Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee.

BACKGROUND: Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS: Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS: The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION: Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.

A Life Cycle Assessment of Reusable and Disposable Surgical Caps.

INTRODUCTION: Surgical cap attire plays an important role in creating a safe and sterile environment in procedural suites, thus the choice of reusable versus disposable caps has become an issue of much debate. Given the lack of evidence for differences in surgical site infection (SSI) risk between the two, selecting the cap option with a lower carbon footprint may reduce the environmental impact of surgical procedures. However, many institutions continue to recommend the use of disposable bouffant caps. METHODS: ISO-14044 guidelines were used to complete a process-based life cycle assessment to compare the environmental impact of disposable bouffant caps and reusable cotton caps, specifically focusing on CO2 equivalent (CO2e) emissions, water use and health impacts. RESULTS: Reusable cotton caps reduced CO2e emissions by 79% when compared to disposable bouffant caps (10 kg versus 49 kg CO2e) under the base model scenario with a similar reduction seen in disability-adjusted life years. However, cotton caps were found to be more water intensive than bouffant caps (67.56 L versus 12.66 L) with the majority of water use secondary to production or manufacturing. CONCLUSIONS: Reusable cotton caps have lower total lifetime CO2e emissions compared to disposable bouffant caps across multiple use scenarios. Given the lack of evidence suggesting a superior choice for surgical site infection prevention, guidelines should recommend reusable cotton caps to reduce the environmental impact of surgical procedures.

Association of social determinants of health-related diagnosis codes with postoperative outcomes.

BACKGROUND: The association of an individual's social determinants of health-related problems with surgical outcomes has not been well-characterized. The objective of this study was to determine whether documentation of social determinants of a health-related diagnosis code (Z code) is associated with postoperative outcomes. METHODS: This retrospective cohort study included surgical cases from a single institution's national surgical quality improvement program (NSQIP) clinical registry from October 2015 to December 2021. The primary predictor of interest was documentation of a Z code for social determinants of health-related problems. The primary outcome was 30-day postoperative morbidity. Secondary outcomes included postoperative length of stay, disposition, and 30-day postoperative mortality, reoperation, and readmission. Multivariable regression models were fit to evaluate the association between the documentation of a Z code and outcomes. RESULTS: Of 10,739 surgical cases, 348 patients (3.2%) had a documented social determinants of health-related Z code. In multivariable analysis, documentation of a Z code was associated with increased odds of morbidity (20.7% vs. 9.9%; adjusted odds ratio [aOR], 1.88; 95% confidence interval [CI], 1.39-2.53), length of stay (median, 3 vs. 1 day; incidence rate ratio, 1.49; 95% CI, 1.33-1.67), odds of disposition to a location other than home (11.3% vs. 3.9%; aOR, 2.86; 95% CI, 1.89-4.33), and odds of readmission (15.3% vs. 6.1%; aOR, 1.99; 95% CI, 1.45-2.73). CONCLUSIONS: Social determinants of health-related problems evaluated using Z codes were associated with worse postoperative outcomes. Improved documentation of social determinants of health-related problems among surgical patients may facilitate improved risk stratification, perioperative planning, and clinical outcomes.

Methods of measurement for pneumothorax in pediatric patients: a systematic review.

Accurate measurement of pneumothorax (PTX) size is necessary to guide clinical decision making; however, there is no consensus as to which method should be used in pediatric patients. This systematic review seeks to identify and evaluate the methods used to measure PTX size with CXR in pediatric patients. A systematic review of the literature through 2021 following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was conducted using the following databases: Ovid/MEDLINE, Scopus, Cochrane Database of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Original research articles that included pediatric patients (< 18 years old) and outlined the PTX measurement method were included. 45 studies were identified and grouped by method (Kircher and Swartzel, Rhea, Light, Collins, Other) and societal guideline used. The most used method was Collins (n = 16; 35.6%). Only four (8.9%) studies compared validated methods. All found the Collins method to be accurate. Seven (15.6%) studies used a standard classification guideline and 3 (6.7%) compared guidelines and found significant disagreement between them. Pediatric-specific measurement guidelines for PTX are needed to establish consistency and uniformity in both research and clinical practice. Until there is a better method, the Collins method is preferred.

ChatGPT: What Every Pediatric Surgeon Should Know About Its Potential Uses and Pitfalls.

ChatGPT - currently the most popular generative artificial intelligence system - has been revolutionizing the world and healthcare since its release in November 2022. ChatGPT is a conversational chatbot that uses machine learning algorithms to enhance its replies based on user interactions and is a part of a broader effort to develop natural language processing that can assist people in their daily lives by understanding and responding to human language in a useful and engaging way. Thus far, many potential applications within healthcare have been described, despite its relatively recent release. This manuscript offers the pediatric surgical community a primer on this new technology and discusses some initial observations about its potential uses and pitfalls. Moreover, it introduces the perspectives of medical journals and surgical societies regarding the use of this artificial intelligence chatbot. As ChatGPT and other large language models continue to evolve, it is the responsibility of the pediatric surgery community to stay abreast of these changes and play an active role in safely incorporating them into our field for the benefit of our patients. LEVEL OF EVIDENCE: V.

Non-surgical approaches to the management of chest wall deformities.

Chest wall deformities in children encompass a broad spectrum of disorders but pectus excavatum and carinatum are by far the most common. Treatment varies substantially by center, and depends on patient symptoms, severity of disease, and surgeon preference. Historically, surgical approaches were the mainstay of treatment for these disease processes but new advances in non-surgical approaches have demonstrated reasonable results in select patients. These non-surgical approaches include vacuum bell therapy, autologous fat grafting and hyaluronic acid injections for pectus excavatum, and orthotic brace therapy for pectus carinatum. There is debate with regards to optimal patient selection for these non-surgical approaches, as well as other barriers including reimbursement issues. This paper will review the current non-surgical approaches to chest wall deformities available, including optimal patient selection, treatment protocols, indications, contraindications, and outcomes.

Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery.

The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.

Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification.

BACKGROUND: Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability. METHODS: Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared. RESULTS: Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery. CONCLUSIONS: The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.

Reduced Long-Term Bowel Obstruction Risk With Minimally Invasive Diaphragmatic Hernia Repair.

INTRODUCTION: The introduction of minimally invasive surgery (MIS) for repair of congenital diaphragmatic hernias (CDH) has reduced postoperative length of stay, postoperative opioid consumption, and provided a more esthetic repair. In adult abdominal surgery, minimally invasive techniques have been associated with decreased long-term rates of small bowel obstruction (SBO), although it is unclear if this benefit carries over into the pediatric population. Our objective was to evaluate the rates of SBO following open versus MIS CDH repair. MATERIAL AND METHODS: Infants who underwent CDH repair between 2010 and 2021 were identified using the PearlDiver Mariner database. Kaplan-Meier curves and Cox proportional hazards models were used to evaluate time to SBO by surgical approach (MIS versus open) while adjusting for mesh use, patient sex, and length of stay. RESULTS: Of 1033 patients that underwent CDH repair, 258 (25.0%) underwent a minimally invasive approach. The overall rate of SBO was 7.5% (n = 77). Rate of SBO following MIS repair was lower than open repair at 1 y (0.8% versus 5.1%), 3 y, (2.3% versus 9.0%), and 5 y (4.4% versus 10.1%, P = 0.004). Following adjustment, the rate of SBO following MIS repair remained significantly lower than open repair (adjusted hazard ratio: 0.37, 95% confidence interval: 0.18, 0.79). CONCLUSIONS: Following CDH repair, long-term rates of SBO are lower among patients treated with MIS approaches. Long-term risk of SBO should be considered when selecting surgical approach for CDH patients.

Surgeon Understanding and Perceptions of Social Determinants of Health.

INTRODUCTION: Social determinants of health impact surgical outcomes. Characterization of surgeon understanding of social determinants of health is necessary prior to implementation of interventions to address patient needs. The study objective was to explore understanding, perceived importance, and practices regarding social determinants of health among surgeons. METHODS: Surgical residents and attending surgeons at a single academic medical center completed surveys regarding social determinants of health. We conducted semi-structured interviews to further explore understanding and perceived importance. A conceptual framework from the World Health Organization (WHO) Commission on Social Determinants of Health informed the thematic analysis. RESULTS: Survey response rate was 47.9% (n = 69, 44 residents [63.8%], 25 attendings [36.2%]). Respondents primarily reported good (n = 29, 42.0%) understanding of social determinants of health and perceived this understanding to be very important (n = 42, 60.9%). Documentation occurred seldom (n = 35, 50.7%), and referrals occurred seldom (n = 26, 37.7%) or never (n = 20, 29.0%). Residents reported a higher rate of prior training than attendings (95.5% versus 56.0%, P < 0.001). Ten interviews were conducted (six residents, four attendings). Residents demonstrated greater understanding of socioeconomic positions and hierarchies shaped by structural mechanisms than attendings. Both residents and attendings demonstrated understanding of intermediary determinants of health status and linked social determinants to impacting patients' health and well-being. Specific knowledge gaps were identified regarding underlying structural mechanisms including the social, economic, and political context that influence an individual's socioeconomic position. CONCLUSIONS: Self-reported understanding and importance of social determinants of health among surgeons were high. Interviews revealed gaps in understanding that may contribute to limited practices.

Exploring Barriers and Facilitators to Reducing the Environmental Impact of the Operating Room.

INTRODUCTION: The operating room (OR) is a major contributor to greenhouse gas emissions both nationally and globally. Successful implementation of quality improvement initiatives requires understanding of key stakeholders' perspectives of the issues at hand. Our aim was to explore surgical, anesthesia, and OR staff member perspectives on barriers and facilitators to reducing OR waste. MATERIALS AND METHODS: Identified stakeholders from a single academic medical center were interviewed to identify important barriers and facilitators to reducing surgical waste. Two team members with qualitative research experience used deductive logic guided by the Theoretical Domains Framework of behavior change to identify themes within transcripts. RESULTS: Nineteen participants including surgeons (n = 3, 15.8%), surgical residents (n = 5, 26.3%), an anesthesiologist (n = 1, 5.3%), anesthesia residents (n = 2, 10.5%), nurse anesthetists (n = 2, 10.5%), nurses (n = 5, 26.3%), and a surgical technologist (n = 1, 5.3%) were interviewed. Twelve of the 14 themes within the Theoretical Domains Framework were discovered in transcripts. Barriers within these themes included lack of resources to pursue environmental sustainability in the OR and the necessity of maintaining sterility for patient safety. Facilitators included emphasizing surgeon leadership within the OR to reduce unused supplies and spreading awareness of the environmental and economic impact of surgical waste. CONCLUSIONS: Interviewed stakeholders were able to identify areas where improvements around surgical waste reduction and management could be made at the institution by describing barriers and facilitators to sustainability-driven interventions. Future surgical waste reduction initiatives at this institution will be guided by these important perspectives.

Operating Room Recycling: Opportunities to Reduce Carbon Emissions Without Increases in Cost.

BACKGROUND: The healthcare industry is a major contributor to greenhouse gas emissions. Within the hospital, operating rooms are responsible for the largest proportion of emissions due to high resource utilization and waste generation. Our aim was to generate estimates of greenhouse gas emissions avoided and cost implications following implementation of a recycling program across operating rooms at our freestanding children's hospital. METHODS: Data were collected from three commonly performed pediatric surgical procedures: circumcision, laparoscopic inguinal hernia repair, and laparoscopic gastrostomy tube placement. Five cases of each procedure were observed. Recyclable paper and plastic waste was weighed. Emission equivalencies were determined using the Environmental Protection Agency Greenhouse Gas Equivalencies Calculator. Institutional cost of waste disposal was $66.25 United States Dollars (USD)/ton for recyclable waste and $67.00 USD/ton for solid waste. RESULTS: The proportion of recyclable waste ranged from 23.3% for circumcision to 29.5% for laparoscopic gastrostomy tube placement. The amount of waste redirected from landfill to a recycling stream could result in annual avoidance of 58,500 to 91,500 kg carbon dioxide equivalent emissions, or 6583 to 10,296 gallons of gasoline. Establishing a recycling program would not require additional cost and could lead to modest cost savings (range $15 to 24 USD/year). CONCLUSIONS: Incorporation of recycling into operating rooms has the potential to reduce greenhouse gas emissions without increased cost. Clinicians and hospital administrators should consider operating room recycling programs as they work towards improved environmental stewardship. LEVEL OF EVIDENCE: Level VI - evidence form a single descriptive or qualitative study.

Laser Ablation of Pilonidal Sinus Disease: A Pilot Study.

BACKGROUND: Pilonidal disease is classically treated with wide local excision, although a number of minimally invasive approaches are currently under investigation. We aimed to determine the safety and feasibility of laser ablation of pilonidal sinus disease. IMPACT OF INNOVATION: Laser ablation provides a minimally invasive means of obliterating pilonidal sinus tracts without a need for excessive tract dilation. Laser ablation can be performed more than once on the same patient if necessary. TECHNOLOGY MATERIALS AND METHODS: This technique uses the NeoV V1470 Diode Laser (neoLaser Ltd, Caesarea, Israel) with a 2-mm probe. We performed laser ablation in adults and pediatric patients. PRELIMINARY RESULTS: We performed 27 laser ablation procedures in 25 patients, with a median operative time of 30 minutes. Eighty percent of patients reported either no pain or mild pain at the 2-week postoperative visit. The median time to return to work or school was 3 days. Eighty-eight percent of patients reported being satisfied or very satisfied with the procedure at their most recent follow-up (median, 6 mo). Eighty-two percent of patients were healed at 6 months. CONCLUSIONS AND FUTURE DIRECTIONS: Laser ablation of pilonidal disease is safe and feasible. Patients experienced short recovery time and reported low levels of pain and high levels of satisfaction.

Disparities in Utilization of Same-Day Discharge Following Appendectomy in Children.

INTRODUCTION: Disparities in the delivery of pediatric surgical care exist for racial and ethnic minority groups. Utilization of same-day discharge (SDD) following appendectomy for acute, uncomplicated appendicitis is increasing; however, rates among diverse populations have not been explored to evaluate equitable care delivery and healthcare utilization. Our objective was to determine whether race and ethnicity are associated with rates of SDD and postdischarge healthcare utilization. We hypothesized that racial and ethnic minority groups would have lower rates of SDD. METHODS: This retrospective cohort study used data from the 2015-2019 American College of Surgeons National Surgical Quality Improvement Program-Pediatric clinical registry and included children who underwent appendectomy. Patients with complicated appendicitis were excluded. Primary exposure was racial or ethnic group. The primary outcome was SDD, and secondary outcomes included postdischarge emergency department visits and hospital readmissions. RESULTS: Of 37,579 simple appendicitis patients, SDD after appendectomy occurred in 10,012 (26.6%). On multivariable analysis, Black or African American race was associated with lower likelihood of SDD (adjusted odds ratio [aOR]: 0.85; 95% confidence interval [95% CI]:0.79-0.92; P < 0.0001). Hispanic ethnicity was associated with higher likelihood of SDD (aOR: 1.19; 95% CI: 1.12-1.25; P < 0.0001). Likelihood of postoperative emergency department visits was higher in Black or African American patients (aOR: 1.36; 95% CI: 1.14-1.62; P < 0.001) and Hispanic patients (aOR: 1.37; 95% CI: 1.12-1.58; P < 0.0001). Hospital readmission rates were similar across groups. CONCLUSIONS: Rates of SDD following appendectomy vary among racial and ethnic groups. Interventions to achieve equitable healthcare delivery including SDD after appendectomy are needed.

Prophylactic antireflux procedures are not necessary in neurologically impaired children undergoing gastrostomy placement.

PURPOSE: Fundoplication is frequently used in children with neurologic impairment even in the absence of reflux due to concerns for future gastric feeding intolerance, but supporting data are lacking. We aimed to determine the incidence of secondary antireflux procedures (fundoplication or gastrojejunostomy (GJ)) post gastrostomy tube (GT) placement in children with and without neurologic impairment. METHODS: Children under 18 undergoing a GT placement without fundoplication between 2010 and 2020 were identified utilizing the PearlDiver Mariner national patient claims database. Children with a diagnosis of cerebral palsy or a degenerative neurologic disease were identified and compared to children without these diagnoses. The incidence of delayed fundoplication or conversion to GJ were compared utilizing Kaplan-Meier and Cox proportional hazards regression analyses. RESULTS: A total of 14,965 children underwent GT placement, of which 3712 (24.8%) had a diagnosis of neurologic impairment. The rate of concomitant fundoplication was significantly higher among children with a diagnosis of neurologic impairment as compared to those without (9.3% vs 6.4%, p < 0.001). While children with neurologic impairment had a significantly higher rate of fundoplication or GJ conversion at 5 years compared to children without (12.6% [95% confidence interval (CI): 11.4%-13.8%] vs 8.6% [95% CI 8.0%-9.2%], p < 0.001), the overall incidence remained low. CONCLUSION: Although children with neurologic impairment have a higher rate of requiring an antireflux procedure or GJ conversion than other children, the overall rate remains less than 15%. Fundoplication should not be utilized in children without clinical reflux on the basis of neurologic impairment alone.

Environmental Impact and Cost Savings of Operating Room Quality Improvement Initiatives: A Scoping Review.

BACKGROUND: Operating rooms are major contributors to a hospital's carbon footprint due to the large volumes of resources consumed and waste produced. The objective of this study was to identify quality improvement initiatives that aimed to reduce the environmental impact of the operating room while decreasing costs. STUDY DESIGN: A literature search was performed using PubMed, Scopus, CINAHL, and Google Scholar and included broad terms for "operating room," "costs," and "environment" or "sustainability." The "triple bottom line" framework, which considers the environmental, financial, and social impacts of interventions to guide decision making, was used to inform data extraction. The studies were then categorized using the 5 "Rs" of sustainability-refuse, reduce, reuse, repurpose, and recycle-and the impacts were discussed using the triple bottom line framework. RESULTS: A total of 23 unique quality improvement initiatives describing 28 interventions were included. Interventions were categorized as "refuse" (n = 11; 39.3%), "reduce" (n = 8; 28.6%), "reuse" (n = 3; 10.7%), and "recycle" (n = 6; 21.4%). While methods of measuring environmental impact and cost savings varied greatly among studies, potential annual cost savings ranged from $873 (intervention: education on diverting recyclable materials from sharps containers; environmental impact: 11.4 kg sharps waste diverted per month) to $694,141 (intervention: education to reduce regulated medical waste; environmental impact: 30% reduction in regulated medical waste). CONCLUSIONS: Quality improvement initiatives that reduce both cost and environmental impact have been successfully implemented across a variety of centers both nationally and globally. Surgeons, healthcare practitioners, and administrators interested in environmental stewardship and working toward a culture of sustainability may consider similar interventions in their institutions.

An Infant with COVID-19-Associated Intussusception.

Intussusception is the most common cause of bowel obstruction in infants four to ten months old and is commonly idiopathic or attributed to lymphoid hyperplasia. Our patient was a 7-month-old male who presented with two weeks of intermittent abdominal pain associated with crying, fist clenching and grimacing. Ultrasound demonstrated an ileocolic intussusception in the right abdomen. Symptoms resolved after contrast enemas, and he was discharged home. He re-presented similarly the next day and was found to be COVID-19 positive. Computed tomography scan demonstrated a left upper quadrant ileal-ileal intussusception. His symptoms spontaneously resolved, and he was discharged home. This suggests that COVID-19 may be a cause of intussusception in infants, and infants presenting with intussusception should be screened for this virus. Additionally, recurrence may happen days later at different intestinal locations. Caregiver education upon discharge is key to monitor for recurrence and need to return.

A shortened course of Amoxicillin/Clavulanate is the preferred antibiotic treatment after surgery for perforated appendicitis in children.

BACKGROUND/PURPOSE: Despite evidence supporting short course outpatient antibiotic treatment following appendectomy for perforated appendicitis, evidence of real-world implementation and consensus for antibiotic choice is lacking. We therefore aimed to compare outpatient antibiotic treatment regimens in a national cohort. METHODS: We identified children who underwent surgery for perforated appendicitis between 2010 and 2018 using the PearlDiver database and compared 45-day disease-specific readmission between children who received shortened (5-8 days) versus prolonged (10-14 day) total antibiotic courses (inpatient intravenous and/or oral) completed with outpatient Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, and compared antibiotic type (5-14 days) to each other. RESULTS: 4916 children were identified, 2001 (90.0%) treated with Amoxicillin/Clavulanate (5-14 days), 381 (19.0%) with shortened (5-8 days), 1464 (73.2%) with prolonged (10-14 days) courses. 222 (10.0%) were treated with Ciprofloxacin/Metronidazole, 44 (19.8%) with shortened, 174 (78.4%) with prolonged courses. Freedom from readmission was not different between prolonged and shortened course whether they received Amoxicillin/Clavulanate (adjusted hazard ratio [AHR] 1.54, 95%CI 0.95-2.5) or Ciprofloxacin/Metronidazole (AHR 3.49, 95%CI 0.45-27.3). Antibiotic type did not affect readmission rate (Amoxicillin/Clavulanate versus Ciprofloxacin/Metronidazole, AHR 1.21, 95%CI 0.71-2.05). CONCLUSION: Prolonged antibiotic regimens are routinely prescribed despite evidence suggesting shorter courses and antibiotic choice are not associated with greater treatment failure. As it is better tolerated, we recommend a shortened course of Amoxicillin/Clavulanate for oral management of perforated appendicitis. STUDY DESIGN: Retrospective. LEVEL OF EVIDENCE: Level III.

Reflux Surgery in Lung Transplantation: A Multicenter Retrospective Study.

BACKGROUND: Aspiration has been associated with graft dysfunction after lung transplantation, leading some to advocate for selective use of fundoplication despite minimal data supporting this practice. METHODS: We performed a multicenter retrospective study at 4 academic lung transplant centers to determine the association of gastroesophageal reflux disease and fundoplication with bronchiolitis obliterans syndrome and survival using Cox multivariable regression. RESULTS: Of 542 patients, 136 (25.1%) underwent fundoplication; 99 (18%) were found to have reflux disease without undergoing fundoplication. Blanking the first year after transplantation, fundoplication was not associated with a benefit regarding freedom from bronchiolitis obliterans syndrome (hazard ratio [HR], 0.93; 95% CI, 0.58-1.49) or death (HR, 0.97; 95% CI, 0.47-1.99) compared with reflux disease without fundoplication. However, a time-dependent adjusted analysis found a slight decrease in mortality (HR, 0.59; 95% CI, 0.28-1.23; P = .157), bronchiolitis obliterans syndrome (HR, 0.68; 95% CI, 0.42-1.11; P = .126), and combined bronchiolitis obliterans syndrome or death (HR, 0.66; 95% CI, 0.42-1.04; P = .073) in the fundoplication group compared with the gastroesophageal reflux disease group. CONCLUSIONS: Although a statistically significant benefit from fundoplication was not determined because of limited sample size, follow-up, and potential for selection bias, a randomized, prospective study is still warranted.