, or exudate are associated with increased surgical site infections and resource utilization. Further investigation is needed to establish the role and duration of postoperative antibiotics and inpatient management to optimize outcomes in this cohort of children.

The International Classification of Disease Critical Care Severity Score demonstrates that pediatric burden of injury is similar to that of adults: Validation using the National Trauma Databank☆

BACKGROUND/PURPOSE

Resource-based severity of injury (SOI) measures, such as the International Classification of Disease (ICD) Critical Care Severity Score (ICASS), may characterize traumatic burden better than standard mortality-based measures. The purpose of this study was to validate the ICASS in a representative national-level trauma cohort and compare SOI measures between children and adults.

METHODS

The National Trauma Databank was used to derive (2008-12) and validate (2013-15) ICASS and ICD Injury Severity Scores (ICISS, standard mortality-based SOI measure). SOI metrics and outcomes were compared between pediatric, adult, and elderly age groups. Logistic regression modeling evaluated predictors of critical care resource utilization.

RESULTS

Derivation and validation cohorts consisted of 3.90 and 1.97 million patients, respectively. ICASS strongly predicted actual critical care utilization (OR 1.04, 95% CI 1.04-1.04, p<0.0001). Mean ICASS was 24.4 for children and 33.0 for adults (ratio 0.74), indicating predicted critical care utilization in children was three-quarters that of adults. In contrast, predicted pediatric mortality was less than half that of adults.

CONCLUSIONS

Mortality-based SOI measures underestimate pediatric burden of injury. This study validates ICASS and demonstrates that pediatric resource-based SOI is more similar to that of adults. ICASS is easily calculated without a trauma registry and complements mortality-based measures. Level of evidence III, retrospective comparative study.

Multicenter Comparison of Laparoscopic Versus Open Repair of Duodenal Atresia in Neonates

Introduction: Traditional duodenal atresia (DA) repair involves a laparotomy. There have been reports of laparoscopic repair (LAP), in lieu of the open laparotomy approach (OPN), with varying degrees of success. The merit of this alternative warrants continued investigation. The purpose of this study was to determine whether there were outcome differences after neonatal DA repair based on surgical approach. Methods: IRB approved retrospective review of the National Surgical Quality Improvement Program Pediatric database (2012-2018) was conducted. International Classification of Diseases (ICD)-9 (751.1) and ICD-10 codes (Q41.0) identified DA repair. Patient demographics, perioperative, and postoperative variables were collected. Univariate and multivariate analysis was performed. Unadjusted and adjusted logistic regression models assessed associations between surgical approach and outcomes. Results: A total of 917 cases were identified, 803 (87.6%) OPN, 75 (8.2%) LAP, and 39 (4.2%) LAP to OPN. Median age at surgery was 2 days (interquartile range [IQR] = 1-3). Females represented 56% of the LAP (n = 42), and 51% of the OPN (n = 412, P = .470). The LAP group had higher weight at surgery (2.8 kg, IQR = 2.3-3.1), compared with the OPN (2.6 kg, IQR = 2.1-2.9, P = .009); and longer operative time (161 minutes, IQR = 107-206; OPN 106 minutes, IQR = 85-135, P < .001). In unadjusted models, median postoperative stay was 4 days shorter (95% confidence interval = -7.5 to -0.5) among LAP compared with OPN. Adjusted models for postoperative stay, complication risks, and unplanned reoperation were not statistically different. Conclusion: Most DA repairs are performed through OPN. LAP resulted in shorter length of stay in unadjusted models. Similar incidence of complications and reoperation suggest that LAP may be as safe as OPN, when employed by skilled experienced pediatric surgeons.

Letters of recommendation for pediatric surgery fellowship: Analysis of linguistic differences based on gender of the applicant

BACKGROUND

Gender bias in letters of recommendation (LOR) has been reported for candidate selection in academic medicine, typically with females frequently described with communal terms (e.g. helpful, kind, interpersonal) and males described more with agentic terms (e.g. assertive, intellectual, ambitious). This study examined the presence of linguistic gender differences in LOR for Pediatric Surgery Fellowship.

METHODS

LOR submitted to a single pediatric surgery fellowship program between 2014 and 2018 were retrospectively reviewed and analyzed using a previously validated Linguistic Inquiry and Word Count Software (LIWC) program. Descriptive statistics and bivariate analysis were employed in our analysis. Multivariable logistic regression models were built to assess independent association of LIWC variables with applicant gender, LOR writer gender, and applicant-writer gender concordance.

RESULTS

1264 LOR from 325 applicants (51% female) were analyzed. Of the letter writers, 83% were male, 57% were professors, and 7.6% were Pediatric Surgery Fellowship Program Directors. The overall median average word count was 518 words, with no significant difference in LOR word count between applicant genders. Compared to male applicants, female applicants were described significantly more with work words (e.g. excellent, work; p = 0.04). Male LOR writers used authentic words (e.g. honest, humble; p = 0.006) and home words (e.g. family, house; p = 0.04) significantly more than female LOR writers. There were no significant differences in the use of agentic and communal words between genders.

CONCLUSION

While there are linguistic differences in LOR for candidates in the Pediatric Surgery match based on gender, previously described overt gender bias was not seen in this study. Interestingly, female candidates were described more with work words, like excellent; a reversal of previously described gender bias in academic medicine. These findings may be due to the unique interpersonal and multidisciplinary skills required in pediatric surgery and may represent a unique form of gender bias that warrants further study.

Does speed matter? A look at NSQIP-P outcomes based on operative time

BACKGROUND

Appendicitis is a common pediatric surgical condition, comprising a large burden of healthcare costs. We aimed to determine if prolonged operative times were associated with increased 30-day complication rates when adjusting for pre-operative risk factors.

METHODS

Patients <18 years old, diagnosed intraoperatively with acute uncomplicated appendicitis and undergoing laparoscopic appendectomy were identified from the NSQIP-P 2012-2018 databases. The primary outcome, "infectious post-operative complications", is a composite of sepsis, deep incisional surgical site infections, wound disruptions, superficial, and organ space infections within 30-days of the operation. Secondary outcomes included return to the operating room and unplanned readmissions within 30 days. Logistic regression models were used to assess associations between operative time and each outcome. A Receiver Operating Characteristic (ROC) curve was generated from the predicted probabilities of the multivariate model for infectious post-operative complications to examine operative times.

RESULTS

Between 2012 and 2018, 27,763 pediatric patients with acute uncomplicated appendicitis underwent a laparoscopic appendectomy. Over half the population was male (61%) with a median operative time of 39 min (IQR 29-52 min). Infectious post-operative complication rate was 2.8% overall and was highest (8%) among patients with operative time ≥ 90 min (Fig. 1). Unplanned readmission occurred in 2.9% of patients, with 0.7% returning to the operating room. Each 30-min increase in operating time was associated with a 24% increase in odds of an infectious post-operative complication (OR=1.24, 95% CI=1.17-1.31) in adjusted models. Operative time thresholds predicted with ROC analysis were most meaningful in younger patients with higher ASA class and pre-operative SIRS/Sepsis/Septic shock. Longer operative times were also associated with higher odds of unplanned readmission (OR=1.11, 95% CI=1.05-1.18) and return to the operating room (OR=1.13, 95% CI=1.02-1.24) in adjusted models.

CONCLUSION

There is a risk-adjusted association between prolonged operative time and the occurrence of infectious post-operative complications. Infectious postoperative complications increase healthcare spending and are currently an area of focus in healthcare value models. Future studies should focus on addressing laparoscopic appendectomy operative times longer than 60 min, with steps such as continuation of antibiotics, shifting roles between attending and resident surgeons, and simulation training.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk factors for complications after abdominal surgery in children with sickle cell disease

BACKGROUND

Abdominal surgery in children with sickle cell disease (SCD) carries an increased risk of postoperative complications. Preoperative transfusions are frequently given to decrease the risk of vasoocclusive events. However, risk factors for postoperative complications are not well-defined in the pediatric population.

METHODS

Pediatric patients with SCD undergoing common abdominal operations were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2018. Outcomes of interest were the incidence rates of 1) any complication or readmission, and 2) serious SCD-related complications (stroke, new onset seizure, ventilator support >24 h postoperatively, or readmission with SCD crisis within 30 days of surgery). Patients were categorized by transfusion approach (transfusion within 48 h before surgery vs. no transfusion) and preoperative hematocrit (<21.0, 21.0-23.9, 24.0-26.9, 27.0-29.9, ≥30.0). Stratified bivariate analyses and multivariable logistic regression were used to identify independent risk factors for complications.

RESULTS

A total of 813 patients met inclusion criteria. There were 470 cholecystectomy, 251 splenectomy, 39 appendectomy, and 53 combination procedures; 13% of cases were urgent or emergent. Preoperative hematocrit levels were <21.0 in 3%, 21.0-23.9 in 10%, 24.0-26.9 in 17%, 27.0-29.9in 30%, and ≥30.0 in 41% of patients; 52% received perioperative transfusion. The 30-day incidences of any complication/readmission and SCD-related complications were 12% and 4%, respectively. On bivariate analyses, urgent/emergent case status was the only significant predictor of complications, carrying risk of 20% and 8% for overall and SCD-related complications, respectively; this finding persisted on multivariable logistic regression (OR 1.83, 95% CI 1.0.2-3.29, p = 0.04). Neither preoperative transfusion nor preoperative hematocrit level was associated with complication risk, although there was a trend toward higher SCD-related complications in patients with preoperative hematocrit <21.0 (p = 0.07).

CONCLUSION

In this large cohort of pediatric SCD patients undergoing abdominal surgery, there was no clear association between postoperative complications and the transfusion approach or the preoperative hematocrit level within the range above 21.0. Urgent/emergent surgical procedures carried a nearly two-fold higher complication risk compared to elective procedures. Future studies should prospectively evaluate preoperative transfusion approaches and compare immediate and delayed operative management to nonoperative management in this population.

LEVEL OF EVIDENCE

III Retrospective review.

Outcomes of Pediatric Central Venous Access Device Placement With Concomitant Surgical Procedures

BACKGROUND

Children frequently undergo placement of a tunneled central venous catheter or port (CVAD) concomitantly with other surgical procedures (CVAD-CP), but the risk factors for early CVAD complications with this practice are unclear.

METHODS

Children undergoing CVAD-CP were identified from the National Surgical Quality Improvement Program-Pediatric 2012-2016 database. Predictor variables included demographics, CP characteristics, malignancy, and CVAD type. Outcome variables were CVAD-associated bloodstream infection (CLABSI) or new deep venous thrombosis (nDVT) within 30 d. Patients with and without CLABSI or nDVT were compared, and the temporal relationship of nDVT and CLABSI was investigated. Multivariable logistic regression modeling was used to assess independent risk factors for CLABSI.

RESULTS

Of 2036 patients included, median age was 1.5 y, 35% had malignancy, and 40% had a clean concomitant procedure. Overall, 1.3% developed CLABSI and 0.7% developed nDVT. Multivariable regression modeling revealed higher risk of CLABSI with clean CPs (odds ratio [OR] 2.4, 95% confidence interval [CI] 1.06-5.34, P = 0.035), tunneled catheters (OR 3.2, 95% CI 1.18-8.56, P = 0.022), and longer anesthesia duration (OR 1.02 per 10 min, 95% CI 1.00-1.04, P = 0.042). nDVT was strongly associated with CLABSI (21% CLABSI among those with DVT, 0.5% among those without, P ≤ 0.0001). In all cases of nDVT with CLABSI, the diagnosis of DVT preceded diagnosis of CLABSI, by a median of 7 d.

CONCLUSIONS

The type of CVAD and characteristics of the concomitant procedure influence early CLABSI after CVAD-CP. The unexpected finding of higher CLABSI rates among clean concomitant procedures suggests that perioperative prophylactic antibiotics should not be withheld in this setting, but requires prospective validation. nDVT is frequently diagnosed prior to CLABSI, suggesting a possible role for antibiotics in the treatment of postoperative DVT after CVAD placement.

Laparoscopic-guided versus transincisional rectus sheath block for pediatric single-incision laparoscopic cholecystectomy: A randomized controlled trial

PURPOSE

The purpose of our study was to compare the effectiveness of transincisional (TI) versus laparoscopic-guided (LG) rectus sheath block (RSB) for pain control following pediatric single-incision laparoscopic cholecystectomy (SILC).

METHODS

Forty-eight patients 10-21 years old presenting to a single institution for SILC from 2015 to 2018 were randomized to TI or LG RSB. Apart from RSB technique, perioperative care protocols were identical between groups. Pain scores were assessed with validated measures upon arrival in the postanesthesia care unit (PACU) and at regular intervals until discharge. The patients and those assessing them were blinded to RSB technique. The primary outcome was pain score 60 min after PACU arrival. Secondary outcomes included pain scores throughout the PACU stay, opioids (reported as morphine milligram equivalents (MME) per kg bodyweight) administered in PACU, length of stay, outpatient pain scores and opioid use, and adverse events. Groups were compared on outcomes using t test and generalized estimating equations for continuous variables and Fisher's exact test for categorical variables with significance at α = 0.05.

RESULTS

Mean age of the 48 subjects was 15 years (range = 11-20). The majority (79%) were female. Indications for surgery included symptomatic cholelithiasis (n = 41), acute cholecystitis (n = 4), gallstone pancreatitis (n = 2) and choledocholithiasis (n = 1). Mean (standard deviation) operative time was 61 (±23) min overall. No statistically significant differences in demographics, indication, operative time, or intraoperative analgesia were observed between TI (n = 24) and LG (n = 24) groups. The mean 60-min pain score was 3.4 (±2.6) in the LG group versus 3.8 (±2.1) in the TI group (p = 0.573). No significant differences were detected between groups in overall PACU or outpatient pain scores, PACU or outpatient opioid use, length of stay, or incidence of complications. Overall, mean opioid use was 0.1 MME/kg in the PACU and 0.5 MME/kg in the outpatient setting. Mean postoperative length of stay was 0.2 day. There were no major complications.

CONCLUSION

Laparoscopic-guided rectus sheath block is not superior to transincisional rectus sheath block for pain control following pediatric single-incision laparoscopic cholecystectomy. The single-incision laparoscopic approach combined with rectus sheath block resulted in effective pain control, low opioid use, and expedited length of stay with no major complications.

LEVEL OF EVIDENCE

Level I, treatment study, randomized controlled trial.

30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis

INTRODUCTION

The optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018.

METHODS

Demographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes.

RESULTS

Of the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009).

CONCLUSIONS

Among children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Same-day Discharge after Appendectomy Results in Cost Savings and Improved Efficiency

Appendectomy incurs significant costs for the healthcare system. There is evidence that patients can be safely discharged the same day after appendectomy. The purpose of this study was to develop an evidence-based protocol for same-day discharge after appendectomy. A fast-track surgery protocol was developed for same-day discharge after appendectomy. This was prospectively applied to all patients presenting for appendectomy from July 2012 to June 2013. Demographics, clinical measures, and outcomes were measured. Of 206 patients eligible for same-day discharge, 185 (90%) were successfully discharged according to the protocol. The mean length of stay after appendectomy was 3.1 ± 1.4 hours. Protocol implementation reduced inpatient use from 99 to 53 per cent. Patient transfers were reduced, resulting in 40 per cent fewer handoffs. The decreased use of hospital resources resulted in a median reduction of hospital charges of $4111 per patient. The complication rate for patients discharged the same day was 2.7 per cent. Appendectomy for acute appendicitis or interval appendectomy can be performed safely as same-day surgery. Implementation of this protocol resulted in optimization of resource use by reducing inpatient admissions, decreasing handoffs, and reducing hospital costs.

Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.

Impact of Magnetic Resonance Imaging in Management of Pediatric Crohn's Disease

Crohn's disease (CD) is a chronic illness and radiographic evaluation is frequently used. Consequently, pediatric patients with CD who are diagnosed in childhood are at risk for high levels of radiation exposure during their lifetimes. We sought to evaluate the impact of magnetic resonance enterography (MRE) in management of pediatric patients with known or suspected Crohn's disease. A retrospective review of patients with known or suspected CD who underwent MRE for new onset of symptoms was conducted. All demographic data, clinical history, and results of all radiographic, endoscopic, and pathology studies were recorded. Twenty-eight patients with known or suspected CD underwent 31 MRE examinations. MRE showed active disease in 16 (52%), fistula or abscess in seven (22%), and no evidence of active disease in eight (26%). Sixty-five per cent of patients underwent MRE with no other radiation-based imaging used. Surgical intervention was deemed necessary after the MRE in 16 per cent. In all cases, surgical findings were consistent with MRE results. Nearly 60 per cent of patients with CD are managed based on the findings of MRE without additional radiographic evaluation. Based on the results of this retrospective study, we propose a clinical pathway for use of MRE in patients with known or suspected CD with new onset of symptoms.

Financial Impact of Surgical Technique in the Treatment of Acute Appendicitis in Children

Appendicitis is the most common emergent problem encountered by pediatric surgeons. Driven by improved cosmetic outcomes, many surgeons are offering pediatric patients single-incision laparoscopic appendectomy. We sought to investigate the financial impact of different surgical approaches to appendectomy. A retrospective study of patients with acute appendicitis undergoing appendectomy from February 2010 to September 2011 was conducted. Based on surgeon preference, patients underwent open appendectomy (OA), laparoscopic appendectomy (LA), or single-incision laparoscopic appendectomy (SILA). Demographic information, surgical outcomes, surgical supply costs, and total direct costs were recorded. A total of 465 patients underwent appendectomy during the study. The mean age of all patients was 11.2 years (range, 1 to 18 years). There were no conversions in the LA or SILA groups. There was a significant difference among surgical technique in regard to surgical supply costs (OA $159 vs LA $650 vs SILA $814, P < 0.01) and total direct costs (OA $2129 vs LA $2624 vs SILA $2991, P < 0.01). In our institution, both multiport laparoscopic and SILA carry higher costs when compared with OA, largely as a result of the cost of disposable instrumentation. Cost efficiency should be considered by surgeons when undertaking a minimally invasive approach to appendectomy.

Risk factors and associated morbidity of urinary tract infections in pediatric surgical patients: A NSQIP pediatric analysis

BACKGROUND

The purpose of this study is to examine the incidence, risk factors, and morbidity of postoperative urinary tract infections (UTI) in pediatric surgical patients.

METHODS

All patients in the 2012-2016 American College of Surgeons National Surgical Quality Improvement Program Pediatric database were included. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of patient and procedure characteristics on the risk for UTI and to estimate the effects of UTI on the risk for readmission and reoperation.

RESULTS

Of 369,176 patients, 1964 (0.5%) developed a postoperative UTI. Those undergoing urological and neurosurgical procedures were at greatest risk. Diabetes, ventilator dependence, and dependence on nutritional support each increased the odds of developing a UTI by more than 60% (P < 0.01). On multivariable analysis, UTI was an independent risk factor for unplanned readmission (OR, 4.93; 95% CI, 4.39-5.54; P < 0.001) and reoperation (OR, 1.21; 95% CI, 1.01-1.45; P = 0.041).

CONCLUSION

Urinary tract infection is an uncommon but not inconsequential complication following surgery in the pediatric population and is associated with increased risk of readmission and reoperation. The identification of risk factors for postoperative UTI provides the opportunity for targeted surveillance and patient-specific interventions to prevent UTIs in children at greatest risk.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk Factors for Adverse Outcomes after Ostomy Reversal in Infants Less than Six Months Old

The purpose of this study was to determine risk factors for 30-day complications, reoperation, and readmission after ostomy reversal in infants less than six months old. Infants aged two weeks to six months who underwent ostomy reversal were identified in the 2012 to 2016 ACS NSQIP Pediatric database. Demographics, comorbidities, and 30-day outcomes were assessed. Multivariable logistic regression was used to estimate the independent effects of clinical variables on risk of 30-day complications, reoperation, and readmission. Among 1021 infants, 163 (16%) suffered a 30-day complication. SSIs were the most common complication (5.7%), followed by unplanned reintubation (5.2%) and bleeding (3%). Mortality was 0.4 per cent. Dependence on nutritional support and hematologic disorders were independently associated with postoperative complications. Forty-five children (4.4%) required reoperation and 22 (2.2%) were readmitted for conditions related to the procedure. Younger age and preoperative dependence on oxygen or nutritional support were associated with increased length of stay. SSI, unplanned reintubation, and bleeding are the most frequent complications after ostomy takedown in infants less than six months old. Attention to risk factors predisposing to these complications, including dependence on nutritional support and hematologic disorders, may contribute to improved surgical outcomes.

Short-term Outcomes After Pectus Excavatum Repair in Adults and Children

BACKGROUND

Pectus excavatum is a common congenital chest wall deformity often repaired during adolescence, although a subset of patients undergo repair as adults. The goal of our study was to determine the effects of age at repair and repair technique on short-term surgical outcomes.

MATERIALS AND METHODS

We performed a cohort study of patients in the 2012 to 2016 American College of Surgeons National Surgical Quality Improvement Project pediatric (age<18 y) and adult databases who underwent pectus excavatum repair. The primary outcome was the incidence of 30-d complications. Secondary outcomes included length of stay, reoperation, and readmission. Multivariable logistic regression was used to estimate the independent effects of patient age and type of repair on postoperative outcomes.

RESULTS

Of the 2268 subjects included, 2089 (92.1%) were younger than 18 y. Overall, 3.4% of patients suffered a 30-d complication, and the risk was similar between age groups (risk ratio [RR], 0.69; 95% confidence interval [CI], 0.08-5.03; P = 0.731). Steroid therapy was an independent risk factor for complications (RR, 8.0; 95% CI, 1.9-19.7; P = 0.006). Median length of stay was 4 d (interquartile range, 3-5) and was similar between age groups. Risk for readmission and reoperation were 2.8% and 1.5%, respectively, and were similar for pediatric and adult patients. When comparing minimally invasive repair with and without thoracoscopy, risk for 30-d complications was lower among patients repaired with thoracoscopy (RR, 0.56; CI, 0.32-0.96; P = 0.034).

CONCLUSIONS

Pediatric and adult patients experience comparable rates of postoperative complications, readmission, and reoperation after pectus excavatum repair. Use of thoracoscopy during minimally invasive repair is associated with lower risk of complications. These findings suggest that thoracoscopy should be used routinely for minimally invasive repair of pectus excavatum.

Outpatient management of intussusception: a systematic review and meta-analysis

BACKGROUND

Variability in management of intussusception after enema reduction exists. Historically, inpatient observation was recommended; however, there is a lack of evidence-based guidelines for this practice.

METHODS

A systematic review and meta-analysis evaluating outcomes between inpatient (IP) and outpatient (OP) management after enema reduction was performed. The following databases were searched: PubMed, EBSCOhost CINAHL, EMBASE, Web of Science, and Cochrane Database. Data from an institutional review were included in the meta-analysis.

RESULTS

Ten studies of patients aged 0-18 years with intussusception who underwent successful enema reduction that reported outcomes of outpatient management were included. Overall recurrence rates were 6% for IP and 8% for OP (p = 0.20). Recurrences within 24 (IP: 1% vs OP: 0%, p = 0.90) and 48 h (IP: 1% vs OP: 2%, p = 0.11) were similar. There was no significant difference in the rate of return to the emergency department (IP: 6% vs OP: 14%, p = 0.11). Both groups had a similar rate of requiring an operation (IP: 2% vs OP: 1%, p = 0.84).

CONCLUSIONS

Outpatient management of intussusception after enema reduction results in a shorter hospital stay with no difference in the rate of return to the emergency department, recurrence, need for operation, or mortality. The findings of the meta-analysis suggest that outpatient management may be safe and could reduce hospital resource utilization.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Effectiveness of a collaborative, student-run campaign to increase safety belt use among adolescents

Background

MVCs are the leading cause of death among adolescents. Seat belts have been shown to decrease MVC-related death. The purpose of this retrospective cohort study was to evaluate the effectiveness of a community-supported, student-run campaign to increase safety belt use among adolescents in Southwest Florida.

Methods

We reviewed results of campaigns at 14 high schools from 2012 to 2018. The primary outcome was change in rates of student-driver seat belt use over the course of each campaign. Secondary outcomes included trends in seat belt use and MVC-related fatalities over the study period. Wilcoxon signed-rank test was used to compare rates of seat belt use before and after each intervention and over the course of the study period. Multivariate logistic regression was used to estimate the independent effects of demographic covariates on outcomes.

Results

Altogether, 85 campaigns were reviewed. A total of 8500 preintervention and 8500 postintervention observations of student seat belt use were assessed. The median rate of seat belt use increased from 82% prior to the intervention to 87% following the intervention (p<0.001). We did not detect a sustained trend in seat belt use or MVC-related fatalities over the study period. On multivariate analysis, schools with a higher proportion of minority students were less likely to experience a substantial increase in seat belt use following the intervention (OR=0.17, 95% CI 0.03 to 0.84, p=0.030).

Conclusion

This collaborative campaign resulted in a modest, short-term increase in seat belt use among high school students. Future studies should evaluate which interventions are most effective and how short-term increases in seat belt use can be sustained.

Ruptured omphalocele: Diagnosis and management

Omphalocele is an abdominal wall defect which can be classified as small, giant, or ruptured. Ruptured omphaloceles require prompt diagnosis and management to prevent associated morbidity and mortality and represent a challenging surgical condition. This review serves to define the etiology, diagnosis, initial resuscitation, and surgical therapy employed in the treatment of ruptured omphalocele. Resuscitation should focus on maintaining hydration and normothermia. Broad spectrum antibiotics should be initiated. Similar to giant omphaloceles, procedural intervention includes primary closure, silo, synthetic and biologic mesh, negative pressure wound therapy, and topical agents. Despite advances in neonatal care, the prognosis remains guarded and mortality is high.

Efficacy of Videoconference Interviews in the Pediatric Surgery Match

PURPOSE

The pediatric surgery match is highly competitive with the interview process requiring significant resources. The purpose of this study was to evaluate the efficacy of videoconference interviewing (VI) as a screening tool in the pediatric surgery match process.

METHODS

During the 2017 interview season, applicants participated in VI prior to on-site interviews. Applicants and faculty completed 15 and 8-question surveys, respectively, regarding their experiences.

RESULTS

Both faculty and applicants agreed VI was easily workable and allowed them to accurately represent themselves. Faculty agreed VI would change how they rank candidates and that it is a helpful screening tool. Most disagreed VI could substitute for on-site interviews. Most applicants reported the cost and time required for on-site interviews was a hardship. Overall, applicants moved an average of 5.5 ± 2.9 (median 3) positions from the pre-VI to post-VI rank list. Thirty-seven percent of applicants moved out of the top ten rank list following VI. Of the lowest 5 applicants on the post-VI rank list, only 20% matched successfully.

CONCLUSION

The pediatric surgery match requires a significant investment of time and money that creates a hardship for most applicants. VI may be an effective screening tool that could potentially reduce on-site interviews and alleviate the burden on applicants and general surgery training programs.

30-Day Outcomes of Laparoscopic Versus Open Total Proctocolectomy with Ileoanal Anastomosis in Children and Young Adults: A Combined Analysis of the National Surgical Quality Improvement Project Pediatric and Adult Databases

BACKGROUND

Studies comparing pediatric laparoscopic and open total proctocolectomy with ileoanal anastomosis (TPC-IAA) are limited in size and number. This study utilized the adult and pediatric databases of the National Surgical Quality Improvement Project (NSQIP) to evaluate 30-day outcomes of these two techniques.

MATERIALS AND METHODS

Patients younger than 21 years who underwent TPC-IAA from 2012 to 2016 were identified in both NSQIP databases. Simple and multivariate logistic regression was used to compare risk of reoperation, readmission, and postoperative occurrences between laparoscopic and open groups. Cox regression was used to evaluate length of stay (LOS).

RESULTS

A total of 440 cases were identified, of which 421 (95.7%) were elective. Median age in the elective group was 15.8 years (interquartile range 13-18). Diagnoses included inflammatory bowel disease (47%), benign neoplasm (42%), and Hirschsprung disease (6%). The laparoscopic group (67.5%, n = 139) had shorter median postoperative LOS (6 versus 8 days, P < .001) and decreased incidence of pulmonary complications (risk ratio [RR] 0.09; CI: 0.01-0.80, P = .031) and superficial surgical site infections (SSI) (RR 0.30; 95% CI: 0.10-0.88, P = .028). Median operative time was shorter (4.6 versus 5.1 hours, P = .013) and risk of organ space SSI was lower (RR = 0.11, 95% CI: 0.01-0.80, P = .037) in the open group (n = 282). Rates of 30-day readmission and reoperation were similar between groups.

CONCLUSIONS

In the first study to utilize data from both the pediatric and adult NSQIP databases, resulting in the largest pediatric sample of TPC-IAA to date, we found that 67.5% of elective cases were performed laparoscopically, the highest reported in a multi-institutional pediatric study, indicating increasing comfort with advanced laparoscopic techniques among pediatric surgeons. The laparoscopic approach resulted in shorter postoperative LOS and decreased risk of superficial SSI, whereas the open approach was associated with shorter operative time and lower risk of organ space SSI.

The idle central venous catheter in the NICU: When should it be removed?

PURPOSE

There is debate regarding the optimal timing of central line removal in the neonatal intensive care unit (NICU). The purpose was to evaluate outcomes of idle peripherally inserted central catheters (PICCs) and tunneled central venous catheters (TCVCs) and determine the incidence of line-related infections and replacements.

METHODS

Patients in the NICU with T-CVCs placed between 11/2008 and 8/2015 (n=134) or PICCs placed between 7/2013 and 10/2015 (n=467) were included. Demographics and outcomes were compared.

RESULTS

The most common indications for line placement were parenteral nutrition for PICCs (74%) and lack of access for T-CVCs (53%). T-CVCs had a greater proportion of idle days (T-CVC- 25.2% vs PICC- 5.1%, p<0.001) and removal within 24h of discharge (T-CVC-53% vs PICC-5.8%, p<0.001). Conversely, 81% of PICCs were removed within 24h of nonuse. Line replacement after removal for nonuse was required in 6% of PICCs and zero T-CVCs. In both groups, the central line-associated bloodstream infection (CLABSI) rate was lower in idle lines compared to ones in use.

CONCLUSION

Patients treated with PICCs and T-CVCs are different populations and should have different guidelines for removal. In neonates with difficult access, the low risk of CLABSIs in idle surgically placed catheters may justify maintaining access until discharge.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Implications of non-accidental trauma on resource utilization and outcomes

PURPOSE

The purpose was to compare the resource utilization and outcomes between patients with suspected (SUSP) and confirmed (CONF) non-accidental trauma (NAT).

METHODS

The institutional trauma registry was reviewed for patients aged 0-18 years presenting from 2007 to 2012 with a diagnosis of suspicion for NAT. Patients with suspected and confirmed NAT were compared.

RESULTS

There were 281 patients included. CONF presented with a higher heart rate (142 ± 27 vs 128 ± 23 bpm, p < 0.01), lower systolic blood pressure (100 ± 18 vs 105 ± 16 mm Hg, p = 0.03), and higher Injury Severity Score (15 ± 11 vs 9 ± 5, p < 0.01). SUSP received fewer consultations (1.6 ± 0.7 vs 2.4 ± 1.1, 95% CI - 0.58 to - 0.09, p < 0.01) and had a shorter length of stay (1.6 ± 1.3 vs 7.8 ± 9.8 days, 95% CI - 4.58 to - 0.72, p < 0.01). SUSP were more often discharged home (OR 94.22, 95% CI: 21.26-417.476, p < 0.01). CONF had a higher mortality rate (8.2 vs 0%, p < 0.01).

CONCLUSIONS

Patients with confirmed NAT present with more severe injuries and require more hospital resources compared to patients in whom NAT is suspected and ruled out.

Effect of hospital type on the treatment of acute appendicitis in teenagers

BACKGROUND

Teenagers receive appendicitis care at both adult and pediatric facilities. The purpose of this study was to evaluate outcomes following treatment of acute appendicitis in teenagers based on the type of hospital facility.

METHODS

Patients aged 13-17years with acute appendicitis who were discharged from acute care hospitals from 2009 to 2014 were identified using a statewide discharge dataset. Hospitals were classified as pediatric or adult and outcomes were compared.

RESULTS

There were 5585 patients treated in adult hospitals and 1625 in pediatric hospitals. Fewer patients at adult hospitals had complicated appendicitis (20.4% vs. 33.0%, p<0.01). Open appendectomy occurred more often in adult hospitals compared to pediatric hospitals (12.6% vs. 6.0%, p<0.01). Pediatric hospitals had higher rates of non-operative management (10% vs. 3.4%, p<0.01) and percutaneous drain placement (1.2% vs. 0.4%, p<0.01). Postoperative complication rates did not significantly differ between hospital types.

CONCLUSION

Most teenagers undergo appendectomy at adult facilities; however, a greater proportion of younger patients and patients with complicated appendicitis is treated at pediatric hospitals. Treatment at a freestanding children's hospital results in lower rates of open procedures and no difference in complications. Opportunities may exist to standardize care across treating facilities to optimize outcomes and resource use.

TYPE OF STUDY

Prognosis study.

LEVEL OF EVIDENCE

II.

Timing of antimicrobial prophylaxis and infectious complications in pediatric patients undergoing appendectomy

PURPOSE

Antibiotic administration within one hour prior to incision is a common quality metric; however, antibiotics are typically started at the time of diagnosis in pediatric patients with acute appendicitis. The purpose was to determine if antibiotic administration within one hour prior to incision reduces the incidence of surgical site infections (SSI) in pediatric patients with acute appendicitis started on parenteral antibiotics upon diagnosis.

METHODS

A retrospective review was performed of 478 patients aged 0-18years who underwent appendectomy for acute appendicitis from 7/2013 to 4/2015. Patients were categorized based on timing of antibiotic administration; there were 198 patients in Group A (<60min before) and 280 in Group B (>60min before).

RESULTS

Demographics and operative time (A: 30.5±9.9 vs B: 30.8±12.2min, p=0.51) were similar. Procedures were performed laparoscopically and the groups had similar proportions of single-incision operations (A: 53% vs B: 55%, p=0.64). There was no difference in the incidence of superficial SSI (A: 2.0% vs B: 2.1%, p=1.0) or intraabdominal abscess (A: 4.0% vs B: 3.6%, p=0.81) and this remained true when stratified by intraoperative classification.

CONCLUSION

Antibiotic administration within one hour of appendectomy in pediatric patients with acute appendicitis who receive antibiotics at diagnosis did not change the incidence of postoperative infectious complications.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

III.

Antibiotic Powder Reduces Surgical Site Infections in Children After Single-Incision Laparoscopic Appendectomy for Acute Appendicitis

BACKGROUND

Single-incision laparoscopic appendectomy (SILA) has a higher rate of wound infection than the multiport technique. The purpose of this project was to determine whether the use of topical antibiotic powder reduces surgical site infections (SSIs) in pediatric patients who undergo SILA.

METHODS

Patients aged 0-21 years who underwent SILA for acute appendicitis from April 2015 to November 2016 were included in this quality improvement initiative. Cefoxitin powder was placed in the umbilical wound before skin closure. Data were prospectively collected and outcome measures were compared with a historical cohort who underwent SILA before the implementation of antibiotic powder.

RESULTS

There were 108 patients in the historical group (HIST) and 126 in the powder group (POWD). The groups were similar in age (HIST: 11.5 ± 3.6 versus POWD: 12.2 ± 3.7 years, P = .15) and body mass index percentile (HIST: 57.6 ± 30.7 versus POWD: 58.8 ± 27.8, P = .84). Operative time was longer in the powder group (HIST: 26.5 ± 7.5 versus POWD: 29.7 ± 8.9 minutes, P = .004). Length of stay (HIST: 0.2 ± 0.4 versus POWD: 0.1 ± 0.4 days, P = .06), 30-day return to emergency department (HIST: 7% versus POWD: 8%, P = 1.0), and hospital readmissions (HIST: 5% versus POWD: 2%, P = .8) were similar. There was a significantly lower rate of superficial SSIs in the powder group (HIST: 4.6% versus POWD: 0%, P = .02).

CONCLUSIONS

In pediatric patients undergoing SILA for acute appendicitis, the use of cefoxitin powder in the umbilical wound is a simple intervention to reduce the incidence of superficial SSIs.