Guidelines on pediatric day surgery of the Italian Societies of Pediatric Surgery (SICP) and Pediatric Anesthesiology (SARNePI).

The Italian Society of Pediatric Surgery (SICP) together with The Italian Society of Pediatric Anesthesia (SARNePI) through a systematic analysis of the scientific literature, followed by a consensus conference held in Perugia on 2015, have produced some evidence based guidelines on the feasibility of day surgery in relation to different pediatric surgical procedures. The main aspects of the pre-operative assessment, appropriacy of operations and discharge are reported.

De-hospitalization of the pediatric day surgery by means of a freestanding surgery center: pilot study in the Lazio Region.

BACKGROUND: Day surgery should take place in appropriate organizational settings. In the presence of high volumes, the organizational models of the Lazio Region are represented by either Day Surgery Units within continuous-cycle hospitals or day-cycle Day Surgery Centers. This pilot study presents the regional volumes provided in 2010 and the additional volumes that could be provided based on the best performance criterion with a view to suggesting the setting up of a regional Freestanding Center of Pediatric Day Surgery. METHODS: This is an observational retrospective study. The activity volumes have been assessed by means of a DRG (Diagnosis Related Group)-specific indicator that measures the ratio of outpatients to the total number of treated patients (freestanding indicator, FI). The included DRGs had an FI exceeding the 3rd quartile present in at least a health-care facility and a volume exceeding 0.5% of the total patients of the pediatric surgery and urology facilities of the Lazio Region. The relevant data have been provided by the Public Health Agency and relate to 2010. The best performance FI has been used to calculate the theoretical volume of transferability of the remaining facilities into freestanding surgery centers. Patients under six months of age and DRGs common to other disciplines have been excluded. The Chi Square test has been used to compare the FI of the health-care facilities and the FI of the places of origin of the patients. RESULTS: The DRG provided in 2010 amounted to a total of 5768 belonging to 121 types of procedures. The application of the criteria of inclusion have led to the selection of seven final DRG categories of minor surgery amounting to 3522 cases. Out of this total number, there were 2828 outpatients and 694 inpatients. The recourse of the best performance determines a potential transfer of 497 cases. The total outpatient volume is 57%. The Chi Square test has pointed to a statistically significant difference of the facilities and to a non-significant difference of inferiority of the regional places of origin with respect to the city of Rome. CONCLUSIONS: The activity volumes would seem to support the setting up of a Freestanding Regional Center of Pediatric Day Surgery. This Center represents the healthcare facility that is most likely to allow a de-hospitalization process. Subsequent studies will be required to confirm the validity of this pilot study.

Willingness to pay for one-stop anesthesia in pediatric day surgery.

BACKGROUND: This study assesses the parents' Willingness To Pay (WTP) for One Stop Anesthesia (OSA). OSA is part of a free screening procedure that determines the timing of the anesthesiological assessment. In OSA-positive patients, the preoperative assessment is carried out on the same day as the surgery. The OSA allows patients who have to undergo surgery in a pediatric day surgery to avoid accessing the pre-admission clinic. METHOD: This is a descriptive cohort study. A sample of 106 parents were interviewed directly by means of a questionnaire. The questionnaire builds a hypothetical scenario where the interviewee has a chance to buy the OSA health service with the WTP. The WTP values are distributed in classes and are contingent to the market built in the questionnaire. The Chi Square and Cramer's V tests evaluate the WTP dependence on the parents' place of origin and occupation. RESULTS: The approximate average of the WTP classes is €87.21 per family. The Chi Square test relative to the WTP classes and the places of origin is statistically significant (p < 0.05). The Cramer's V test is 0.347 and points to a positive association between the two demographics. The Cramer's V test of the WTP classes and the types of job is 0.339 and indicates a positive association. CONCLUSION: Nearly 90% of pediatric patients who were screened for timing the preoperative assessment are true positives to OSA. This allows doing away with the pre-hospitalization, with definite advantages for the families. This screening is a health service that families would be hypothetically willing to pay.

Diagnostic accuracy of anesthesiology evaluation timing: the 'One-Stop Anesthesia' in pediatric day-surgery.

OBJECTIVE: Assessing timing efficacy of anesthetic evaluation in pediatric day-surgery by a diagnostic accuracy study. AIM: Lowering hospital visits in patients with negative medical history. BACKGROUND: Pediatric patients scheduled for day-surgery procedures can be categorized, according to their history, in two groups. One, the largest, includes healthy patients and the other includes those with medical conditions that necessitate further evaluation. MATERIALS AND METHODS: Clinical data are collected by the pediatric surgeons of our department and reviewed by an anesthetist who then selects the timing of anesthesiology evaluation, which will take place in the same day of the procedure (One-Stop Anesthesia), or some days before it, in a dedicated setting (Pre-Admission Clinic). In 2008, 332 children, older than 12 months, screened by that method, underwent surgical procedures in general anesthesia. RESULTS: Our data were examined using Bayesian Statistical Analysis. In the 'One-Stop Anesthesia' group, true positive were 290 (87.4%) and false positive 4 (1.2%). Of the 38 patients assessed by our Pre-Admission Clinic, true negative were 30 (9%) and false negative 8 (2.4%). Sensibility (97.3%), specificity (88.2%), positive predictive value (98.6%), negative predictive value (78.9%), diagnostic accuracy (96.4%), likelihood positive (8.3), and likelihood negative (0.03) were calculated. CONCLUSIONS: Timing the preoperative anesthesiologist's evaluation avoided 88% of hospital visits, usually to the Pre-Admission Clinic, and thus, it was cost effective, reducing direct and indirect costs of healthcare providers.

Usefulness of large pleural flap for the treatment of children with recurrent tracheoesophageal fistula.

PURPOSE: Recurrent tracheoesophageal fistula (RTF) complicates 5-11% of cases of children treated at birth for esophageal atresia with inferior tracheoesophageal fistula (ITF), and it represents an important problem of respiratory morbility and mortality. Surgical correction of RTF is complex with high incidence of recurrence. The aim of this work is to demonstrate the usefulness of large vascularized pleural flap in the treatment of RTF and the prevention of recurrences. METHODS: From 2000 to 2007, four children (3 males and 1 female) referred to our hospital for respiratory symptoms secondary to RTF. Diagnosis of RTF was made by bronchoscopy and esophagogram with contrast medium. Operative repair involved resection of the fistula, suture of trachea and esophagus followed by interposition of large vascularized pleural flap (PF). RESULTS: There were no complications during surgical procedure and after 48 h, with easy respiratory weaning after 24 h. Hospital discharge ranged from 5 to 10 days. Long-term follow-up (range 18 months-5 years) demonstrated no evidence of recurrences. CONCLUSION: Large vascularized PF to closure RTF is a highly effective and physiologic method for preventing second recurrences.

Prenatal diagnosis of duodenal obstruction selects cases with a higher risk of maternal-foetal complications and demands in utero transfer to a tertiary centre.

OBJECTIVES: It was the aim of this study to determine if prenatal diagnosis of congenital duodenal obstruction (CDO) selects high-risk pregnancies and demands special perinatal attention. METHODS: Medical records of 62 neonates with intrinsic CDO, admitted since 1981 in 2 institutions, were reviewed and divided into 2 groups: 39 cases, detected in utero by a prenatal ultrasonogram (group A), and 23 diagnosed at birth (group B). Prevalence of complete CDO, mean gestational age, mean birth weight, hydramnios, as well as maternal-foetal complications requiring emergency Caesarean section and associated with premature delivery were compared in the 2 groups. RESULTS: A complete CDO was found in 77% of patients in group A versus 48% of patients in group B (p < 0.02). Differences in mean gestational age and mean birth weight in the 2 groups were non-significant. Prenatally diagnosed patients presented a higher prevalence of hydramnios, maternal-foetal complications and premature delivery. CONCLUSIONS: Prenatal diagnosis selects patients with complete CDO and hydramnios. These pregnancies present a high incidence of maternal-foetal complications, which may require an emergency Caesarean section, and are frequently associated with premature delivery. These aspects must be considered in prenatal counselling. In utero transfer to a tertiary centre for delivery and appropriate perinatal care should be recommended.

Tracheomalacia in esophageal atresia. Usefulness of preoperative imaging evaluation for tailored surgical correction.

Tracheomalacia (TM) associated with esophageal atresia (OA) generally is located in the thoracic segment of the trachea, and the close anatomical relationships it has with the aortic arch and the other mediastinal structures play a remarkable role in the dynamic obstruction of the airways. Only correct preoperative imaging studies permit a precise anatomic description of TM, reducing the risk of incomplete treatment owing to the persistence of other undervalued problems. This report describes the usefulness of preoperative imaging by dynamic fiberoptic bronchoscopy and spiral multilayer computed tomography with 3-dimensional reconstruction in 7 symptomatic children with segmentary TM associated with esophageal atresia and treated surgically "case by case" based on dynamic fiberoptic bronchoscopy and computed tomography data.