Pre-operative mechanical bowel preparation and prophylactic oral antibiotics for pediatric patients undergoing elective colorectal surgery: a protocol for a randomized controlled feasibility trial.

BACKGROUND: Infections after elective colorectal surgery remain a significant burden for patients and the healthcare system. Adult studies suggest that the combination of oral antibiotics and mechanical bowel preparation is effective at reducing infections after colorectal surgery. In children, there is limited evidence for either of these practices and the utility of combining oral antibiotics with mechanical bowel preparation remains uncertain. METHODS: This study aims to determine the feasibility of conducting a randomized controlled trial assessing the efficacy of oral antibiotics, with or without mechanical bowel preparation, in reducing the rates of post-operative infection in pediatric colorectal surgery. Participants aged 3 months to 18 years undergoing elective colorectal surgery will be randomized pre-operatively to one of three trial arms: (1) oral antibiotics; (2) oral antibiotics and mechanical bowel preparation; or (3) standard care. Twelve patients will be included in each trial arm. Feasibility outcomes of interest include the rate of participant recruitment, post-randomization exclusions, protocol deviations, adverse events, and missed follow-up appointments. Secondary outcomes include the rate of post-operative surgical site infections, length of hospital stay, time to full enteral feeds, reoperation, readmission, and complications. DISCUSSION: If the results of this trial prove feasible, a multi-center trial will be completed with sufficient power to evaluate the optimal pre-operative bowel preperation for pediatric patients undergoing elective colorectal surgery. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03593252.

A Study of Safety and Effectiveness of Evicel Fibrin Sealant as an Adjunctive Hemostat in Pediatric Surgery.

INTRODUCTION: Data on the use of fibrin sealants to control intraoperative bleeding in children are scarce. Evicel Fibrin Sealant (Ethicon Inc., Raritan, New Jersey, United States) was found safe and effective in clinical trials of adults undergoing various surgery types. We evaluated the safety and efficacy of Evicel versus Surgicel Absorbable Hemostat (Ethicon Inc.) as adjunctive topical hemostats for mild/moderate raw-surface bleeding in pediatric surgery. METHODS: A phase III randomized clinical trial was designed as required by the European Medicines Agency's Evicel Pediatric Investigation Plan: 40 pediatric subjects undergoing abdominal, retroperitoneal, pelvic, or thoracic surgery were randomized to Evicel or Surgicel, to treat intraoperative mild-to-moderate bleeding. Descriptive analyses included time-to-hemostasis and rates of treatment success (4, 7, 10 minutes), intraoperative treatment failure, rebleeding, and thromboembolic events. RESULTS: Forty of 130 screened subjects aged 0.9 to 17 years were randomized 1:1 to Evicel or Surgicel. Surgeries were predominantly open abdominal procedures. The median bleeding area was 4.0 cm2 for Evicel and 1.0 cm2 for Surgicel. The median time-to-hemostasis was 4.0 minutes for both groups. The 4-, 7-, and 10-minute treatment success rates were 80.0% versus 65.0%, 100.0% versus 80.0%, and 95.0% versus 90.0%, whereas treatment failure rates were 5.0% versus 25.0%, for Evicel and Surgicel, respectively. No deaths or thrombotic events occurred. Re-bleeding occurred in 5.0% of Evicel and 10.0% of Surgicel subjects. CONCLUSIONS: In accordance with adult clinical trials, this randomized study supports the safety and efficacy of Evicel for controlling mild-to-moderate surgical bleeding in a broad range of pediatric surgical procedures.

Diagnosis and management of congenital diaphragmatic hernia: a 2023 update from the Canadian Congenital Diaphragmatic Hernia Collaborative.

OBJECTIVE: The Canadian Congenital Diaphragmatic Hernia (CDH) Collaborative sought to make its existing clinical practice guideline, published in 2018, into a 'living document'. DESIGN AND MAIN OUTCOME MEASURES: Critical appraisal of CDH literature adhering to Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. Evidence accumulated between 1 January 2017 and 30 August 2022 was analysed to inform changes to existing or the development of new CDH care recommendations. Strength of consensus was also determined using a modified Delphi process among national experts in the field. RESULTS: Of the 3868 articles retrieved in our search that covered the 15 areas of CDH care, 459 underwent full-text review. Ultimately, 103 articles were used to inform 20 changes to existing recommendations, which included aspects related to prenatal diagnosis, echocardiographic evaluation, pulmonary hypertension management, surgical readiness criteria, the type of surgical repair and long-term health surveillance. Fifteen new CDH care recommendations were also created using this evidence, with most related to the management of pain and the provision of analgesia and neuromuscular blockade for patients with CDH. CONCLUSIONS: The 2023 Canadian CDH Collaborative's clinical practice guideline update provides a management framework for infants and children with CDH based on the best available evidence and expert consensus.

Cost effectiveness of the quality assurance and performance improvement project for suspected appendicitis study.

INTRODUCTION: Appendicitis is the most common pediatric emergent surgical condition, with 77,000 American pediatric admissions costing $680 million US annually. Diagnosing appendicitis can be challenging. The prospective Quality Assurance and performance improvement project for suspected aPPEndicitis (QAPPE) study implemented a standardized appendicitis assessment pathway. This current study aims to assess the cost-effectiveness of the QAPPE pathway. METHODS: QAPPE data (February 2018-January 2019) were compared to retrospective data from the year prior (January-December 2017). Patients aged <18, presenting with suspicion of appendicitis were identified using the emergency department patient database. Patients were excluded if they were transferred from an outside center or if appendicitis was not suspected. Study arms were compared using Student's t-test and assessed with standard costing techniques. The Incremental Cost-Effectiveness Ratio (ICER) was determined. Deterministic and probabilistic sensitivity analyses of the model were performed. Effectiveness was assessed by percent of negative appendectomies where alternate diagnosis was made intraoperatively or histologically. Significance was set at p < 0.05. RESULTS: QAPPE (n = 247) and traditional care (n = 234) patients were compared. Traditional care had higher admission frequency and lower pediatric appendicitis score. Demographics between all included patients and those admitted were similar overall. Patient costs were $3656.32 (95% CI $2407-$5250) Canadian (CAD) for QAPPE and $3823.56 (95% CI $2604-$5451) CAD for traditional care. QAPPE was the dominant strategy in the base model and probabilistic simulation found it favored in 64.7% of model iterations with a willingness to pay of $70,000 CAD. CONCLUSION: Using the QAPPE pathway to assess patients with suspected appendicitis reduced costs and improved effectiveness of patient care. LEVEL OF EVIDENCE: 2.

Quality Assurance and Performance Improvement Project for Suspected Appendicitis.

INTRODUCTION: Considerable variability exists in the diagnosis and management of acute appendicitis, affecting both quality and costs of care. This prospective cohort study aimed to decrease unnecessary radiological investigations, standardize radiological imaging, avoid unnecessary hospital admissions, and decrease our institution rate of negative appendectomy. METHODS: A multidisciplinary appendicitis care pathway was implemented. This pathway involved the use of the Pediatric Appendicitis Score, standardization of ultrasound reporting, and risk stratification to determine patient disposition. Patients were prospectively enrolled in the pathway and compared a preimplementation retrospective cohort. RESULTS: We included 235 patients in this study that took place between February 2017 and January 2018. An 88.5% pathway adherence rate for appropriate referral for ultrasounds, an 84% compliance rate for correct risk stratification, and the need for a surgical consult were achieved. After implementation, standardization of ultrasound (U/S) reporting increased from 0% to 78%. The rate of computed tomography utilization decreased from 7.3% to 4.7%. An appendectomy was completed in 68 (29%) of patients. There was only 1 (1.5%) negative appendectomy, compared to the prepathway institutional negative appendectomy rate of 4%. CONCLUSION: The implementation of a standardized, evidence-based, appendicitis care pathway has the potential to improve quality of care by reducing negative appendectomies, unnecessary computed tomography scans, and unnecessary hospital admissions. The participation of the emergency and diagnostic imaging departments is critical to the successful implementation of this quality improvement measure. This simple, effective model can be easily implemented at other centers to improve the care of children.

Gastric necrosis in a term infant treated with near-total gastrectomy and delayed reconstruction with a Hunt-Lawrence pouch.

The creation of an intestinal pouch following total gastrectomy is exceedingly rare in infants. We present the case of a term infant who underwent a near-total gastrectomy on day 2 of life for diffuse gastric necrosis with perforation due to severe hypoxemia from an intrapartum nuchal cord. Gastrointestinal continuity was restored at 5 months of age with a Hunt-Lawrence pouch. The child is now 3 years old and has achieved a weight in the 47th percentile despite challenges with micronutrient deficiencies, reduced caloric intake and renal insufficiency requiring 8 months of intermittent haemodialysis.

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study.

BACKGROUND/PURPOSE: Appendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system. METHODS: Using administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression. RESULTS: Over the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those >125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31-4. 02, p = 0.001; and OR 2.55, 95%CI 1.35-4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates. CONCLUSIONS: In this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada. LEVEL OF EVIDENCE: Prognosis study, level II.

A population-based cohort examining factors affecting all-cause morbidity and cost after pediatric appendectomy: Does annual adult procedure volume matter?

BACKGROUND: The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume. MATERIALS AND METHODS: This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes. RESULTS: Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p < 0.001), patients with comorbidities (OR = 2.20, 95%CI 1.96-2.46, p < 0.001), and those with perforated appendicitis (OR = 5.95, 95%CI 5.44-6.50, p < 0.001) were more susceptible to morbidity. Annual pediatric appendectomy volume was a significant predictor of reduced morbidity (OR = 0.85/20 cases, 95%CI 0.76-0.93, p < 0.001) as was the use of laparoscopy (OR = 0.81, 95%CI 0.72-0.91, p = 0.001). Conversely, annual adult appendectomy volume conferred no benefit nor did pediatric surgery specialty training. CONCLUSION: Outcomes after pediatric appendectomy are influenced by pediatric case volume, regardless of specialty training, but extra adult surgical volume confers no benefit.

Earlier anterior cruciate ligament reconstruction is associated with a decreased risk of medial meniscal and articular cartilage damage in children and adolescents: a systematic review and meta-analysis.

PURPOSE: To evaluate the association between surgical timing and the incidence of secondary meniscal or chondral damage in children and adolescents with anterior cruciate ligament (ACL) ruptures. METHODS: Three electronic databases, PubMed, MEDLINE, and EMBASE, were systematically searched from database inception until October 16, 2017 by two reviewers independently and in duplicate. The inclusion criteria were English language studies that reported the incidence of meniscal and articular cartilage damage in children or adolescent athletes with ACL injuries as well as the timing of their ACL reconstruction (ACLR). Risk ratios were combined in a meta-analysis using a random effects model. RESULTS: A total of nine studies including 1353 children and adolescents met the inclusion criteria. The mean age of patients included was 14.2 years (range 6-19), and 45% were female. There was a significantly decreased risk of concomitant medial meniscal injury in those reconstructed early (26%) compared to those with delayed reconstruction (47%) [pooled risk ratio (RR) = 0.49, 95% CI 0.36-0.65, p < 0.00001]. There was also a significantly reduced risk of medial femoral chondral (RR = 0.48, 95% CI 0.31-0.75, p = 0.001), lateral femoral chondral (RR = 0.38, 95% CI 0.20-0.75, p = 0.005), tibial chondral (RR = 0.45, 95% CI 0.27-0.75, p = 0.002), and patellofemoral chondral (RR = 0.41, 95% CI 0.20-0.82, p = 0.01) damage in the early reconstruction group in comparison to the delayed group. CONCLUSION: Pooled results from observational studies suggest that early ACLR results in a significantly decreased risk of secondary medial meniscal injury, as well as secondary medial, lateral, and patellofemoral compartment chondral damage in children and adolescents. This study provides clinicians with valuable information regarding the benefits of early ACL reconstruction in children and adolescents, and can be used in the decision making for athletes in this population. LEVEL OF EVIDENCE: IV.

Factors Associated With Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy.

Importance: The prevalence of pediatric cholelithiasis is increasing with the epidemic of childhood obesity. With this rise, the outcomes and costs of pediatric laparoscopic cholecystectomy become an important public health and economic concern. Objective: To assess patient and health system factors associated with the outcomes and costs after laparoscopic cholecystectomy among Canadian children. Design, Setting, and Participants: This was a retrospective, population-based study of children 17 years and younger undergoing laparoscopic cholecystectomy from April 1, 2008, until March 31, 2015. The data source was the Canadian Institute for Health Information. The Canadian Institute for Health Information Discharge Abstract Database includes data from all Canadian hospitals. The analysis was limited to inpatient cholecystectomies. All Canadian children undergoing laparoscopic cholecystectomy were included. Exposure: The exposure in this study was laparoscopic cholecystectomy. Main Outcomes and Measures: The primary outcome was all-cause morbidity, a composite outcome of any complication that prolonged length of stay by 24 hours or required a second, unplanned procedure. The cost of the index admission was also calculated as a secondary outcome. These outcomes of interest were determined before data analysis. Odds ratios and 95% CIs were estimated using multilevel logistic regression models. Results: During the study period, 3519 laparoscopic cholecystectomies were performed; of these, 79.1% (n = 2785) were in girls, and 98.0% (n = 3450) were for gallstone disease. The overall morbidity rate was 3.9% (n = 137). After adjustment, patients with comorbidities were more susceptible to morbidity (odds ratio, 2.68; 95% CI, 1.78-3.86; P < .001). Operations for gallstones were less morbid. High-volume general surgeons had lower morbidity rates compared with low-volume pediatric surgeons (odds ratio, 0.32; 95% CI, 0.12-0.69; P = .005) independent of pediatric volumes. The mean (SD) unadjusted cost of a laparoscopic cholecystectomy was $4115 ($7273). Operative indication, complications, comorbidities, emergency admission, and surgeon volume were associated with cost. Conclusions and Relevance: The high-volume nature of adult general surgery translated to lower morbidity and cost after pediatric laparoscopic cholecystectomy, suggesting that adult volume is associated with pediatric outcomes. As the rate of pediatric gallstone disease increases, surgeon volume, rather than specialty training, should be considered when pursuing operative management.

Effectiveness and meaningful use of paediatric surgical safety checklists and their implementation strategies: a systematic review with narrative synthesis.

OBJECTIVE: To examine the effectiveness and meaningful use of paediatric surgical safety checklists (SSCs) and their implementation strategies through a systematic review with narrative synthesis. SUMMARY BACKGROUND DATA: Since the launch of the WHO SSC, checklists have been integrated into surgical systems worldwide. Information is sparse on how SSCs have been integrated into the paediatric surgical environment. METHODS: A broad search strategy was created using Pubmed, Embase, CINAHL, Cochrane Central, Web of Science, Science Citation Index and Conference Proceedings Citation Index. Abstracts and full texts were screened independently, in duplicate for inclusion. Extracted study characteristic and outcomes generated themes explored through subgroup analyses and idea webbing. RESULTS: 1826 of 1921 studies were excluded after title and abstract review (kappa 0.77) and 47 after full-text review (kappa 0.86). 20 studies were of sufficient quality for narrative synthesis. Clinical outcomes were not affected by SSC introduction in studies without implementation strategies. A comprehensive SSC implementation strategy in developing countries demonstrated improved outcomes in high-risk surgeries. Narrative synthesis suggests that meaningful compliance is inconsistently measured and rarely achieved. Strategies involving feedback improved compliance. Stakeholder-developed implementation strategies, including team-based education, achieved greater acceptance. Three studies suggest that parental involvement in the SSC is valued by parents, nurses and physicians and may improve patient safety. CONCLUSIONS: A SSC implementation strategy focused on paediatric patients and their families can achieve high acceptability and good compliance. SSCs' role in improving measures of paediatric surgical outcome is not well established, but they may be effective when used within a comprehensive implementation strategy especially for high-risk patients in low-resource settings.

Quality of reporting of the literature on gastrointestinal reflux after repair of esophageal atresia-tracheoesophageal fistula.

OBJECTIVES: There is variation in the management of postoperative gastroesophageal reflux (GER) in esophageal atresia-tracheoesophageal fistula (EA-TEF). Well-reported literature is important for clinical decision-making. We assessed the quality of reporting (QOR) of postoperative GER management in EA-TEF. METHODS: A comprehensive search of MEDLINE, EMBASE, CINHAL, CENTRAL databases and gray literature was conducted. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with antireflux medications. The QOR was assessed using the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) checklist. RESULTS: Retrieval of 2910 articles resulted in 48 relevant articles (N=2592 patients) with an overall quality percentage score of 48%-95% (median=65%). The best reported items were "participants" and "outcome data" (93.8% each), "generalisability" (91.7%) and "background/rationale" (89.6%). Less than 20% of studies provided detailed "main results"; less than 5% of studies reported adequately on "bias" or "funding." Sample size calculation and study limitations were included in 17 (35.4%) and 16 (33.3%) studies respectively. Follow-up time was inconsistently reported. CONCLUSIONS: Although the overall QOR is moderate using STROBE, important areas are underreported. Inadequate methodological reporting may lead to inappropriate clinical decisions. Awareness of STROBE, emphasizing proper reporting is needed.

The level of evidence keeps improving: An updated analysis of the scientific program at the Canadian Association of Paediatric Surgeons Annual Meeting.

INTRODUCTION: The purpose of this study is to examine the scientific program of the Canadian Association of Pediatric Surgeons (CAPS) to determine if the quality of research has improved. METHODS: CAPS abstracts from 2010 to 2013 were reviewed by two independent researchers. Presentation type, study design, and level of evidence (LOE) were recorded. All differences were adjudicated by an epidemiologist. Fisher's exact test compared results to a previous study that assessed LOE in CAPS abstracts from 2005 to 2009. RESULTS: 291 abstracts were reviewed with 53 excluded and 238 included in final analysis. Reviewers demonstrated high agreement for study design (ICC=0.767 95%CI 0.715-0.810) and LOE (ICC=0.914 95%CI 0.892-0.931). Out of 238 studies, 117 (49%) were podium and 122 (51%) posters. Number of high-quality studies increased in 2010-2013 versus 2005-2009 (n=253), specifically systematic reviews (n=15 (6%) vs. n=3 (1%) p<0.01), randomized controlled trials (n=4 (2%) vs. n=0 (0%), p=0.05), and prospective cohort studies (n=41 (17%) vs. n=26 (10%), p<0.001). Retrospective cohort is still the most common. However, the number of studies has significantly decreased (n=121 (51%) vs. n=171 (68%), p<0.001). The proportion of high-level studies (LOE 2 or better) also improved (48 (20%) vs. 24 (10%) p<0.001). CONCLUSION: The quality of research presented at CAPS has greatly improved, especially in the past five years.

Compliance with published recommendations for postoperative antibiotic management of children with appendicitis: A chart audit.

BACKGROUND: Recommendations for postoperative antibiotics for appendicitis were published by the American Pediatric Surgical Association (APSA) in 2010. However, implementation of practice recommendations often takes years. We measured compliance of pediatric surgeons (who receive reminders every 6months from the Division Chief) with the APSA recommendations. METHODS: With Research Ethics Board approval, we completed a retrospective review of children who underwent appendectomy since 2010. Compliance with APSA recommendations was analyzed descriptively. Agreement between pediatric surgeons and pathologists was analyzed by kappa. RESULTS: We reviewed 242 charts. Patients were excluded for missing data (n=5) and diagnosis other than appendicitis (n=27), resulting in 210 patients with appendicitis (119 acute, 91 perforated). Agreement of perforation status between surgeons and pathologists was good (κ=0.75; 95% CI: 0.66-0.83). Many patients with nonperforated appendicitis received antibiotics in excess of the APSA recommendations (62/119 (52%)), as did those with uncomplicated perforated appendicitis (52/84 (62%)). CONCLUSIONS: Despite the availability of published recommendations, surgeons continue to prescribe postoperative antibiotics for appendicitis in excess of the recommendations. Overtreatment leads to potential medication errors and increased length-of-stay/medication costs. An intensive implementation program with ongoing education/monitoring may improve compliance with established recommendations to decrease the use of excess postoperative antibiotics and their associated costs/risks.

Post-Operative Impact of Nasogastric Tubes on length of stay in infants with pyloric Stenosis (POINTS): A prospective randomized controlled pilot trial.

INTRODUCTION: Postoperative emesis commonly affects infants after pyloromyotomy for pyloric stenosis. This randomized controlled trial investigates the impact of preoperative nasogastric tubes (NGTs) on postoperative emesis rate and length of stay (LOS). METHODS: Patients from January 2010 to June 2012 were screened and randomized to have an 8 French NGT or no NGT inserted prior to surgery. Patients contraindicated for NGT or pyloromyotomy, those < 6 months of age, born prematurely, or with cardiac malformations were excluded. Patient demographics, blood work, postoperative feeding, postoperative emesis rate, and postoperative LOS were collected. Student's t test and Fisher's exact test were used to compare postoperative emesis rate and LOS. RESULTS: Of 125 patients screened, 65 (52%) were eligible, and 50 (77%) were recruited. The NGT (n = 25) and no NGT (n = 25) groups had no significant difference in baseline characteristics. Postoperative emesis occurred in 17 (68%) patients with NGT compared to 12 (48%) in patients with no NGT (p = 0.25). Postoperative emesis events (52 [23%] vs. 47 [20%], p = 0.50), emesis per patient (2.08 ± 2.23 vs. 1.88 ± 2.70, p = 0.76 95% CI: -1.21 to 1.61), and LOS (34.77 ± 13.74 vs. 36.33 ± 19.36, p = 0.74 95% CI: -11.11 to 7.98) were similar between NGT and no NGT groups. CONCLUSION: Preoperative NGT insertion had no demonstrable effect on LOS or postoperative emesis rate after pyloromyotomy.

The management of postoperative reflux in congenital esophageal atresia-tracheoesophageal fistula: a systematic review.

PURPOSE: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is associated with postoperative gastroesophageal reflux (GER). We performed a systematic review of the literature regarding routine anti-reflux medication post EA-TEF repair and its impact on postoperative GER and associated complications. METHODS: A comprehensive search was conducted using MEDLINE, EMBASE, CINHAL, CENTRAL (Cochrane library) electronic databases and gray literature. Full-text screening was performed in duplicate. Included articles reported a primary diagnosis of EA-TEF, a secondary diagnosis of postoperative GER, and primary treatment of GER with anti-reflux medications. RESULTS: Screening of 2,910 articles resulted in 25 articles (1,663 patients) for analysis. Most were single-center studies (92%) and retrospective (76%); there were no randomized control trials. Fifteen studies named the class of anti-reflux agent used, 3 the duration of therapy, and none either the dose prescribed or number of doses. Complications were inconsistently reported. Anti-reflux surgery was performed in 433/1,663 (26.0%) patients. Average follow-up was 53.2 months (14 studies). CONCLUSION: The quality of literature regarding anti-reflux medication for GER post EA-TEF repair is poor. There are no well-outlined algorithms for anti-reflux agents, doses, or duration of therapy. Standardized protocols and reliable reporting are necessary to develop guidelines to better manage postoperative GER in EA-TEF patients.

Post-operative management of esophageal atresia-tracheoesophageal fistula and gastroesophageal reflux: a Canadian Association of Pediatric Surgeons annual meeting survey.

BACKGROUND: Esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair. METHODS: A pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated. RESULTS: We distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8-10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3-6 months (37%) or 6-12 months (35%). CONCLUSIONS: Most CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

Antibiotics administration before enema reduction of intussusception: is it necessary?

BACKGROUND: Some centers advocate using antibiotics before enema reduction to prevent septic complications. Our objective was to determine whether using antibiotics before reduction provided any improvement in outcomes. METHODS: With institutional review board approval, patients from 2 centers were compared: 1 where antibiotics were administered, and one where they were not. This retrospective cohort study from January 2005 to December 2010 evaluated demographic data, episodes of postreduction fever, hospital stay, and analgesia requirements. RESULTS: One hundred eighteen patients were identified: 83 males (70.3%) and 35 females (29.7%). The median age was 24 months (range, 1-180). Fifty-six patients (57.7%) received antibiotics, whereas 41 (42.7%) did not. Twenty-one patients (17.8%) had missing data and were excluded. The incidence of fever postreduction was not statistically different between groups: 12.8% for those who received antibiotics vs 17.9% for those who did not (P = .7367). No adverse antibiotic reactions were reported. Average time to oral feeds was 7.3 vs 10.6 hours (P = .06), and the length of stay was 1.7 vs 1.4 days (P = .07). CONCLUSION: Although antibiotics are administered routinely in some centers, they appear of little value. Financial costs and potential adverse reactions must be considered. Further prospective evaluation is being conducted using a larger sample size to confirm these results.

Influence of maternal factors on health outcomes in gastroschisis: a Canadian population-based study.

BACKGROUND: Gastroschisis is increasing in incidence worldwide. There is a need for a disease-specific, population-based approach to determining factors linked with gastroschisis and its outcome. OBJECTIVES: To examine racial, socioeconomic, health and geographic predictors of gastroschisis and its outcome in Canada. METHODS: 535 cases of gastroschisis from the Canadian Pediatric Surgery Network national database were included from May 2005 to May 2010. Baseline characteristics of mothers were compared with those reported by Statistics Canada. Factors associated with adverse neonatal outcomes were examined using regression analyses. RESULTS: Mothers of infants with gastroschisis are young, often from small communities. Smoking (37%) and illicit drug use are common in this population. Single mothers receive less perinatal care (OR 0.06; 95% CI 0.02-0.28). Geographically isolated mothers are more likely to undergo caesarian section (OR 3.84; 95% CI 1.26-11.74). Cocaine use predicts a lower odds of delivering at a planned center (OR 0.25; 95% CI 0.08-0.79), and is also associated with an increased likelihood of intestinal injury at birth (OR 6.26; 95% CI 1.52-25.72). Infants of mothers from isolated communities will spend a mean of 31.9 days longer in hospital. Aboriginal status is not independently predictive of perinatal or neonatal outcome. CONCLUSION: Gastroschisis in Canada occurs frequently in young mothers, aboriginals and smokers. Features associated with worse outcomes include single parent status, cocaine use and maternal hometown geographic isolation.