Search

Purpose: To describe and evaluate safety and feasibility of the robotic modified Sugarbaker technique with intraperitoneal underlay mesh (IPUM) for repairing parastomal hernias associated with ileal conduits (ICPSH)., Methods: This retrospective, single-center cohort study analyzed data from 15 adult patients who underwent robotic ICPSH repair using the modified Sugarbaker IPUM technique between July 2021 and July 2023. The primary endpoints were hernia recurrence rates and 30-day morbidity. Secondary endpoints included length of stay, conversion to open surgery, 30-day readmission, and 30-day reoperation., Results: The mean patient age was 69.1 years, and 53.3% were female. Most patients (86.6%) had undergone radical cystectomy as the index surgery. The mean operative time was 249 min, with no conversions to open surgery. The 30-day complication rate was 26.7%, and the mean hospital stay was 3.6 days. No hernia recurrences, hydronephrosis, rise in creatinine or distended conduit on imaging suggesting poor drainage were observed during a mean follow-up of 15.2 months., Conclusions: The robotic modified Sugarbaker IPUM technique appears safe and feasible for PSH repair in IC patients, with promising short-term outcomes. Further studies with larger cohorts and longer follow-up are needed to confirm its long-term efficacy and establish its role in ICPSH management., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objective: To study the impact of frailty on healthcare utilization in patients undergoing benign pelvic reconstructive surgery; specifically, bladder augmentation., Methods: American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for adults undergoing bladder augmentation between 2005 and 2022. The Five-Item Frailty Index (FFI) was used to assign a score from 0 to 6. Healthcare resource utilization (HRU) was defined by 4 metrics: prolonged length of stay (PLOS), 30-day postoperative readmissions (AR), discharge to continued care (ie, non-home location) (DCC), overall HRU which is a composite of the other 3 outcomes, and complications. Multivariable risk-adjusted regression models were generated., Results: Three hundred sixty-four patients were included, the majority being white (71%), female (52%), with a median age of 49 years. After controlling for baseline variables, higher FFI score (≥2) was independently associated with PLOS (OR 1.90 [1.02-3.53], P = .04), DCC (OR 2.76 [1.24-6.15], P = .01), and greater overall HRU (OR 2.64 [1.29-5.40], P = .008) but not AR (OR 2.27 [0.99-5.19], P = .05). Higher frailty (FFI ≥2) was independently associated with experiencing any complication (OR 2.32 [1.16-4.64], P = .02) as well as major complications (Clavien ≥3) (OR 2.56 [1.15-5.7] P = .02)., Conclusion: Frail adults undergoing bladder augmentation experience greater HRU and complications. This highlights the importance of frailty in benign pelvic reconstructive surgery and stresses the need for interventions to optimize frail patients., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: We describe the surgical management of intravesical mesh perforation following transvaginal mesh surgery for pelvic organ prolapse., Methods: A 73-year-old woman presented with intravesical mesh perforation 17 years following transvaginal mesh-based prolapse repair at an outside hospital. The patient presented with intermittent hematuria and recurrent urinary tract infections. Cystoscopy demonstrated an approximately 3-cm area of intravesical mesh with associated stone spanning from the bladder neck through the left trigone and ureteral orifice. A robotic-assisted transvesical mesh excision and left ureteroneocystostomy was carried out. Robotic-assisted repair was performed transvesically via transverse bladder dome cystotomy. Dissection was carried out circumferentially around the mesh in the vesicovaginal plane, including a 1-cm margin of healthy tissue. The eroded mesh was excised, and the vaginal wall and bladder were closed with running absorbable sutures. Given the location of the mesh excision and repair, a left ureteral reimplantation was performed. The transverse cystotomy was closed and retrograde bladder filling with methylene blue-stained saline confirmed watertight repairs, with no vaginal extravasation., Results: The patient was discharged the following morning and had an uneventful recovery, including transurethral indwelling catheter removal at 2 weeks after CT cystogram and subsequent ureteral stent removal at 6 weeks postoperatively. At 2-month follow-up she had no new urinary symptoms or obstruction of the ureteral reimplantation on renal ultrasound., Conclusions: A robotic-assisted approach is a feasible option for managing transvaginal prolapse mesh perforation into the bladder. Pelvic surgeons must be well equipped to handle transvaginal mesh complications in a patient-specific manner., (© 2024. The International Urogynecological Association.)

Objective: To determine the role of near-infrared fluorescence imaging (NIFI) combined with indocyanine green (ICG) to assess ureteral tissue perfusion in a benign genitourinary reconstruction cohort with a high prevalence of prior abdominopelvic radiation and surgery., Materials and Methods: A prospective, single-surgeon series, between June 2018 and April 2022, of patients who underwent open genitourinary reconstructive surgeries in which NIFI/ICG was utilized to intraoperatively assess ureteral tissue perfusion prior to ureteral anastomosis. Primary outcome was ureteroanastomotic stricture (UAS). Secondary outcomes included impact of NIFI/ICG on surgical decision-making and ureter resection length., Results: Thirty nine patients, median age 66, underwent 40 multimodality reconstructive surgeries during which NIFI/ICG was utilized in the open setting. Radiation-induced etiology was present in 32 of 40 (80%) patients. UAS occurred in 1 of 57 (1.8%) anastomoses with median follow-up of 23.4 months. Use of NIFI/ICG changed intraoperative decision-making in 63% of cases. Change in intraoperative decision-making was more common in patients with prior abdominopelvic radiation (66%) compared to non-radiated patients (13%), P = .007. Discordance between subjective (white-light) and objective (NIFI/ICG) ureteral perfusion (white-light) occurred in 61% of ureters. Mean length of resected ureter was higher following objective assessment with NIFI/ICG (3.6 cm) versus subjective assessment (white light) conditions (1.8 cm), P = .001., Conclusion: Use of NIFI/ICG was associated with low rates of UAS at 2-year follow-up in a cohort with high prevalence of prior radiation. NIFI/ICG was associated with longer lengths of ureter resection and ureteral perfusion assessment discordance compared to subjective surgeon assessment under white-light conditions., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of a standardized perioperative pain management pathway on postoperative opioid prescribing practices following male perineal reconstructive surgery at our institution., Methods: Patients undergoing perineal reconstructive surgery (urethroplasty, artificial urinary sphincter, urethral sling) by a single surgeon from July 2022 to June 2023 were prospectively followed. A standardized nonopioid pathway was implemented in the perioperative period. Intraoperative local anesthetic included liposomal bupivacaine mixed with 0.25% bupivacaine. Opioids are administered in the recovery room at the discretion of anesthesiology providers. As of July 2022, our standard practice does not include a postoperative opioid prescription unless pain is poorly controlled in the recovery area. Postoperative communication encounters and opioid prescriptions were tracked through the electronic health record (EHR) in order to assess the efficacy of an opioid-free pathway., Results: Sixty-seven patients met the criteria during the study period, 64/67 performed in an outpatient setting. 6/67 (9%) patients were prescribed an opioid postoperatively; 4 related to post-surgical pain, and 2 related to chronic pain. No refills were prescribed. Of the 26 patients who received an opioid in the recovery area, 2 (7.6%) were prescribed an opioid at discharge. 15/67 (22%) patients had a communication encounter related to pain within 30 days, most commonly related to bladder spasm management. Only 2 of these encounters resulted in an electronic opioid prescription., Conclusion: An opioid-free pathway is appropriate for opioid naive men undergoing perineal reconstructive surgery. When necessary, electronic opioid prescribing should be employed following discharge for breakthrough pain., Competing Interests: Declaration of Competing Interest The authors declare that they have no conflict of interest., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: To characterize our single institutional experience with robotic and open uretero-enteric stricture (UES) repair. Materials and Methods: We queried our ureteral reconstructive database for UES repair between 01/2017 and 10/2023. Patients with <3 months follow-up were excluded. Prior to surgery, patients underwent ureteral rest (4 weeks) with conversion to nephrostomy tube. Clinical characteristics, complications, reconstructive success (uretero-enteric patency), need for repeat intervention, and renal function were assessed in patients undergoing open and robotic UES reconstruction. Results: Of 50 patients undergoing UES repair during the study period, 45 were included for analysis due to complete follow-up (34 [76%] robotic and 11 [24%] open repair). UES repair was performed in 50 renal units a median of 13 months (interquartile range 7-30) from index surgery, and most often involved the left renal unit (34/50; 68%). Compared with robotic, open cases were significantly more likely to have undergone open cystectomy (100% vs 68%, p = 0.04), have longer strictures (median 4 vs 1 cm, p < 0.001), require tissue substitution (27% vs 3%, p = 0.04), and have lengthier postoperative hospitalization (5 vs 2 days, p < 0.001). There was no significant difference in total operative time (410 vs 322 minutes) or 30d major complications (18% vs 21%). At a follow-up of 13 months, per patient reconstructive success was 100% (11/11) for open and 97% (33/34) for robotic, respectively. Conclusion: In select patients with short UES unlikely to require advanced reconstructive techniques, a robotic-assisted approach can be considered. Careful patient selection is associated with limited morbidity and high reconstructive success.

Objectives: To characterise the prevalence of impostor phenomenon (IP; tendency for high-achieving individuals to perceive themselves as fraudulent in their successes) amongst attending staff in urology, to identify variables that predict more severe impostorism, and to study the association of IP with burnout., Subjects and Methods: A survey composed of the Clance Impostor Phenomenon Scale (CIPS), demographic information, practice details, and burnout levels was e-mailed to urologists via urological subspecialty societies. Survey results were analysed to identify associations between IP severity, survey respondent characteristics, and symptoms of professional burnout. This study was conducted in the United States of America., Results: A total of 614 survey responses were received (response rate 11.0%). In all, 40% (n = 213) of responders reported CIPS scores qualifying as either 'frequent' or 'intense' impostorism (i.e., scores of 61-100). On multivariable analysis, female gender, fewer years in practice (i.e., 0-2 years), and lower academic rank were all independently associated with higher CIPS scores (adjusted P < 0.05). Regarding burnout, 46% of responders reported burnout symptoms. On multivariable analysis, increase in CIPS score was independently associated with higher odds of burnout (odds ratio 1.06, 95% confidence interval 1.04-1.07; P < 0.001)., Conclusion: Impostor phenomenon is prevalent in the urological community and is experienced more severely in younger and female urologists. IP is also independently associated with burnout. Increased female representation may improve IP amongst our female colleagues. More work is needed to determine strategies that are effective in mitigating feelings of IP and professional burnout amongst urologists, particularly those earlier in their careers., (© 2024 BJU International.)

Competing Interests: Declaration of Competing Interest None Declared.

Background: A pilot randomized controlled trial (RCT) conducted in children (2-17 ​y) with perforated appendicitis demonstrated an 89% probability of reduced intra-abdominal abscess (IAA) rate with povidone-iodine (PVI) irrigation, compared with no irrigation (NI). We hypothesized that PVI also reduced 30-day hospital costs., Methods: We conducted a retrospective economic analysis of a pilot RCT. Hospital costs, inflated to 2019 U.S. dollars, were obtained for index admissions and 30-day emergency visits and readmissions. Cost differences between groups were assessed using frequentist and Bayesian generalized linear models., Results: We observed a 95% Bayesian probability that PVI reduced 30-day mean total hospital costs ($16,555 [PVI] versus $18,509 [NI]; Bayesian cost ratio: 0.90, 95% CrI, 0.78-1.03). The mean absolute difference per patient was $1,954 less with PVI (95% CI, -$4,288 to $379)., Conclusions: PVI likely reduced the IAA rate and 30-day hospital costs, suggesting the intervention is both clinically superior and cost saving., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Surgeons play a central role in the opioid epidemic. We aim to evaluate the efficacy of a standardized perioperative pain management pathway and postoperative opioid requirements in men undergoing outpatient anterior urethroplasty at our institution., Methods: Patients undergoing outpatient anterior urethroplasty by a single surgeon from August 2017 to January 2021 were prospectively followed. Standardized nonopioid pathways were implemented based on location (penile vs bulbar) and need for buccal mucosa graft. A practice change in October 2018 transitioned (1) from oxycodone to tramadol, a weak mu opioid receptor agonist, postoperatively and (2) from 0.25% bupivacaine to liposomal bupivacaine intraoperatively. Postoperative validated questionnaires included 72-hour pain level (Likert 0-10), pain management satisfaction (Likert 1-6), and opioid consumption., Results: A total of 116 eligible men underwent outpatient anterior urethroplasty during the study period. One-third of patients did not use opioids postoperatively, and nearly 78% of patients used ≤5 tablets. The median number of unused tablets was 8 (IQR 5-10). The only predictor for use of >5 tablets was preoperative opioid use (75% vs 25%, P < .01). Overall, patients using tramadol postoperatively reported higher satisfaction (6 vs 5, P < .01) and greater percentages of pain reduction (80% vs 50%, P < .01) compared to those using oxycodone., Conclusions: For opioid-naïve men, 5 tablets or less of opioid medication with a nonopioid care pathway provides satisfactory pain control following outpatient urethral surgery without excessive overprescribing of narcotic medication. Overall, multimodal pain pathways and perioperative patient counseling should be optimized to further limit postoperative opioid prescribing.

Objective: To determine patient outcomes across a range of pelvic fracture urethral injury (PFUI) severity. PFUI is a devastating consequence of a pelvic fracture. No study has stratified PFUI outcomes based on severity of the urethral distraction injury., Methods: Adult male patients with blunt-trauma-related PFUI were followed prospectively for a minimum of six months at 27 US medical centers from 2015-2020. Patients underwent retrograde cystourethroscopy and retrograde urethrography to determine injury severity and were categorized into three groups: (1) major urethral distraction, (2) minor urethral distraction, and (3) partial urethral injury. Major distraction vs minor distraction was determined by the ability to pass a cystoscope retrograde into the bladder. Simple statistics summarized differences between groups. Multi-variable analyses determined odds ratios for obstruction and urethroplasty controlling for urethral injury type, age, and Injury Severity Score., Results: There were 99 patients included, 72(72%) patients had major, 13(13%) had minor, and 14(14%) had partial urethral injuries. The rate of urethral obstruction differed in patients with major (95.8%), minor (84.6%), and partial injuries (50%) (P < 0.001). Urethroplasty was performed in 90% of major, 66.7% of minor, and 35.7% of partial injuries (P < 0.001)., Conclusion: In PFUI, a spectrum of severity exists that influences outcomes. While major and minor distraction injuries are associated with a higher risk of developing urethral obstruction and need for urethroplasty, up to 50% of partial PFUI will result in obstruction, and as such need to be closely followed., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: A successful urethroplasty has been defined in different ways across studies. This variety in the literature makes it difficult to compare success rates and techniques across studies. We aim to evaluate the success of anterior urethroplasty based on different definitions of success in a single cohort., Materials and Methods: Data were collected from a multi-institutional, prospectively maintained database. We included men undergoing first-time, single-stage, anterior urethroplasty between 2006 and 2020. Exclusion criteria included lack of followup, hypospadias, extended meatotomy, perineal urethrostomy, posterior urethroplasty and staged repairs. We compared 5 different ways to define a "failed" urethroplasty: 1) stricture retreatment, 2) anatomical recurrence on cystoscopy, 3) peak flow rate <15 ml/second, 4) weak stream on questionnaire and 5) failure by any of these measures. Kaplan-Meier survival curves were generated for each of the definitions. We also compared outcomes by stricture length, location and etiology., Results: A total of 712 men met inclusion criteria, including completion of all types of followup. The 1- and 5-year estimated probabilities of success were "retreatment," 94% and 75%; "cystoscopy," 88% and 71%; "uroflow," 84% and 58%; "questionnaire," 67% and 37%; and "any failure," 57% and 23%. This pattern was inconsistent across stricture length, location and etiology., Conclusions: The estimated probability of success after first-time, anterior urethroplasty is highly dependent on the way success is defined. The variability in definitions in the literature has limited our ability to compare urethroplasty outcomes across studies.

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., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction., Materials and Methods: A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed., Results: Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included benign prostatic hypertrophy treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (benign prostatic hypertrophy), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (P = .52). Median length of stay after reconstruction was 2, 1, and 2 days (P = .45). Thirty-day complications occurred in 0%, 20%, 40% (P = .19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (P = .004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (P = .63), with functional success rates of 100%, 100%, 60% (P = .035). Median postoperative pad/day usage was 0,0, 10.5 (P <.001), and ultimately 0%, 30%, 80% (P = .013) underwent artificial urinary sphincter placement., Conclusion: Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Abstract: Congenital cardiac comorbidities represent a potentially elevated risk for complications in patients undergoing cleft lip repair. National databases, such as the National Surgical Quality Improvement Program Pediatric (NSQIP-P) allow for analysis of large national datasets to assess these risks and potential complications. The aim of this study is to assess the risk of complications in patients undergoing cleft lip repair with congenital cardiac co-morbidities using the NSQIP-P.The 2012 to 2014 NSQIP-P databases were queried for patients undergoing cleft lip repair. Data abstracted for analysis included demographic, clinical, and outcomes data. Patients with cleft lip were stratified based on the presence or absence of congenital cardiac comorbidities. Univariate analysis and step-wise, forward logistic regression were performed to compare these groups.Nationally, between 2012 and 2014, 2126 patients underwent cleft lip repair, 227 with cardiac disease, and 1899 without cardiac disease. Weights were similar between the groups at the time of surgery, though patients with cardiac comorbidities were older. Postoperatively, cardiac disease patients were more likely to experience an adverse event. Specifically, they were more likely to experience reintubation, reoperation, longer length of stay, and death. Rates of surgical site infection and dehiscence were not different between the groups.This study demonstrates that cleft lip repair in patients with congenital heart defects is safe. However, patients undergoing cleft lip repair with comorbid congenital cardiac disease were more likely to experience adverse events. Cardiac patients require special preoperative evaluation before repair of their cleft lip, but do not appear to experience worse wound-related outcomes., Competing Interests: The authors report no conflicts of interest., (Copyright © 2020 by Mutaz B. Habal, MD.)

Background/purpose: Prophylactic, intraabdominal drains have been used to prevent intraabdominal abscess (IAA) after perforated appendicitis. We hypothesized that routine drain placement would reduce the IAA rate in pediatric perforated appendicitis., Methods: A 27-month quality improvement (QI) initiative was conducted: closed-suction, intraabdominal drains were placed intraoperatively in pediatric (age < 18) perforated appendicitis patients. QI patients were compared to controls admitted during the preceding 8 months and following 4 months. The primary outcome was 30-day IAA rate. Univariate and multivariate analyses were performed., Results: Two hundred seventy QI patients were compared to 109 controls. There was 100% compliance during 21 of 27 months of the QI initiative; only 7 QI patients did not receive drains. IAA occurred in 20.0% of QI patients and 22.9% of control (p = 0.52). After adjustment, the QI initiative was not associated with reduced odds of IAA (OR 0.83, 95% CI 0.48-1.44). Median length of stay was longer in QI patients during the index admission (p = 0.03) and over 30 postoperative days (p = 0.03), but these relationships did not persist after adjustment., Conclusions: A QI initiative investigating prophylactic, intraabdominal drain placement in perforated appendicitis did not reduce the IAA rate. We recommend against routine drain placement in pediatric perforated appendicitis., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: We hypothesized that general surgery programs with more female faculty and leadership may be associated with more female residents., Methods: The Fellowship and Residency Electronic Interactive Database Access system (FREIDA) was assessed for chair gender, program director gender, percentage of female faculty, and percentage of female residents at general surgery residency programs. Programs were stratified by type: university-based (UB), community-based/university-affiliated (UA) and community-based (CB)., Results: 304 general surgery programs reported a mean of 38.4% female residents which did not differ by program type. Chairs were more likely female in UB programs (12.8%) versus 5.5% in UA and CB programs (p = 0.05). There were more female faculty at UB programs (23.3%) versus UA (21.7%) and CB (17.4%) (p = 0.04). Chair (p = 0.21), program director (p = 0.98) and faculty gender proportion (p = 0.40) was not associated with female resident complement., Conclusions: In general surgery programs, faculty and leadership gender composition was not associated with proportion of female residents., Competing Interests: Declaration of competing interest We have no conflict of interests to report for all authors (K. Tinsley Anderson, Simone Hyman, Marion C.W. Henry)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: A randomized controlled trial was conducted to test the hypothesis that povidone-iodine (PVI) irrigation versus no irrigation (NI) reduces postoperative intra-abdominal abscess (IAA) in children with perforated appendicitis., Methods: A 100 patient pilot randomized controlled trial was conducted. Consecutive patients with acute perforated appendicitis were randomized (1:1) to PVI or NI from April 2016 to March 2017 and followed for 1 year. Patients and postoperative providers were blinded to allocation. The primary endpoint was 30-day image-confirmed IAA. Secondary outcomes included initial and total 30-day length of stay (LOS), emergency department (ED) visits, and readmissions. Intention-to-treat analyses were performed to estimate the probability of clinical benefit using Bayesian regression models (an optimistic prior for the primary outcome and neutral priors for secondary outcomes). Frequentist statistics were also used., Results: Baseline characteristics were similar between treatment arms. The PVI arm had 12% postoperative IAA versus 16% in the NI arm (relative risk 0.72, 95% credible interval 0.38-1.23). Bayesian analysis estimates 89% probability that PVI reduces IAA. High probability of benefit was seen in all secondary outcomes for the PVI arm: fewer ED visits and readmissions, and shorter initial and total 30-day LOS. The probability of benefit in reduction of total 30-day LOS in PVI patients was 96% and was significant (P = 0.05) on frequentist analysis., Conclusions: PVI irrigation for perforated appendicitis in children demonstrated a strong probability of reduction in postoperative IAA with a high probability of decreased LOS. With the favorable probability of benefit in all outcomes, this pilot study serves as evidence to continue a definitive trial.

Background: The definition of massive transfusion (MT) in civilian pediatric trauma patients is not established. In combat-injured pediatric patients, the definition of MT is based on the volume of total blood products transfused. The aim of this study is to define MT in civilian pediatric trauma patients based on a packed red blood cell (PRBC) volume threshold and compare its predictive power to a total blood products volume threshold., Methods: An analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program database was performed (2014-2016) including pediatric trauma patients (4-18 years) who received blood products within 24 hours. Receiver operator characteristic curves for predicting mortality determined the optimal PRBC MT threshold. Area under receiver operating characteristic curve (AUROC) curve analysis was performed to compare the predictive power of a PRBC threshold to a total blood product threshold., Results: A total of 1,495 patients were included. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at a PRBC threshold of 20 mL/kg. As compared with total blood products threshold, 20 mL/kg PRBCs volume achieved higher discriminatory power for predicting 24-hour (AUROC, 0.803 vs. 0.672; p < 0.001) and in-hospital mortality (AUROC, 0.815 vs. 0.686, p < 0.001). Patients who received an MT had higher Injury Severity Score (p < 0.001) and were more likely to receive mechanical ventilation (p < 0.001) and intensive care unit admission (p < 0.001). Overall 24-hour mortality (23.1% vs. 7.6%, p < 0.001) and in-hospital mortality (44.9% vs. 15.8%, p < 0.001) were higher in the MT group. On regression analysis, MT significantly predicted in-hospital mortality (odds ratio, 3.8 [2.9-4.9, 95% CI]) and 24-hour mortality (odds ratio, 3.3 [2.4-4.7, 95% CI])., Conclusion: The use of a PRBCs MT definition in civilian pediatric patients is a better predictor of mortality compared with total blood products threshold. These results provide a framework for MT protocol development., Level of Evidence: Prognostic study, level III.

Objective: To assess the risk of complication in patients undergoing cleft palate repair with congenital cardiac comorbidities in a large, national cohort., Design: Retrospective review., Patients/setting: Using the 2012-2014 National Surgical Quality Improvement Program (NSQIP) Pediatric database, patients undergoing cleft palate repair were selected for analysis. Patients with cleft palate repairs were stratified based on the presence or absence congenital cardiac comorbidities. Univariate and stepwise forward logistic regression were conducted., Main Outcome Measures: It is hypothesized that risk of postoperative adverse events in patients with congenital cardiac comorbidities is higher than in patients without cardiac disease., Results: Nationally, between 2012 and 2014, 3240 patients underwent cleft palate repair, 422 (13.0%) with cardiac disease, and 2818 (87.0%) without cardiac disease. Patients with cardiac disease were smaller (10.5 [6.6] kg vs 11.6 [8.6] kg, P < .01) and more likely to be premature (4.6% vs 13.0%, P < .01) compared to those without cardiac disease. Postoperatively, patients with cardiac conditions were more likely to experience an adverse event (8.8% vs 4.2%, P < .01). Specifically, they were more likely to experience reintubation (1.7% vs 0.4%, P < .01), reoperation (2.1% vs 0.6%, P < .01), and longer length of stay (2.7 [7.0] vs 1.6 [2.8] days, P < .01). Rates of surgical site infection and dehiscence were not different., Conclusions: Cleft palate repair in patients with concurrent congenital cardiac defects is a safe procedure but carries elevated risk in the postoperative period as demonstrated in this analysis of the NSQIP-Pediatric database. Technical risks are equivalent. Additional anesthesia and surgical awareness of these potential complications is essential to minimize perianesthesia risks.

Background: Evidence-based guidelines recommend ultrasound (US) over computed tomography (CT) as the primary imaging modality for suspected pediatric appendicitis. Continued high rates of CT use may result in significant unnecessary radiation exposure in children. The purpose of this study was to evaluate variables associated with preoperative CT use in pediatric appendectomy patients., Methods: A retrospective cohort study of pediatric patients who underwent appendectomy for acute appendicitis in 2015-2016 at National Surgical Quality Improvement Program for Pediatrics (NSQIP-P) hospitals was conducted. Pediatric (<18 years old) patients who underwent appendectomy for acute appendicitis in an NSQIP-P hospital from 2015 to 2016 were included. Patients were excluded if they underwent interval or incidental appendectomy or did not have a final diagnosis of appendicitis. Variables associated with imaging evaluation, including age, body mass index (BMI), race/ethnicity, gender and hospital of presentation (NSQIP-P vs. non-NSQIP-P hospital) were evaluated. The primary outcome was receipt of preoperative CT. Secondary outcomes include reimaging practices and trends over time., Results: 22,333 children underwent appendectomies, of which almost all were imaged preoperatively (96.5%) and 36% of whom presented initially to a non-NSQIP-P hospital. Overall, US only was the most common imaging modality (52%), followed by CT only (27%), US+CT (16%), no imaging (3%), MRI +/- CT/US (1%) and MRI only (<1%). On regression, older age (>11 years), obesity (BMI >95th percentile for age), and female gender were associated with increased odds of receiving a CT scan. However, initial presentation to a non-NSQIP-P hospital was the strongest predictor of CT use (OR 9.4, 95% CI 8.1-10.8). Reimaging after transfer was common, especially after US and MRI at a non-NSQIP-P hospital. CT use decreased between 2015 and 2016 in non-NSQIP-P hospitals but remained the same (25%) in NSQIP-P facilities., Conclusions: Though patient characteristics were associated with different imaging practices, presentation at a referral, nonchildren's hospital is the strongest predictor of CT use in children with appendicitis. NSQIP-P hospitals frequently reimage transferred patients and have not reduced their CT use. Novel strategies are required for all hospital types in order to sustain reduction in CT use and mitigate unnecessary imaging., Level of Evidence: Level III., Type of Study: Retrospective comparative study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The purpose of this study was to characterize emergency pediatric burn care triage at a tertiary children's hospital to identify targets for quality improvement., Methods: A retrospective review of patients <18 years with primary burn injuries who presented to a children's emergency department in 2016 was conducted. Demographic and injury characteristics were recorded. Low acuity was defined by size (<5% total body surface area burn), depth (not third degree), and no need for conscious sedation for debridement. Multiple logistic regression was used for analysis., Results: A total of 309 pediatric burn patients were triaged in the emergency department. Patients were typically young (median 3.3 years), male (59%), Hispanic (47%), publically insured (77%), and transferred in (65%). Scalding was the most common mechanism (59%). Though most burns were small (median 2% total body surface area), not deep (

Introduction: Accurate data are essential for the validity of clinical registries. This study aimed to validate NSQIP-P data, assess representativeness, and evaluate risk-adjusted predictive ability at a single institution., Methods: A prospective appendectomy-specific pediatric surgery research database (RD) maintained by clinical researchers was compared to the NSQIP-P data for appendectomies performed in 2016 at a tertiary children's hospital. NSQIP-P sampled data collected by trained surgical clinical reviewers (SCRs) were compared to matched RD patients. Both datasets used NSQIP-P definitions. Using χ 2 , datasets were compared by patient demographics, disease severity (simple vs. complicated), and outcomes., Results: 458 appendectomies for acute appendicitis were performed in 2016, of which 250 (55%) were abstracted by SCRs and matched to RD patients. Patient demographics were similar between datasets. Disease severity (NSQIP-P:50% complicated vs RD:31% complicated) and composite morbidity (NSQIP-P:6.0% vs RD:14.4%) were significantly different (both p < 0.01). Demographics and outcomes were similar between matched (n = 250) and unsampled patients in the RD (n = 208). NSQIP-P's risk-adjusted predicted morbidity was significantly lower than morbidity observed in all (n = 458) RD patients (NSQIP-P:9.9% vs RD:14.2%, p < 0.01)., Conclusions: Though constituting a representative sample, NSQIP-P appendectomy data were inconsistent with department data. Discrepancies appear to be the result of underreporting of outcome variables and disease misclassification., Type of Study: Retrospective comparative review., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Opioid misuse is a public health crisis in the United States. This study aimed to evaluate the discharge opioid prescription practices for pediatric simple appendectomy patients., Methods: A retrospective review of pediatric appendectomy patients at a tertiary children's hospital was conducted from October 2016 to January 2018. Only patients with simple appendicitis were included. Written opioid prescriptions were found in the electronic medical record (EMR) or through a statewide prescription monitoring database. All dosing data were converted to oral morphine equivalents (OMEs). Analysis of variance and logistic regression were used., Results: During the study, 590 patients underwent appendectomy, of which 371 (62.9%) were diagnosed as having simple acute appendicitis. The majority of patients were prescribed an opioid analgesic (62.5%). Demographics were similar between those who received opioids and those who did not. The OME prescribed per day (range 0.2 to 3.4 mg/kg/day) was highly variable as was duration of prescription (1 to 30 days). Odds of emergency department visit were 3.3 times higher (95% CI 1.3-8.2) in those who received opioids., Conclusion: Postdischarge prescription practices for pediatric appendectomy are highly variable. Two-thirds of patients who received narcotics had a higher rate of complications. Greater scrutiny is required to optimize opioid stewardship., Type of Study: Retrospective comparative study., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The purposes of this study were to evaluate the efficacy of failure-of-discharge criteria and identify the cohort of pediatric patients after appendectomy in whom postoperative imaging would impact management., Methods: Pediatric patients who underwent an appendectomy from July 2009 to May 2017 were included. Complicated appendicitis was defined based on the intraoperative diagnosis. Postoperative imaging was recommended at postoperative days 5-7 for patients who met at least one criterion of failure of standard management: fever (>38°C), leukocytosis (white blood cell count >12,000/mm 3 ), diet intolerance, or uncontrolled pain by oral analgesics at postoperative day 5. Primary outcomes included any intervention (reoperation, drainage procedures, or change in antibiotics)., Results: In all, 3,276 pediatric patients undergoing appendectomy were identified. Of these patients, 12% met at least 1 discharge criterion of failure Most discharge failures (79%) underwent postoperative imaging, such as computed tomography (68%), ultrasonography then computed tomography (20%), or ultrasonography only (12%); 39% of imaging patients required intervention. On multiple logistic regression, 3 criteria (diet intolerance, fever, and leukocytosis), complicated disease, and age were associated with the need for intervention after imaging. The type of imaging modality did not discriminate need for intervention., Conclusion: Standardized criteria identifying failure of ability to discharge the patient after appendectomy limits the need for unnecessary imaging. In the management of pediatric appendicitis, a selective approach resulted in a high yield of complications requiring intervention after obtaining postoperative imaging., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Parenteral nutrition for intestinal failure (IF) often requires a tunneled central venous catheter (CVC). The purpose of this study was to characterize complications after CVC placement and contributors to line loss in pediatric IF patients., Methods: An institutional review board-approved retrospective review of pediatric (<18 y) IF patients who had a silicone tunneled CVC newly inserted or exchanged from 2012 to 2016 in an IF center was conducted. Patient demographics, procedure service (surgery versus interventional radiology), procedure type (new versus exchange), vessel, and complications related to CVCs were evaluated. Complications included dislodgement, infection, break, occlusion/malfunction, and others. An ethanol-lock protocol for silicone CVCs in IF patients was instituted in January 2012., Results: Twenty-nine IF patients with tunneled CVCs were identified with 182 lines and 18,534 line d. Median age at line insertion was 17.1 mo (interquartile range [IQR] 7.6-31.5) with a median of five catheters (IQR 2-8) per patient. There were 19.2 complications per 1000 line d. Occlusions/malfunctions were the most common complication (6.0/1000 line d) followed by breaks (5.6/1000 line d). Median life of catheters was 51.5 d (IQR 21-129). On regression, adjusting for age, insertion service, and procedure type, shorter line life was associated with younger age (P = 0.04) and placement by interventional radiology (P < 0.01). Dislodgement was associated with newly placed lines relative risk 6.5 (95% CI 2.2-28.8)., Conclusions: CVCs in pediatric IF patients have frequent complications and short line lifetimes. Dislodgement of CVC was an unexpectedly common complication with loss of access in newly placed lines. There may be modifiable processes to mitigate CVC complications., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Down syndrome (DS) is a genetic condition associated with multiple comorbidities. While physicians may perceive that DS patients have more postoperative complications, the literature remains unclear. This study compared postoperative complications for children with and without DS who underwent abdominal and thoracic procedures., Methods: The National Surgical Quality Improvement Program Pediatric was queried for patients aged <18 years, who underwent abdominal and noncardiac thoracic operations (by Current Procedural Terminology codes) from 2012 to 2015. The analysis compared patients based on the presence or absence of DS. The primary outcome was a composite of all postoperative complications as defined by the National Surgical Quality Improvement Program Pediatric. The analysis utilized chi-square, Student's t-test, and univariate and multiple logistic regression., Results: There were 91,478 patients included, of which 1476 (1.6%) had a diagnosis of DS. Patients with DS had higher rates of preoperative nutritional support (38.8% versus 15.0%), developmental delay (61.9% versus 10.4%), and cardiac risk factors (76.5% versus 13.8%). The overall rate of postoperative complications was 11.1%, with a greater proportion in DS patients (16.2% versus 10.8%, P < 0.001). On univariate analysis, DS was associated with increased odds of postoperative complications (odds ratio 1.6 95% confidence interval 1.4-1.9) compared with the non-DS group; however, DS was not a risk factor after adjusting for other covariates (adjusted odds ratio 0.86 95% confidence interval 0.7-1.1)., Conclusions: A higher proportion of postoperative complications were observed in patients with DS. However, after adjusting for other risk factors, DS was not an independent risk factor. The increased rate of complications is likely related to the presence of multiple comorbidities in DS., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Machine-learning can elucidate complex relationships/provide insight to important variables for large datasets. This study aimed to develop an accurate model to predict neonatal surgical site infections (SSI) using different statistical methods., Methods: The 2012-2015 National Surgical Quality Improvement Program-Pediatric for neonates was utilized for development and validations models. The primary outcome was any SSI. Models included different algorithms: full multiple logistic regression (LR), a priori clinical LR, random forest classification (RFC), and a hybrid model (combination of clinical knowledge and significant variables from RF) to maximize predictive power., Results: 16,842 patients (median age 18 days, IQR 3-58) were included. 542 SSIs (4%) were identified. Agreement was observed for multiple covariates among significant variables between models. Area under the curve for each model was similar (full model 0.65, clinical model 0.67, RF 0.68, hybrid LR 0.67); however, the hybrid model utilized the fewest variables (18)., Conclusions: The hybrid model had similar predictability as other models with fewer and more clinically relevant variables. Machine-learning algorithms can identify important novel characteristics, which enhance clinical prediction models., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: The role of home antibiotics (HA) at discharge in children after perforated appendicitis is unclear. This study evaluates the outcomes of complicated appendicitis in patients being discharged with or without HA after initial operation and inpatient treatment., Study Design: The 2015 and 2016 NSQIP-Pediatric database was queried for patients younger than 18 years of age with complicated appendicitis. Home antibiotics were prescribed or not (no home antibiotics [NHA]). Patients were stratified based on presence or absence of predischarge surgical site infection (SSI) and postoperative day of discharge (≤5 days or >5 days). The primary end point was 30-day postdischarge composite morbidity, including emergency department visit, readmission, postdischarge reoperation, and SSI. Multivariable logistic regression was used to adjust for baseline covariables., Results: Of 6,412 patients with complicated appendicitis, the majority were discharged with HA (HA 56.4%; NHA 43.6%). Patients receiving HA had higher preoperative leukocytosis, longer procedures, higher incidence of sepsis, more predischarge SSIs, and longer length of stay than the NHA cohort (all p < 0.01), suggesting greater severity of illness. In adjusted multivariable models, HA patients without a predischarge SSI had higher postdischarge morbidity (adjusted odds ratio [aOR] 1.22; 95% CI 1.04 to 1.44), as did HA patients discharged ≤5 days post operation (aOR 1.28; 95% CI 1.04 to 1.57) compared with NHA patients. Composite morbidity was similar between NHA and HA patients with predischarge SSIs (aOR 1.06; 95% CI 0.56 to 2.00) or who were discharged >5 days post operation (aOR 1.14; 95% CI 0.89 to 1.46)., Conclusions: Although the majority of pediatric patients with complicated appendicitis are discharged with HA, NSQIP-Pediatric data suggest there is no evidence of a significant benefit. There might be a cohort of patients with more severe disease who require continued antibiotics., (Copyright © 2018 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The World Health Organization recommends including the parents in completion of the pediatric surgical safety checklist. At our hospital, the preinduction surgical safety checklist is conducted in the preoperative holding with anesthesia, nursing, and often with the parents of children undergoing an operative procedure. We hypothesized that adherence to the preinduction checklist is better when parents are engaged in surgical safety checklist performance., Methods: An observational study of adherence to the preinduction checklist for nonemergent pediatric operations was performed (2016-2017). Adherence was defined as verbalization of checkpoints. Only checkpoints (patient identification, procedure, site marking, weight, allergies, and NPO status) relevant to parental knowledge were evaluated. Parental engagement was based on: positive body language, eye contact, lack of distractions, and understanding of checkpoints., Results: 484 preinduction surgical safety checklists were observed (interrater reliability >0.7). Partial completion occurred in 55% cases; only 41% checklists were fully completed. Parents were present for 81% of checklists, and more checkpoints were performed when parents were present (5, IQR 4-6) versus absent (2, IQR 1-3, P < .001). Increased preinduction adherence was associated with increased parent engagement by linear regression analysis (1.20, 95%CI 1.05-1.33). Staff confirmed more checkpoints with engaged parents (28-78%) versus when parents were not engaged (1-9%, P < .001 for all checkpoints)., Conclusion: Overall preinduction surgical safety checklist performance was poor (less than half of checklists fully completed). In contrast, checklist adherence improved with parental presence and engagement during performance of the checklist., (Copyright © 2018 Elsevier Inc. All rights reserved.)

For decades, safe surgery focused on intraoperative technique and decision-making. The traditional hierarchy placed the surgeon as the leader with ultimate authority and responsibility. Despite the advances in surgical technique and equipment, too many patients have suffered unnecessary complications and suboptimal care. Today, we understand that the conduct of safe and effective surgery requires evidence-based decision-making, multifaceted treatment approaches to prevent complications, and effective communication in and out of the operating room. In this manuscript, we describe three significant advances in quality and safety that have changed the approach to surgical care: the National Surgical Quality Improvement Program, evidence-based bundled prevention of surgical site infections, and the Surgical Safety Checklist., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Purposeful completion (fidelity) more than simple adherence to items in the surgical safety checklist may improve operating room efficiency and patient safety. The purpose of this study was to evaluate intraoperative delays and correlate them with adherence and fidelity to the preincision surgical safety checklist., Methods: Trained observers evaluated surgical safety checklist compliance during 3 observation periods from 2014-2016. Degree of adherence, checkpoint verbalization, fidelity, and meaningful completion were assessed. Delays were categorized as missing or malfunctioning equipment, staff error, and medication issues. Descriptive statistics, analysis of variance, logistic regression, χ 2 and Student t test were used to analyze results., Results: Of the 591 cases observed, 19% (n = 110) had at least one documented, intraoperative delay. The majority of delays were related to missing (50%) or malfunctioning (30%) equipment. Compared with cases without delays, cases with delays did not have a different mean degree of adherence (96.3 ± 7.6% vs 95.6 ± 5.8%, P = .36). Degree of fidelity was different between cases with and without delays (mean fidelity 77.1 ± 14.9% vs 80.5 ± 7.14.2%, P = .03)., Conclusion: The preincision SSC is a communication tool offering an opportunity to discuss potential concerns and anticipated intraoperative needs. Fidelity rather than adherence to the surgical safety checklist seems to diminish intraoperative delays., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Because of awareness of iatrogenic radiation exposure, there is a national trend of diminishing computed tomography (CT) use for pediatric suspected appendicitis. The purpose of this study was to evaluate the effects of a CT reduction program for evaluation of appendicitis., Methods: A multidisciplinary group (emergency medicine, radiology, and surgery) at a children's hospital developed a reduction program which included: ultrasound (U/S) first (2012), magnetic resonance imaging (MRI) second (2014), and standardized U/S reports (2016). Imaging modality, negative appendectomy rate, time from first image to incision, and imaging costs were evaluated over time., Results: Of the 571 patients evaluated from 2012 to 2016, there was a significant decrease in CT use and increase U/S and MRI use over the study period (all p<0.01). CT use approached zero in 2016. Time from first image to incision (median 10.7h, IQR 5.6-15.5) and negative appendectomy rate (mean 3.7±0.2%) did not change. Median imaging costs ($88, IQR $52-$169) and radiology percent of total costs (range 0.8%-3.9%) increased over time (both p<0.01)., Conclusion: Approaching zero CT use for evaluation of pediatric appendicitis is possible through a multidisciplinary protocol without impacting clinical outcomes. However, increased MRI use led to higher costs. Cost-effectiveness of replacing CT with MRI warrants further study., Type of Study: Retrospective comparative study., Level of Evidence: Level III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Institutional protocols for preincisional antibiotic prophylaxis can standardize care and improve outcomes. However, challenges remain in compliance with such protocols for urgent or emergent operations. We hypothesized that compliance with an institutional protocol for antibiotic prophylaxis for appendectomy for appendicitis in pediatric patients results in reduced surgical site infections (SSIs) after simple appendectomy., Methods: This retrospective study assessed all pediatric patients (≤18 y) who underwent appendectomy for confirmed simple appendicitis at a tertiary children's hospital between 2012 and 2015. Demographic, admission, and outcome data were recorded. Compliance with the protocol was assessed. Univariate analyses were performed to identify factors associated with any SSI and protocol noncompliance., Results: Overall compliance with antibiotic prophylaxis occurred in 590 of 697 patients (85%). Compliance was high with timing (91%), spectrum (95%), and protocol-recommended drug (87%). Admission antibiotics alone were administered in 65 patients (9%), preincisional antibiotics alone in 254 patients (36%), and both in 378 patients (55%). Patients included in the analysis received a median of 2 (range 1-6) doses of antibiotics preoperatively. Ten patients (1.4%) developed an SSI. Only receipt of any antibiotics within an hour of incision was associated with decreased odds of SSI (odds ratio 0.22, 95% confidence interval 0.06-0.87). No factors were associated with noncompliance., Conclusions: An institutional appendicitis protocol yields high compliance with prophylactic antibiotic administration and associated low SSI rates, but at a cost of antibiotic over-administration. Further efforts are necessary to sustain compliance while also practicing appropriate antibiotic stewardship., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The debriefing phase of the surgical safety checklist (SSC) provides the operative team an opportunity to share pertinent intraoperative information and communicate postoperative plans. Prior quality improvement initiatives at our institution focused on the preincision phase of the SSC; however, the debriefing phase has not been evaluated. We aimed to assess adherence to the debrief checklist at our institution and identify areas for improvement., Materials and Methods: An observational study was conducted from 2014 to 2016 with a convenience sample of pediatric surgery cases at an academic children's hospital over 8-wk periods annually to evaluate the debriefing checklist across 14 subspecialties. Intraoperative team members' adherence to eight prespecified checkpoints was assessed. Descriptive statistics, Pearson's chi square, Kruskal-Wallis rank test, and Cohen's kappa for interrater reliability were used (P < 0.05 was significant)., Results: A total of 603 cases were observed (2014 n = 191; 2015 n = 195; 2016 n = 217). The debriefing checklist was conducted in 90.6%, 90.3%, and 94.9% of observed cases each year respectively with the median number of checklist items completed relatively unchanged (8, 7, and 7, range 0-8). However, the checklist was only fully completed in 55%, 48%, and 50% of cases over the study period (P = 0.001) with no debriefing at all in approximately 9% of cases in 2014 and 2015 versus 5% in 2016 (P < 0.001). Interrater reliability annually was >0.65., Conclusions: Despite slight increases annually in overall compliance to the debriefing checklist, only half of all checklists were completed in full. Future efforts to augment adherence are needed and will include interventions targeting the debriefing phase and increasing operating room efficiency., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The aim of our study was to assess the impact of helmet legislations on the incidence and the mortality rate of motorcycle collision (MCC)-related traumatic brain injury (TBI) in young adult trauma patients. A 1-year (2011) retrospective analysis was performed of all patients under 21 years old with trauma-related hospitalization using the Nationwide Inpatient Sample database (representing 20% of all in-patient admissions). Patients with MCC were identified using E-codes. States were classified into three groups based on helmet legislations: universal age helmet legislation, <18 years helmet legislation, and <21 years helmet legislation. Outcome measures were the rates of TBI and mortality. Linear regression analysis was used to assess outcomes among the states. A total of 1,165,150 patients with trauma-related hospitalizations across 29 states were reviewed of which, 587 patients with MCC were included. Ten states had universal age legislation; 13 states had age <18 years legislation, and 6 states had age <21 years legislation. There was a lower incidence in the rate of TBI (P = 0.03) in states with universal helmet legislations compared with states with age-restricted helmet legislation. Universal helmet legislations lowered the rate of MCC-related TBI injures by a factor of 2.15 (β coefficient: 2.15; 95% confidence interval: 0.91-10.18; P = 0.04). States with age-restricted helmet legislations have a higher rate of traumatic brain injury and mortality compared with states with universal helmet legislations. Establishing universal helmet legislations across the states may provide a potential preventive strategy against traumatic brain injury.

Background: Growing concerns regarding radiation exposure in children have led to recommendations to minimize computed tomography imaging for appendicitis. We hypothesized that within a metropolitan hospital system (1 children's hospital and 8 non-children's hospitals), use of preoperative computed tomography is much greater in non-children's hospitals., Methods: We conducted a retrospective study of patients <18 years of age undergoing appendectomy for acute appendicitis from April 2012 to April 2015. Patient demographics, location, and imaging modality (computed tomography and ultrasonography) were evaluated., Results: A total of 1,448 pediatric patients were identified (children's hospital = 215, 15%; non-children's hospitals = 1,233, 85%). Children's hospital patients had fewer computed tomography scans (23% vs 70%, P < .01) and more ultrasonography (75% vs 20%, P < .01). On multivariate regression, increased preoperative computed tomography use was significantly associated with non-children's hospitals (odds ratio 7.6, 95% confidence interval 5.4-10.8). At non-children's hospitals, older age (age >10: odds ratio 2.4, 95% confidence interval 1.8-3.1) and higher patient weight (>45 kg odds ratio 2.0, 95% confidence interval 1.4-2.8) predicted computed tomography use. Children presenting at a children's hospital were much more likely to undergo ultrasonography (odds ratio 11.7, 95% confidence interval 8.3-16.6)., Conclusion: There are significant differences in imaging modalities for pediatric appendicitis between a children's hospital and non-children's hospitals. Further investigation is needed to identify other factors contributing to imaging preference in the pediatric population in order to establish clinical practice guidelines to decrease or prevent unnecessary radiation exposure in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: The purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure., Methods: The 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality., Results: 878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events., Conclusions: Although overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: Surgical site infection (SSI) rate in pediatric appendicitis is a commonly used hospital quality metric. We hypothesized that surveillance of organ-space SSI (OSI) using cultures alone would fail to capture many clinically-important events., Methods: A prospective, multidisciplinary surveillance program recorded 30-day SSI and hospital length of stay (LOS) for patients <18years undergoing appendectomy for perforated appendicitis from 2012 to 2015. Standardized treatment pathways were utilized, and OSI was identified by imaging and/or bacterial cultures., Results: Four hundred ten appendectomies for perforated appendicitis were performed, and a total of 84 OSIs (20.5%) were diagnosed with imaging. Positive cultures were obtained for 39 (46%) OSIs, whereas 45 (54%) had imaging only. Compared to the mean LOS for patients without OSI (5.2±2.9days), LOS for patients with OSI and positive cultures (13.7±5.4days) or with OSI without cultures (10.4±3.7days) was significantly longer (both p<0.001). The OSI rate identified by positive cultures alone was 9.5%, whereas the clinically-relevant OSI rate was 20.5%., Conclusions: Using positive cultures alone to capture OSI would have identified less than half of clinically-important infections. Utilizing clinically-relevant SSI is an appropriate metric for comparing hospital quality but requires agreed upon standards for diagnosis and reporting., Level of Evidence: II., Type of Study: Diagnostic study., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: A pediatric computed tomography (CT) radiation dose reduction program was implemented throughout our children's associated hospital system in 2010. We hypothesized that the CT dose received for evaluation of appendicitis in children would be significantly higher among the 40 referral, nonmember hospitals (NMH) than the 9 member hospitals (MH)., Methods: Preoperative CTs of pediatric (<18years) appendectomy patients between April 2012 and April 2015 were reviewed. Size specific dose estimate (SSDE), an approximation of absorbed dose incorporating patient diameter, and Effective Dose (ED) were calculated for each scan., Results: 1128 (65%) of 1736 appendectomy patients underwent preoperative CT. 936 patients seen at and 102 children evaluated at NMH had dosing and patient diameter data for analysis. SSDE and ED were significantly higher with greater variance at NMH across all ages (all p<0.05, Figure). NMH's SSDE and ED also exceeded reference levels., Conclusion: Radiation exposure in CT scans for evaluation of pediatric appendicitis is significantly higher and more variable in NMH. A proactive approach to reduce dose, in addition to frequency, of CT scans in pediatric patients is essential., Level of Evidence: Level III., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The benefit of utilizing surgical safety checklists has been recently questioned. We evaluated our checklist performance after implementing a program that includes checklist-related good catches., Methods: Multifaceted interventions aimed at the preincision checklist and 5 prospective audits were conducted from 2011-2015. We documented adherence to the checklist (verbalization of each checkpoint), fidelity (meaningful performance of each checkpoint), and good catches (events with the potential to cause the patient harm but that were prevented from occurring). Good catches were divided into quality improvement-based categories (processes, medication, safety, communication, and equipment)., Results: A total of 1,346 checklist performances were observed (range, 144-373/yr). Adherence to the preincision checklist improved from 30% to 95% (P < .001), while adherence to the preinduction and debriefing checklists decreased (71% to 56%, P = .002) and remained unchanged (76%), respectively. Preincision fidelity decreased from 86% to 76% (P = .012). Good catches were identified during 16% of preincision checklist performances; process issues were most common (32%) followed by issues of medication administration (30%) and safety (22%)., Conclusion: Implementation of a systematic checklist program resulted in significant and sustainable improvement in performance. Meaningful use and associated good catches may be more appropriate metric than actual patient harm for measuring checklist effectiveness. Although not previously described, checklist-related good catches represent an unknown benefit of checklists., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Intestinal malrotation can lead to volvulus resulting in necrosis, sepsis, and death. For symptomatic patients, treatment includes the Ladd procedure. However, debate remains regarding the timing and need for intervention for asymptomatic infants. We evaluated our experience with Ladd procedures including a clinical practice of prophylactic surgery for asymptomatic patients., Materials and Methods: A retrospective review of pediatric patients undergoing the Ladd procedure was performed. Prophylactic Ladd procedures were identified as those occurring before any malrotation-related symptoms. Results were analyzed with student t test, Mann-Whitney U, and chi-squared tests., Results: From 2011-2014, 42 patients (prophylactic = 19, symptomatic = 23) underwent the Ladd procedure. The median age (IQR, interquartile range) of patients was 9.6 (3.9-18) mo and 18 (2.4-52) mo for prophylactic and symptomatic patients, respectively (P = 0.38). In patients who underwent symptomatic Ladd procedures, nine (39%) had volvulus and one (4.3%) had bowel necrosis at time of surgery. No prophylactic Ladd procedure patients required reoperation, whereas six (26%) symptomatic patients required malrotation-related reoperations (P = 0.02). Median (IQR) days to full enteral feeds were 5.0 d (3.3-6.8) versus 7.4 (5.0-11; P = 0.11), whereas median days to discharge were 8.0 d (6.1-11) versus 11 d (7.5-32) until discharge (P = 0.09) for prophylactic and symptomatic patients, respectively., Conclusions: Although symptomatic patients represent sicker children, the postoperative complications appear to be higher. For infants with known malrotation, prophylactic operations may be beneficial and should be considered. A larger, prospective study to demonstrate effectiveness and generalizability for prophylactic Ladd procedure is warranted., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Breath alcohol analyzers are used to detect ethanol in motorists and others suspected of public intoxication. One concern is their ability to detect interfering substances that may falsely increase the ethanol reading. A 47-year-old-man was found in a public park, acting intoxicated. A breath analyzer test (Intoxilyzer 5000EN) measured 0.288 g/210 L breath ethanol, without an interferent noted. In the emergency department, the patient admitted to drinking HEET Gas-Line antifreeze, which contains 99% methanol. Two to three hours after ingestion, serum and urine toxicology screen results were negative for ethanol and multiple other substances. His serum methanol concentration was 589 mg/dL, serum osmolality 503 mOsm/kg, osmolar gap 193 mOsm/kg, and anion gap 17 mmol/L. The patient was treated with intravenous ethanol, fomepizole, and hemodialysis without complication. This is a unique clinical case of a breath alcohol analyzer reporting methanol as ethanol. Intoxilyzer devices have been shown to indicate some substances (acetone) as interferents in humans but not methanol. Increased serum concentrations of methanol can be reported as ethanol by a commonly used breath alcohol analyzer, which can result in a delayed diagnosis or misdiagnosis and subsequent methanol toxicity if antidotal treatment is not administered in a timely manner., (Copyright (c) 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.)

Background: Toxicology screens obtained on patients who have overdosed on drugs frequently include tricyclic antidepressants (TCAs) as part of the evaluation. Quetiapine is an antipsychotic agent with structural similarity to the TCAs., Objective: To determine whether quetiapine may cross-react with plasma TCA immunoassays in vitro using commonly available autoanalyzers., Methods: Quetiapine stock solution was added to 9 separate samples of pooled drug-free human plasma to produce concentrations ranging from 1 to 640 ng/mL that were verified by gas chromatography. No quetiapine metabolites were present. Each spiked plasma sample was tested in a blinded fashion using the Abbott Tricyclic Antidepressant TDx Assay on the TDxFLx autoanalyzer in 2 separate laboratories, the Syva Emit tox Serum Tricyclic Antidepressant Assay on the AU400 autoanalyzer and the S TAD Serum Tricyclic Antidepressant Screen on the ACA-Star 300 autoanalyzer. The TDx assay is quantitative, while Emit and S TAD are qualitative screening assays with a threshold of 300 ng/mL for TCA positivity. The outcome of interest was a positive TCA result., Results: The quantitative assay showed concentration-related TCA cross-reactivity beginning at quetiapine concentrations of 5 ng/mL. The 640-ng/mL spiked sample produced TCA results of 379 and 385 ng/mL in labs 1 and 2, respectively. The qualitative assays were screened as TCA positive at quetiapine concentrations of 160 and 320 ng/mL for the S TAD and Emit assays, respectively., Conclusions: Quetiapine cross-reacts with quantitative and qualitative plasma TCA immunoassays in a concentration-dependent fashion. Therapeutic use or overdose of quetiapine may result in a false-positive TCA immunoassay result.