Defining the Full Spectrum of Pediatric Firearm Injury and Death in the United States: It is Even Worse Than We Think

OBJECTIVE

To characterize the full spectrum of pediatric firearm injury in the United States by describing fatal and nonfatal injury data epidemiology, vulnerable populations, and temporal trends.

BACKGROUND

Firearm injury is the leading cause of death in children and adolescents in the United States. Nonfatal injury is critical to fully define the problem, yet accurate data at the national level are lacking.

METHODS

A cross-sectional study combining national firearm injury data from the Centers for Disease Control (fatal) and the National Trauma Data Bank (nonfatal) between 2008 and 2019 for ages 0 to 17 years. Data were analyzed using descriptive and χ 2 comparisons and linear regression.

RESULTS

Approximately 5000 children and adolescents are injured or killed by firearms each year. Nonfatal injuries are twice as common as fatal injuries. Assault accounts for the majority of injuries and deaths (67%), unintentional 15%, and self-harm 14%. Black youth suffer disproportionally higher injuries overall (crude rate: 49.43/million vs White, non-Hispanic: 15.76/million), but self-harm is highest in White youth. Children <12 years are most affected by nonfatal unintentional injuries, 12 to 14 years by suicide, and 15 to 17 years by assault. Nonfatal unintentional and assault injuries, homicides, and suicides have all increased significantly ( P < 0.05).

CONCLUSIONS

This study adds critical and contemporary data regarding the full spectrum and recent trends of pediatric firearm injury in the United States and identifies vulnerable populations to inform injury prevention intervention and policy. Reliable national surveillance for nonfatal pediatric firearm injury is vital to accurately define and tackle this growing public health crisis.

Implications of Tumor Characteristics and Treatment Modality on Local Recurrence and Functional Outcomes in Children With Chest Wall Sarcoma: A Pediatric Surgical Oncology Research Collaborative Study

OBJECTIVE

To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development, and (3) patient-reported quality of life in children with sarcoma of the chest wall.

SUMMARY OF BACKGROUND DATA

Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery, and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence.

METHODS

A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008 and 2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys.

RESULTS

The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (interquartile range = 1-3), and number of ribs resected did not correlate with margin status ( P = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor(HR 2.24, P = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posteriorrib resection (HR 8.43; P= 0.003) and increased number of ribs resected (HR 1.78; P = 0.02). Overall, patient-reported quality of life is not impaired after chest wall tumor resection.

CONCLUSIONS

Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent.

Characteristics and predictors of intensive care unit admission in pediatric blunt abdominal trauma

BACKGROUND

Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT.

METHODS

Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC).

RESULTS

Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88-0.92).

CONCLUSION

Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT.

STUDY DESIGN

Prognosis study.

LEVEL OF EVIDENCE: 1

Surgical Approach to Pediatric Ovarian Growing Teratoma Syndrome: A Case Report

BACKGROUND

Growing teratoma syndrome is defined as conversion of a metastatic immature tumor to a mature tumor after adjuvant chemotherapy and remains an area of investigation because of its unclear pathogenesis. Because of its risk of malignant transformation, the primary treatment strategy for pediatric patients is surgical resection.

CASE

In this report we present a case of a pediatric patient with recurrent growing teratoma syndrome who was treated with chemotherapy, debulking procedures, and cryoablation for the growing nodules throughout her abdominal cavity. The patient has had a good clinical outcome without recurrent malignant tumor.

SUMMARY AND CONCLUSION

These masses do not always regress with chemotherapy and complete surgical excision or ablation should be attempted when possible.

The utility and promise of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in the pediatric population: An evidence-based review

Hemorrhage is the main cause of preventable death in both military and civilian trauma, and many of these patients die from non-compressible torso injuries. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a minimally invasive method used for hemodynamic control of the hemorrhaging patient and has been compared to resuscitative thoracotomy (RT) with cross clamping of the aorta. REBOA has received a great deal of attention in recent years for its applicability and promise in adult trauma and non-trauma settings, but its utility in children is mostly unknown. The purpose of this review article is to summarize and consolidate what is currently known about the use of REBOA in children. Some of the challenges in implementing REBOA in children include small vascular anatomy and lack of outcomes data. Although the evidence is limited, there are established instances in the literature of children and adolescents who have undergone endovascular occlusion of the aorta for hemorrhage control with positive outcomes and survival rates equivalent to their adult counterparts. There is a need for further formal evaluation of REBOA in pediatric patients with prospective studies to look at the safety, feasibility and efficacy of the technique. STUDY TYPE: Narrative Literature Review LEVEL OF EVIDENCE: IV.

Renal Lymphangiectasia in a Pediatric Patient

Renal lymphatic abnormalities are rare, and the understanding of pathophysiology involving renal lymphatics is limited. Symptoms can include hypertension, hematuria, proteinuria, chyluria, and abdominal and lumbar pain. Imaging techniques specific to the renal lymphatics have not been clarified. We review the intrahospital imaging evaluation/workup and clinical course of a 6-year-old male who presented to our institution with a large perirenal cyst. His presentation presented a diagnostic and management challenge. The cyst was determined to be lymphatic in origin and required multiple interventional radiology and surgical procedures for management.

Keeping Children Safe at Home: Parent Perspectives to Firearms Safety Education Delivered by Pediatric Providers

OBJECTIVES

The aims of this study were to assess parent acceptance of firearms education delivered by clinical providers, determine whether parents engage in firearms safety dialog with their children, and evaluate reasons for ownership and storage behaviors.

METHODS

The parents of children ages 0 to 18 years completed surveys while in a pediatric inpatient setting in Texas. Demographics, acceptability, current behaviors, and storage practices were queried. Responses between firearms owners and nonowners were analyzed using the Fisher exact and χ² tests.

RESULTS

Of the 115 parents who completed surveys, 41% reported owning firearms. Most parents were likely or highly likely to follow their pediatrician's gun safety advice (67%), were accepting of safety videos in waiting rooms (59%), and accepted firearms locks distributed by clinical providers (69%). Nonowners were less likely than owners to have spoken to their children about gun safety (P = 0.004). Parents owned firearms for self-protection and recreation (50%), self-protection only (38%), or recreation only (12%). Owners stored them unloaded (75%), used safety devices (95%), and stored them in the closet of the master bedroom (54%).

CONCLUSIONS

Talking about firearms safety in a healthcare setting was not a contentious issue in the majority of our sample. Parents were accepting of provider-led firearms guidance regardless of ownership status. This provides an opportunity for providers to focus on effective messaging and time-efficient delivery of firearms safety education.

Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma

BACKGROUND

Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma.

PROCEDURE

A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification.

RESULTS

A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy.

CONCLUSIONS

PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.

Establishing a regional pediatric trauma preventable/potentially preventable death rate

PURPOSE

Although trauma is the leading cause of death for the pediatric population, few studies have addressed the preventable/potentially preventable death rate (PPPDR) attributable to trauma.

METHODS

This is a retrospective study of trauma-related death records occurring in Harris County, Texas in 2014. Descriptive and Chi-squared tests were conducted for two groups, pediatric and adult trauma deaths in relation to demographic characteristics, mechanism of injury, death location and survival time.

RESULTS

There were 105 pediatric (age < 18 years) and 1738 adult patients. The PPPDR for the pediatric group was 21.0%, whereas the PPPDR for the adult group was 37.2% (p = 0.001). Analysis showed fewer preventable/potentially preventable (P/PP) deaths resulting from any blunt trauma mechanism in the pediatric population than in the adult population (19.6% vs. 48.4%, p < 0.001). Amongst the pediatric population, P/PP traumatic brain injury (TBI) were more common in the youngest age range (age 0-5) vs. the older (6-12 years) pediatric and adolescent (13-17 years) patients.

CONCLUSION

Our results identify areas of opportunities for improving pediatric trauma care. Although the overall P/PP death rate is lower in the pediatric population than the adult, opportunities for improving initial acute care, particularly TBI, exist.

Accuracy of surgeon prediction of appendicitis severity in pediatric patients

PURPOSE

Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity.

METHODS

From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ². A p-value<0.05 was considered statistically significant.

RESULTS

Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 10³/μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F).

CONCLUSION

While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited.

TYPE OF STUDY

Prospective survey.

LEVEL OF EVIDENCE

II.

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction

PURPOSE

Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR.

METHODS

Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression.

RESULTS

Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001).

CONCLUSION

For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.

Management and outcomes of peripancreatic fluid collections and pseudocysts following non-operative management of pancreatic injuries in children

BACKGROUND

Peripancreatic fluid collection and pseudocyst development is a common sequela following non-operative management (NOM) of pancreatic injuries in children. Our purpose was to review management strategies and assess outcomes.

METHODS

A multicenter, retrospective review was conducted of children treated with NOM following blunt pancreatic injury at 22 pediatric trauma centers between the years 2010 and 2015. Organized fluid collections were called "acute peripancreatic fluid collection" (APFC) if identified < 4 weeks and "pseudocyst" if > 4 weeks following injury. Data analysis included descriptive statistics Wilcoxon rank-sum, Kruskal-Wallis and t tests.

RESULTS

One hundred patients with blunt pancreatic injury were identified. Median age was 8.5 years (range 1-16). Forty-two percent of patients (42/100) developed organized fluid collections: APFC 64% (27/42) and pseudocysts 36% (15/42). Median time to identification was 12 days (range 7-42). Most collections (64%, 27/42) were observed and 36% (15/42) underwent drainage: 67% (10/15) percutaneous drain, 7% (1/15) needle aspiration, and 27% (4/15) endoscopic transpapillary stent. A definitive procedure (cystogastrostomy/pancreatectomy) was required in 26% (11/42). Patients with larger collections (≥ 7.1 cm) had longer time to resolution. Comparison of outcomes in patients with observation vs drainage revealed no significant differences in TPN use (79% vs 75%, p = 1.00), hospital length of stay (15 vs 25 median days, p = 0.11), time to tolerate regular diet (12 vs 11 median days, p = 0.47), or need for definitive procedure (failure rate 30% vs 20%, p = 0.75).

CONCLUSIONS

Following NOM of blunt pancreatic injuries in children, organized fluid collections commonly develop. If discovered early, most can be observed successfully, and drainage does not appear to improve clinical outcomes. Larger size predicts prolonged recovery.

LEVEL OF EVIDENCE

III STUDY TYPE: Case series.

Variability in the evalution of pediatric blunt abdominal trauma

PURPOSE

To describe the practice pattern for routine laboratory and imaging assessment of children following blunt abdominal trauma (BAT).

METHODS

Children (age < 16 years) presenting to 14 pediatric trauma centers following BAT over a 1-year period were prospectively identified. Injury, demographic, routine laboratory and imaging utilization data were collected. Descriptive, comparative, and correlation analysis was performed.

RESULTS

2188 children with a median age of 8 (4,12) years were included and the median injury severity score was 5 (1,10). There were significant differences in activation status, injury severity, and mechanism across centers; however, there was no correlation of level of activation, injury severity, or severe mechanism with test utilization. Routine laboratory and imaging utilization for hematocrit, hepatic enzymes, pancreatic enzymes, base deficit urine microscopy, chest and pelvis X-ray, and abdominal computed tomography (CT) varied significantly among centers. Only obtaining a hematocrit had a moderate correlation with CT use. There was no correlation between centers that were high or low frequency laboratory utilizers with CT use.

CONCLUSIONS

Wide variability exists in the routine initial laboratory and imaging assessment in children following BAT. This represents an opportunity for quality improvement in pediatric trauma.

LEVEL OF EVIDENCE

Level II.

Comparison of diagnostic imaging modalities for the evaluation of pancreatic duct injury in children: a multi-institutional analysis from the Pancreatic Trauma Study Group

PURPOSE

Determining the integrity of the pancreatic duct is important in high-grade pancreatic trauma to guide decision making for operative vs non-operative management. Computed tomography (CT) is generally an inadequate study for this purpose, and magnetic resonance cholangiopancreatography (MRCP) is sometimes obtained to gain additional information regarding the duct. The purpose of this multi-institutional study was to directly compare the results from CT and MRCP for evaluating pancreatic duct disruption in children with these rare injuries.

METHODS

Retrospective study of data obtained from eleven pediatric trauma centers from 2010 to 2015. Children up to age 18 with suspected blunt pancreatic duct injury who had both CT and MRCP within 1 week of injury were included. Imaging findings of both studies were directly compared and analyzed using descriptive statistics, Chi square, Wilcoxon rank-sum, and McNemar's tests.

RESULTS

Data were collected for 21 patients (mean age 7.8 years). The duct was visualized more often on MRCP than CT (48 vs 5%, p < 0.05). Duct disruption was confirmed more often on MRCP than CT (24 vs 0%), suspected based on secondary findings equally (38 vs 38%), and more often indeterminate on CT (62 vs 38%). Overall, MRCP was not superior to CT for determining duct integrity (62 vs 38%, p = 0.28).

CONCLUSIONS

In children with blunt pancreatic injury, MRCP is more useful than CT for identifying the pancreatic duct but may not be superior for confirmation of duct integrity. Endoscopic retrograde cholangiogram (ERCP) may be necessary to confirm duct disruption when considering pancreatic resection.

LEVEL OF EVIDENCE

III.

A High Ratio of Plasma: RBC Improves Survival in Massively Transfused Injured Children

BACKGROUND

Massive transfusion protocols with balanced blood product ratios have been associated with improved outcomes in adult trauma. The impact on pediatric trauma is unclear.

MATERIAL AND METHODS

A retrospective review of the Pediatric Trauma Quality Improvement Program data set was performed using data from January 2015 to December 2016. Trauma patient's ≤ 18 y of age, who received red blood cells (RBCs) and were massively transfused were included. Children with burns, dead on arrival, and nonsurvivable injuries were excluded. Outcome data and mortality were assessed based on low (<1:2), medium (≥1:2, <1:1), and high (≥1:1) plasma and platelet to RBC ratios.

RESULTS

There were 465 children included in the study (median age, 8 [2-16] y; median injury severity score, 34 [29-34]; mortality rate, 38%). Those transfused a medium plasma:RBC ratio received the greatest blood product volume in 24 h (90 [56-164] mL/kg; P < 0.01). Those in the low plasma:RBC group underwent fewer hemorrhage control procedures [56 (34%); P < 0.01], but ratio was not significant when controlling for age and other variables. Survival was improved for those who received a high plasma:RBC ratio (P = 0.02). Platelet transfusions were skewed toward lower ratios (95%) with no difference in clinical outcomes between the groups.

CONCLUSIONS

A high ratio of plasma:RBC may result in decreased mortality in severely injured children receiving a massive transfusion. Prospective, multicenter studies are needed to determine optimal resuscitation strategies for these critically ill children.

Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers

PURPOSE

This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers.

METHODS

We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries.

RESULTS

Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001).

CONCLUSION

Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority.

TYPE OF STUDY

Retrospective Review.

LEVEL OF EVIDENCE

II.

The utility of ERCP in pediatric pancreatic trauma

BACKGROUND/PURPOSE

Endoscopic retrograde cholangiopancreatography (ERCP) is an adjunct for pediatric pancreatic injury management, but its use and utility in pediatric patients are unclear. We set out to evaluate the use of ERCP and its effects on outcomes.

METHODS

A retrospective review was performed for children who had pancreatic injuries at 22 pediatric trauma centers between 2010 and 2015. ERCP details and outcomes were collected. Analysis was performed using descriptive statistics and Wilcoxon rank-sum tests.

RESULTS

ERCP was used at 14/22 centers for 26 patients. Indications were duct evaluation, duct leak control, pseudocyst, fistula, and stricture. ERCP altered management or improved outcomes in 13/26 (50%), most commonly in patients with ERCP for duct evaluation, stricture, and fistula. In patients managed nonoperatively, those with early endoscopic intervention (within one week of injury) with stent or sphincterotomy (n=9) had similar time to regular diet [median (IQR)]: [10 (7-211) vs 7 (4-12) days; p=0.55], similar hospital days: [12 (8-20) vs 11 (6-19) days, p=0.63], and similar time on parenteral nutrition: [17 (10-40) vs 10 (6-18) days; p=0.19] compared to patients who were only observed.

CONCLUSIONS

In children with blunt pancreatic injury, ERCP can be useful to diagnose duct injury and for management of late complications such as stricture and fistula. However, early endoscopic intervention for pancreatic duct disruption may not improve outcome or expedite recovery. Further study is needed.

STUDY TYPE

Retrospective Study; Treatment Study.

LEVEL OF EVIDENCE

III.

A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition

PURPOSE

Standardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis.

METHODS

All children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients.

RESULTS

Of 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0h, p<0.001), but postoperative LOS (4.4 vs. 17.4h, p<0.001) and overall LOS (17.1 vs. 31.2h, p<0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode ($8073 vs $8424, p=0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10).

CONCLUSIONS

Safe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system.

LEVEL OF EVIDENCE

Prognosis study, Level II.

In-utero radiofrequency ablation in fetal piglets: Lessons learned

INTRODUCTION

Radiofrequency ablation (RFA) is increasingly utilized in minimally invasive fetal intervention. However, the response of different fetal tissues to RFA is poorly characterized. We sought to determine the extent of RFA damage in a fetal environment.

METHODS

90Day gestation Yorkshire piglets (term 115days) were subjected to RFA of the chest and abdominal viscera under various temperatures and wattages. The extent of tissue damage was determined by NADPH diaphorase histochemistry.

RESULTS

Tyne temperature was widely variable and displayed varying responses between lung and liver tissue. Tyne exposure to amniotic fluid resulted in an increase in amniotic fluid temperature. Collateral damage, even across the diaphragm, was readily seen, and ultrasonography did not always reflect this injury.

CONCLUSIONS

Utilization of extracorporeal tynes heats fluid at a greater rate than solid tissue and reliance on temperature sensitive probes may result in overheating. The extent of injury may extend beyond damage observed by ultrasound examination and varies for different tissues. Additional studies on the use of devices that regulate tyne temperature are needed to define optimal conditions and better define the extent of adjacent tissue injury.

Routine gastrostomy tube placement in children: Does preoperative screening upper gastrointestinal contrast study alter the operative plan?

BACKGROUND

Upper GI (UGI) studies are routinely ordered to screen for malrotation before routine placement of gastrostomy (G) tubes. However, the usefulness of this study is unknown.

METHODS

A retrospective review of children with surgically placed G-tubes over a 2 year period (2011-2013) was performed. Patients with concomitant fundoplications were excluded.

RESULTS

Three hundred ninety-three patients underwent G-tube placement. Of these, 299 patients (76%) had preoperative UGI, and 11 patients (3.7%) were identified with malrotation on UGI. Five (1.7%) patients underwent a Ladd's procedure. The remaining 6 either had malrotation associated with gastroschisis (n=5) or were lost to follow-up (n=1). Children <1 year did not have different rates of malrotation compared to older children (4.3% vs. 3.2%, p=0.617). Likewise, children with neurologic impairment (NI) had similar rates of malrotation compared to neurologically normal (NN) children (2.6% vs. 3.8%, p=0.692). The only significant difference in malrotation rate was between those with congenital gastrointestinal anomalies (24%) and those without (1.5%) (p<0.001).

CONCLUSION

Preoperative screening UGI before routine G-tube placement led to an unexpected diagnosis of malrotation in only 1.7%. Given the added radiation risk associated with an UGI, our data suggest that an UGI is unnecessary prior to routine G-tube placement. A larger prospective study is warranted to validate these results.

Management of pediatric snake bites: are we doing too much?

BACKGROUND

The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas).

METHODS

This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone.

RESULTS

One hundred fifty-one children (mean age 8.4±4.3years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61±0.81). The median hospital stay for admitted patients (79%) was 2days (range 1-7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics.

CONCLUSION

Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.

Use of the harmonic blade scalpel as a novel technique for thoracoscopic resection of pediatric paraspinal masses in children

INTRODUCTION

Data support use of video-assisted thoracoscopic surgery (VATS) for safe and effective resection of paraspinal masses in children. Our aim was to describe outcomes following this operation using a novel technique and to compare its use with that of other established techniques.

SUBJECTS AND METHODS

We performed a retrospective chart review of all children (<18 years old) undergoing thoracoscopic resection of paraspinal masses in 2000-2011. Demographics, operative details, and clinical outcomes were summarized and compared between those undergoing resection using a Harmonic (Ethicon Endo-Surgery, Blue Ash, OH) blade scalpel (HBS) and those who did not.

RESULTS

Sixteen cases were identified (median age, 57.5 months; range, 2-204 months). Six cases (37%) underwent VATS with use of the HBS, and 10 (63%) did not. Demographic and clinical factors were well matched. Median tumor diameter was larger in the HBS group (49.2 cm(3) versus 18.7 cm(3); P=.07). Operative time was similar between groups (121 versus 138 minutes; P=.25), as was the estimated blood loss (10 mL versus 30 mL; P=.91) and chest tube duration (2.1 versus 1.8 days; P=.78). Three cases of Horner's syndrome developed in the standard resection group, and one complication occurred in the HBS group.

CONCLUSIONS

The Harmonic blade scalpel can be used as a simple alternative to standard dissection techniques for thoracoscopic resection of paraspinal masses in children.

Needle decompression to avoid tension pneumoperitoneum and hemodynamic compromise after pneumatic reduction of pediatric intussusception

BACKGROUND

The contemporary management of children with ileocolic intussusception often includes pneumatic reduction. While failure of the procedure or recurrence after reduction can result in the need for surgical treatment, more serious adverse sequelae can occur including perforation and, rarely, tension pneumoperitoneum. During the last year, four cases of perforation during attempted pneumatic reductions complicated by tense pneumoperitoneum have occurred in our center.

OBJECTIVE

We have elected to report our patient experience, describe methods of management and review available literature on this uncommon but serious complication.

MATERIALS AND METHODS

Using ICD-9 diagnosis codes, we reviewed the records of children with intussusception during 2011. Demographic and therapeutic clinical data were collected and summarized.

RESULTS

During the study period, 101 children with intussusception were treated at our institution, with 19% (19/101) of them requiring surgical intervention. Four children (4%) experienced a tense pneumoperitoneum during air enema reduction, prompting urgent needle decompression in the fluoroscopy suite. These children required bowel resection during subsequent laparotomy. No deaths occurred.

CONCLUSION

Pneumoperitoneum is a real and life-threatening complication of pneumatic enemas. It requires immediate intervention and definitive surgical management. Caution should be exercised by practitioners performing this procedure at institutions where pediatric radiology experience is limited and immediate pediatric surgical support is not available.

Traumatic hepatic artery laceration managed by transarterial embolization in a pediatric patient

While blunt abdominal trauma with associated liver injury is a common finding in pediatric trauma patients, hepatic artery transection with subsequent treatment by transarterial embolization has rarely been reported. We present a case of a child who suffered from a hepatic artery injury which was successfully managed by supraselective transarterial microcoil embolization, discuss management strategies in these patients, and provide a review of currently available literature.

Management of rectal pyogenic granuloma with transanal mucosal sleeve resection

In children, pyogenic granulomas are most commonly cutaneous benign vascular lesions but can also present in the gastrointestinal tract. When they occur in the intestine, they can cause acute or chronic gastrointestinal bleeding. We present an unusual case of rectal pyogenic granuloma and our management strategy.

Giant cystic meconium peritonitis presenting in a neonate with classic radiographic eggshell calcifications and treated with an elective surgical approach: a case report

INTRODUCTION

Giant cystic meconium peritonitis is relatively rare. Patients often present with nonspecific physical findings such as distension and emesis. Plain abdominal films remain invaluable for identifying the characteristic calcifications seen with a meconium pseudocyst, and large eggshell calcifications are pathognomonic for the giant cystic subtype.

CASE PRESENTATION

We present classic plain X-ray findings and an intraoperative image of a premature low birth weight two-day-old Hispanic male baby treated for giant cystic meconium peritonitis with a staged procedure involving peritoneal drainage, ostomy creation and closure.

CONCLUSION

Pediatric surgeons have a range of potential therapeutic approaches for giant cystic meconium peritonitis. A delay of definitive surgical management in the setting of massive abdominal soiling is a safe and acceptable strategy if adequate temporizing drainage is performed in the early perinatal period.

Right-sided congenital diaphragmatic hernia, hepatic pulmonary fusion, duodenal atresia, and imperforate anus in an infant

We present a case of a neonate with VACTERL-like association, with the VACTERL association defined as the non-random association of vertebral, anal, cardiac, esophageal, renal/kidney, and limb defects, as manifested by a hemivertebra, imperforate anus, and digit anomalies, in rare association with duodenal atresia and right-sided diaphragmatic hernia. This constellation is previously undescribed and may offer insight into the pathogenesis of VACTERL and associated birth defects.

Imaging accuracy and incidence of Wilms' and non-Wilms' renal tumors in children

PURPOSE

The purpose of this study is to determine the actual incidence, age distribution, and preoperative imaging accuracy of non-Wilms' tumors (nWT) in children with renal masses.

METHODS

Pathologic reports from all tumor nephrectomies or open renal biopsies performed at a single institution from September 1999 to June 2005 were analyzed. Patient demographics, pathologic findings, specific imaging study descriptors, and differential diagnoses were tabulated. Accuracy of imaging studies in identifying specific tumors was calculated.

RESULTS

Ninety-two patients were identified. Sixty-eight had Wilms' tumor (WT) and 24 had an nWT. The nWT group included congenital mesoblastic nephroma (5), clear cell sarcoma (4), neuroblastoma (4), renal cell carcinoma (4), lymphoma (2), angiomyolipoma (2), teratoma (1), hemangioma (1), and renal epithelial tumor (1). When grouped by ages, the incidence of nWT was between 0% and 83%. Sensitivity, specificity, positive predictive value, and negative predictive value for computed tomography (CT) determining a diagnosis of WT were 0.92, 0.55, 0.84, and 0.73, respectively. The CT reports explicitly stated a potential diagnosis in 89% of cases, with a diagnostic accuracy of 82%.

CONCLUSIONS

Non-Wilms' tumors may represent a significant proportion of renal tumors in children, especially in children aged less than 6 months or greater than 12 years. Preoperative imaging is of limited value in differentiating these tumors. These data have significant implications for parental counseling, surgical plan, and the choice of neoadjuvant chemotherapy and argue in favor of obtaining a tissue diagnosis before instituting therapy.

Negative pressure therapy is effective to manage a variety of wounds in infants and children

Negative pressure therapy (NPT) has been accepted as a valuable adjunct for wound closure in adults; however, reports on its effectiveness in young children and infants, including neonates, are limited. A retrospective chart review was conducted on children treated with NPT at a single institution between January 2003 and December 2005. Wound volumetric measurements were calculated at the start and end of therapy. Sixty-eight patients with 82 wounds were identified. The mean age was 8.5 years (range 7 days-18 years). Twenty patients (29%) were 2 years of age or younger, including eight neonates. Wound types included: pressure ulcers (n=13), extremity wounds (n=18), dehisced surgical wounds (n=19), open sternal wounds (n=10), wounds with fistulas (n=3), and complex abdominal wall defects (n=6). Low suction pressures (<100 mmHg) were generally used in children younger than 4 years of age. Following NPT, 93% of wounds decreased in volume. The average wound volume decrease was 80% (p<0.01, n=56). NPT can be effectively used to manage a variety of wounds in children and neonates. No major complications were identified in our retrospective review. Prospective studies are required to better refine the use of this technology in children.