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Speck KE, Kulaylat AN, Baerg JE, Acker SN, Baird R, Beres AL, Chang H, Derderian SC, Englum B, Gonzalez KW, Kawaguchi A, Kelley-Quon L, Levene TL, Rentea RM, Rialon KL, Ricca R, Somme S, Wakeman D, Yousef Y, St Peter SD, Lucas DJ. Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee. J Pediatr Surg 2023; 58:1873-1885. [PMID: 37130765 DOI: 10.1016/j.jpedsurg.2023.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/15/2023] [Accepted: 03/31/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. METHODS Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. RESULTS Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment. CONCLUSIONS The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention. LEVEL OF EVIDENCE Level 4. TYPE OF STUDY Systematic Review of Level 1-4 studies.
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Affiliation(s)
- K Elizabeth Speck
- Mott Children's Hospital, University of Michigan, Division of Pediatric Surgery, Ann Arbor, MI, USA.
| | - Afif N Kulaylat
- Penn State Children's Hospital, Division of Pediatric Surgery, Hershey, PA, USA
| | - Joanne E Baerg
- Presbyterian Health Services, Division of Pediatric Surgery, Albuquerque, NM, USA
| | | | - Robert Baird
- British Columbia Children's Hospital, Vancouver, Canada
| | - Alana L Beres
- St. Christopher's Hospital for Children, Drexel University College of Medicine, Philadelphia, PA, USA
| | - Henry Chang
- Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | | | - Brian Englum
- University of Maryland Children's Hospital, Baltimore, MD, USA
| | | | | | | | | | - Rebecca M Rentea
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | | | - Robert Ricca
- University of South Carolina, Greenville, SC, USA
| | - Stig Somme
- Children's Hospital Colorado, Aurora, CO, USA
| | | | - Yasmine Yousef
- Montreal Children's Hospital, McGill University, Montreal, Canada
| | - Shawn D St Peter
- Children's Mercy-Kansas City, Department of Surgery, Kansas City, MO, USA
| | - Donald J Lucas
- Division of Pediatric Surgery, Naval Medical Center San Diego, CA, USA; Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Ott KC, McMahon MA, Vacek JC, Zeineddin S, Hu YY, Raval MV, Goldstein SD. The costs and benefits of emergent surgical workflow for acute appendicitis in children. J Pediatr Surg 2022; 57:896-901. [PMID: 35934527 DOI: 10.1016/j.jpedsurg.2022.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls. METHODS Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome. RESULTS 298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS. CONCLUSION Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States.
| | - Maxwell A McMahon
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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Butler H, Chrisanthopoulos V, Harous A, Eattimoottil SS, Senthilkumaran D, Tanious P, Wang B, Arruzza E. A scoping review of clinical practice guidelines for the diagnosis of primary spontaneous pneumothorax. J Med Imaging Radiat Sci 2022; 53:728-736. [PMID: 36184269 DOI: 10.1016/j.jmir.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 09/07/2022] [Accepted: 09/13/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION/BACKGROUND Primary spontaneous pneumothorax (PSP) is characterised by the onset of pneumothorax with no evidence of trauma or associated co-morbidities. Several clinical practice guidelines (CPGs) have been published regarding the management of PSP. Inconsistency in imaging protocols across clinics globally may indicate variability in the recommendations within these guidelines. We aimed to support clinical decision making with an assessment of CPGs regarding PSP diagnosis. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews was utilised. A systematic search of databases Medline, Embase, and Scopus was conducted. Manual searches of the grey literature and guideline-focused databases was undertaken Inclusion criteria included English-language CPGs pertaining to the management of PSP. Publications were independently extracted and critically appraised by two reviewers using the AGREE-II tool. Recommendations were assessed and tabulated. RESULTS Eight CPGs met the eligibility criteria. 16 recommendations were identified relating to assessment of medical history, physical examination, assessment of clinical stability, posterior-anterior chest X-ray (CXR) on held inspiration, computed tomography following inconclusive CXR, and ultrasound to complement other imaging modalities. CONCLUSION There is universal agreement on the exclusion of expiratory and lateral images in the conventional radiographic series, suggesting that these clinical behaviours may be influenced by local preferences or inhibitors to knowledge translation. This scoping review has summarised the key recommendations of CPGs regarding PSP diagnosis and assessed the methodological quality of the current evidence-base.
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Affiliation(s)
- Holly Butler
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Victoria Chrisanthopoulos
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Andreas Harous
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Stalin Saji Eattimoottil
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Darshna Senthilkumaran
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Philopater Tanious
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Bing Wang
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia
| | - Elio Arruzza
- UniSA Allied Health & Human Performance, University of South Australia, Adelaide, SA 5001, Australia.
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Contemporary Role of Computed Tomography in Managing Pediatric Primary Spontaneous Pneumothorax. J Surg Res 2022; 276:256-260. [PMID: 35398629 DOI: 10.1016/j.jss.2022.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 02/23/2022] [Accepted: 03/11/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION The value of chest computed tomography (CT) in pediatric primary spontaneous pneumothorax (PSP) remains controversial. This study sought to evaluate the utility of CT scans in a contemporary cohort of children with PSP. MATERIALS AND METHODS An institutional review board approval was obtained for a retrospective review of all children (aged ≤18 y) who underwent video-assisted thoracoscopic surgery (VATS) for PSP between 2009 and 2019 at a university-affiliated pediatric hospital. Preoperative CT scans were evaluated for diagnostic accuracy of the CT of bleb disease. RESULTS Thirty nine patients underwent VATS procedures for PSP, 34 (87%) of the patients were noted to have blebs. Twenty eight (72%) patients received preoperative CT scans with a 5.5:1 male to female ratio. On CT, 17 (61%) were diagnosed with blebs and all had blebs intraoperatively. CT did not identify disease in 11 patients, but seven had blebs intraoperatively. The positive and negative predictive values of preoperative CT for detecting ipsilateral bleb disease were 100% and 36%, respectively, with a sensitivity of 71%. Eleven patients had a contralateral disease on CT (39%). Five received elective contralateral VATS and three developed spontaneous PSP, with intraoperative blebs in all eight patients. Three never developed contralateral PSP. Six (21%) patients with no contralateral disease on CT developed spontaneous PSP with intraoperative blebs. CONCLUSIONS The decision to operate for PSP should be made based on clinical findings rather than on the presence or absence of blebs identified by CT.
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Wilson PM, Rymeski B, Xu X, Hardie W. An evidence-based review of primary spontaneous pneumothorax in the adolescent population. J Am Coll Emerg Physicians Open 2021; 2:e12449. [PMID: 34179877 PMCID: PMC8212556 DOI: 10.1002/emp2.12449] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Revised: 04/16/2021] [Accepted: 04/20/2021] [Indexed: 02/03/2023] Open
Abstract
Primary spontaneous pneumothorax (PSP) is a relatively common problem in emergency medicine. The incidence of PSP peaks in adolescence and is most common in tall, thin males. Recent advances in the care of patients with PSP have called into question traditional approaches to management. This clinical review highlights the changing management strategies for PSP and concludes with a proposed evidence-based pathway to guide the care of adolescents with PSP.
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Affiliation(s)
- Paria M. Wilson
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Emergency MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Beth Rymeski
- Division of Pediatric SurgeryCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
| | - Xuefeng Xu
- Department of RheumatologyImmunology & AllergyRespiratory MedicineThe Children's HospitalZhejiang University School of MedicineNational Clinical Research Center for Child HealthHangzhouChina
| | - William Hardie
- Department of PediatricsUniversity of CincinnatiCollege of MedicineCincinnatiOhioUSA
- Division of Pulmonary MedicineCincinnati Children's Hospital Medical CenterCincinnatiOhioUSA
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Hung CS, Chen YC, Yang TF, Huang FH. Systematic review and meta-analysis on juvenile primary spontaneous pneumothorax: Conservative or surgical approach first? PLoS One 2021; 16:e0250929. [PMID: 33930078 PMCID: PMC8087103 DOI: 10.1371/journal.pone.0250929] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/18/2021] [Indexed: 11/18/2022] Open
Abstract
Background Primary spontaneous pneumothorax (PSP) prevalence is typically higher in juvenile patients than in adults. We aimed to evaluate the optimal treatment for primary spontaneous pneumothorax and its efficacy and safety in juveniles. Materials and methods We searched PubMed, Embase, and Cochrane databases for eligible studies published from database inception to October 10, 2020, and conducted a systematic review and meta-analysis according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The primary and secondary outcomes were recurrence rate and hospital stay length, respectively. Odds ratios (OR) and mean differences were used for quantitatively analyzing binary and continuous outcomes, respectively. In total, nine retrospective studies with 1,452 juvenile patients (aged <21) were included for the quantitative analysis. The surgical approach led to a lower recurrence rate than did conservative approaches (OR: 1.95, 95% confidence interval: 1.15–3.32). Moreover, the recurrence rate was low in patients who underwent conservative treatment first and received surgery later. Conclusions Surgical approach for first-line management might have a greater effect on recurrence prevention than do conservative approaches. An upfront surgery might be an optimal choice for juvenile primary spontaneous pneumothorax.
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Affiliation(s)
- Chun-Shan Hung
- Department of Medical Education, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yang-Ching Chen
- Department of Family Medicine, Taipei Medical University Hospital, Taipei City, Taiwan
- Department of Family Medicine, School of medicine, College of medicine, Taipei Medical University, Taipei City, Taiwan
| | - Ten-Fang Yang
- Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
- Graduate Institute of Biomedical Informatics, Taipei Medical University and Hospital, Taipei City, Taiwan
| | - Fu-Huan Huang
- Department of Biological Science and Technology, National Chiao-Tung University, Hsinchu City, Taiwan
- Division of Pediatric Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei City, Taiwan
- * E-mail:
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