Reducing Constipation-Related Admissions: The Effectiveness of Antegrade Continence Enema Procedures in Children.

INTRODUCTION: Constipation in pediatrics remains a common problem. Antegrade continence enema (ACE) procedures have been shown to decrease the distress of daily therapy. Patients are able to administer more aggressive washouts in the outpatient setting. Therefore, we hypothesize that patients following an ACE procedure would have reduced admissions for constipation. METHODS: Patients who underwent an ACE procedure at a large children's hospital from 2015 to 2018 were included. Demographics, diagnosis, procedure, and preoperative/postoperative hospital admissions were analyzed. RESULTS: Forty-eight patients were included in the study. Over half were diagnosed with idiopathic constipation. Majority of patients underwent an appendicostomy (88%, n = 42). Preoperatively, 26 patients were admitted for a combined total of 63 times for constipation. Postoperatively, 4 patients were admitted for a total of 5 visits (P = .021). Twenty-eight patients required a nonscheduled appendicostomy tube replacement. CONCLUSION: This study demonstrates ACE procedures can improve constipation-related symptoms in children and are associated with decrease hospital admissions.

Perforated Appendicitis During a Pandemic: The Downstream Effect of COVID-19 in Children.

INTRODUCTION: Coronavirus Disease-19 (COVID-19) was declared a pandemic in March 2020. States issued stay-at-home orders and hospitals cancelled non-emergent surgeries. During this time, we anecdotally noticed more admissions for perforated appendicitis. Therefore, we hypothesized that during the months following the COVID-19 pandemic declaration, more children were presenting with perforated appendicitis. MATERIALS AND METHODS: This is a retrospective cohort study reviewing pediatric patients admitted at a single institution with acute and/or perforated appendicitis between October 2019 to May 2020. Interval appendectomies were excluded. COVID-19 months were designated as March, April, and May 2020. Additional analysis of March, April, and May 2019 was performed for comparison purposes. Analyzed data included demographics, symptoms, white blood cell count, imaging findings, procedures performed, and perforation status. Statistical analysis was performed. RESULTS: During the study period, 285 patients were admitted with the diagnosis of acute appendicitis with 95 patients being perforated. We identified a significant increase in perforated appendicitis cases in the three COVID-19 months compared with the preceding five months (45.6% vs 26.4%; P <0.001). In addition, a similar significant increase was identified when comparing to the same months a year prior (P = 0.003). No significant difference in duration of pain was identified (P=0.926). CONCLUSION: The COVID-19 pandemic and its associated stay-at-home orders have had downstream effects on healthcare. Our review has demonstrated a significant increase in the number of children presenting with perforated appendicitis following these stay-at-home ordinances. These results demonstrate that further investigations into the issues surrounding access to healthcare, especially during this pandemic, are warranted.

The diminishing experience in pediatric surgery for general surgery residents in the United States.

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) regulates the general surgery residency curriculum. Case volume remains a priority as recent concerns surrounding a lack of proficiency for certain surgical cases have circulated. We hypothesize that there is a significant decrease in pediatric surgery case numbers during general surgery residency despite residents meeting the minimum case requirements. METHODS: We reviewed publicly available ACGME case reports for general surgery residency from 1999 to 2018. Cases are classified as Surgeon Chief or Surgeon Junior. Analyzed data included case classifications, number of residents, and number of residency programs. Simple linear regression analysis was performed. RESULTS: We identified a significant decrease in total number of logged pediatric surgery cases over the past 20 years (p<0.001). Nearly 60% of cases were logged under a single category - inguinal/umbilical hernia. From the past five years, pyloric stenosis was the only other category with an average of greater than two cases logged (range 2.1-2.8). CONCLUSION: We identified a significant decrease in total pediatric surgery case numbers during general surgery residency from 1999 to 2018. Though meeting set requirements, overall case variety was limited. With minimal number of cases required by the ACGME, graduating general surgery residents may lack proficiency in simple pediatric surgery cases.

A Novel Use of Artificial Intelligence to Examine Diversity and Hospital Performance.

BACKGROUND: The US population is becoming more racially and ethnically diverse. Research suggests that cultural diversity within organizations can increase team potency and performance, yet this theory has not been explored in the field of surgery. Furthermore, when surveyed, patients express a desire for their care provider to mirror their own race and ethnicity. In the present study, we hypothesize that there is a positive correlation between a high ranking by the US News and World Report for gastroenterology and gastrointestinal (GI) surgery and greater racial, ethnic, and gender diversity among the physicians and surgeons. METHODS: We used the 2019 US News and World Report rankings for best hospitals by specialty to categorize gastroenterology and GI surgery departments into 2 groups: 1-50 and 51-100. Hospital websites of these top 100 were viewed to determine if racial diversity and inclusion were highlighted in the hospitals' core values or mission statements. To determine the rates of diversity within departments, Betaface (Betaface.com) facial analysis software was used to analyze photos taken from the hospitals' websites. This software was able to determine the race, ethnicity, and gender of the care providers. We examined the racial and ethnic makeup of the populations served by these hospitals to see if the gastroenterologists and surgeons adequately represented the state population. We then ran the independent samples t-test to determine if there was a difference in rankings of more diverse departments. RESULTS: Hospitals with gastroenterology and GI surgery departments in the top 50 were more likely to mention diversity on their websites compared with hospitals that ranked from 51-100 (76% versus 56%; P = 0.035). The top 50 hospitals had a statistically significant higher percentage of underrepresented minority GI physicians and surgeons (7.01% versus 4.04%; P < 0.001). In the 31 states where these hospitals were located, there were more African Americans (13% versus 3%; P < 0.001) and Hispanics (12% versus 2%; P < 0.001), while there were fewer Asians (4% versus 21%; P < 0.001) in the population compared with the faculty. CONCLUSIONS: We used artificial intelligence software to determine the degree of racial and ethnic diversity in gastroenterology and GI surgery departments across the county. Higher ranking hospitals had a greater degree of diversity of their faculty and were more likely to emphasize diversity in their mission statements. Hospitals stress the importance of having a culturally diverse staff, yet their care providers may not adequately reflect the populations they serve. Further work is needed to prospectively track diversity rates over time and correlate these changes with measurable outcomes.

The Fellowship Effect: Does Surgical Subspecialty Training Affect Pediatric Surgery Case Volume?

PURPOSE: The Accreditation Council for Graduate Medical Education (ACGME) monitors fellow case numbers. Previous literature has shown new fellowships detrimentally affecting general surgery residency case numbers. We hypothesize that an increase in pediatric otolaryngology and pediatric urology fellowships would decrease overlapping case numbers in pediatric surgery fellowships. MATERIALS AND METHODS: A review of each specialties' fellowship match results was performed. Publicly available pediatric surgery cases logs were reviewed for overlapping cases including thyroidectomy, parathyroidectomy, branchial cleft cyst excision, thyroglossal duct cyst excision, major neck tumor excision, nephrectomy, orchidopexy, inguinal hernia, and testicular torsion. Analyzed data included average case numbers and number of fellows each year. Linear regression analysis was performed. RESULTS: We identified a significant increase in fellowship graduates from 2003 to 2018 (p < 0.006). Reviewed cases showed little fluctuation despite an increase in graduates. A decrease in tumor-related nephrectomies and orchidopexies was identified for pediatric surgery fellows (p < 0.001; p < 0.004). Though significant, nephrectomy fluctuation was between 2 and 4 cases. Similarly, we identified a significant rise in thyroidectomies (p < 0.001). Again, the increase was by 3 cases each year. CONCLUSIONS: Despite the increase in number of fellowships, there has been a minimal overall effect on pediatric surgery case volume. Continuing to monitor these trends will help ensure adequate training for all pediatric surgical subspecialties.

Effect of the COVID-19 Pandemic on Pediatric Intestinal Failure Healthcare Delivery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has influenced how healthcare is being provided, particularly in patients whose diagnoses require multidisciplinary care, such as pediatric intestinal failure (IF). We sought to ascertain the effects of the COVID-19 pandemic on healthcare delivery for pediatric patients with IF. METHODS: A 20-question survey was administered to members of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Intestinal Rehabilitation (IR) Special Interest Group. Input values were "yes" and "no," along with a free-text response. Following a 10-day open survey period, data were divided into cohorts based on patient population size and disease burden by state. Analysis was then performed using the χ2 test application. RESULTS: Responses from 29 centers were included in analysis. Centers that followed >50 patients on parenteral nutrition (PN) were more likely to have social workers present in telemedicine visits and observed more central line difficulties among families. Centers located in states with <40,000 reported cases of COVID-19 saw patients less frequently and were more likely to withhold changes to PN prescriptions. Additionally, the survey revealed a significant degree of financial hardship and food insecurity among families. CONCLUSION: Many aspects of pediatric IF healthcare delivery have been impacted by the COVID-19 pandemic, both for care providers and caregivers. Despite the availability of telemedicine, IR centers should remain attentive to the global needs of the pediatric IF patient, as well as their families.

The Disturbing Findings of Pediatric Firearm Injuries From the National Trauma Data Bank: 2010-2016.

BACKGROUND: Trauma is the leading cause of pediatric and adolescent morbidity and mortality. Firearm-related injuries and deaths contribute substantially to the overall disease burden. This study described the intent, location, demographics, and outcomes of a nationally representative pediatric population with firearm injuries. We hypothesized that younger patients would have a higher percentage of unintentional and self-inflicted injuries with associated higher mortality rates. MATERIALS AND METHODS: The National Trauma Data Bank, maintained by the American College of Surgeons, from 2010 to 2016 was utilized. All pediatric patients (0-19 y) with firearm injuries who had complete data were analyzed for mechanism, location, demographics, and outcomes. Basic descriptive statistics were used to compare subgroups. Multivariable logistic regression analysis was applied to investigate risk factors for firearm injury-caused mortality. RESULTS: In the study period, 46,039 pediatric patients sustained firearm injuries (median age = 17 y). Males, Blacks, ages 15-19, and the Southern region were the most common injured demographics. However, subgroup analysis showed the demographics differ for self-inflicted and unintentional firearm injuries, which had significantly higher White patients (66.6% and 47.9%, respectively; P < 0.001). Nearly 76% of injuries were related to assaults, 14% were unintentional, 5% were self-inflicted, and 5% were undetermined. The overall mortality was nearly 12%. The youngest population had higher proportion of unintentional injuries and highest mortality rate when compared with other classifications of intent (P < 0.001). CONCLUSIONS: Pediatric firearm injuries have high mortality, especially in the youngest populations. Age-tailored prevention strategies, such as strict child access prevention laws and enforced gun storage violations, may help in reducing firearm injuries and improving health outcomes.

Esophageal Foreign Body Management in Children: Can It Wait?

Introduction: Pediatric foreign body ingestion remains a common reason for emergency department (ED) visits. Button battery ingestion is an established surgical emergency, requiring immediate removal. Timing of removal for other foreign bodies remains controversial. We hypothesize that there is no difference in complication rate or successful removal of esophageal foreign bodies that wait until the following morning for removal. Materials and Methods: A retrospective review for cases involving esophageal foreign body removal by pediatric surgery or pediatric gastroenterology from November 2015 to November 2019 was performed. Patients were divided into two groups based on ED arrival-daytime (05:00-16:59); nighttime (17:00-04:59). Imaging confirmed an esophageal foreign body. Data collected included basic demographics, time of presentation, time of procedure, symptoms, location of the foreign body, and complications within 30 days. Statistical analysis was performed. Results: After excluding button batteries, 273 children underwent esophageal foreign body removal. Two-thirds presented at night. A significant difference was identified in the median time from ED to the operating room when comparing daytime (194.8 minutes; interquartile range [IQR]: 108.5-347) versus nighttime groups (643 minutes; IQR: 471.5-745; P < .001). Nine children had a complication or readmission within 30 days of their procedure and 25 patients had migration of their foreign body into the stomach, both with no significant difference (P = .94; P = .98, respectively). Conclusion: We found that waiting until the following morning had minimal impact on complications or success rate when removing esophageal foreign bodies. By waiting, institutions with limited personnel can keep resources and staff available for more pressing emergencies.

Curriculum Change Needed: A Decline in Antireflux Surgery in the Pediatric Surgery Fellowship.

BACKGROUND: Case number requirements by the Accreditation Council for Graduate Medical Education (ACGME) have recently changed in general surgery residency and pediatric surgery fellowship. Overall, pediatric surgery fellowship case volumes remain high, but there may be limited exposure to many index cases. We hypothesize that pediatric antireflux surgery is decreasing nationally, and this trend is independent of the fluctuating number of pediatric surgery fellows. MATERIALS AND METHODS: A review of publicly available ACGME case reports from 2003 to 2018 was performed. Both open and laparoscopic antireflux surgery cases were evaluated. Analyzed data included average case number per fellow, minimum and maximum case numbers, and number of fellows each year. Simple and multiple linear regression analyses were performed. RESULTS: We identified a significant relationship (P < 0.001) between the total number of antireflux procedures and the years of operation. The slope coefficient was -1.45, meaning the number of operations decreased by an average of 1.45 per year from 2003 to 2018 . The number of fellows fluctuated during this time period (range: 24-45). With multiple linear regression analysis, we found that the number of fellows did not affect the decline of antireflux surgery seen over the years (P = 0.91). CONCLUSIONS: Case numbers continue to be an important topic in ACGME discussions for surgical residency and subspecialty fellowships. Our review has shown a national decline in the number of pediatric antireflux surgeries performed in pediatric surgery fellowship. Identifying additional trends in surgical management of diseases may aid in the evolution of the pediatric surgery curriculum.

A Synopsis of Pediatric Patients With Hepatoblastoma and Wilms Tumor: NSQIP-P 2012-2016.

BACKGROUND: Hepatoblastoma and Wilms tumor are the most common primary liver and kidney tumor in children, respectively, and little is documented about patient outcomes in the immediate perioperative period. The aim of this study was to analyze the short-term outcomes of pediatric patients after surgical resection for hepatoblastoma and Wilms tumor. METHODS: We queried the 2012-2016 ACS National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database for patients with hepatoblastoma who underwent liver resection and patients with Wilms tumor who underwent a partial or total nephrectomy. Patient demographics, preoperative, intraoperative, and postoperative characteristics were analyzed. Multivariate logistic regression was used to determine independent risk factors for unplanned reoperations. RESULTS: There were a total of 189 patients with hepatoblastoma and 586 patients with Wilms in National Surgical Quality Improvement Program-Pediatric. The mean age of patients with hepatoblastoma was 3.1 y and 4.2 y in the Wilms group. Nine percent (n = 17) of patients underwent an unplanned reoperation after hepatectomy, and 4.1% (n = 24) of patients with Wilms experienced an unplanned reoperation. Over half of patients with hepatoblastoma (59.8%, n = 113) and 29.7% (n = 174) patients with Wilms tumor received a blood transfusion in the perioperative period. Patients in both groups demonstrated low rates of surgical site infections, but 6.3% (n = 12) of hepatoblastoma patients showed evidence of sepsis. CONCLUSIONS: This study will allow providers to more effectively counsel families of the common morbidities in the associated perioperative period following surgical resection of either solid tumor type including the substantial risk of blood transfusion.