Presence of Sonographic Secondary Signs Without Visualization of Appendix Is Indicative of Appendicitis in Children Younger Than 5 Years.

Purpose: Diagnosis of acute appendicitis is more difficult in children aged 0-4 years due to atypical clinical presentation, leading to delay in diagnosis and higher incidence of complications. Nonvisualization of the appendix on ultrasound increases diagnostic challenge. We examined the utility of standardized reporting of sonographic secondary signs of appendicitis in children younger than 5 years with nonvisualization of the appendix.

Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative.

Background: Appendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative.

Hospital-level factors associated with nonoperative management in common pediatric surgical procedures.

Purpose: Our purpose was to examine patient- and hospital-level factors associated with nonoperative management in common pediatric surgical diagnoses.

Methods: Using the 2012 Kid's Inpatient Database (KID), we identified patients <20 years old diagnosed with cholecystitis (CHOL), bowel obstruction (BO), perforated appendicitis (PA), or spontaneous pneumothorax (SPTX). Logistic regression models were used to identify factors associated with nonoperative management.

Decreased opioid prescribing in children using an enhanced recovery protocol.

Background: A previously implemented Enhanced Recovery Protocol (ERP) for children undergoing elective gastrointestinal operations demonstrated decreased length of stay (LOS) and in-hospital opioid use. We hypothesized that the ERP would be associated with decreased postdischarge opioid prescribing.

Methods: Demographic, operative, and opioid prescription data were retrospectively compared between elective gastrointestinal surgical patients in the pre-ERP (1/2012-12/2014) and the post-ERP periods (1/2015-12/2017).

Pediatric Inpatient-Status Volume and Cost at Children's and Nonchildren's Hospitals in the United States: 2000-2009.

Objectives: The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs.

Methods: A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database.

Implementing a surgeon-reported categorization of pediatric appendicitis severity.

Purpose: The purpose of this study was to implement a novel surgeon-reported categorization (SRC) for pediatric appendicitis severity and determine if SRC was associated with outcomes.

Methods: We conducted a retrospective review of appendectomies by 15 surgeons within a single center from January to December 2016. The SRC was defined as: simple (category 1), gangrenous or adherent (category 2A), perforation with localized abscess (category 2B), and perforation with gross contamination (category 2C).

Parent reported long-term quality of life outcomes in children after congenital diaphragmatic hernia repair.

Purpose: The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including quality of life (QoL), symptom burden, reoperation rates, and health status.

Methods: A chart review and phone QoL survey were performed for patients who underwent CDH repair between 2007 and 2014 at a tertiary free-standing children's hospital. Comprehensive outcomes were collected including subsequent operations and health status.

Short-term and family-reported long-term outcomes of simple versus complicated gastroschisis.

Background: Our goal is to determine short- and long-term outcomes of simple gastroschisis (SG) and complicated gastroschisis (CG) patients including quality of life (QoL) measures, surgical reoperation rates, and residual gastrointestinal symptom burden.

Materials And Methods: Retrospective chart review of patients who underwent surgical repair of gastroschisis between January 1, 2009, and December 31, 2012, was performed at a quaternary children's hospital. Parent telephone surveys were conducted to collect information on subsequent operations and current health status as well as to assess QoL using two validated tools.

The "Flat Diaphragm": Does the Degree of Curvature of the Diaphragm on Postoperative X-Ray Predict Congenital Diaphragmatic Hernia Recurrence?

Purpose: The appearance of the diaphragmatic curvature and the rib insertion level of the diaphragm on postoperative chest X-ray (CXR) may predict recurrence. Our purpose was to examine the relationship between the curvature of the diaphragm on postoperative CXR and recurrence.

Methods: We performed a retrospective review of left-sided, Bochdalek congenital diaphragmatic hernia (CDH) surgical repairs from 2004 to 2015 at a single institution.

Trends in common surgical procedures at children's and nonchildren's hospitals between 2000 and 2009.

Purpose: Though growth in children's surgical expenditures has been documented, procedure-specific differences in volume and costs at children's hospitals (CH) and non-hildren's hospitals (NCH) have not been explored. Our purpose was to compare trends in volume and costs of common pediatric surgical procedures between CH and NCH.

Methods: We performed a review of the 2000-2009 Kids' Inpatient Database identifying all cases of appendectomy for uncomplicated appendicitis (AP), tonsillectomy and adenoidectomy (TA), fundoplication (FP), humeral fracture repair (HFR), pyloromyotomy (PYL), and cholecystectomy (CHOLE).

Appropriateness of a pediatric-specific enhanced recovery protocol using a modified Delphi process and multidisciplinary expert panel.

Purpose: Despite Enhanced Recovery After Surgery (ERAS) protocols demonstrating improved outcomes in a wide variety of adult surgical populations, these protocols are infrequently and inconsistently being used in pediatric surgery. Our purpose was to develop a pediatric-specific ERAS protocol for use in adolescents undergoing elective intestinal procedures.

Methods: A modified Delphi process including extensive literature review, iterative rounds of surveys, and expert panel discussions was used to establish ERAS elements that would be appropriate for children.

Variation in Preoperative Testing and Antireflux Surgery in Infants.

Background: Despite the availability of objective tests, gastroesophageal reflux disease (GERD) diagnosis and management in infants remains controversial and highly variable. Our purpose was to characterize national variation in diagnostic testing and surgical utilization for infants with GERD.

Methods: Using the Pediatric Health Information System, we identified infants <1 year old diagnosed with GERD between January 2011 and March 2015.

Challenge of balancing duration of stay and readmissions in children's operation.

Background: Surgeons balance competing interests of minimizing duration of stay with readmissions. Complications that occur early after discharge often result in readmissions. This study examines the relationship between duration of stay, timing of complications, and readmission risk.

A survey of pediatric surgeons' practices with enhanced recovery after children's surgery.

Purpose: Enhanced Recovery After Surgery (ERAS) protocols have been shown to improve outcomes in adult abdominal surgical populations. Our purpose was to survey pediatric surgeons' opinions regarding applicability of individual ERAS elements to children's surgery.

Methods: A survey of the American Pediatric Surgical Association was conducted electronically.

Exploring regional variability in utilization of antireflux surgery in children.

Background: There is significant variation surrounding the indications, surgical approaches, and outcomes for children undergoing antireflux procedures (ARPs) resulting in geographic variation of care. Our purpose was to quantify this geographic variation in the utilization of ARPs in children.

Methods: A cross-sectional analysis of the 2009 Kid's Inpatient Database was performed to identify patients with gastroesophageal reflux disease or associated diagnoses.

Implementation of an enhanced recovery protocol in pediatric colorectal surgery.

Purpose: Enhanced recovery protocols (ERPs) have been shown to improve outcomes in adult surgical populations. Our purpose was to compare outcomes before and after implementation of an ERP in children undergoing elective colorectal surgery.

Methods: A pediatric-specific colorectal ERP was developed and implemented at a single center starting in January 2015.

Defining the association between operative time and outcomes in children's surgery.

Introduction: Prolonged operative time (OT) is considered a reflection of procedural complexity and may be associated with poor outcomes. Our purpose was to explore the association between prolonged OT and complications in children's surgery.

Methods: 182,857 cases from the 2012-2014 NSQIP-Pediatric were organized into 33 groups.

Regional variation in rates of pediatric perforated appendicitis.

Background: While trends in perforated appendicitis (PA) rates have been studied, regional variability in pediatric admissions for PA remains unknown.

Methods: A retrospective, cross-sectional analysis of the 2006-2012 Kids' Inpatient Database was conducted to examine variation in PA admission rates by region of the United States and insurance status. PA rates were calculated and reported as per 1000 admissions in accordance with national quality measure specifications.

Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children.

Background: Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule.

Increased morbidity and mortality in cardiac patients undergoing fundoplication.

Background: Infants with congenital cardiac disease (CCD) often require gastrostomy tube placement (GT) and need antireflux procedures, such as fundoplications. Our purpose was to compare morbidity/mortality rates among infants with CCD undergoing GT, fundoplication, or both.

Methods: Using the NSQIP-Pediatric, we identified 4070 patients <1-year-old who underwent GT and/or fundoplication from 2012 to 2014.

Improving ultrasound for appendicitis through standardized reporting of secondary signs.

Objective: Our aim was to implement a standardized US report that included secondary signs of appendicitis (SS) to facilitate accurate diagnosis of appendicitis and decrease the use of computed tomography (CT) and admissions for observation.

Methods: A multidisciplinary team implemented a quality improvement (QI) intervention in the form of a standardized US report and provided stakeholders with monthly feedback. Outcomes including report compliance, CT use, and observation admissions were compared pretemplate and posttemplate.

Clinical validity and relevance of accidental puncture or laceration as a patient safety indicator for children.

Purpose: Accidental puncture or laceration (APL) has been endorsed as a patient safety indicator and is being used to compare hospital performance and for reimbursement. We sought to determine the positive predictive value (PPV) of APL as a quality metric in a pediatric population.

Methods: We retrospectively reviewed all cases that met APL administrative criteria over 5years in a quaternary pediatric hospital system.

Return to the System Within 30 Days of Discharge after Pediatric Appendectomy.

Postprocedural revisits, readmissions, and reoperations are commonly tracked quality metrics and have reimbursement and hospital-level comparison implications. Our purpose was to document these rates after pediatric appendectomy and to identify patient factors related to these metrics. This study included 3756 appendectomies performed at a single institution from 2009 to 2013.

Enhancing recovery in pediatric surgery: a review of the literature.

Background: Enhanced recovery after surgery (ERAS), guidelines entail a strategy of perioperative management proven to hasten postoperative recovery and reduce complications in adult populations. Relatively few studies have investigated the applicability of this paradigm to pediatric populations. Our objective was to perform a systematic review of existing evidence regarding the use and efficacy of enhanced recovery protocols (ERPs) in the pediatric population.