Management of undifferentiated embryonal sarcoma of the liver: A Pediatric Surgical Oncology Research Collaborative study

BACKGROUND

Undifferentiated embryonal sarcoma of the liver (UESL) is a rare tumor for which there are few evidence-based guidelines. The aim of this study was to define current management strategies and outcomes for these patients using a multi-institutional dataset curated by the Pediatric Surgical Oncology Research Collaborative.

METHODS

Data were collected retrospectively for patients with UESL treated across 17 children's hospitals in North America from 1989 to 2019. Factors analyzed included patient and tumor characteristics, PRETEXT group, operative details, and neoadjuvant/adjuvant regimens. Event-free and overall survival (EFS, OS) were the primary and secondary outcomes, respectively.

RESULTS

Seventy-eight patients were identified with a median age of 9.9 years [interquartile range [IQR): 7-12]. Twenty-seven patients underwent resection at diagnosis, and 47 patients underwent delayed resection, including eight liver transplants. Neoadjuvant chemotherapy led to a median change in maximum tumor diameter of 1.6 cm [IQR: 0.0-4.4] and greater than 90% tumor necrosis in 79% of the patients undergoing delayed resection. R0 resections were accomplished in 63 patients (81%). Univariate analysis found that metastatic disease impacted OS, and completeness of resection impacted both EFS and OS, while multivariate analysis revealed that R0 resection was associated with decreased expected hazards of experiencing an event [hazard ratio (HR): 0.14, 95% confidence interval (CI): 0.04-0.6]. At a median follow-up of 4 years [IQR: 2-8], the EFS was 70.0% [95% CI: 60%-82%] and OS was 83% [95% CI: 75%-93%].

CONCLUSION

Complete resection is associated with improved survival for patients with UESL. Neoadjuvant chemotherapy causes minimal radiographic response, but significant tumor necrosis.

Survival outcomes in pediatric patients with metastatic Ewing sarcoma who achieve a rapid complete response of pulmonary metastases

PURPOSE

Our objectives were to compare overall survival (OS) and pulmonary relapse between patients with metastatic Ewing sarcoma (EWS) at diagnosis who achieve rapid complete response (RCR) and those with residual pulmonary nodules after induction chemotherapy (non-RCR).

PATIENTS AND METHODS

This retrospective cohort study included children under 20 years with metastatic EWS treated from 2007 to 2020 at 19 institutions in the Pediatric Surgical Oncology Research Collaborative. Chi-square tests were conducted for differences among groups. Kaplan-Meier curves were generated for OS and pulmonary relapse.

RESULTS

Among 148 patients with metastatic EWS at diagnosis, 61 (41.2%) achieved RCR. Five-year OS was 71.2% for patients who achieved RCR, and 50.2% for those without RCR (p = .04), and in multivariable regression among patients with isolated pulmonary metastases, RCR (hazards ratio [HR] 0.42; 95% confidence interval [CI]: 0.17-0.99) and whole lung irradiation (WLI) (HR 0.35; 95% CI: 0.16-0.77) were associated with improved survival. Pulmonary relapse occurred in 57 (37%) patients, including 18 (29%) in the RCR and 36 (41%) in the non-RCR groups (p = .14). Five-year pulmonary relapse rates did not significantly differ based on RCR (33.0%) versus non-RCR (47.0%, p = .13), or WLI (38.8%) versus no WLI (46.0%, p = .32).

DISCUSSION

Patients with EWS who had isolated pulmonary metastases at diagnosis had improved OS if they achieved RCR and received WLI, despite having no significant differences in rates of pulmonary relapse.

Biocompatible Cable Ties Are an Alternative to Metal Stabilizers for Bar Securement During Minimally Invasive Pectus Excavatum Repair

Background: Bar stabilization during minimally invasive pectus excavatum repair (MIRPE) is critical to avoid dislodgement. Multiple techniques are described including stabilizers, wires, and sutures. This retrospective study compared bar movement and outcomes between existing techniques and ZipFix™, a biocompatible cable tie. Methods: Patients ≤20 years of age who underwent MIRPE with ZipFix between January 2021 and September 2022 were compared with historical controls who underwent repair by same surgeons between January 2018 and December 2020 using stabilizers or polydioxanone suture (PDS). Demographics, clinical details, and outcomes were compared using Kruskal-Wallis and chi-square tests. Results: Of the 116 patients who underwent repair, 45 had bars secured with ZipFix (39%) and 71 (61%) were historical controls (35 stabilizer, 36 PDS). Median (interquartile range) age was 15 (14-16) years and Haller index was 3.9 (3.6-4.5). Nine (8%) patients required two bars. Haller index and use of second bar were comparable between stabilization techniques (P > .05). In total, 49 patients (40%) reported any pain at 1 month and this was similar between stabilization techniques (P = .45). Median bar movement was greater for bars secured with PDS than with ZipFix or stabilizers at 1 month (5.5 versus 2.3 versus 3.3°, P = .010) and last follow-up (6.5 versus 2.1 versus 3.6°, P < .001). One patient whose bar was secured with PDS required revision for dislodgement. Conclusion: Pectus bar stabilization with ZipFix is a safe alternative to metal stabilizers and both techniques are superior to suture stabilization alone. The use of ZipFix may be preferred given its lower cost and ease of use.

Embryonal sarcoma of the liver in pediatric and young adult patients: A report from Children's Oncology Group study ARST0332

BACKGROUND

Embryonal sarcoma of the liver (ESL) is a rare mesenchymal tumor most common in childhood; the optimal treatment approach is uncertain. The clinical features and outcomes of patients with ESL enrolled in a Children's Oncology Group (COG) clinical trial that evaluated a risk-based strategy for treating soft tissue sarcomas in patients aged <30 years were evaluated.

METHODS

This subset analysis included patients with ESL enrolled in COG study ARST0332. Central review of records, pathology, and imaging confirmed the diagnosis, presenting features, and surgery extent and complications. All patients received dose-intensive ifosfamide/doxorubicin chemotherapy, with cycle timing dependent on surgery and radiotherapy. Tumor resection occurred before study entry or after four cycles of chemotherapy; radiotherapy for residual tumor was optional.

RESULTS

Thirty-nine eligible/evaluable patients with ESL were analyzed. All tumors were >10 cm in diameter; four were metastatic. Tumor resection was performed upfront in 23 and delayed in 16. Positive surgical margins (n = 6) and intraoperative tumor rupture (n = 6) occurred only in upfront resections. Eight patients received radiotherapy. Estimated 5-year event-free and overall survival were 79% (95% confidence interval [CI], 65%-93%) and 95% (95% CI, 87%-100%), respectively. Positive margins increased the local recurrence risk. One of 13 patients with documented hemorrhagic ascites and/or tumor rupture developed extrahepatic intra-abdominal tumor recurrence.

CONCLUSIONS

The treatment strategy used in ARST0332 achieved favorable outcomes for patients with ESL despite a substantial proportion having high-risk disease features. Deferring tumor resection until after neoadjuvant chemotherapy may decrease the risk of intraoperative tumor rupture and improve the likelihood of adequate surgical margins.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children

BACKGROUND

The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock.

METHODS

A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths.

RESULTS

Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05).

CONCLUSION

Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers.

LEVEL OF EVIDENCE

Prospective cohort study, Level II.

Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study

OBJECTIVE

The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus.

BACKGROUND

The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported.

METHODS

Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed.

RESULTS

Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival.

CONCLUSIONS

Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.

Comparison of Outcomes Between Surveillance Ultrasound and Completion Lymph Node Dissection in Children and Adolescents With Sentinel Lymph Node-Positive Cutaneous Melanoma

OBJECTIVE

To determine the impact of nodal basin ultrasound (US) surveillance versus completion lymph node dissection (CLND) in children and adolescents with sentinel lymph node (SLN) positive melanoma.

BACKGROUND

Treatment for children and adolescents with melanoma are extrapolated from adult trials. However, there is increasing evidence that important clinical and biological differences exist between pediatric and adult melanoma.

METHODS

Patients ≤18 years diagnosed with cutaneous melanoma between 2010 and 2020 from 14 pediatric hospitals were included. Data extracted included demographics, histopathology, nodal basin strategies, surveillance intervals, and survival information.

RESULTS

Of 252 patients, 90.1% (n=227) underwent SLN biopsy (SLNB), 50.9% (n=115) had at least 1 positive node. A total of 67 patients underwent CLND with 97.0% (n=65/67) performed after a positive SLNB. In contrast, 46 total patients underwent US observation of nodal basins with 78.3% (n=36/46) of these occurring after positive SLNB. Younger patients were more likely to undergo US surveillance (median age 8.5 y) than CLND (median age 11.3 y; P =0.0103). Overall, 8.9% (n=21/235) experienced disease recurrence: 6 primary, 6 nodal, and 9 distant. There was no difference in recurrence (11.1% vs 18.8%; P =0.28) or death from disease (2.2% vs 9.7%; P =0.36) for those who underwent US versus CLND, respectively.

CONCLUSIONS

Children and adolescents with cutaneous melanoma frequently have nodal metastases identified by SLN. Recurrence was more common among patients with thicker primary lesions and positive SLN. No significant differences in oncologic outcomes were observed with US surveillance and CLND following the identification of a positive SLN.

Factors Associated With Long-term Survival in Children With Bronchial and Lung Carcinoid Tumors

BACKGROUND AND AIMS

Bronchial carcinoids are rare in children and the treatment is based on tumor behavior in adults. The purpose of this study was to determine factors and management strategies associated with long-term survival in the pediatric population using a national cohort.

METHODS

Patients aged ≤20 years with bronchial carcinoid tumors were identified in the 2004-2020 National Cancer Database using ICD-O-3 codes. Tumor characteristics and management were compared among typical (TC) and atypical (AC) histological subtypes using Chi-square and Fisher's exact tests. Kaplan-Meier and univariate Cox proportional hazards analyses were used to assess survival.

RESULTS

Of 273 patients, 251 (92%) had TCs, and 22(8%) had ACs. The median (IQR) age was 18 (16,19) years. Most patients underwent lobectomy or bilobectomy (67%), followed by sublobar resection (17%), no resection or bronchoscopic excision or ablation (8%), and pneumonectomy (7.7%). Margins were negative in 96%. Lymph node (LN) assessment was performed in 216 patients (84%) with a median (IQR) of 7(3,13) LNs, and 50 (23%) had ≥1 positive LN. There was no difference in age, resection, margin status, LN assessment, or positivity between TC and AC (all p > 00.05). Detection of nodal metastasis did not increase beyond the resection of 1-3 LNs (p = 0.72). Ten-year survival was worse for AC than TC (79% (41, 100) vs 98% (95, 100), HR = 6.9 (95% CI: 1.2-38.3, p = 0.03). Ten-year survival among those with and without LN assessment was 97% (94, 100) vs 91% (81, 100), HR = 4.0, 95% CI: 0.8-19.9, p = 0.09). There were no deaths in those with negative LN while 10-year survival was 89% (72, 100) in those with ≥1 positive LN.

CONCLUSION

Among children with bronchial carcinoids, survival is excellent with TC or negative LN. Atypical histology and positive LN have poor survival and should prompt close monitoring. These risk factors may be missed in the absence of surgical resection and lymph node sampling.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Retrospective Study.

MR Lymphangiography in Lymphatic Disorders: Clinical Applications, Institutional Experience, and Practice Development

Lymphatic flow and anatomy can be challenging to study, owing to variable lymphatic anatomy in patients with diverse primary or secondary lymphatic pathologic conditions and the fact that lymphatic imaging is rarely performed in healthy individuals. The primary components of the lymphatic system outside the head and neck are the peripheral, retroperitoneal, mesenteric, hepatic, and pulmonary lymphatic systems and the thoracic duct. Multiple techniques have been developed for imaging components of the lymphatic system over the past century, with trade-offs in spatial, temporal, and contrast resolution; invasiveness; exposure to ionizing radiation; and the ability to obtain information on dynamic lymphatic flow. More recently, dynamic contrast-enhanced (DCE) MR lymphangiography (MRL) has emerged as a valuable tool for imaging both lymphatic flow and anatomy in a variety of congenital and acquired primary or secondary lymphatic disorders. The authors provide a brief overview of lymphatic physiology, anatomy, and imaging techniques. Next, an overview of DCE MRL and the development of an MRL practice and workflow in a hybrid interventional MRI suite incorporating cart-based in-room US is provided, with an emphasis on multidisciplinary collaboration. The spectrum of congenital and acquired lymphatic disorders encountered early in an MRL practice is provided, with emphasis on the diversity of imaging findings and how DCE MRL can aid in diagnosis and treatment of these patients. Methods such as DCE MRL for assessing the hepatic and mesenteric lymphatic systems and emerging technologies that may further expand DCE MRL use such as three-dimensional printing are introduced. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.

Progress in precision pediatric surgical oncology

The increasingly targeted and personalized care of pediatric solid tumors extends to the surgical realm. Enhancing sentinel lymph node biopsy with fluorescence‐guided surgery is one example of this innovation in pediatric surgical oncology.

Critical elements of pediatric rhabdomyosarcoma surgery

Rhabdomyosarcoma (RMS), the most common soft tissue sarcoma in children, requires multimodal therapy which is determined by risk group stratification. Local control may be achieved by surgical resection, radiation, or both. Resection may occur upfront or following induction chemotherapy as a delayed primary excision. An R1 resection may allow a reduction in radiation exposure; however, debulking is not indicated nor is excision of residual masses at the end of therapy. Regional lymph node assessment is an important component of surgical care, as positive nodal basins require radiation. Depending on the tumor site and biology, sentinel lymph node biopsy vs biopsy of clinically or radiographically concerning nodes is indicated. Therapeutic lymph node dissection is never indicated. Familiarity with site-specific oncologic principles for RMS and participation in a multidisciplinary team including Pediatric Oncology and Radiation Oncology are necessary components of surgical care to ensure optimal outcomes.

Plasma thrombin generation kinetics vary by injury pattern and resuscitation characteristics in pediatric and young adult trauma patients

BACKGROUND

Thrombin generation kinetics are not well studied in children. This study aimed to assess how thrombin generation kinetics vary in pediatric and young adult (YA) trauma patients by clinical characteristics and injury pattern.

METHODS

Prospective cohort study where plasma samples were obtained from pediatric (ages 0-17 years) and YA (ages 18-21 years) trauma patients upon emergency department arrival. Thrombin generation (calibrated automated thrombogram [CAT]) was quantified as lag time (LT, minutes), peak height (PH, nM), time to peak (ttPeak, minutes), and endogenous thrombin potential (ETP, nM × minute). Results are expressed as median and quartiles [Q1, Q3] and compared using Wilcoxon rank sum testing with p < 0.05 considered significant.

RESULTS

We enrolled 47 pediatric (median age, 15 [14, 17] years, 78% male, 87% blunt, median Injury Severity Score, 12) and 49 YA (median age 20 [18, 21] years, 67% male, 84% blunt, median Injury Severity Score, 12) patients. Pediatric and YA patients had similar rates of operative intervention (51% vs. 57%), transfusion (25% vs. 20%), and traumatic brain injury (TBI) (53% vs. 49%). Pediatric patients who required an operation had accelerated initiation of thrombin generation, with shorter LT than those who did not (2.58 [2.33, 2.67]; 2.92 [2.54, 3.00], p = 0.034). Shorter LT (2.41 [2.22, 2.67]; 2.67 [2.53, 3.00]) and ttPeak (4.50 [4.23, 4.73]; 5.22 [4.69, 5.75], both p < 0.01) were noted in pediatric patients who required transfusion as compared with those who did not. The YA patients requiring transfusion had shorter LT (2.33 [2.19, 2.74]; 2.83 [2.67, 3.27]) and ttPeak (4.48 [4.33, 5.65]; 5.33 [4.85, 6.28] both p < 0.04) than those who were not transfused. Young adults with TBI had greater ETP than those without (1509 [1356, 1671]; 1284 [1154, 1471], p = 0.032).

CONCLUSION

Thrombin generation kinetics in pediatric trauma patients prior to intervention vary with need for operation and transfusion, while thrombin generation kinetics in young adult patients are influenced by TBI and need for operation or transfusion. This is a promising tool for assessing coagulopathy in young trauma patients.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis

OBJECTIVE

This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI.

METHODS

This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses.

RESULTS

There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010).

CONCLUSION

Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

Proton Whole-Lung Irradiation: Initial Report of Outcomes

PURPOSE

Whole-lung irradiation is typically used in pediatric patients to decrease the risk of future lung metastases, but radiation dose to normal tissue is associated with long-term risks. Proton whole-lung irradiation (PWLI) provides an opportunity to decrease radiation dose to normal tissue and potentially decrease late toxicity.

METHODS AND MATERIALS

This retrospective study included patients treated with spot-scanning PWLI at a single institution. Toxicity and oncologic outcomes were reviewed. Intensity modulated radiation therapy (IMRT) plans were created prospectively or retrospectively for dosimetric comparisons. Simple paired t tests were performed to assess differences between IMRT and PWLI dosimetric parameters.

RESULTS

Twelve patients treated with PWLI were included in this study. Median age was 15 years (range, 3-34). Most (75%) had Ewing sarcoma. Most (92%) received 15 Gy in 10 fractions PWLI, and 3 (25%) received a focal pulmonary boost. Median follow-up was 16.5 months (range, 0-40.4 months). At last follow-up, 1 patient died of disease, while 11 were still alive (7 without disease, 4 with ongoing disease). During and immediately after treatment, 5 patients developed fatigue, 2 patients developed cough, and 1 patient developed nausea. Each treatment-related adverse event was Common Terminology Criteria for Adverse Events (version 5.0) grade 1 and resolved within 3 weeks of treatment completion. No patients have experienced clinical or radiographic pneumonitis or evidence of clinically apparent cardiac toxicity. Compared with IMRT plans, PWLI decreased mean dose to the heart, coronary artery, cardiac valve, left ventricle, aorta, breast, esophagus, kidney, liver, pancreas, thyroid, stomach, and spleen (all P < .001), without sacrificing target coverage.

CONCLUSIONS

PWLI is feasible to deliver, decreases dose to normal tissue compared with IMRT, and appears to be well-tolerated. PWLI provides potential for decreased late toxicity and merits further investigation.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions

OBJECTIVE

The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor.

DESIGN

This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results.

SETTING

The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019.

PARTICIPANTS

All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019.

RESULTS

There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it.

CONCLUSIONS

A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

Incidence and Management of Pleural Effusions in Patients with Wilms Tumor: A Pediatric Surgical Oncology Research Collaborative Study

Wilms tumor (WT) is the most common renal malignancy in children. Children with favorable histology WT achieve survival rates of over 90%. Twelve percent of patients present with metastatic disease, most commonly to the lungs. The presence of a pleural effusion at the time of diagnosis of WT may be noted on staging imaging; however, minimal data exist regarding the significance and prognostic importance of this finding. The objectives of this study are to identify the incidence of pleural effusions in patients with WT, and to determine the potential impact on oncologic outcomes. A multi-institutional retrospective review was performed from January 2009 to December 2019, including children with WT and a pleural effusion on diagnostic imaging treated at Pediatric Surgical Oncology Research Collaborative (PSORC) participating institutions. Of 1,259 children with a new WT diagnosis, 94 (7.5%) had a pleural effusion. Patients with a pleural effusion were older than those without (median 4.3 vs 3.5 years; p=0.004), and advanced stages were more common (local stage III 85.9% vs 51.9%; p<0.0001). Only 14 patients underwent a thoracentesis for fluid evaluation; 3 had cytopathologic evidence of malignant cells. Event-free and overall survival of all children with WT and pleural effusions was 86.2% and 91.5%, respectively. The rate and significance of malignant cells present in pleural fluid is unknown due to low incidence of cytopathologic analysis in our cohort; therefore, the presence of an effusion does not appear to necessitate a change in therapy. Excellent survival can be expected with current stage-specific treatment regimens.

Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study

BACKGROUND

Pulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodules in pediatric patients.

METHODS

A retrospective review was performed on patients < 21 years of age undergoing localization of pulmonary nodules at 15 institutions. Localization and resection success, time in interventional radiology (IR), operating room (OR) and total anesthesia time, complications, and technical problems were compared between techniques.

RESULTS

225 patients were included with an average of 1.3 lesions (range 1-5). Median nodule size and depth were 4 mm (range 0-30) and 5.4 mm (0-61), respectively. The most common localization techniques were: wire + methylene blue dye (MBD) (28%), MBD only (25%), wire only (14%), technetium-99 only (11%), coil + MBD (7%) and coil only (5%). Localization technique was associated with institution (p < 0.01); technique and institution were significantly associated with mean IR, OR, and anesthesia time (all p < 0.05). Comparing techniques, there was no difference in successful IR localization (range 92-100%, p = 0.75), successful resection (94-100%, p = 0.98), IR technical problems (p = 0.22), or operative complications (p = 0.16).

CONCLUSIONS

Many IR localization techniques for small pulmonary nodules in children can be successful, but there is wide variability in application by institution and in procedure time.

LEVEL OF EVIDENCE

Retrospective review, Level 3.

Inflammatory Myofibroblastic Tumor: A Multi-Institutional Study from the Pediatric Surgical Oncology Research Collaborative

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000-2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. 182 patients were identified with median age of 11 years. 33% of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%), and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. 7% of patients had distant disease at diagnosis. 91% of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. 12% of patients received an ALK inhibitor. 66% of surgical patients had complete resection, with 20% positive microscopic margins, and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival (OS) was 95% and 5-year event-free survival (EFS) was 80%. Predictors of recurrence included respiratory symptoms, tumor size, and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted. This article is protected by copyright. All rights reserved.

Inflammatory myofibroblastic tumor: A multi-institutional study from the pediatric surgical oncology research collaborative

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Background: Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy, predominantly seen in children and young adults. Given its rarity, data are limited. We describe the largest cohort of patients with IMT to date, with an aim to further characterize this poorly understood tumor. Methods: A multi-institutional review was performed at 18 North American hospitals participating in the Pediatric Surgical Oncology Research Collaborative to identify IMT patients ≤39 years, diagnosed from 2000-2018. Descriptive statistics are described as median and interquartile range. Multivariable analysis was used to identify predictors of event free survival (EFS). Results: 182 patients were identified with a median age of 11 years (5-17); 52% were female. 33% of tumors were thoracic, 26% abdominal/pelvic, 20% head/neck, and 14% genitourinary. Common presenting symptoms included pain (29%), respiratory symptoms (24%), weight loss (12%), and a palpable mass (10%). Median tumor size was 3.9 cm (1.9-6.5). Anaplastic lymphoma kinase (ALK) overexpression was identified via immunohistochemistry in 53% of patients tested. One third of patients had abnormal cytogenetics, with 12% of the entire cohort having an ALK mutation. 7% of patients had distant disease at diagnosis. 13% of patients received neoadjuvant therapy including chemotherapy (3%), ALK inhibitor (4%), radiation (0.5%), non-steroidal anti-inflammatories (NSAIDs) (7%), or steroids (2%). Of those who underwent resection with known margin status (n = 158), 66% had complete resection, 20% had microscopic positive margins, and 14% had gross residual disease. Just over 40% of patients had an en bloc resection of involved organs, most commonly lung (26%). 21% of patients received adjuvant therapy, including chemotherapy (3%), ALK inhibitor (9%), radiation (0.5%), NSAIDs (8%), or steroids (5%). 12% of all patients received an ALK inhibitor: 24% neoadjuvant, 62% adjuvant, and 14% without surgery. Median follow-up time was 36 months (14-69). Overall 5-year survival (OS) was 95% and 5-year EFS was 80%. Predictors of recurrence included respiratory symptoms, larger tumor size, or distant disease at diagnosis. Gender, race, age and primary site were not predictive of EFS. Likewise, there was no association of ALK overexpression or ALK mutation with EFS. The presence of gross or microscopic margins following resection was not associated with recurrence. Conclusions: IMT is a rare tumor with favorable OS. Five year recurrence rate was 20%. Presenting with respiratory symptoms, larger tumor size, or metastatic disease was associated with recurrence, while ALK positivity was not. Notably, a positive margin after resection was not associated with increased recurrence, indicating that aggressive attempts at surgical resection that would compromise form or function may not be warranted.

The incidence of venous thromboembolism in children following colorectal resection for inflammatory bowel disease: A multi-center study

BACKGROUND/PURPOSE

Children with inflammatory bowel disease (IBD) have increased risk for venous thromboembolism (VTE). We sought to determine incidence and risk factors for postoperative VTE in a multicenter cohort of pediatric patients undergoing colorectal resection for IBD.

METHODS

Retrospective review of children ≤18 years who underwent colorectal resection for IBD from 2010 to 2016 was performed at four children's hospitals. Primary outcome was VTE that occurred between surgery and last follow-up. Factors associated with VTE were determined using univariable and multivariable analyses.

RESULTS

Two hundred seventy-six patients were included with median age 15 years [13,17]. Forty-two children (15%) received perioperative VTE chemoprophylaxis, and 88 (32%) received mechanical prophylaxis. DVT occurred in 12 patients (4.3%) at a median of 14 days postoperatively [8,147]. Most were portomesenteric (n = 9, 75%) with the remaining catheter-associated DVTs in extremities (n = 3, 25%). There was no association with chemoprophylaxis (p > 0.99). On Cox regression, emergent procedure [HR 18.8, 95%CI: 3.18-111], perioperative plasma transfusion [HR 25.1, 95%CI: 2.4-259], and postoperative infectious complication [HR 10.5, 95%CI: 2.63-41.8] remained predictive of DVT.

CONCLUSION

Less than 5% of pediatric IBD patients developed postoperative VTE. Chemoprophylaxis was not protective but rarely used. Patients with risk factors identified in this study should be monitored or given prophylaxis for VTE.

LEVEL OF EVIDENCE

Treatment Study, Level III.

Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study

BACKGROUND

To better characterize short-term and long-term outcomes in children with pancreatic tumors treated with pancreaticoduodenectomy (PD).

METHODS

Patients 21 years of age or younger who underwent PD at Pediatric Surgical Oncology Collaborative (PSORC) hospitals between 1990 and 2017 were identified. Demographic, clinical information, and outcomes (operative complications, long-term pancreatic function, recurrence, and survival) were collected.

RESULTS

Sixty-five patients from 18 institutions with a median age of 13 years (4 months-22 years) and a median (IQR) follow-up of 2.8 (4.3) years were analyzed. Solid pseudopapillary tumor of the pancreas (SPN) was the most common histology. Postoperative complications included pancreatic leak in 14% (n = 9), delayed gastric emptying in 9% (n = 6), marginal ulcer in one patient, and perioperative (30-day) death due to hepatic failure in one patient. Pancreatic insufficiency was observed in 32% (n = 21) of patients, with 23%, 3%, and 6% with exocrine, or endocrine insufficiencies, or both, respectively. Children with SPN and benign neoplasms all survived. Overall, there were 14 (22%) recurrences and 11 deaths (17%). Univariate analysis revealed non-SPN malignant tumor diagnosis, preoperative vascular involvement, intraoperative transfusion requirement, pathologic vascular invasion, positive margins, and need for neoadjuvant chemotherapy as risk factors for recurrence and poor survival. Multivariate analysis only revealed pathologic vascular invasion as a risk factor for recurrence and poor survival.

CONCLUSION

This is the largest series of pediatric PD patients. PD is curative for SPN and benign neoplasms. Pancreatic insufficiency is the most common postoperative complication. Outcome is primarily associated with histology.

Single-stage embolization with n-butyl cyanoacrylate and surgical resection of venous malformations

PURPOSE

Sclerotherapy or surgical resection is options for symptomatic venous malformations (VM). Sclerotherapy may require repetitive intervention and resection is often avoided due to operative morbidity. The purpose of this study was to report use of single-stage n-butyl cyanoacrylate glue embolization and surgical resection of focal VM.

METHODS

A review of patients with focal VM who underwent glue embolization followed by resection at a single tertiary care vascular malformations center was performed. All embolizations were performed with ultrasound and fluoroscopy under the same anesthetic as resection. Patient characteristics and outcomes were evaluated.

RESULTS

Fifteen procedures were performed in 12 patients with a total of 20 VM addressed, as several patients had multiple VM. Mean age was 16 ± 9 years. Malformation locations included scalp, hip, gluteal, labial, toe, finger, face, lip, chest, and foot and size ranged from 1.0 to 10.5 cm. Median (range) of prior sclerotherapy treatments was 3 (0-5) and three patients previously underwent surgical resection. Median blood loss was zero (0-10) mL. Surgical complications occurred after five procedures (33%) including superficial wound dehiscence and cellulitis. No complications required readmission or reoperation. At a median follow up of 195 (103-266) days, no patients have required additional treatment.

CONCLUSION

Glue embolization and resection of focal VM of variable size and location appears to have durable results and low surgical morbidity. This single-stage procedure, often performed as an outpatient, may be utilized as upfront treatment for symptomatic malformations or for VM refractory to other treatments.

Opioid use and length of stay following minimally invasive pectus excavatum repair in 436 patients - Benefits of an enhanced recovery pathway

PURPOSE

The purpose of this study was to determine outcomes of an enhanced recovery pathway (ERP) for minimally invasive repair of pectus excavatum (MIRPE) at a high volume center, hypothesizing it is associated with decreased opioid requirement and shorter hospital stay.

METHODS

Patients were categorized into pre-ERP (1998-2006), transition (2007-2011), and ERP (2012-2017) cohorts. Data were abstracted from medical records. Univariate and multivariable analyses compared opioid utilization, length of stay (LOS), and complications between cohorts. Opioids were converted to morphine daily dose per kilogram (MEDD/kg).

RESULTS

Of 436 patients, 186 were ERP, 104 were transition, and 146 were pre-ERP. ERP was associated with decreased hospital opioid utilization (mean MEDD/kg 0.5 ± 0.2 vs 0.7 ± 0.4 vs 0.7 ± 0.8 p < .001) and shorter median LOS (3 vs 4 vs 5 days, p < .001) despite equivalent pain scores at discharge (2.7 ± 0.1 vs 2.8 ± 0.2 vs 2.9 ± 0.3, p = .73). Most ERP patients (76%) had LOS ≤3 days. Differences in LOS between ERP, transition, and pre-ERP persisted on multivariable analysis after adjusting for confounding factors. Post-operative complications were rare and not different between groups (p > .05).

CONCLUSIONS

Implementation of our ERP was associated with decreased opioid requirement and shorter hospital stay. ERPs are a valuable tool in pediatric surgery given the current emphasis on optimizing opioid and resource utilization.

LEVELS OF EVIDENCE

Level III (Retrospective comparative study).

Implications of transfer status on bowel loss in children undergoing emergency surgery for malrotation

OBJECTIVE

Malrotation with midgut volvulus is a time-sensitive pediatric surgical disease that requires emergent operative exploration to avoid bowel loss; however, it also requires specialized pediatric care. The purpose of this study was to identify disparities in bowel resection in children who underwent emergency surgery for malrotation; particularly the role of transfer status.

METHODS

The Pediatric Health Information System was used to identify a multicenter cohort of patients who underwent emergency surgical intervention for malrotation. Univariate and multivariable analyses were used to determine factors associated with the primary outcome of bowel resection; secondary outcomes included surgical complications, prolonged length of stay, TPN dependence, and death.

RESULTS

Of 3373 patients with malrotation included, 44.8% were transferred in. Younger age, prematurity and other comorbidity, nonwhite race, and public insurance were associated with transfer. Transferred patients were more likely to undergo bowel resection on univariate (30.7 vs 16.4%, p < .001) and multivariable analysis (RR =1.38, p < .010). After adjusting for bowel resection, only patient factors including age and comorbidity were associated with surgical complications, TPN dependence, and death.

CONCLUSION

Patients who require hospital-to-hospital transfer for emergent surgical management of malrotation are more likely to require bowel resection which is in turn associated with greater morbidity. Further work is needed to optimize access to prompt surgical care for this condition especially given race and insurance disparities in transfer status.

LEVEL OF EVIDENCE

III, prognostic study.

Trauma registry data as a tool for comparison of practice patterns and outcomes between low- and middle-income and high-income healthcare settings

PURPOSE

There is a lack of data-driven, risk-adjusted mortality estimates for injured children outside of high-income countries (HIC). To inform injury prevention and quality improvement efforts, an upper middle-income country (UMIC) pediatric trauma registry was compared to that of a HIC.

METHODS

Clinical data, injury details, and mortality of injured children (< 18 years) hospitalized in two centers (USA and South African (SA)) from 2013 to 2017 were abstracted. Univariate and multivariable analyses evaluated risk of mortality and were expressed as odds ratios (OR) with 95% confidence intervals (CI).

RESULTS

Of 2089 patients, SA patients had prolonged transfer times (21.1 vs 3.4 h) and were more likely referred (78.2% vs 53.9%; both p < 0.001). Penetrating injuries were more frequent in SA (23.2% vs 7.4%, p < 0.001); injury severity (9 vs 4) and shock index (0.90 vs 0.80) were greater (both p < 0.001). SA utilized cross-sectional imaging more frequently (66.4% vs 37.3%, p < 0.001). In-hospital mortality was similar (1.9% SA, 1.3% USA, p = 0.31). Upon multivariable analysis, ISS > 25 [210.50 (66.0-671.0)] and penetrating injury [5.5 (1.3-23.3)] were associated with mortality, while institution [1.7 (0.7-4.2)] was not.

CONCLUSIONS

Despite transfer time, the centers demonstrated comparable survival rates. Comparison of registry data can alert clinicians to problematic practice patterns, assisting initiatives to improve trauma systems.

Surgical resection of infantile hemangiomas following medical treatment with propranolol versus corticosteroids

PURPOSE

There has been a paradigm shift from corticosteroid to propranolol treatment for infantile hemangiomas (IHs), with surgical resection reserved for complicated or persistent IHs. The purpose of this study was to determine if propranolol treatment was associated with decreased utilization of surgical resection compared to corticosteroids.

METHODS

A single center retrospective chart review of all corticosteroid or propranolol treated IHs between 2005 and 2014 was performed. Demographic and clinical data were collected. Both univariate and multivariate analyses were performed with the primary outcome of requiring surgical intervention.

RESULTS

Of 652 patients with IH, 52 were treated with oral corticosteroids and 195 with propranolol only. Surgical intervention was required in 14 (27%) of steroid patients vs 18 (9%) of propranolol patients (p < .001). On multivariable analysis patients treated with steroids had 3.3 the odds of requiring surgery when compared to propranolol patients (p = .001). Prematurity (<37 weeks) was also associated with increased odds of surgery (OR = 2.8, p = .003).

CONCLUSION

Patients treated with propranolol required significantly fewer surgical interventions than those treated with corticosteroids suggesting a more efficacious treatment paradigm. Prematurity increases the need for surgical intervention regardless of the modality of medical treatment.

LEVEL OF EVIDENCE

Level III, treatment study.

Thoracoscopic posterior tracheopexy for tracheomalacia: A minimally invasive technique

BACKGROUND

Tracheomalacia is the most common congenital abnormality of the trachea. Posterior tracheopexy to alleviate posterior intrusion contributing to dynamic tracheal collapse has been reported using thoracotomy or median sternotomy. Here we describe the minimally invasive operative technique of thoracoscopic posterior tracheopexy with bronchoscopic guidance.

OPERATIVE TECHNIQUE

After preoperative computed tomography and bronchoscopy, a right thoracoscopic approach is utilized. The esophagus is mobilized and the membranous trachea is sutured to the prevertebral fascia under direct bronchoscopic visualization. Immediate improvement in tracheal collapse is noted. No major complications are reported and length of stay is short. Aortopexy may also be required to address anterior vascular compression.

CONCLUSION

Thoracoscopic posterior tracheopexy is safe and feasible. Further studies with more patients and longer follow-up are needed to assess durability.

Appendicitis: Rural Patient Status is Associated with Increased Duration of Prehospital Symptoms and Worse Outcomes in High- and Low-Middle-Income Countries

INTRODUCTION

Appendicitis is a significant economic and healthcare burden in low-, middle-, and high-income countries. We aimed to determine whether urban and rural patient status would affect outcomes in appendicitis in a combined population regardless of country of economic status. We hypothesize that patients from rural areas and both high- and low-middle-income countries would have disproportionate outcomes and duration of symptoms compared to their urban counterparts.

METHODS

Adults (≥18 years) with appendicitis during 2010-2016 in South Africa and USA were reviewed using multi-institutional data. Baseline demographic, operative details, durations of stay, and complications (Clavien-Dindo index) were collected. AAST grades were assigned by two independent reviewers based on operative findings. Summary, univariate, and multivariable analyses of rural and urban patients in both countries were performed.

RESULTS

There were 2602 patients with a median interquartile range [IQR] of 26 [18-40] years; 45% were female. Initial management included McBurney incisions (n = 458, 18%), laparotomy (n = 915, 35%), laparoscopic appendectomy (n = 1185, 45%), and laparoscopy converted to laparotomy (n = 44, 2%). Comparing rural versus urban patient status, there were increased overall median [IQR] AAST grades (3 [1-5] vs. 2 [1-3], p = 0.001), prehospital duration of symptoms (2 [1-5] vs. 2 [1-3], p = 0.001), complications (44.3 vs. 23%, p = 0.001), and need for temporary abdominal closure (20.3 vs. 6.9%, p = 0.001).

CONCLUSION

Despite socioeconomic status and country of origin, patients from more rural environments demonstrate poorer outcomes notwithstanding significant differences in overall disease severity. The AAST grading system may serve a potential benchmark to recognize areas with disparate disease burdens. This information could be used for strategic improvements for surgeon placement and availability.

Propranolol versus steroids for the treatment of ulcerated infantile hemangiomas

BACKGROUND

There has been a paradigm shift from steroids to propranolol for the pharmacologic treatment of infantile hemangiomas (IH); however, the outcomes for ulcerated IH are not well studied. The purpose of this study was to compare the efficacy of steroids and propranolol specifically for ulcerated IH.

METHODS

A retrospective review was conducted on patients with ulcerated IH treated with propranolol or steroids at a single tertiary care institution between 2007 and 2014. Patient characteristics, hemangioma features, and outcomes, including time to heal and medication complications, were compared between propranolol and steroid patients.

RESULTS

There were 29 patients treated with propranolol and 23 with steroids. There were no significant differences in the two treatment groups including age, race, sex, size, or insurance status. There were more head/neck IH in the steroid group. There was no significant difference in the percentage of healed lesions (93 vs. 74%, P = 0.12) or the median time to heal (80 vs. 126 days, p = 0.21) between groups. Overall complication rates also did not vary between medications (24 vs. 44%, P = 0.14).

CONCLUSION

Propranolol is noninferior to steroids for the treatment of ulcerated IH; however, healing time is lengthy regardless of treatment. While side effect profiles differed between medications, the overall complication rate was similar.

Undertriage after severe injury among United States trauma centers and the impact on mortality

INTRODUCTION

Severely injured patients should receive definitive care at high acuity trauma centers. The purposes of this study were to determine the undertriage (UT) rate within a national sample of trauma centers and to identify characteristics of UT patients.

METHODS

Severely injured adults ≥16 years were identified from the 2010-2012 NTDB. UT was defined as those who received definitive care or died at hospitals without state or ACS level I or II verification. Risk factors for UTT and the impact of UT on mortality were determined.

RESULTS

Of 348,394 severely injured patients, 11,578 (3.3%) were UT. Older, less severely injured, and certain minority patients were most likely to be UT. After risk adjustment, predictors of UT included increased age and minority race. Increased injury severity and comorbidity were protective (all p < .05). Mortality was greater in UT patients regardless of ISS (OR = 1.32, p < .001).

CONCLUSION

The low UT rate in this study demonstrates the effectiveness of triage practices amongst ACS and state verified centers however age, race, and insurance disparities in UT should be improved.

Rural versus urban pediatric non-accidental trauma: different patients, similar outcomes

Objective

Our aim was to compare urban and rural non-accidental trauma for trends and characterize where injury prevention efforts can be focused. Pediatric trauma patients (age 0–14 years) at two level I adult and pediatric trauma centers, one rural and one urban, were included and data from the trauma registries at each center was abstracted.

Results

Of 857 pediatric admissions, 10% of injuries were considered non-accidental. The mean age for all non-accidental trauma patients was significantly lower than the overall pediatric trauma population (2.6 vs. 7.7 years, P < 0.001). Significantly more fatalities occurred in the non-accidental trauma cohort (5.7% vs. 1% P = 0.007). In nearly half of all non-accidental trauma patients, the primary insurance was government programs (49%) and 46% were commercial insurance. The proportion of government insurance in non-accidental trauma was higher in both urban and rural cohorts. There were similar rates of urban and rural patients sustaining non-accidental trauma who were uninsured (6.5 vs. 5.3%). Patients that were younger, in a rural location, and receiving government insurance were at higher risk of non-accidental trauma on univariable analysis. However, only age remained an independent predictor on multivariable analysis.

Use of radiotracer labeling of pulmonary nodules to facilitate excisional biopsy and metastasectomy in children with solid tumors

PURPOSE

Excision of suspected pulmonary metastases in children is challenging in the setting of multiple nodules or nodules that are small, deep, or soft. This study describes preoperative technetium macro-aggregated albumin (Tc 99m MAA) localization of pulmonary lesions to aid in intraoperative identification and resection.

METHODS

Patients with past or present pediatric solid tumors who underwent resection of pulmonary nodules following CT-guided Tc 99m MAA labeling were identified. The primary outcomes were successful preoperative localization and subsequent resection.

RESULTS

Metastasectomy following Tc 99m MAA localization was performed 15 times in 11 patients from 2014 to 2016. Mean age was 13years; the most common diagnosis was osteosarcoma (33%). Tc 99m MAA labeling was attempted in 24 nodules with mean nodule diameter 6±5mm and mean depth from the pleural surface of 12±17mm; localization was successful in 23 nodules (96%). Subsequent resection was performed by thoracotomy in 12 cases and thoracoscopy in 3. All labeled nodules were identified intraoperatively; two were not resected and 17 of the 21 nodules resected demonstrated metastatic disease on pathology.

CONCLUSION

Tc 99m MAA labeling of pulmonary nodules in children is effective in facilitating resection of sub-centimeter intraparenchymal metastases identified on preoperative imaging. Furthermore, this technique allows for thoracoscopic metastasectomy in select patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Case Series/Level IV.

Safety on the slopes: ski versus snowboard injuries in children treated at United States trauma centers

PURPOSE

Skiing and snowboarding are popular winter sports. The purpose of this study was to determine differences in injury patterns and severity between children participating in these sports treated at trauma centers in the United States.

METHODS

Ski and snowboard injuries in children <15 identified from the 2011-2015 National Trauma Data Bank were compared using t tests, chi squared tests, and multivariable analyses. Time trends were evaluated using the Cochran Armitage trend test.

RESULTS

We identified 1613 injured snowboarders and 1655 skiers. Snowboarders were older (12 vs. 11years, p<.001) and more likely to be male (84 vs. 68%, p<.001). The proportion of ski to snowboard injuries increased over time (p<.001). Skiers had greater median ISS than snowboarders (5 vs. 4, p<.001) but similar severe injuries ISS ≥16 (9 vs. 8%, p=.31). Head injuries were more frequent among snowboarders (26 vs. 23%, p=.013). Helmet use was greater in skiers (46 vs. 34%, p<.001). Skiers were more likely to sustain face, chest, and lower extremity injuries. Snowboarders had more abdominal and upper extremity injuries (p<.05). Snowboarders were more likely to undergo CT (20 vs. 16%, p=.008), and skiers were more likely to undergo surgery (25 vs. 22% p=.021). Need for intensive care (12 vs. 13%, p=.43) and mortality (0.3 vs. 0.3%, p=.75) were similar. Median length of stay was greater for skiers (2 days vs. 1day, p<.001).

CONCLUSION

Many children are treated at United States trauma centers for ski and snowboard injuries. One in 10 is severely injured. Different injury patterns between sports can be used to tailor prevention efforts. However, avoiding head injury and improving helmet use should be a priority for all children on the slopes.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Prognostic.

Measuring Anatomic Severity in Pediatric Appendicitis: Validation of the American Association for the Surgery of Trauma Appendicitis Severity Grade

OBJECTIVE

To assess whether the American Association for the Surgery of Trauma (AAST) grading system accurately corresponds with appendicitis outcomes in a US pediatric population.

STUDY DESIGN

This single-institution retrospective review included patients <18 years of age (n = 331) who underwent appendectomy for acute appendicitis from 2008 to 2012. Demographic, clinical, procedural, and follow-up data (primary outcome was measured as Clavien-Dindo grade of complication severity) were abstracted. AAST grades were generated based on intraoperative findings. Summary, univariate, and multivariable regression analyses were performed to compare AAST grade and outcomes.

RESULTS

Overall, 331 patients (46% female) were identified with a median age of 12 (IQR, 8-15) years. Appendectomy was laparoscopic in 90% and open in 10%. AAST grades included: Normal (n = 13, 4%), I (n = 152, 46%), II (n = 90, 27%), III (n = 43, 13%), IV (n = 24 7.3%), and V (n = 9 2.7%). Increased AAST grade was associated with increased Clavien-Dindo severity, P =.001. The overall complication rate was 13.6% and was comprised by superficial surgical site infection (n = 13, 3.9%), organ space infection (n = 15, 4.5%), and readmission (n = 17, 5.1%). Median duration of stay increased with AAST grade (P < .0001). Nominal logistic regression identified the following as predictors of any complication (P < .05): AAST grade and febrile temperature at admission.

CONCLUSIONS

The AAST appendicitis grading system is valid in a single-institution pediatric population. Increasing AAST grade incrementally corresponds with patient outcomes including increased risk of complications and severity of complications. Determination of the generalizability of this grading system is required.

In vitro Analysis of the Hemostatic Properties of Whole Blood Products Prepared with a Platelet-Sparing Leukoreduction Filter

Background

Warm fresh whole blood (WFWB) is an ideal resuscitation fluid for exsanguinating patients but there are myriad logistic and infectious issues associated with its use. Cold whole blood (CWB) may be an acceptable alternative to the reconstituted whole blood (RWB), the current standard of care. A leukoreduction filter has been developed which maintains platelet count while eliminating white blood cells but its effect on platelet function is unknown. We hypothesize that CWB will retain an acceptable functional coagulation profile after filtration and over time.

Study Design and Methods

WFWB and CWB samples were obtained from eight donors and four units of RWB were created. The quantitative and qualitative in vitro coagulation profiles of WFWB, RWB, and CWB over time were compared.

Results

Filtration was successful at removing white blood cells (5.5 ± 1.2 vs. 0.3 ± 0.3 × 10⁶/L) while retaining an adequate platelet count (172.0 ± 47.0 to 166.0 ± 42.3 × 10⁹/L) and hemoglobin concentration (13.7 ± 0.5 vs. 13.0 ± 0.7 g/dL). Rotational Thromboelastography (ROTEM) results revealed a similar clotting time (CT) before and after filtration (64.9 ± 5.1 vs. 64.1 ± 6.8 s) but a decreased maximum clot firmness (MCF) (58.6 ± 4.2 vs. 54.9 ± 4.6 mm). Platelet aggregation decreased substantially (28.8 ± 6.7 vs. 9.3 ± 2.1 ohm) immediately after filtration. CWB function continued to diminish over time.

Conclusion

CWB holds great promise as a surrogate for WFWB, but use of a platelet-sparing LR filter diminishes platelet function almost immediately after filtration.

Rates and risk factors of unplanned 30-day readmission following general and thoracic pediatric surgical procedures

BACKGROUND/PURPOSE

Postoperative unplanned readmissions are costly and decrease patient satisfaction; however, little is known about this complication in pediatric surgery. The purpose of this study was to determine rates and predictors of unplanned readmission in a multi-institutional cohort of pediatric surgical patients.

METHODS

Unplanned 30-day readmissions following general and thoracic surgical procedures in children <18 were identified from the 2012-2014 National Surgical Quality Improvement Program- Pediatric. Time-dependent rates of readmission per 30 person-days were determined to account for varied postoperative length of stay (pLOS). Patients were randomly divided into 70% derivation and 30% validation cohorts which were used for creation and validation of a risk model for readmission.

RESULTS

Readmission occurred in 1948 (3.6%) of 54,870 children for a rate of 4.3% per 30 person-days. Adjusted predictors of readmission included hepatobiliary procedures, increased wound class, operative duration, complications, and pLOS. The predictive model discriminated well in the derivation and validation cohorts (AUROC 0.710 and 0.701) with good calibration between observed and expected readmission events in both cohorts (p>.05).

CONCLUSIONS

Unplanned readmission occurs less frequently in pediatric surgery than what is described in adults, calling into question its use as a quality indicator in this population. Factors that predict readmission including type of procedure, complications, and pLOS can be used to identify at-risk children and develop prevention strategies.

LEVEL OF EVIDENCE

III.

Prehospital blood transfusions in pediatric trauma and nontrauma patients: a single-center review of safety and outcomes

PURPOSE

Prehospital transfusions are a novel yet increasingly accepted intervention in the adult population as part of remote damage control resuscitation, but prehospital transfusions remain controversial in children. Our purpose was to review our pediatric prehospital transfusion experience over 12 years to describe the safety of prehospital transfusion in appropriately triaged trauma and nontrauma patients.

METHODS

Children (<18 years) transfused with packed red blood cells (pRBC) or plasma during transport to a single regional academic medical center between 2002 and 2014 were identified. Admission details, in-hospital clinical course, and outcomes were analyzed.

RESULTS

28 children were transfused during transport; median age was 8.9 ± 7 years and 15 patients were male (54%). Most patients required at least one additional unit of blood products during their hospitalization (79%), and/or required operative intervention (53%), endoscopy (7%), or died during their hospitalization (14%). Comparison of trauma patients (n = 16) and nontrauma patients (n = 12) revealed that nontrauma patients were younger, more anemic, more coagulopathy on admission, and required more ongoing transfusion in the hospital. Trauma patients were more likely to need operative intervention. No patient had a transfusion reaction.

CONCLUSION

Remote damage control prehospital transfusions of blood products were safe in this small group of appropriately triaged pediatric patients. Further studies are needed to determine if outcomes are improved and to devise a rigorous protocol for this prehospital intervention for critically ill pediatric patients.

Mortality following helicopter versus ground transport of injured children

INTRODUCTION

Injured children may be transported to trauma centers by helicopter air ambulance (HAA); however, a benefit in outcomes to this expensive resource has not been consistently shown in the literature and there is concern that HAA is over-utilized. A study that adequately controls for selection biases in transport mode is needed to determine which injured children benefit from HAA. The purpose of this study was to determine if HAA impacts mortality differently in minimally and severely injured children and if there are predictors of over-triage of HAA in children that can be identified.

METHODS

Children ≤18 years of age transported by HAA or ground ambulance (GA) from scene to a trauma center were identified from the 2010-2011 National Trauma Data Bank. Analysis was stratified by Injury Severity Score (ISS) into low ISS (≤15) and high ISS (>15) groups. Following propensity score matching of HAA to GA patients, conditional multivariable logistic regression was performed to determine if transport mode independently impacted mortality in each stratum. Rates and predictors of over-triage of HAA were also determined.

RESULTS

Transport by HAA occurred in 8218 children (5574 low ISS, 2644 high ISS) and by GA in 35305 (30506 low ISS, 4799 high ISS). Overall mortality was greater in HAA patients (4.0 vs 1.4%, p<0.001). After propensity score matching, mortality was equivalent between HAA and GA for low ISS patients (0.2 vs 0.2%, p=0.82) but, for high ISS patients, mortality was lower in HAA (9.0 vs 11.1% p=0.014). On multivariable analysis, HAA was associated with decreased mortality in high ISS patients (OR=0.66, p=0.017) but not in low ISS patients (OR=1.13, p=0.73). Discharge within 24h of HAA transport occurred in 36.5% of low ISS patients versus 7.4% high ISS patients (p<0.001).

CONCLUSIONS

Based on a national cohort adjusted for nonrandom assignment of transport mode, a survival benefit to HAA transport exists only for severely injured children with ISS >15. Many children with minor injuries are transported by helicopter despite frequent dismissal within 24h and no mortality benefit.

Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery

PURPOSE

The American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) is a clinically-derived, validated tool to track outcomes in surgery. The Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) are a set of computer algorithms run on administrative data to identify adverse events. The purpose of this study is to compare complications following orthopedic surgery identified by ACS-NSQIP and AHRQ-PSI.

METHODS

Patients between 2010 and 2012 who underwent orthopedic procedures (arthroplasty, spine, trauma, foot and ankle, hand, and upper extremity) at our tertiary-care, academic institution were identified (n = 3,374). Identification of inpatient adverse events by AHRQ-PSI in the cohort was compared with 30-day events identified by ACS-NSQIP. Adverse events common to both AHRQ-PSI and ACS-NSQIP were infection, sepsis, venous thromboembolism, bleeding, respiratory failure, wound disruption, and renal failure. Concordance between AHRQ-PSI and ACS-NSQIP for identifying adverse events was examined.

RESULTS

A total of 729 adverse events (21.6%) were identified in the cohort using ACS-NSQIP methodology and 35 adverse events (1.0%) were found using AHRQ-PSI. Only 12 events were identified by both methodologies. The most common complication was bleeding in ACS-NSQIP (18.1%) and respiratory failure in AHRQ-PSI (0.53%). The overlap was highest for venous thromboembolic events. There was no overlap in adverse events for 5 of the 7 categories of adverse events.

CONCLUSIONS

A large discrepancy was observed between adverse events reported in ACS-NSQIP and AHRQ-PSI. A large percentage of clinically important adverse events identified in ACS-NSQIP were missed in AHRQ-PSI algorithms. The ability of AHRQ-PSI for detecting adverse events varied widely with ACS-NSQIP.

CLINICAL RELEVANCE

AHRQ-PSI algorithms currently are insufficient to assess the quality of orthopedic surgery.

Ideal hemoglobin transfusion target for resuscitation of massive-transfusion patients

BACKGROUND

Overtransfusion of packed red blood cells is known to increase the risk of death in stable patients. With the delineation of minimum transfusion ratios in hemorrhaging patients complete, attention must be turned to the other end of the massive transfusion spectrum-that of defining the maximum transfusion of packed red blood cells. We aimed to define the ideal hemoglobin range 24 hours after anatomic hemostasis associated with the lowest mortality.

METHODS

Massive-transfusion patients (≥10 units packed red blood cells within 24 hours) were reviewed from 2010-2013. The hemoglobin 24 ± 6 hours after anatomic hemostasis was used to stratify patients into undertransfusion (<8.0 g/dL), hemoglobin transfusion target (8.0-11.9 g/dL), and overtransfusion (>12.0 g/dL) groups; patients not surviving to 24 hours were excluded.

RESULTS

We identified 418 patients (351 [84%] in the hemoglobin transfusion target group, 38 [9%] in the undertransfusion group, and 29 [7%] in the overtransfusion group) with an overall mortality of 18%. Undertransfusion patients had the greatest risk of death (odds ratio 3.3; 95% confidence interval 1.6-6.7) followed by overtransfusion patients (odds ratio 2.5; 95% confidence interval 1.1-5.6). Though pretransfusion hemoglobin was similar (9.5 ± 2.2 g/dL vs 9.5 ± 2.3 g/dL), overtransfusion patients had greater hemoglobin values during massive transfusion (8.3 ± 3.0 g/dL vs 6.9 ± 1.4 g/dL), persisting until hospital dismissal/death (11.4 ± 2.3 g/dL vs 9.6 ± 1.1 g/dL). In total, 657.4 excess packed red blood cell units were transfused (1.9 ± 1.5 per patient).

CONCLUSION

Overtransfusion patients had increased mortality, comparable to undertransfusion patients, despite younger age and fewer comorbidities. Shorter massive transfusion durations foster a scenario in which patients are at greater risk of overtransfusion.

Thoracoscopic Vs open resection of congenital cystic lung disease- utilization and outcomes in 1120 children in the United States

PURPOSE

To determine if utilization of thoracoscopic resection of congenital cystic lung disease (CLD) is increasing and if this approach is associated with improved outcomes using a large national sample.

METHODS

Children ≤20years old who underwent resection of a congenital cystic adenomatoid malformation, bronchopulmonary sequestration, or bronchogenic cyst were identified from the Healthcare Cost and Utilization Project Kids' Inpatient Database (2009, 2012) and Nationwide Inpatient Sample (2008, 2010-2011). Patient characteristics and outcomes were compared between thoracoscopic and open approaches using univariate and multivariable analyses stratified by magnitude of resection.

RESULTS

Thoracoscopic resection was used in 39.4% of 1120 children who underwent resection of CLD. Utilization of the thoracoscopic approach increased from 32.2% in 2008 to 48.2% in 2012. Use of thoracoscopy was lower in lobectomy than segmental resection (32.5 vs 48.4%, p<.001). Newborns, those with comorbid congenital conditions, and those with respiratory infections also had lower rates of thoracoscopy. After stratifying by magnitude of resection and adjusting for patient complexity, complication rates and postoperative length of stay were similar between thoracoscopic and open approaches.

CONCLUSION

Utilization of thoracoscopic resection for CLD in the United States is increasing with time. After adjusting for patient complexity, there is no difference in postoperative length of stay or complications between thoracoscopic and open lobectomy and sub-lobar resection.

Pretransfer computed tomography delays arrival to definitive care without affecting pediatric trauma outcomes

PURPOSE

Children with thoracic or abdominal trauma, presenting to referring hospitals, may undergo CT imaging prior to transfer to a pediatric trauma center (PTC). We sought to determine if children who undergo pretransfer imaging experience a delay in definitive care and worse clinical outcomes.

METHODS

Pediatric blunt trauma patients transferred to our level I PTC were identified in this IRB approved study. Those transferred with CT imaging of the chest or abdomen/pelvis prior to transfer were compared to those transferred without imaging.

RESULTS

Of 246 patients with a mean age of 12.4±5.3years (64% male), 128 patients (52%) underwent chest (n=85) and/or abdominal (n=115) CT studies prior to transfer. Among those patients with pretransfer CT, 14% of CT scans were repeated. On multivariate analysis accounting for distance, time from injury to arrival at our PTC was significantly greater in children who underwent pretransfer CT (320±216 vs. 208±149minutes, p<0.001). Median length of stay (3 vs. 3days) and mortality (3% vs. 3%) were similar between groups (all p>0.05).

CONCLUSIONS

A substantial number of pediatric blunt trauma patients underwent CT scans prior to transfer, which is associated with a delay in transfer but not worse outcomes.