Home intravenous versus oral antibiotics following appendectomy for perforated appendicitis in children: a randomized controlled trial

PURPOSE

To compare the effect of home intravenous (IV) versus oral antibiotic therapy on complication rates and resource utilization following appendectomy for perforated appendicitis.

METHODS

This was a randomized controlled trial of patients aged 4-17 with surgically treated perforated appendicitis from January 2011 to November 2013. Perforation was defined intraoperatively and divided into three grades: I-contained perforation, II-localized contamination to right gutter/pelvis, and III-diffuse contamination. Patients were randomized to complete a ten-day course of home antibiotic therapy with either IV ertapenem or oral amoxicillin-clavulanate. Thirty-day postoperative complication rates including abscess, readmission, wound infection, and charges were compared.

RESULTS

Eighty-two patients were enrolled. Forty four (54%) were randomized to the IV group and 38 (46%) to the oral group. IV patients were older (12.3 ± 3.6 versus 10.1 ± 3.6, p < 0.05) with higher BMI (20.9 ± 5.8 versus 17.9 ± 3.5, p < 0.05). There were no differences in gender, comorbidities, or perforation grade (I-20.4% vs. 26.3%, II-36.4% vs. 34.2%, III-43.2% vs. 39.5%, all p > 0.05). Comparing IV to oral, there was no difference in length of stay (4.4 ± 1.5 versus 4.4 ± 2.0 days, p > 0.05), postoperative abscess rate (11.6% vs. 8.1%, p > 0.05), or readmission rate (14.0% vs. 16.2%, p > 0.05). Hospital and outpatient charges were higher in the IV group (p < 0.0001).

CONCLUSION

Oral antibiotics had equivalent outcomes and incurred fewer charges than IV antibiotics following appendectomy for perforated appendicitis.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AAwith ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm–7 am weekdays and on weekends, 70.7%) than during business hours (7 am–7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of non-diagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 x 103/μL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

Predictors and Outcomes of Nondiagnostic Ultrasound for Acute Appendicitis in Children

Ultrasound assessments of children with possible acute appendicitis (AA) are often nondiagnostic. We aimed to identify the predictors of nondiagnostic ultrasound and to investigate the outcomes. A retrospective review was conducted on children aged 4 to 17 years evaluated in 2013 for AA with ultrasound at a tertiary hospital pediatric emergency department. Demographics, clinical data, and outcomes were analyzed. Of 528 children, 194 (36.7%) had diagnostic ultrasounds and 334 (63.3%) had nondiagnostic ultrasounds. Nondiagnostic ultrasounds were more common after-hours (7 pm-7 am weekdays and on weekends, 70.7%) than during business hours (7 am-7 pm weekdays; 29.3%). After-hours timing and female sex were identified as independent predictors of nondiagnostic ultrasounds (P < 0.05 for both). AA was diagnosed in 35 children with a nondiagnostic ultrasound (10.5%; P < 0.05). No child who underwent a nondiagnostic ultrasound was found to have AA with laboratory values of white blood cell < 11 × 103/µL and c-reactive protein (CRP) < 5 mg/dL. Children with nondiagnostic ultrasounds have a low likelihood of AA if white blood cell < 11 and CRP < 5. We propose a management algorithm that we hope will help reduce admissions and decrease the use of computed tomography scans.

Thoracoscopic Versus Open Congenital Diaphragmatic Hernia Repair: Single Tertiary Center Review

BACKGROUND

Congenital diaphragmatic hernia (CDH) can be repaired open or through thoracoscopy. Thoracoscopic CDH repair could improve cosmesis and avoid the complications of laparotomy, but may have higher recurrence rates. The purpose of this study was to examine the outcomes of thoracoscopic versus open CDH repair, with regard to recurrence, perioperative parameters, and postoperative complications.

METHODS

We performed a retrospective review of open versus thoracoscopic CDH repairs over an 8.5-year period. The primary outcome was hernia recurrence. Secondary outcomes included intraoperative partial pressure of carbon dioxide (pCO₂) levels, length of stay, and postoperative complications. All statistical analyses were performed using standard statistical methods.

RESULTS

A total of 54 infants underwent CDH repair during the study period, of whom 25 underwent successful thoracoscopic repair. Two patients who had undergone open repair developed recurrent diaphragmatic hernias (recurrence rate 3.7%). Operative time and intraoperative pCO₂ levels did not differ between groups. Length of stay was shorter in the thoracoscopic cohort. Four patients in the open cohort developed ventral hernias and five developed bowel obstructions during follow-up. No long-term complications were identified in the thoracoscopic cohort. The median follow-up was 27 months.

CONCLUSIONS

In our experience, thoracoscopic CDH repair was performed safely and with similar outcomes compared to open repair. In addition to improved cosmesis, thoracoscopic repair may avoid some of the long-term complications of laparotomy. In our series, none of the thoracoscopic CDH repairs recurred. We conclude that thoracoscopic CDH repair is a safe and appropriate technique for select neonates.

Return of the surgeon in the diagnosis of pyloric stenosis

BACKGROUND

The diagnosis of pyloric stenosis (PS) by physical examination is a lost art that has been replaced by radiology-performed ultrasound (US). The purpose of this study is to demonstrate that the diagnosis of PS can be made solely upon the surgeons US evaluation.

METHODS

Surgical ultrasonographers included 2 senior general surgery residents and 2 pediatric surgery residents without prior formal US experience. These surgeons underwent proctored training in the use of US for PS. Measurements including channel length and muscle thickness were recorded at bedside. A positive examination included muscle thickness more than 4 mm and channel length more than 16 mm. Patients with positive results underwent pyloromyotomy. Negative results were confirmed with a repeat US through the radiology department, and infants without PS were subsequently referred for appropriate medical management.

RESULTS

Thirty-two consecutive patients with suspected PS were evaluated using surgeon-performed ultrasonography. All examinations were diagnostically accurate. There were no false-positive or false-negative result. Seven patients (22%) were correctly determined to be negative for PS. The remaining 25 infants underwent successful pyloromyotomy with resolution of symptoms.

CONCLUSION

Surgeons who have undergone focused training to perform US for PS can diagnose the condition without confirmatory testing by a radiologist.

Tracheobronchial injury diagnosed by computed tomography scan: a case report

Tracheobronchial injuries are uncommon after pediatric blunt trauma. Because they are easily missed and potentially life-threatening, surgeons caring for pediatric patients with trauma should be aware of this spectrum of injuries. We present a case of tracheobronchial injury in a 10-year-old girl caused by blunt trauma sustained during an all-terrain vehicle collision. This injury was diagnosed in a timely fashion with computed tomography scan, and operative repair was accomplished. A discussion of the management of tracheobronchial injury with brief literature review follows.

Surgeon-performed ultrasound for diagnosis of pyloric stenosis is accurate, reproducible, and clinically valuable

PURPOSE

We will demonstrate that a surgical resident with proven accuracy in the diagnosis of hypertrophic pyloric stenosis (HPS) can teach other surgeons to diagnose HPS with reproducible accuracy.

METHODS

A surgical resident with proven sonographic accuracy in diagnosing HPS instructed 5 other surgical residents in the technique. Consecutive patients referred to pediatric surgery with a presumed clinical diagnosis of HPS were examined, and measurements of residents were compared with formal radiology studies. Each surgeon was proctored for 5 examinations before independent evaluation and was blinded to results from both radiologists and other residents. Results were evaluated using Student's t test; P less than .05 was considered significant.

RESULTS

Seventy-one patients were evaluated by 5 surgical residents. Residents were diagnostically accurate in all cases. There was no statistically significant difference between pyloric muscle thickness or channel length measurements obtained by radiology and any of the residents.

CONCLUSION

Surgeon-performed ultrasound examination for the diagnosis of HPS is accurate and reproducible through surgeon-to-surgeon instruction on appropriate technique. This skill is a valuable asset in the initial surgical evaluation of any patient with suspected HPS, expediting appropriate management.

Residency training in pyloromyotomy: a survey of 331 pediatric surgeons

PURPOSE

Both pediatric and general surgeons perform pyloromyotomy. Laparoscopic pyloromyotomy (LAP), and changes in referral patterns have affected the training of pediatric surgery fellows and general surgery residents. We surveyed pediatric surgeons regarding these issues.

METHODS

We mailed an Institutional Review Board of New Hanover Regional Medical Center-approved survey to 701 members of the American Pediatric Surgical Association within the United States to determine each surgeon's preferred technique for pyloromyotomy (LAP vs Ramstedt or transumbilical procedures [OPEN]), practice setting, involvement with trainees, and opinions regarding pyloromyotomy. Significance was determined using chi(2) analyses.

RESULTS

A total of 331 (48%) surgeons responded: 197 (60%) performed most or all OPEN, and 85 (26%), most or all LAP. Laparoscopic pyloromyotomy was more likely in academic practices and children's hospitals (P < .05). Residents under surgeons performing LAP were less likely to participate (58% vs 91%; P < .05) or gain competence (22% vs 42%; P < .5). Only 34% of surgeons performing LAP believed that general surgery residents should learn pyloromyotomy, whereas 67% of surgeons performing OPEN believed that residents should learn the procedure (P < .05). A total of 307 (93%) surgeons believed at least 4 OPEN were necessary to become competent, but 126 (44%) reported that their residents performed fewer than 4. Only 104 (31%) surgeons believed that their residents were competent in pyloromyotomy. There were 303 (92%) surgeons who believed that pyloromyotomy should be performed only by pediatric surgeons when possible.

CONCLUSIONS

Most general surgical residents are not learning pyloromyotomy, in part because of the adoption of laparoscopic technique, limited operative experience, and the opinion of most pediatric surgeons that the procedure should be performed only by pediatric surgeons.

Hospital Characteristics Affect Outcomes for Common Pediatric Surgical Conditions

Appendicitis, hypertrophic pyloric stenosis (HPS), and intussusception are common conditions treated in most hospitals. In which hospital settings are children with these conditions treated? Are there differences in outcomes based on hospital characteristics? Our purpose was to use a nationwide database to address these questions. Data were extracted from Kids’ Inpatient Database 2000. Data were queried by International Classification of Diseases procedure code for appendectomy and pyloromyotomy and by diagnosis code for intussusception. Length of stay (LOS) and hospital charges were analyzed based on hospital size, location, teaching status, and specialty designation. There were 73,618 appendectomies, with 5,910 (8%) in children's hospitals. Overall LOS was 3.1 days, and was the longest in children's hospitals (3.9). Overall charges were $10,562, with the highest in children's hospitals ($14,124). There were 11,070 pyloromyotomies, with 2,960 (27%) in children's hospitals. Overall LOS was 2.7 days, the shortest being in children's hospitals (2.5). Overall charges were $7,938, with the highest in children's hospitals ($8,676). There were 2,677 intussusceptions, with 921 (34%) in children's hospitals. Overall LOS was 3.0 days, the shortest being in children's hospitals (2.8). Overall charges were $9,558, with the highest in children's hospitals ($10,844). Most children with appendicitis, HPS, and intussusception are treated in nonspecialty hospitals. HPS (27%) and intussusception (34%) are more likely than appendicitis (8%) to be treated in children's hospitals. Children's hospitals have higher charges for all three conditions despite shorter LOS for HPS and intussusception.

Hospital characteristics affect outcomes for common pediatric surgical conditions

Appendicitis, hypertrophic pyloric stenosis (HPS), and intussusception are common conditions treated in most hospitals. In which hospital settings are children with these conditions treated? Are there differences in outcomes based on hospital characteristics? Our purpose was to use a nationwide database to address these questions. Data were extracted from Kids' Inpatient Database 2000. Data were queried by International Classification of Diseases procedure code for appendectomy and pyloromyotomy and by diagnosis code for intussusception. Length of stay (LOS) and hospital charges were analyzed based on hospital size, location, teaching status, and specialty designation. There were 73,618 appendectomies, with 5,910 (8%) in children's hospitals. Overall LOS was 3.1 days, and was the longest in children's hospitals (3.9). Overall charges were dollar 10,562, with the highest in children's hospitals (dollar 14,124). There were 11,070 pyloromyotomies, with 2,960 (27%) in children's hospitals. Overall LOS was 2.7 days, the shortest being in children's hospitals (2.5). Overall charges were dollar 7,938, with the highest in children's hospitals (dollar 8,676). There were 2,677 intussusceptions, with 921 (34%) in children's hospitals. Overall LOS was 3.0 days, the shortest being in children's hospitals (2.8). Overall charges were dollar 9,558, with the highest in children's hospitals (dollar 10,844). Most children with appendicitis, HPS, and intussusception are treated in nonspecialty hospitals. HPS (27%) and intussusception (34%) are more likely than appendicitis (8%) to be treated in children's hospitals. Children's hospitals have higher charges for all three conditions despite shorter LOS for HPS and intussusception.