Common Pediatric Operations Research Articles

Surgery and pain relief: A closer look at opioid prescription trends

BackgroundPublished guidelines to reduce the use and misuse of opioids in pediatrics are limited. After the implementation of an opioid stewardship program, we aimed to investigate the prescribing patterns in pediatric surgery. MethodsA retrospective chart review of pediatric patients who underwent general pediatric surgery procedures at a single institution between July 2021 and July 2023 was conducted. Demographics, procedure details, and opioid prescriptions at discharge were collected. The Texas Prescription Monitoring Program was cross-referenced for prescription-filled data. Descriptive statistics were performed. ResultsOf the 4,323 patients included, 9% (391) received an opioid prescription at the time of discharge. Among these, 82% were for burns, 7% for trauma, and 4% for pectus excavatum. Appendectomy, inguinal hernia repair, umbilical hernia repair, and circumcision did not receive any opioid prescriptions. In those who received a prescription, the median age was 4.2 years (interquartile range (IQR) 1.6, 10.4), with 58.6% being male. A total of 82.6% of patients also received prescriptions for nonopioid analgesics. The median number of prescribed doses was 13 (IQR 7, 15) for burns, 12 (IQR 9, 15) for trauma, and 12 (IQR 10, 12) for pectus excavatum. In total, 87% of prescriptions were filled. ConclusionA small proportion of pediatric patients who underwent general surgery received opioid prescriptions at the time of discharge and were limited to a few conditions. Common pediatric operations received no opioid prescriptions in the 2-year study period. A total of 13% of the written prescriptions were unfilled. Future studies are needed to optimize the target pediatric patient population for opioid prescribing.

Factors associated with inguinal hernia repair in premature infants during neonatal admission

IntroductionTiming of inguinal hernia repair (IHR) in premature infants is variable and influenced by surgeon preference and complication profile. The purpose of this study was to evaluate factors related to early IHR, defined as hernia repair during initial neonatal admission, in premature infants. MethodsNeonatal hospitalizations of premature infants (gestational age at birth < 37 weeks and ≤ 28 days old at admission), with a diagnosis of inguinal hernia from 2010 to 2017 in HCUP National Inpatient Sample and Kid's Inpatient Sample databases were evaluated. Multivariable Cox proportional hazard models was used to estimate associations between demographics, additional procedures, hospital characteristics, and early IHR. ResultsOverall, 30,298 neonatal hospitalizations of premature infants with inguinal hernia were identified; 13,228 (43.3%) underwent early IHR. Early IHR was more likely with older gestational age at birth (35–36 weeks vs < 24 weeks, HR 6.05, 95% CI 4.17, 8.79), female sex (HR 1.20, 95% CI 1.07, 1.34), and undergoing concomitant gastrostomy (HR 2.51, 95% CI 1.72, 3.66). Non-Hispanic Black infants (HR 0.84, 95% CI 0.75, 0.95), infants at urban non-teaching hospitals (HR 0.15, 95% CI 0.07, 0.33), and infants at rural hospitals (HR 0.81, 95% CI 0.70, 0.97) were less likely to undergo early IHR. ConclusionsUsing a nationally representative database, early IHR in premature neonates was more commonly performed in non-Hispanic White, female neonates and at urban teaching hospitals. Patient race and hospital type were determinants of early IHR in premature neonates. There is a need to further evaluate the impact of race and socioeconomic factors on outcomes of common pediatric operations like inguinal hernia repairs. Level of EvidenceLevel III.

The history of the pediatric inguinal hernia repair

The history of inguinal hernia repair is a rich one. For centuries, hernia healers, doctors, anatomists, surgeons and quacks have been devoted to this pathology that has afflicted mankind throughout its evolution. The development of surgical correction mainly focused on adult pathology, with treatments that often involved the loss of the testis. Hernia management in children, however, also dates from antiquity. Described as a swelling on the surface of the belly in ancient papyri, it was treated with tight bandages by the early physicians of Alexandria. For centuries, conservative treatment had been used for the child using primordial trussess, many prayers, and often pagan rituals as the arboreal passage of children described by Marcello of Bordeaux, doctor of the Emperor Theodosius I (347-395 AD), reserving medical intervention only for cases of strangulation in which only reduction was attempted. The middle ages were characterized by an increase in cultural and scientific exchange, during which the first comprehensive surgical textbooks and atlases were written. Different approaches to the inguinal hernia were not taught and passed down through generations of surgeons. The modern era brought a better understanding of the inguinal anatomy, which led to surgical techniques associated with less post-operative complications. Today, the pediatric inguinal hernia repair is one of the most common pediatric operations performed. It is considered a safe procedure with very low complication rate.

Most Common Pediatric Operations Are Performed by General Surgeons: The Reality of Pediatric Surgical Care Delivery

Purcell, Laura N. MD, MPH; Charles, Anthony G. MD, MPH, FACS; Ricketts, Thomas C. PhD; MPH; McLean, Sean E. MD, FACS; Akinkuotu, Adesola MD; Hayes-Jordan, Andrea A. MD, FACS; Phillips, Michael R. MD Author Information

Factors Associated with Inguinal Hernia Repair in Premature Infants during Neonatal Admission

Abstract Introduction Timing of inguinal hernia repair (IHR) in premature infants is variable and influenced by surgeon preference and complication profile. The purpose of this study was to evaluate factors related to early IHR, defined as hernia repair during initial neonatal admission, in premature infants. Methods Neonatal hospitalizations of premature infants (gestational age at birth Results Overall, 30,298 neonatal hospitalizations of premature infants with inguinal hernia were identified; 13,228 (43.3%) underwent early IHR. Early IHR was more likely with older gestational age at birth (35–36 weeks vs Conclusions Using a nationally representative database, early IHR in premature neonates was more commonly performed in non-Hispanic White, female neonates and at urban teaching hospitals. Patient race and hospital type were determinants of early IHR in premature neonates. There is a need to further evaluate the impact of race and socioeconomic factors on outcomes of common pediatric operations like inguinal hernia repairs. Level of Evidence Level III.

Specialty-specific reduction in opioid prescribing after common pediatric surgical operations

BackgroundOpioid misuse has reached epidemic proportions, and postoperative opioids have been linked to overdose, diversion, and dependency. We recently found our opioid prescribing practices following common pediatric operations to be inconsistent and excessive. In this study, we evaluate the efficacy of an educational intervention on opioid prescriptions following tonsillectomy and hernia repair. MethodsRetrospective chart review of prescriptions following outpatient tonsillectomies and hernia repairs at a single institution before and after an educational intervention was performed. The intervention consisted of a single campus-wide grand rounds presentation detailing the surgeon's role in the opioid epidemic. ResultsPostoperative opioid prescriptions were significantly reduced for hernia repair following the educational intervention: 4.2 ± 2.9 vs 2.7 ± 2.6 days' supply (p = 0.004). Such a reduction was not observed for post-tonsillectomy opioid prescriptions: 6.3 ± 4.4 vs 5.4 ± 3.0 days' supply (p = 0.226). A greater decrease in interprovider variation was observed for hernia providers after the educational intervention than for tonsillectomy providers, though significant variation continued to be present for both procedures after the intervention. ConclusionsThe efficacy of an educational intervention at reducing postoperative pediatric opioid prescribing may be tied to the specialty-specific role model relationship of the educator to the prescriber.Type of study: retrospective comparative chart review.Level of evidence: IV.

Outcomes of circumcision in children with single ventricle physiology.

Children with single ventricle physiology (SVP) have been shown to have a high morbidity and mortality after non-cardiac surgical procedures. Elective circumcision is one of the most common pediatric operations with low morbidity and mortality. The purpose of our study was to review our institutional experience with SVP children undergoing circumcisions to determine peri-operative course and outcomes. We performed a retrospective review of children with SVP who underwent an elective circumcision from 2000 to 2017. Children with non-single ventricle physiology or children undergoing circumcision in combination with another case were excluded. Demographics, surgical characteristics, and outcomes were analyzed. Descriptive statistics were performed, all medians were reported with interquartile range. 15 males underwent elective circumcision with a median age at the time of surgery of 1.13 (1.03, 1.38) years. Eighty-four percent underwent their circumcision after their 2nd stage cardiac operation. Most common operative indication was uncomplicated phimosis. Median operative time was 20 (16, 27)mins. Median total length of stay was 229 (185, 242)mins with no admissions. Post-operative complications included two (16%) hematomas with one requiring surgical intervention. There were no deaths. Children with SVP who undergo elective circumcision may have a higher risk of bleeding.

A multicenter, pediatric quality improvement initiative improves surgical wound class assignment, but is it enough?

Background/PurposeSurgical wound classification (SWC) is widely utilized for surgical site infection (SSI) risk stratification and hospital comparisons. We previously demonstrated that nearly half of common pediatric operations are incorrectly classified in eleven hospitals. We aimed to improve multicenter, intraoperative SWC assignment through targeted quality improvement (QI) interventions. MethodsA before-and-after study from 2011–2014 at eleven children’s hospitals was conducted. The SWC recorded in the hospital’s intraoperative record (hospital-based SWC) was compared to the SWC assigned by a surgeon reviewer utilizing a standardized algorithm. Study centers independently performed QI interventions. Agreement between the hospital-based and surgeon SWC was analyzed with Cohen’s weighted kappa and chi square. ResultsSurgeons reviewed 2034 cases from 2011 (Period 1) and 1998 cases from 2013 (Period 2). Overall SWC agreement improved from 56% to 76% (p<0.01) and weighted kappa from 0.45 (95% CI 0.42–0.48) to 0.73 (95% CI 0.70–0.75). Median (range) improvement per institution was 23% (7–35%). A dose-response-like pattern was found between the number of interventions implemented and the amount of improvement in SWC agreement at each institution. ConclusionsIntraoperative SWC assignment significantly improved after resource-intensive, multifaceted interventions. However, inaccurate wound classification still commonly occurred. SWC used in SSI risk-stratification models for hospital comparisons should be carefully evaluated.

P177: Training general surgery residents in pediatric surgery: Analysis of time and cost

Background: Resident participation in the pediatric surgery service is essential to their training. The impact with regard to operative time and hospital cost is not well-defined. Hypothesis: Training general surgery residents in pediatric surgery significantly increases operative time and hospital cost. Methods: A retrospective analysis of operative times was performed for three common pediatric operations: unilateral inguinal herniorraphy, bilateral inguinal herniorraphy, and open pyloromyotomy. All cases occured between July 2004 and July 2006. In Group 1 all operations were performed by a single attending pediatric surgeon. Group 2 involved the same attending surgeon directing a 3rd -year general surgery resident through the operations. Operative time was defined as the time from skin incision to placement of the final dressing. Surgery schedules and a cost analysis were also analyzed for the 2 groups. Statistical analysis was performed using student t-test. Results: Demographics between the two groups were similar. Mean operative time was shorter in Group 1 with respect to unilateral and bilateral herniorraphy. Mean operative time for pyloromyotomy was similar between the 2 groups. No perioperative complications or recurrent hernias occured in either group. Surgery schedules (number of operations per day) were similar between the 2 groups. Furthermore, decreased time in performing herniorraphy without surgery residents would not lead to more operative cases performed per day, thus hospital cost and surgeon fees are similar between the 2 groups. Conclusion: Training general surgery residents in pediatric surgery increased operative time with respect to unilateral and bilateral herniorraphy. There was no increase in operative with respect to pyloromyotomy. Increased operative time to train general surgery residents did not influence surgical scheduling, thus there was no increase in cost to the hospital or surgeon. Tabled 1Operative time (minutes) between the 2 groups Group 1 Group 2 p Unilateral herniorraphy 31.2 ± 10.4 (n=41) 40.1 ± 15.2 (n=35) 0.003 Bilateral herniorraphy 44.9 ± 13.4 (n=30) 54.0 ± 16.6 (n=20) 0.04 Pyloromyotomy 32.9 ± 9.6 (n=10) 34.6 ± 7.4 (n=15) 0.61 Open table in a new tab

Relative value units correlate with pediatric surgeons' operating time: when perceived myth becomes reality

Purpose In 1992, the Congress implemented a Medicare payment system based on relative value units (RVUs). Today, RVUs are increasingly used to determine surgeon reimbursement from Medicare, Medicaid, and private third-party payers. We questioned whether current RVU assignments accurately reflect the quantity of time that surgeons spend operating. Methods Over a 12-month period, 59 common pediatric operations were identified and classified as general surgery (n = 34), urology (n = 13), or minimally invasive (n = 10). Only operations performed as an outpatient or requiring less than one inpatient day of direct surgeon involvement were included. By regression analysis, correlation coefficients were generated comparing average operating time per procedure to the corresponding RVU generated. Results Of 59 specific operations, a total of 744 general surgery cases, 1155 urological cases, and 370 minimally invasive cases were performed. RVU efficiency was greatest in general surgery (1 RVU = 5.18 operating minutes), followed by minimally invasive operations (1 RVU = 6.80 minutes) and urological operations (1 RVU = 8.59 minutes). Regression analysis proved minimally invasive operations to correlate best with RVUs with R 2 = 0.8376, followed by urology at R 2 = 0.6753, and then general surgery at R 2 = 0.649. Conclusions The RVU has emerged as the most dominant factor influencing reimbursement of practicing pediatric surgeons. Despite common surgeon bias, RVUs do correlate with current operating times. These data prove important as surgeons analyze cost, negotiate contracts, and strategically plan for fiscal success.

Pediatric Regional Anesthesia: Beyond the Caudal

Pediatric Regional Anesthesia: Beyond the Caudal