General Surgery Resident Operative Experiences in Solid Organ Injury: An Examination of Case Logs.

BACKGROUND: Non-operative management (NOM) of traumatic solid organ injury (SOI) has become commonplace. This paradigm shift, along with reduced resident work hours, has significantly impacted surgical residents' operative trauma experiences. We examined ongoing changes in residents' operative SOI experience since duty hour restriction implementation, and assessed whether missed operative experiences were gained elsewhere in the resident experience. METHODS: We examined data from American College of Graduate Medical Education case log reports from 2003 to 2018. We collected mean case volumes in the categories of non-operative trauma, trauma laparotomy, and splenic, hepatic, and pancreatic trauma operations; case volumes for comparable non-traumatic solid organ operations were also collected. Solid organ injury operative volumes were compared against non-traumatic cases, and change over time was analyzed. RESULTS: Over the study period, both trauma laparotomies and non-operative traumas increased significantly (P < .001). In contrast, operative volumes for splenic, hepatic, and pancreatic trauma all significantly decreased (P < .001; P = .014; P < .001, respectively). Non-traumatic spleen cases also significantly decreased (P < .001), but liver cases and distal pancreatectomies increased (P < .001; P = .017). Pancreaticoduodenectomies increased, albeit not to a significant degree (P = .052). CONCLUSIONS: Continuing increases in NOM of SOI correlate with declining resident experience with operative solid organ trauma. These decreases can adversely affect residents' technical skills and decision-making, although trends in specific non-traumatic areas may help to mitigate such losses. Further work should determine the impact of these trends on resident competence and autonomy.

Secondary overtriage in a pediatric level one trauma center.

BACKGROUND: Previous studies have explored under- and overtriage, and the means by which to optimize these rates. Few have examined secondary overtriage (SO), or the unnecessary transfer of minimally injured patients to higher level trauma centers. We sought to determine the incidence and impact of SO in our pediatric level one trauma center. METHODS: We performed a retrospective analysis of all trauma activations at our institution from 2015 through 2017. SO was defined as transferred patients who required neither PICU admission nor an operation, with ISS ≤ 9 and LOS ≤ 24 h. We compared SO patients against all trauma activation transfers, and against similar non-transferred patients. RESULTS: We identified 1789 trauma activations, including 766 (42.8%) transfers. Of the transfers, 335 (43.7%) met criteria for SO. Compared to other transfers, SO patients had a shorter mean travel distance (52.9 v 58.1 mi; p = 0.02). Compared to similar patients transported from the trauma scene, SO patients were more likely to be admitted (52.2% v 29.2%; p < 0.001), with longer inpatient stay and greater hospital charges. CONCLUSIONS: SO represents an underrecognized burden to trauma centers which could be minimized to improve resource allocation. Future research should evaluate trauma activation criteria for transferred pediatric patients.

Decreasing surgical site infections in pediatric stoma closures.

INTRODUCTION: Gastrointestinal (GI) operations represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. We have previously demonstrated that a GI bundle decreases SSI rates, length of stay (LOS), and hospital charges. Following this success, we hypothesized that by targeting the preoperative antibiotics for stoma closures based on organisms found in infected wounds, we could further decrease SSI rates. METHODS: As part of a broad quality improvement effort to reduce SSI rates, we reviewed the responsible pathogens and their sensitivities as well as the preoperative antibiotic used, and found that 15% of wound infections were caused by enterococcus. Based on this information, starting in April 2017, we changed the prior preoperative antibiotic cefoxitin to ampicillin-sulbactam, which more accurately targeted the prevalent pathogens from April 2017 to October 2018. RESULTS: The baseline SSI rate for all stoma takedown patients was 21.4% (25 of 119). After bundle implementation, this decreased to 7.9% (17 of 221; p = 0.03) over a period of 2.5 years. Then, after changing the preoperative antibiotics, our rate of SSI decreased further to 2.2% (1 of 44; p = 0.039) over a period of 1.5 years. CONCLUSION: Significant reduction of SSI in GI surgery can be accomplished with several prevention strategies (our GI bundle). Then a change of the preoperative antibiotic choice, chosen based on causative wound infection organisms, may further decrease SSI rates. We recommend an institution specific analysis of wound infections and modification of preoperative antibiotics if the responsible organisms are resistant to the original antibiotic choice. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level III.

An Enhanced Recovery Protocol that Facilitates Same-day Discharge for Simple Laparoscopic Appendectomies.

Acute appendicitis is the most common gastrointestinal condition requiring urgent operation in the pediatric population with laparoscopic appendectomy (LA) being the current surgical technique. We describe the implementation of a standardized protocol to reduce postoperative nausea and vomiting (PONV) and facilitate same-day discharge after LA. METHODS: A multidisciplinary team developed this protocol to facilitate same-day discharge after observing high rates of overnight stay due to PONV among simple appendectomies performed in 2011-2012. The protocol was implemented in November 2014 and underwent a revision in June 2016. Following the implementation of the protocol, we monitored the patients undergoing an LA at Nationwide Children's Hospital between November 2014 and August 2017. RESULTS: We identified 691 patients (255 female) who underwent a simple LA at Nationwide Children's Hospital between November 2014 and August 2017. The patient population had a median age of 11 years (interquartile range: 9, 14). Among these patients, 514 (74%) were discharged on the day of surgery, and 387 (56%) were protocol compliant. The rate of same-day discharge was higher for compliant cases (79%) than noncompliant cases (69%, P = 0.003). Multivariable statistical analysis associated compliance with an increased likelihood of same-day discharge (Odds ratio [OR] = 1.7, 95% CI: 1.2, 2.4, P = 0.002). CONCLUSIONS: Implementation of the LA protocol to reduce PONV demonstrated a significant increase in the rate of same-day discharge from the hospital among compliant patients. Also, the adoption of a protocol to select patients for early discharge after LA has shown results with a 45% reduction in the need for inhospital beds.

Gangrenous appendicitis: No longer complicated.

BACKGROUND: Appendicitis presents on a spectrum ranging from inflammation to gangrene to perforation. Studies suggest that gangrenous appendicitis has lower postoperative infection rates relative to perforated cases. We hypothesized that gangrenous appendicitis could be successfully treated as simple appendicitis, reducing length of stay (LOS) and antibiotic usage without increasing postoperative infections. METHODS: In February 2016, we strictly defined complex appendicitis as a hole in the appendix, extraluminal fecalith, diffuse pus or a well-formed abscess. We switched gangrenous appendicitis to a simple pathway and reviewed all patients undergoing laparoscopic appendectomy for 12 months before (Group 1) and 12 months after (Group 2) the protocol change. Data collected included demographics, appendicitis classification, LOS, presence of a postoperative infection, and 30-day readmissions. RESULTS: Patients in Group 1 and Group 2 were similar, but more cases of simple appendicitis occurred in Group 2. Average LOS for gangrenous appendicitis patients decreased from 2.5 to 1.4 days (p < 0.001) and antibiotic doses decreased from 5.2 to 1.3 (p < 0.001). Only one gangrenous appendicitis patient required readmission, and one patient in each group developed a superficial infection; there were no postoperative abscesses. CONCLUSIONS: Gangrenous appendicitis can be safely treated as simple appendicitis without increasing postoperative infections or readmissions. TYPE OF STUDY: Prognosis study. LEVEL OF EVIDENCE: Level II.

Ambulatory pediatric surgery.

Ambulatory pediatric surgery has become increasingly common in recent years, with greater numbers of procedures being performed on an outpatient basis. This practice has clear benefits for hospitals and healthcare providers, but patients and families also often prefer outpatient surgery for a variety of reasons. However, maximizing the potential opportunities requires critical attention to patient and procedure selection, as well as anesthetic choice. A subset of outpatient procedures can be performed as single visit procedures, further simplifying the process for families and providers.

Standardized ultrasound templates for diagnosing appendicitis reduce annual imaging costs.

BACKGROUND: Ultrasound is preferred over computed tomography (CT) for diagnosing appendicitis in children to avoid undue radiation exposure. We previously reported our experience in instituting a standardized appendicitis ultrasound template, which decreased CT rates by 67.3%. In this analysis, we demonstrate the ongoing cost savings associated with using this template. METHODS: Retrospective chart review for the time period preceding template implementation (June 2012-September 2012) was combined with prospective review through December 2015 for all patients in the emergency department receiving diagnostic imaging for appendicitis. The type of imaging was recorded, and imaging rates and ultrasound test statistics were calculated. Estimated annual imaging costs based on pretemplate ultrasound and CT utilization rates were compared with post-template annual costs to calculate annual and cumulative savings. RESULTS: In the pretemplate period, ultrasound and CT rates were 80.2% and 44.3%, respectively, resulting in a combined annual cost of $300,527.70. Similar calculations were performed for each succeeding year, accounting for changes in patient volume. Using pretemplate rates, our projected 2015 imaging cost was $371,402.86; however, our ultrasound rate had increased to 98.3%, whereas the CT rate declined to 9.6%, yielding an annual estimated cost of $224,853.00 and a savings of $146,549.86. Since implementation, annual savings have steadily increased for a cumulative cost savings of $336,683.83. CONCLUSIONS: Standardizing ultrasound reports for appendicitis not only reduces the use of CT scans and the associated radiation exposure but also decreases annual imaging costs despite increased numbers of imaging studies. Continued cost reduction may be possible by using diagnostic algorithms.

U.S. Pediatric Burn Patient 30-Day Readmissions.

The objectives of the study were to determine unscheduled 30-day readmission rates for pediatric burn patients and to identify readmission reasons. We used the 2013-2014 National Readmission Database to produce 30-day all-cause unscheduled readmission rates by patient and hospital characteristics. Readmission risk factors were evaluated with multivariable logistic regression. An estimated 11,940 U.S. pediatric burn patients were discharged in January through November 2013 and 2014, and 325 had unscheduled readmissions within 30 days (2.7%; 95% confidence interval [CI], 1.5-3.9). This rate is higher than that seen in pediatric trauma patients (1.7%; P = 0.04]. Higher rates were seen in children with TBSA burned ≥ 10% (4.1%; 95% CI, 2.3-6.0) and patients with third-degree burns (5.5%; 95% CI, 1.4-9.6). The majority (86%) had index admissions in hospitals treating 100 or more burn patients annually, and 98% returned to the same hospital. Over two-thirds had an operating room procedure during their readmission; 15% had infections. The highest adjusted odds of readmission (AOR = 2.7; 95% CI, 1.7-4.2) was for patients with third-degree burns. When compared with patients with lengths of stay (LOS) of 1 day, those with LOS of 2 to 3 days had a higher odds (AOR = 1.7; 95% CI, 1.03-2.9), but the AOR was not different for those with LOS > 3 days. TBSA, index operating room procedure, and patient residence were associated with readmission. This national dataset enhances our ability to predict patients at risk for unscheduled readmission and to plan for appropriate patient discharge, potentially reducing readmissions.

Effective methods to decrease surgical site infections in pediatric gastrointestinal surgery.

BACKGROUND: Gastrointestinal (GI) surgeries represent a significant proportion of the surgical site infection (SSI) burden in pediatric patients, resulting in significant morbidity. Previous studies have shown that perioperative bundles reduce SSIs, but few have focused on pediatric GI operations. We hypothesized that a GI bundle would decrease SSI rates, length of stay (LOS), and hospital charges. METHODS: After establishing baseline SSI rates, a GI bundle was created and implemented in November 2014. We prospectively collected data including demographics, procedure type, LOS, inpatient charges, bundle compliance, and SSI development. We analyzed SSI rates, LOS, and charges using process control charts. RESULTS: The baseline SSI rate for all GI operations was 3.4%, which increased to 7.1%, then decreased to 4.7%. Midgut/hindgut and stoma closure SSI rates decreased from 11.3% to 8.0% (p<0.05) and 21.4% to 7.9%, respectively (p<0.05). Although overall LOS and charges were unchanged, average LOS for midgut/hindgut surgeries and stoma closures decreased from 20.3 to 13.6days (p=0.015) and 12.6 to 7.9days (p=0.04), respectively. Stoma closure charges decreased from $94,262 to $50,088 (p=0.01). CONCLUSIONS: Our perioperative GI bundle decreased SSI rates, primarily among midgut/hindgut operations. Bundle usage decreased LOS and charges most effectively in stoma closures. TYPE OF STUDY: Prognosis Study. LEVEL OF EVIDENCE: Level 2.

The use of spinal angiography in the management of posterior mediastinal tumors: case series and review of the literature.

INTRODUCTION: Resection of inferiorly located posterior mediastinal tumors can be complicated by their proximity to the artery of Adamkiewicz (AKA). Although uncommon, intraoperative injury to the AKA may result in paraparesis or paralysis secondary to spinal cord ischemia. The use of preoperative spinal angiography may serve as a useful adjunct to the surgeon in guiding extent of resection of the tumor to avoid injury to this critical artery. METHODS: After IRB approval (H-31712), three patients, from 2008 to 2011, with lower posterior mediastinal tumors were identified. Their charts were reviewed for information concerning preoperative imaging, operative details, and postoperative neurologic complications. The literature regarding imaging of the AKA, cases of injury in pediatric patients, and recommendations for treatment after its injury were reviewed. RESULTS: One patient, who did not have preoperative spinal angiography, developed transient paresis lasting 6 weeks after posterior mediastinal tumor resection. Two patients underwent preoperative spinal angiography with successful localization of the AKA. In both cases, the patients subsequently underwent posterior mediastinal tumor resection without injury to the artery and without postoperative neurologic sequelae. CONCLUSIONS: Preoperative spinal angiography may serve as a useful adjunct in the evaluation of children with inferior posterior mediastinal tumors in order to delineate the relationship of the artery of Adamkiewicz to the tumor for the purpose of guiding surgical resection.

Congenital hepatic cyst with antenatal diagnosis: a case report and literature review.

Congenital hepatic cysts are rare lesions of infancy. While operative management and outcomes have been extensively studied in adult patients with hepatic cysts, data in pediatric patients are limited. We discuss our experience in an infant and review relevant literature regarding operative technique and surgical outcomes.