Major morbidity and mortality associated with delays to emergent surgery in children: a risk-adjusted analysis.

BACKGROUND: Delay of emergency surgery contributes to morbidity and mortality, and physiologic status affects outcomes of patients requiring emergent surgery. Our purpose was to determine whether delays to emergent surgery in children were associated with increased major morbidity or mortality in a risk-adjusted population. METHODS: We performed a retrospective review of class 1 (≤ 60 min to operating room) surgical procedures from July 11, 2011, to July 30, 2016, at BC Children's Hospital, Vancouver. Data sources included the operating room database, patient charts, American Society of Anesthesiologists classification, Neonatal Acute Physiology (SNAP II) and Pediatric Risk of Mortality (PRISM III) scores, time from booking to operating room and outcome. Patients were classified as being at low or high risk for death. We defined major morbidity as unintended loss of an organ, limb or function related to surgery, and delay to surgery as more than 60 minutes from booking to in room. We used the χ2 test for univariate analysis and logistic regression for multivariate analysis. RESULTS: There were 384 cases (367 patients), 223 high-risk and 161 low-risk. The median age was 4 years (range 0 d-18 yr). Overall, 184 cases (47.9%) were delayed. Major morbidity occurred in 94 cases (24.5%), and 28 patients (7.6%) (all in the high-risk group) died. The mean time to the operating room was 1.46 hours for patients with major morbidity/mortality and 1.17 hours for those without. After adjustment for risk level, multivariate analysis showed delay to surgery to be associated with 85% increased odds of morbidity and/or mortality (adjusted odds ratio 1.85, 95% confidence interval 1.20-2.94) compared to no delay. CONCLUSION: Delay to emergent surgery was associated with a significant increase in major morbidity and/or mortality. Children who require emergency surgery need their care prioritized by not only operating room teams but also hospitals and government; otherwise, they will continue to experience unintended consequences.

Training low-middle-income (LMIC) pediatric surgeons in a high-income country (HIC) program.

BACKGROUND: A popular paradigm to support surgical education for low- and middle-income countries (LMICs) is partnering with high-income country (HIC) surgeons. These relationships may, however, be asymmetric and fail to optimally address the most pressing curricular needs. We explored the effectiveness of our LMIC-HIC educational partnership. METHODS: Through a partnership between a HIC (Canada) and a LMIC (Uganda), three candidate surgeons were commissioned for a custom designed 1-year training experience at our HIC accredited pediatric surgical training centre as part of their overall formal education. The training curriculum was developed in collaboration with the LMIC pediatric surgeon and utilized competency-based medical education principles. A Likert and short-answer survey tool was administered to these trainees upon completion of their training. RESULTS: All prescribed milestones as well as specialty certification by examination of the College of Surgeons of East, Central and Southern Africa was achieved by participating fellows, each of whom have begun clinical practice, leadership and teaching roles in their home country. Although several obstacles were identified by fellows, all agreed that the experience boosted their clinical and teaching abilities, and was worth the effort. CONCLUSION: This endeavour in global pediatric surgical training represents a significant innovation in surgical education partnerships and would be reproducible across different surgical subspecialties and contexts. Such collaborative efforts represent a feasible upskilling opportunity towards addressing global surgical service capacity. LEVEL OF EVIDENCE: V.

NeoCHIRP: A model for intestinal rehabilitation in the neonatal intensive care unit.

Multidisciplinary intestinal rehabilitation (IR) teams have transformed care in pediatric intestinal failure (IF).1 Although most children with IF are identified in the neonatal intensive care unit (NICU), IR teams may not be involved at this stage. We describe our collaborative model, blending NICU and IR expertise to optimize care. Over 6 years, the NeoCHIRP (Neonatal Children's IR Program) team followed 164 babies for weekly visits (median, 8; range, 1-27). Bedside rounds included CHIRP team physician and surgeons, neonatologist champion, attending neonatologist and fellow, NICU dietitian, bedside nurse, and family. Medical and nutrition status, nutrition history, and laboratory data were discussed, and a nutrition plan to support IR, considering the child's other medical needs, was created to guide the next week's management. Typical issues addressed included parenteral nutrition (PN) composition, enteral nutrition plan, oral feeding, management of small-intestinal bacterial overgrowth and sodium status, and cholestasis. A total of 164 babies were followed by the NeoCHIRP team. Of 153 survivors, IF resolved by discharge in 89% (136 of 153). Seventeen of 153 babies (11%) went on to require home PN and were transferred from NICU directly to the CHIRP team. By discharge, 99% of babies were orally fed (69/136, 50% fully, 67/136, 49% partially), and cholestasis improved or resolved in 80/105 (76%). Eleven babies (7%) died; four deaths were unrelated to IF, but in seven babies, IF was at least a contributing factor. In this high-risk cohort, most babies achieved good outcomes, and those who required longer-term IR transitioned smoothly to the CHIRP team.

The 51st annual meeting of the canadian association of pediatric surgeons.

This is the report of the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons held in Quebec City, Quebec, Canada, from September 19-21, 2019.

The 50th Annual Meeting of the Canadian Association of Pediatric Surgeons.

This is the report of the 50th Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) held in Toronto, Ontario, Canada, from September 26th to September 28th, 2018.

Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study.

BACKGROUND: Whereas the adult literature has demonstrated the acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in children. The purpose of this study is to compare the anastomotic outcomes of both techniques in children under 5years of age. METHODS: A retrospective analysis of patients undergoing intestinal anastomosis at a single tertiary centre (2012-2016) was undertaken. Demographics, diagnosis, anatomy, and complications were compared between the hand-sewn (HS) and stapled anastomosis (SA) groups. Primary outcomes were anastomotic leak and/or stricture requiring intervention. RESULTS: There were 72 patients with 90 intestinal anastomoses (67 HS, 23 SA). Baseline demographics between the two anastomotic groups were comparable. The overall anastomotic complication rate was 23.9% (HS) and 17.4% (SA). In the ileocolic subgroup, anastomotic complications occurred in 3/7 HS vs. 0/5 SA (ns). There were no statistically significant differences in primary outcomes between HS and SA. All SA complications occurred with 3.5 or 3.8mm staples. CONCLUSIONS: In our study population, no statistically significant difference between hand-sewn and stapled intestinal anastomosis outcomes was found. However, further investigation is warranted. LEVEL OF EVIDENCE: 3 (Retrospective Comparative Treatment Study).

Dressed for success? Silver impregnated nanocrystalline dressing for initial treatment of giant omphalocele.

OBJECTIVE: The purpose of this study was to describe outcomes and resource utilization in patients treated with twice-weekly silver impregnated (SI) nanocrystalline dressings for initial non-operative management of giant omphalocele (GO). METHODS: A retrospective review of patients with GO treated with SI dressings was undertaken. Clinical parameters, cost, and complications were recorded. RESULTS: Five patients with GO were treated with SI dressings between 2014 and 2016. Clinical characteristic (mean ± SD) included gestational age 36 ± 4 weeks, birth weight 2.6 ± 0.63 kg, GO size 10.2 ± 4.7 cm, ventilator days 7.5 ± 8.7 d, days in NICU 41 ± 20 d, days to full feeds, 30 ± 15 d, and LOS 62 ± 41 d. The average in-hospital cost of SI dressings was $110 CAD/week. This is comparable to daily silver sulfadiazine dressings ($109CAD/week) which were used historically. All patients were discharged with once- or twice-weekly dressing changes. No ruptures occurred. There was one mortality secondary to pulmonary sepsis. CONCLUSIONS: For initial non-operative management of GO, twice weekly SI nanocrystalline dressings is safe and effective. Use of SI dressings results in decreased handling of infants, reduced physician and nursing resource utilization, and favourable outcomes. LEVEL OF EVIDENCE: IV (Retrospective Case Series).

Pleurectomy versus pleural abrasion for primary spontaneous pneumothorax in children.

PURPOSE: Primary spontaneous pneumothorax (PSP) represents a common indication for urgent surgical intervention in children. First episodes are often managed with thoracostomy tube, whereas recurrent episodes typically prompt surgery involving apical bleb resection and pleurodesis, either via pleurectomy or pleural abrasion. The purpose of this study was to assess whether pleurectomy or pleural abrasion was associated with lower postoperative recurrence. METHODS: The records of patients undergoing surgery for PSP between February 2005 and December 2015 were retrospectively reviewed. Recurrence was defined as an ipsilateral pneumothorax requiring surgical intervention. Bivariate logistic regressions were used to identify factors associated with recurrence. RESULTS: Fifty-two patients underwent 64 index operations for PSP (12 patients had surgery for contralateral pneumothorax, and each instance was analyzed separately). The mean age was 15.7±1.2years, and 79.7% (n=51) of patients were male. In addition to apical wedge resection, 53.1% (n=34) of patients underwent pleurectomy, 39.1% (n=25) underwent pleural abrasion, and 7.8% (n=5) had no pleural treatment. The overall recurrence rate was 23.4% (n=15). Recurrence was significantly lower in patients who underwent pleurectomy rather than pleural abrasion (8.8% vs. 40%, p<0.01). In patients who underwent pleural abrasion without pleurectomy, the relative risk of recurrence was 2.36 [1.41-3.92, p<0.01]. CONCLUSION: Recurrence of PSP is significantly reduced in patients undergoing pleurectomy compared to pleural abrasion. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

Safety and Dosing Study of Glucagon-Like Peptide 2 in Children With Intestinal Failure.

BACKGROUND AND AIMS: A glucagon-like peptide 2 (GLP-2) analogue is approved for adults with intestinal failure, but no studies of GLP-2 have included children. This study examined the pharmacokinetics, safety, and nutritional effects of GLP-2 in children with intestinal failure. METHODS: Native human GLP-2(1-33) was synthesized following good manufacturing practices. In an open-label trial, with parental consent, 7 parenteral nutrition-dependent pediatric patients were treated with subcutaneous GLP-2 (20 µg/kg/d) for 3 days (phase 1) and, if tolerated, continued for 42 days (phase 2). Nutritional treatment was directed by the primary caregivers. Patients were followed to 1 year. RESULTS: Seven patients were enrolled (age: 4.0 ± 0.8 years; bowel length, mean ± SEM: 24% ± 4% of predicted). All were parenteral nutrition dependent since birth, receiving 44% ± 5% of calories by parenteral nutrition. GLP-2 treatment had no effect on vital signs (blood pressure, heart rate, and temperature) and caused no significant adverse events. Peak GLP-2 levels were 380 pM (day 3) and 295 pM (day 42), with no change in half-life or endogenous GLP-2 levels. Nutritional indices showed a numeric improvement in z scores and citrulline levels; the z score was maintained while citrulline levels returned to baseline once GLP-2 was discontinued. CONCLUSIONS: GLP-2 was well tolerated in children, with a pharmacokinetic profile similar to that of adults. There were no changes in endogenous GLP-2 release or metabolism. These results suggest that GLP-2 ligands may be safely used in pediatric patients; larger trials are suggested to investigate nutritional effects.

Chronic appendicitis in children.

QUESTION: While the diagnosis of acute appendicitis is relatively straightforward, chronic appendicitis is an entity that can be controversial and is often misdiagnosed. How and when should clinicians be investigating chronic appendicitis as a cause of chronic and recurrent abdominal pain in the pediatric population? ANSWER: Chronic appendicitis is a long-standing inflammation or fibrosis of the appendix that presents clinically as prolonged or intermittent abdominal pain. It is often a challenging diagnosis and might result in complications such as intra-abdominal infections or bowel obstruction or perforation. Clinical presentation, along with imaging studies, can help the clinician rule out other conditions, and among those who are diagnosed, for many children, appendectomy results in partial or complete resolution of pain symptoms.

Audit of emergent and urgent surgery for acutely ill pediatric patients: is access timely?

UNLABELLED: There is a paucity of literature about wait times for urgent/emergent surgeries in Canada. Delays and performance of non-emergent operations overnight increase morbidity and mortality. The study aim was to determine patterns of delays and performance of less-emergent surgery overnight. METHODS: A retrospective analysis (June 2011-December 2013) of emergent/urgent surgeries was conducted using the ORSOS database (prospective patient and operative data). Surgeries were classified: class 1, 2A, 2B, and 3: target times of 1, 6, 24 and 72h. In hours (IH)=7:45AM-3:30PM, M-F; others were out of hours (OOH) and overnight =2300-0700. RESULTS: There were 4668 operations: class 1 (5.8%), 2A (29.1%), 2B (42.1%), and 3(23%). For class 1, 2A, 2B, and 3 surgeries, mean in-room times were 2, 4.7, 15.4, and 54h respectively; 59.2% (class 1), 81.9% (class 2A), 81.2% (class 2B) and 74.4%(class 3) were performed in target. OOH occurred for 73.2% (class 1), 71.5%(class 2A), 54.7% (class 2B), and 27.7% (class 3). There were 37 class 2B and 3 surgeries overnight. There was a significant increase surgeries IH: 41.8% to 49.6%. CONCLUSION: The majority of urgent/emergent surgery occurred OOH and the most unstable patients are least likely to have their operation within target. LEVEL OF EVIDENCE: 4.

Major thrombotic complications with lower limb PICCs in surgical neonates.

BACKGROUND: PICC lines are now used routinely to provide central access for neonatal intensive care unit (NICU) patients. Neonates are known to be at risk for venous thromboembolism (VTE) related to central catheters. No literature exists about VTE PICC-related morbidity in the NICU abdominal surgery subgroup. METHODS: With REB approval, a retrospective review of a NICU database of PICC insertions performed at a tertiary children's hospital was conducted (January 2010-June 2013). Information about PICCs and complications was recorded. For patients with a major thrombotic complication, charts were reviewed. A major thrombotic complication was defined as a thrombosis which required medical and/or surgical intervention. RESULTS: 692 PICCs were inserted (485 in the upper extremity, 142 in the lower extremity, and 65 in the scalp). Seventy-four patients had significant intraabdominal pathology, and 5 had a major thrombotic complication. All patients with a major thrombotic complication had a lower extremity PICC which was at or below L1 (L1-S1) running parenteral nutrition. CONCLUSIONS: In the current study, only neonates with abdominal pathology and a lower extremity insertion site suffered major thrombotic complications from PICC lines. Given all patients' PICC tips were below the recommended location, more rigorous surveillance (with repositioning if required) may avoid these complications for future patients.

Mucous fistula refeeding in neonates with enterostomies.

BACKGROUND/PURPOSE: Neonates with intestinal pathology may require staged surgery with creation of an enterostomy and mucous fistula (MF). Refeeding (MFR) of ostomy output may minimize fluid and electrolyte losses and reduce dependence on parenteral nutrition (PN), though a paucity of evidence exists to support this practice. The purpose of this study was to assess the outcomes of infants undergoing MFR and document associated complications. METHODS: With REB approval, infants with intestinal failure undergoing MFR between January 2000 and December 2012 were identified. A chart review was conducted and relevant data were collected. Descriptive statistics were used. RESULTS: Twenty-three neonates underwent MFR. Mean gestational age and birth weight were 35weeks and 2416grams. Pathologies included intestinal atresia (n=12), necrotizing enterocolitis (n=5), meconium ileus (n=4), and other (n=6). Seven patients were able to wean from PN. Four patients had complications: 3 had perforation of the MF, 1 had bleeding. Four patients died, with one death directly attributable to MFR. CONCLUSIONS: In this cohort MF refeeding was associated with significant complications and ongoing PN dependence. With advances in intestinal rehabilitation and PN, the benefit of MF refeeding must be weighed against the potential complications.

A comparison of surgical outcomes between in-hours and after-hours tracheoesophageal fistula repairs.

BACKGROUND: Emerging literature has found increased complications for some patients undergoing nonemergent surgeries performed after-hours. For infants born with esophageal atresia and tracheoesophageal fistula (EA/TEF), no literature exists addressing the impact of the timing of surgery on outcomes. METHODS: With IRB approval, EA/TEF repairs (2005-2010) performed at a tertiary children's hospital were reviewed retrospectively. All patients had an esophageal anastomosis. After-hours surgeries were defined as 1530-0800 Monday to Friday, weekends/holidays. Demographics, EA/TEF type, operative details, anastomotic tension, and complications were compared. Outcomes measured included intraoperative desaturations, esophageal complications (leak, stricture, recurrence), pneumothorax, and mortality. RESULTS: There were 28 patients, of which 21 underwent the procedure in-hours and 7 after-hours. Patient age, gestational age, weight, EA/TEF type, cardiac anomalies, and preoperative, intraoperative, and postoperative variables were not different between the groups. Operative time, intraoperative desaturations, anastomotic tension, blood loss, total ventilation days, or length of hospitalization were not significantly different. There was a significant increase in esophageal leaks in the after-hours group (n=3) vs. the in-hours (n=0) group (p=0.014). CONCLUSIONS: In this study, infants with an EA/TEF repaired after-hours had a significant increase in anastomotic leaks. The observed increase in leaks requires further evaluation to ensure more optimal outcomes for this fragile group of patients.

Perioperative outcomes of primary renal tumour resections: comparison of in-hours to out-of-hours surgery.

PURPOSE: Primary resection is typically performed for children with localised suspected Wilms tumours. Resource limitation may necessitate performing these operations nights and weekends. We hypothesise that outcomes will be worse in patients having nephrectomies out-of-hours (OOH) compared to those in-hours (IH). METHODS: With IRB ethics approval, primary renal tumour resections performed on oncology patients from 1989-2011 were reviewed retrospectively. IH operations were defined as Monday-Friday 0745-1530 hours. Outcomes included major intraoperative complications, capsule rupture, and blood loss. Data were analysed using Fischer Exact and Mann-Whitney U tests. RESULTS: There were 64 patients with renal tumours who underwent primary resection. Forty-five procedures were performed IH, and 19 OOH. Groups were similar in age, ASA status, tumour size and grade. In a comparison of major intraoperative complications, capsule rupture, and mean blood loss, differences were 2 vs. 26% (p = 0.007), 27 vs. 42% (p = 0.12), 178 vs. 244 ml (p = 0.15) for IH and OOH respectively. There was one perioperative mortality (OOH). CONCLUSIONS: Primary renal tumour resections performed OOH were associated with an increase in major complications compared to those performed in standard hours. Avoidance of OOH operating where possible may reduce morbidity for children undergoing primary renal tumour resections.

Evaluation of sodium deficit in infants undergoing intestinal surgery.

BACKGROUND: Sodium is a critical growth factor for children. Severe deficits cause growth impairment and cognitive dysfunction. Both the diagnosis and risk of sodium depletion in children undergoing intestinal surgery are poorly understood. METHODS: With IRB approval, children undergoing intestinal surgery (2009-2012) who had a urine sodium measurement were retrospectively reviewed. Sodium deficits were defined: urine sodium <30 mmol/L and <10 mmol/L were deficient and severely deficient, respectively. Demographics, weight changes, and intake (sodium, fluid, and nutritional) were tabulated. Data were analyzed using regression analysis and Mann Whitney U tests. RESULTS: Thirty-nine patients, 51.3% female, with a gestational age of 32.2 weeks and weight of 1.43 kg were identified. The most common diagnoses were NEC (38.5%), intestinal atresia (20.5%), and isolated perforation (10.3%). Sodium deficiency was documented in 36/39 (92%) and 92.9% for those in continuity. Severe deficiency occurred in 64%. Urine sodium was significantly correlated with weight gain (p=0.002). Weight gain in patients with urine sodium <30 mmol/L was significantly decreased vs. those ≥30 mmol/L (+0.58 g/d vs. +21.6 g/d, p=0.016). CONCLUSION: In this population, sodium depletion is common in children undergoing intestinal surgery, even when the colon is in continuity. Correction of the sodium deficit to achieve urine sodium >30 mmol/L is associated with improved weight gain.