National Surgical Quality Improvement Program-Pediatric Research Articles

Access to Laparoscopic Pediatric Surgery: Do Ethnic and Racial Disparities Exist?

IntroductionDisparate access to laparoscopic surgery may contribute to poorer health outcomes among racial and ethnic minorities, especially among children. We investigated whether racial and ethnic disparities in laparoscopic procedures existed among four common surgical operations in the pediatric population in the United States. MethodsUsing the American College of Surgeons National Surgical Quality Improvement Program–Pediatrics, we conducted a retrospective review of pediatric patients, aged less than 18 y old, undergoing appendectomy, fundoplication, cholecystectomy, and colectomy from 2012 to 2021. To compare the surgical approach (laparoscopy or open), a propensity score matching algorithm was used to compare laparoscopic and open procedures between non-Hispanic Black with non-Hispanic White children and Hispanic with non-Hispanic White children. Results143,205, 9,907, 4,581, and 26,064 children underwent appendectomy, fundoplication, colectomy, and cholecystectomy, respectively. After propensity score matching, non-Hispanic Black children undergoing appendectomy were found to be treated laparoscopically less than non-Hispanic White children (93.5% versus 94.4%, P = 0.007). With fundoplication, Hispanic children were more likely to be treated laparoscopically than White ones (86.7% versus 80.9%, P < 0.0001). There were no statistically significant differences between Black or Hispanic children and White children in rates of laparoscopy for other procedures. ConclusionsThough some racial and ethnic disparities exist with appendectomies and fundoplications, there is limited evidence to indicate that widespread inequities among common laparoscopic procedures exist in the pediatric population.

Hepatic resections for pediatric hepatoblastoma: analysis of 30-day outcomes using the National Surgical Quality Improvement Program-Pediatric database.

Surgical resection remains the cornerstone of treatment for hepatoblastoma in children and offers the best chance of disease-free survival. We aimed to analyze the 30day outcomes of hepatic resection for hepatoblastoma stratified by extent using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P). We queried NSQIP-P for children undergoing resection of Hepatoblastoma from 2012 to 2021. Relevant clinical characteristics and outcomes were extracted for multivariate logistic regression to identify predictors of common adverse outcomes. We included 458 children with a median age of 1.90years. Overall complications were rare, and perioperative blood transfusion (64.2%) and postoperative ventilation > 48h (10.0%) were the only adverse events prevalent in more than 5% of patients. Median transfusion volume was 15.7ml/kg. On multivariate regression, only patients undergoing Trisectionectomy (aOR = 3.387, 95% C.I. = 1.348-8.510) had higher odds of receiving > 75th percentile blood transfusion. Furthermore, only perioperative transfusion and postoperative ventilation > 48h were statistically more common in patients undergoing extended versus standard resections. Outcomes following resection of hepatoblastoma are excellent, with low rates of postoperative adverse events. Although children undergoing trisectionectomy likely require greater transfusion volume, extended hepatic resections do not appear to have worse 30day outcomes despite greater operative complexity and duration.

Evaluation of Limited English Proficiency in the Management and Outcomes of Appendicitis in Children

IntroductionAppendectomies are one of the most common pediatric surgical procedures. Limited English proficiency (LEP) may lead to disparities in health outcomes between English-proficient and LEP patients. This study assesses the association between LEP and postoperative outcomes in pediatric appendectomy. MethodsWe analyzed records from the American College of Surgeons National Surgical Quality Improvement Program–Pediatric database from 2010 to 2023 under 18 y of age undergoing appendectomy at our institution. LEP was defined as the need for an interpreter. Primary outcomes were postoperative complications, length of stay (LOS), and postoperative emergency department (ED) visits within 30 d of discharge. Multivariable analyses were performed. ResultsOne thousand one hundred forty three children with appendicitis were identified, with 208 (18.2%) LEP and 935 (81.8%) English-proficient patients. LEP children were more likely to present with complicated appendicitis (42.8% versus 25.5%, P < 0.0001) and sepsis (34.1% versus 21.6%, P = 0.0003). LEP patients experience more serious (8.6% versus 3.9%, P = 0.02), overall complications (10.1% versus 5.5%, P = 0.006), and organ/surgical space site infections (8.2% versus 3.3%, P = 0.003). On multivariable analysis controlling for ethnicity and factors associated with complicated presentation, LEP was associated with increased postoperative ED visits (adjusted odds ratio [aOR] 2.64, 95% confidence interval [CI] = 1.40-4.39), but not LOS (aOR 1.86, 95% CI = 0.87-3.97) or complications (aOR 1.76, 95% CI = 0.79-4.00). ConclusionsLEP is independently associated with increased postoperative ED visits. Higher rates of complications and longer LOS may be related to increased complicated appendicitis at presentation. The role of cultural preferences and other social determinants of health that contribute to these disparities needs more investigation.

Population-Based Intraoperative Disease Severity Criteria for Pediatric Appendicitis

A standardized severity assessment approach is needed in children with appendicitis for postoperative adverse event estimation and severity adjustment for hospital-level comparative performance reporting. To examine the association between the presence and number of National Surgical Quality Improvement Program (NSQIP) Pediatric-defined intraoperative criteria for complicated appendicitis and outcomes in a population-based sample of children. This cohort study used data from the American College of Surgeons NSQIP Pediatric Appendectomy Procedure Targeted Participant Use Data File and General Participant Use Data File for children younger than 18 years who underwent appendectomy from January 1, 2019, through December 31, 2022, at 148 hospitals participating in NSQIP Pediatric. The presence of NSQIP Pediatric intraoperative criteria for complicated appendicitis (ie, visible perforation, intraperitoneal abscess, extraluminal fecalith, and diffuse fibrinopurulent exudate). Adverse event outcomes included postoperative rates of any surgical site infection (incisional or organ space), percutaneous drainage, sepsis, and reoperation. Resource use outcomes included operative duration and hospital length of stay, and rates of postoperative imaging, parenteral nutrition use, and revisits. Multivariable regression was used to explore the influence of individual and combinations of intraoperative criteria on outcomes after adjusting for patient characteristics. Of 82 950 patients included, 23 221 (27.9%) had at least 1 finding of complicated appendicitis. Compared with cases without any criteria present, the presence of each finding of complicated appendicitis was independently associated with higher rates of any adverse events; adjusted odds ratios (AORs) by finding were 5.57 (95% CI, 5.04-6.15) for visible hole, 4.83 (95% CI, 4.17-5.59) for diffuse fibrinopurulent exudate, 7.06 (95% CI, 5.77-8.63) for abscess, and 6.62 (95% CI, 4.78-9.15) for fecalith. An increasing number of criteria was associated with a stepwise increase in risk of any adverse events; AOR by number of criteria met were 5.55 (95% CI, 5.09-6.05) for 1 criterion, 8.86 (95% CI, 8.16-9.62) for 2 criteria, and 16.65 (95% CI, 15.10-18.35) for ≥3 criteria. Similar patterns in criteria-specific and cumulative implications for outcomes were observed with each individual adverse event and resource use measure. This cohort study found that postoperative complications and increased resource use are associated with the presence and number of NSQIP Pediatric criteria for complicated appendicitis. These criteria should be considered the gold standard, evidence-based severity assessment framework for estimating risk of adverse events and resource use in children with appendicitis.

The Impact of Higher BMI on Wound Complications Following Adolescent Breast Reduction: A Retrospective Study of 1215 Cases.

Macromastia is a physically and psychologically distressing condition for adolescents. While reduction mammaplasty is often the best treatment, risk factors for adolescent wound complications remain unclear. This study aims to investigate the impact of obesity and other predictors of postoperative wound complications following adolescent reduction mammaplasty using a national database. The 2012-2019 National Surgical Quality Improvement Program Pediatric (NSQIP-P) databases were reviewed to identify primary reduction mammaplasty encounters. World Health Organization Body Mass Index (BMI), alongside patient and case characteristics, were assessed for association for 30-day wound disruption or surgical site complications. Statistical analyses were performed to identify independent predictors for complications and determine a potential BMI cutoff for risk stratification. There were 1215 patients with an average age of 16.6 years. The average BMI was 30.7 kg/m2, and 593 (48.8%) patients were nonobese while 622 (51.2%) were obese. The incidence of complications was 5.27%. Independent predictors of complications included a BMI 35-39.9, BMI > 40, and an American Society of Anesthesiologists (ASA) Classification > 3. A receiver operating characteristic curve determined that a BMI of 34.6 can be a potential cutoff for increased complication risk. Higher obesity increases risk of wound complications; however, complication rates remain low. A BMI of 34.6 is a potential screening metric for counseling and monitoring patients. Reduction mammaplasty should remain a viable option as it can significantly improve quality of life. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

8. National Trends of Gynecologic Surgery Across Pediatric Hospitals: A National Surgical Quality Improvement Program Pediatric (NSQIP-P) Database Analysis

8. National Trends of Gynecologic Surgery Across Pediatric Hospitals: A National Surgical Quality Improvement Program Pediatric (NSQIP-P) Database Analysis

Renal function in pediatric urologic surgical patients: Insight from the National Surgical Quality Improvement Program—Pediatric cohort

Abstract Background Renal protection is a frequent indication for urological surgery in pediatric patients; however, preoperative assessment is not routinely performed. We assessed the rates of preoperative renal function testing and stratified outcomes after major pediatric urological surgery. Pediatric urology patients, specifically high-risk patients undergoing genitourinary surgeries, are likely to have an underdiagnosis of renal dysfunction after surgery. Materials and methods Cases were identified from the 2012 to 2019 National Surgical Quality Improvement Program—Pediatric database. Patients who underwent major urological surgery on an inpatient basis were included in this study. Abnormal renal function was defined as a creatinine (Cr) level of ≥0.5 mg/dL (younger than 2 years) and a glomerular filtration rate of &lt;90 mL/min (2 years or older). Glomerular filtration rate was calculated using the bedside Schwartz equation (2 years or older): estimated glomerular filtration rate = 0.413 × (height/Cr). Results A total of 17,315 patients were included, of whom 3792 (21.9%) had documented Cr values. Based on the defined criteria, abnormal renal function was found in 7.3% of infants (younger than 2 years), 33.6% of children (2–9 years), and 52.5% of adolescents (10–18 years). Patients with abnormal preoperative renal function values were significantly (p &lt; 0.001) more likely to experience readmission (10.2% vs. 5.8%), reoperation (3.7% vs. 1.6%), surgical organ/space infection (0.9% vs. 0.4%), transfusion (1.5% vs. 0.6%), renal insufficiency (1.6% vs. 0.4%), or urinary tract infection (5.1% vs. 3.6%). Conclusions In this pediatric population, 21.9% of the patients had documented preoperative Cr values before major urological surgery. Patients with documented abnormal preoperative renal function tests experienced higher complication rates. These patients have higher rates of progressive renal insufficiency and acute renal failure than those with normal renal function. The introduction of a standardized and unbiased risk assessment tool has the potential to offer patients benefits by pinpointing individuals with a heightened risk of complications. Further investigation is necessary to enhance the precise categorization of at-risk patients.

Reduction of Urinary Tract Infection in Pediatric Surgical Patients Using NSQIP-P and Quality Improvement Methodology.

Hospital-acquired urinary tract infections (UTIs) have a detrimental effect on patients, families, and hospital resources. The Sydney Children's Hospital Network (SCHN) participates in the NSQIP-Pediatric (NSQIP-P) to monitor postoperative complications. NSQIP-P data revealed that the median UTI rate at SCHN was 1.75% in 2019, 3.5 times higher than the NSQIP-P target rate of 0.5%. Over three quarters of the NSQIP-P identified patients with UTI also had a urinary catheterization performed intraoperatively. A quality improvement project was conducted between mid-2018 and 2021 to minimize catheter-associated UTIs (CAUTIs) at SCHN. NSQIP-P samples include pediatric (younger than 18 years) surgical patients from an 8-day cycle operative log. NSQIP-P data are statistically analyzed by the American College of Surgeons and provide biannual internationally benchmarked reports. The project used clinical redesign methodology with a 6-phase process for quality improvement projects. The objectives of the project were to reduce urinary catheter duration of use, educate parents or carers, and improve catheter care and insertion technique by health staff. The duration of a urinary catheter in situ reduced from a median of 4.5 to 3 days from 2017 to 2021. The median NSQIP-P UTI rate at SCHN was reduced by 47.4% from 1.75% in 2019 to 0.9% in 2022. A multifactorial approach in quality improvement has been shown to be an effective strategy to reduce UTI rates at SCHN, and patient outcomes were improved within a 3-year timeframe. Although this project has reduced UTI rates at SCHN, there remain opportunities for further improvement.

Preoperative and Intraoperative Urine Cultures and Its Association With Postoperative Infection After Ureteroneocystostomy

To unveil this association, and we hypothesize that preoperative and intraoperative UTI will be correlated with postoperative UTI and sepsis occurrence. The 2020 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data was analyzed for patients undergoing ureteroneocystostomy for VUR. Patients that underwent UNC for treatment of VUR with UCx obtained within 2 weeks preoperatively or on the day of surgery were identified. The patients were divided into 3 groups: no bacterial growth, bacterial growth with UTI, and bacterial growth PMG (polymicrobial growth). Patient demographics and preoperative variables were evaluated. The postoperative urinary tract infection rate of the three groups were 2.0%, 9.2%, and 9.9% for group A, B, C respectively (p<0.001). Postoperative sepsis was noted to be 0.5%, 1.3%, and 3.6% for group A, B, C (p<0.01). Additionally, there was a difference between mean operative time (p<0.001), mean length of stay (p=0.03), and mean days from operation to discharge (p<0.01). On adjusted analysis, both groups B and C had higher rates of UTI compared to group A. Group C was also seen to have greater rates of sepsis on adjusted analysis. The association found between preoperative UTI with less than 2 species of microorganisms (group B) and postoperative UTI indicates that UTI treatment and antibiotic prophylaxis should be considered when undergoing UNC for VUR. The results of this study may lead to more careful consideration of the use of preoperative and intraoperative UCx as well as treatment of UTI in pediatric patients with VUR undergoing UNC.

Reducing Unplanned Intubations in the Neonatal Intensive Care Unit After Children's Surgery: A Quality Improvement Project

BackgroundUnplanned intubation following children's surgery is associated with increased postoperative mortality. In response to being a National Surgical Quality Improvement Program - Pediatric (NSQIP-P) high outlier for postoperative unplanned intubation, we aimed to reduce postoperative unplanned intubation events by 25% in one year. Methods/InterventionA multidisciplinary team of stakeholders was assembled in 2018. Most unplanned intubation events occurred in the neonatal intensive care unit (NICU). Based on apparent causes of unplanned intubations identified in case reviews, an extubation readiness checklist and a postoperative pain management guideline emphasizing non-opioid analgesics were implemented for NICU patients in September 2019. Postoperative unplanned intubation events were tracked prospectively and evaluated using quality improvement statistical process control methods. ResultsUnplanned intubations in the NICU decreased from 0.27 to 0.07 events per patient in the post-intervention group (September 2019–June 2022, n = 145) compared to the pre-intervention group (January 2016–August 2019, n = 200), representing a 76% reduction. Postoperative opioid administration decreased significantly, while acetaminophen usage increased significantly over time. Balancing measures of postoperative pneumonia rate (1.5% vs 0.0%, p = 0.267) and median hospital length of stay [40 (IQR 51) days vs 27 (IQR 60), p = 0.124] were not different between cohorts. The 30-day mortality rate for postoperative patients in the NICU significantly declined [6.5% (n = 13) vs 0.7% (n = 1), p < 0.001]. ConclusionsPostoperative unplanned intubation rates for NICU patients decreased following a quality improvement effort focused on opioid stewardship and extubation readiness. Type of StudyProspective Quality Improvement. Level of EvidenceLevel III.

High Rates of Pediatric Venous Thromboembolism After Elective Laparoscopic Splenectomy Suggest Need for Perioperative Prophylaxis

IntroductionIn adult populations, postoperative venous thromboembolism (VTE) is a reported complication of up to 8% of elective laparoscopic splenectomy (LS) cases. VTE is a rare event in the pediatric population, affecting less than 1% of all pediatric surgical patients. We hypothesized that pediatric patients are at a higher risk of postoperative VTE after undergoing elective LS relative to other laparoscopic procedures and may warrant prophylactic treatment. Materials and methodsWe queried the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database from 2012 to 2020. Patients were identified using the Current Procedural Terminology code 38120 and only elective cases were analyzed. ResultsThe incidence of VTE in all pediatric patients undergoing surgery in the American College of Surgeons NSQIP-P database was 0.13%. The incidence of VTE in pediatric patients undergoing elective laparoscopic abdominopelvic procedures was 0.17%. There were seven total cases of VTE (0.41%) in pediatric patients undergoing elective LS, more than twice the rate of the general population (P = 0.001). Eighty percent of pediatric patients undergoing elective LS had an underlying hematological disorder. ConclusionsBy analyzing the NSQIP-P database, we evaluated the largest cohort of pediatric patients undergoing elective LS to date. We identified a higher incidence of VTE following this procedure relative to the rate of VTE in the overall population in the NSQIP-P database, as well as those undergoing elective laparoscopic abdominopelvic operations. The relatively higher incidence of VTE after elective LS is likely due to the presence of underlying hematological conditions. Given the low incidence of complications associated with pharmacologic VTE prophylaxis, the results of this study suggest that further research is warranted to establish the efficacy of perioperative pharmacological VTE prophylaxis in pediatric patients undergoing elective LS.

344 Drivers of Adverse 30-Day Outcomes for Pediatric Spine Tumor Surgery Patients: A Nationwide Analysis

INTRODUCTION: Spine tumors in children are an uncommon clinical entity. Drivers of reoperation and readmission following surgery for this pathology are poorly characterized. METHODS: We conducted a retrospective cohort analysis of all spine tumor surgery cases in the National Surgical Quality Improvement Program-Pediatrics database from 2012-2020, using diagnosis and Current Procedural Terminology codes. The primary outcome was a composite of 30-day mortality, reoperation, readmission, and non-home discharge disposition. Stepwise regression with bidirectional elimination via the Akaike Information Criterion was used to identify predictors of adverse 30-day outcomes. 25 candidate variables were assessed, including tumor characteristics, patient demographics, preoperative comorbidities, operative details, and postoperative complications. RESULTS: The analytic cohort included 728 pediatric patients undergoing spine tumor surgery. Patients predominantly had intradural intramedullary tumors (79.3%). Average age was 7.7 years and 54% were male. 86.5% were discharged to home. 30-day mortality rate was 0.4%. 48 patients (6.6%) required reoperation, with the most common reasons being infection (n = 14), repair of cerebrospinal fluid leak (n = 8), shunt placement (n = 8), and tumor recurrence (n = 6). 39 patients (5.4%) underwent readmission within 30 days, primarily for surgical site infection (n = 11), nervous system complication (n = 8), or wound dehiscence (n = 7). Stepwise regression identified predictors of adverse 30-day outcomes including emergent surgery (OR = 2.64, P = 0.014), operative time (OR = 1.03 per +10 minutes, P &lt; 0.001), length of stay (OR = 1.03 per +1 day, P = 0.035), surgical site infection or dehiscence (OR = 5.26, P &lt; 0.001), nervous system complications (OR = 10.31, P = 0.009), and non-surgical site infections (OR = 27.95, P &lt; 0.001). When mortality, reoperation, and readmission were analyzed in aggregate, emergent surgery and postoperative complications remained as significant predictors. CONCLUSIONS: 30-day adverse events following pediatric spine tumor surgery were predominantly driven by emergent surgery, prolonged operative or hospitalization time, and postoperative complications.

Postoperative Outcomes in Pediatric Septoplasty.

Identify risk factors and perioperative morbidity for pediatric patients undergoing septoplasty. The American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was retrospectively queried to identify patients who underwent septoplasty (CPT 30520) for a diagnosis of deviated nasal septum (ICD J34.2) from 2018 to 2019. Outcomes analyzed include patient demographics, medical comorbidities, surgical setting, operative characteristics, length of stay, and postoperative outcomes. A total of 729 children were identified. Median age at time of surgery was 15.8 years, with most patients (82.8%) >12 years of age; no significant association was identified between age at time of surgery and adverse surgical outcomes. Overall, postoperative complications were uncommon (0.6%), including readmission (0.4%), septic shock (0.1%), and surgical site infection (0.1%). A history of asthma was found to be a significant risk factor for postoperative complications (P = .035) as well as BMI (P = .028). The 30-day postoperative complications following pediatric septoplasty in children reported in the NSQIP-P database are infrequent. Special considerations regarding young age, complex sinonasal anatomy, and surgical technique remain important features in considering corrective surgery for the pediatric nose and certainly warrant further investigation in subsequent studies.

Open versus minimally invasive ureteroneocystostomy: trends and outcomes in a NSQIP-P cohort.

Although surgical intervention has commonly been performed using an open approach for vesicoureteral reflux (VUR), this is rapidly changing due to adoption of minimally invasive surgery (MIS). Success rates with MIS are similar to open for re-implantation (> 90%); however, open ureteral re-implantation is still widely considered the gold standard. Using national surgical quality improvement program-pediatric (NSQIP-P) data, this manuscript evaluates recent large population trends of open versus robotic-assisted and laparoscopic ureteroneocystostomy for complications and factors associated with worse outcomes. Cases were identified in the 2012-2019 NSQIP-P database using the ureteroneocystostomy operative codes and vesicoureteral reflux post-operative diagnosis codes. A 1:1 propensity score match (PSM) analysis was performed comparing surgical outcomes while matching patients with similar characteristics to reduce bias. A total of 4183 patients were included; 621 patients with MIS and 3562 with open approach. Patients in the MIS approach tended to be older (67months vs. 53months) and non-Caucasian (12.9% vs. 6.3%) with no differences in other demographics. After 1:1 PSM, 30-day complications after ureteroneocystostomy showed no significant differences in readmission, reoperation, or extended hospital stay. A multivariate analysis found patients with CNS structural abnormalities (such as spina bifida) had 4.5 times greater odds of experiencing a reoperation (pvalue < 0.05). Similarly, patients with an ASA above two had 2.0 times greater odds of an UTI (pvalue < 0.05). The cohorts undergoing open and MIS approaches are well matched overall, without profound differences in outcomes overall.

Association between index complication and outcomes after inpatient pediatric surgery

PurposeA cascade of complications is believed to be the primary mechanism underlying failure to rescue (FTR), or death of a patient after a postoperative complication. It is unknown whether specific types of index complications are associated with the incidence of secondary complications and FTR after pediatric surgery. MethodsNational cohort study of patients within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery (2012–2019). Index complications were grouped into nine categories (cardiovascular, venous thromboembolism, pulmonary, bleeding/transfusion, renal, central nervous system, wound, infectious, or minor [defined as having an associated mortality rate <1%]). The association between the type of index complication with FTR, secondary complications, reoperation, unplanned readmission, and postoperative length of stay was evaluated with multivariable logistic regression and generalized linear modeling. ResultsAmong 425,386 patients, 15.5% had at least one complication, 16.6% had one or more secondary complications, 13.9% reoperation, 14.5% readmission, and 2.4% FTR. Secondary complication (10.8–59.7%) and FTR (0.3–31.1%) rates varied by type of index complication. Relative to patients who had an index minor complication, those with an index infectious complication were most likely to have secondary complication (Odds Ratio [OR] 10.3, 95% CI [9.36–11.4]). Index CV complications were most strongly associated with FTR (OR 30.7 [24.0–39.4]). Index wound complications had the greatest association with reoperation (OR 21.9 [20.5–23.4]) and readmission (OR 18.7 [17.6–19.9]). Index pulmonary complications had the strongest association with length of stay (coefficient 9.39 [8.95–9.83]). ConclusionsDifferent types of index complications are associated with different perioperative outcomes. These data can help identify patients potentially at risk for suboptimal outcomes and can inform pediatric quality improvement interventions. Type of studyCohort study. Level of evidenceLevel II.

An evaluation of perioperative surgical procedures and complications in classic bladder exstrophy patients Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P)

Classic bladder exstrophy (CBE) repair report wide variation in success. Given the complexity of CBE care, benefit would be derived from validation of reported outcomes. Using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) data, this manuscript evaluates surgical complications for bladder closure and advanced urologic reconstruction in CBE patients. The primary aim of this study was to determine complication rates in the CBE population for bladder closure and advanced urologic reconstruction in national studies compared to single-institutional studies. Pediatric cases and complications were identified in the 2012-2019 NSQIP-P database in CBE patients who had either bladder closure or advanced urologic reconstruction. Bladder closure was further defined as early (<7 days) or delayed (>7 days). Differences were assessed using Fisher's exact test and analysis was conducted using SPSS with significance defined as p-value <0.05. 302 patients were included; 152 patients underwent bladder closure, and 150 patients underwent advanced urologic reconstruction. The 30-day complication rate for bladder closure is 30.3% and for advanced urologic reconstruction is 24.0% in the CBC cohort. No differences were found in the rates of NSQIP complications between early and delayed bladder closure, though significant differences (p<0.001) were found in the rates of blood transfusion (17.9 vs 65.3%). This may be due to the different rates of osteotomy (25.0 vs 48.3%) between early and delayed bladder closure. Rates of readmission are 14.7% and rates of reoperation are 8.0% for advanced urologic reconstruction procedures. Both bladder closure and advanced urologic reconstruction had infectious issues in greater than 10% of the population. CBE surgeries nationally carry a higher risk of complications than is reported in most institutional studies. Infectious complications occur greater than 10% of the time in both bladder closure and advanced urologic reconstruction, which should be the source of additional study given the inverse relationship infections pose to surgical success in BE patients. A limitation of this study is that the data is derived from Children's hospitals that elect to participate and includes only data from 30 days after a procedure. CBE complication data for both bladder closure and advanced urologic reconstruction may be underrepresented in the literature.

Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations.

No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database. Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed. A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index (P = .015, OR = 0.96), structural CNS abnormality (P = .034, OR = 1.95), preoperative oxygen supplementation (P = .043, OR = 1.28), operative time (P = .019, OR = 1.84, 95% CI = 1.28-2.54), and concurrent procedure (P < .001, OR = 2.21) were all independently associated with LOS. Postoperative complications had no significantly associated variables, with an overall low incidence of readmission (5.0%), reoperation (1.7%), and reintubation (1.1%). In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

Association of red blood cell transfusion volume with postoperative complications and mortality in neonatal surgery

IntroductionRed blood cell transfusion (RBCT) is commonly administered in neonatal surgical care in the absence of clear clinical indications such as active bleeding or anemia. We hypothesized that higher RBCT volumes are associated with worse postoperative outcomes. MethodsNeonates within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery (2012–2016) were stratified by weight-based RBCT volume: <20cc/kg, 20–40cc/kg, and >40cc/kg. Postoperative complications were categorized as wound, systemic infection, central nervous system (CNS), renal, pulmonary, and cardiovascular. Multivariable logistic regression and cubic spline analysis were used to evaluate the association between RBCT volume, postoperative complications, and 30-day mortality. Sensitivity analysis was conducted by performing propensity score matching. ResultsAmong 9,877 neonates, 1,024 (10%) received RBCTs. Of those who received RBCT, 53% received <20cc/kg, 27% received 20–40cc/kg, and 20% received >40cc/kg. Relative to neonates who were not transfused, RBCT volume was associated with a dose-dependent increase in renal complications, CNS complications, cardiovascular complications, and 30-day mortality. With cubic spline analysis, a lone inflection point for 30-day mortality was identified at a RBCT volume of 30 – 35 cc/kg. After propensity score matching, the dose-dependent relationship was still present for 30-day mortality. ConclusionTotal RBCT volume is associated with worse postoperative outcomes in neonates with a significant increase in 30-day mortality at a RBCT volume of 30 – 35 cc/kg. Future prospective studies are needed to better understand the association between large RBCT volumes and poor outcomes after neonatal surgery. Level of evidenceLevel IV, Retrospective cohort study

Allogeneic Red Blood Cell Transfusion and Infectious Complications Following Pediatric Spinal Fusion: NSQIP-P Analysis.

Background:Substantial bleeding occurs during spinal fusion surgery in the pediatric population, and many patients receive allogeneic red blood cell transfusion (ARBT) for the treatment of resulting perioperative anemia. ARBT is thought to increase vulnerability to postoperative infections following major surgical procedures, but studies of this relationship in children undergoing spinal fusion have yielded conflicting results.Methods:Patients who underwent spinal fusion before the age of 18 years were identified from the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) 2016 to 2019 databases, along with patient and procedure-specific characteristics, transfusion events and volumes, and postoperative infectious complications such as wound-related infection, pneumonia, urinary tract infection (UTI), and sepsis. Multivariable logistic regression analyses provided adjusted odds ratios (aORs) and 95% confidence intervals (CIs) for the association between ARBT and each infection outcome and the overall risk of infection.Results:Among 19,159 patients studied, 714 (3.7%) developed a total of 931 episodes of postoperative infection. In multivariable logistic regression analyses, perioperative ARBT was independently associated with postoperative pneumonia (aOR = 1.93, 95% CI = 1.40 to 2.68), UTI (aOR = 1.80, 95% CI = 1.19 to 2.73), sepsis (aOR = 1.58, 95% CI = 1.10 to 2.28), and the overall risk of infection (aOR = 1.40, 95% CI = 1.20 to 1.64). The risk of any postoperative infection increased in a dose-response fashion with transfusion volume.Conclusions:ARBT in pediatric spinal fusion is associated with significantly increased risks of postoperative pneumonia, UTI, and sepsis. The overall risk of postoperative infection increases with the volume transfused. Enhanced efforts to minimize perioperative anemia and ARBT should be considered as a means of improving patient outcomes.Level of Evidence:Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Racial and Ethnic Disparities in Primary Cleft Lip and Cleft Palate Repair.

To examine the impact of race/ethnicity on timing and postoperative outcomes of primary cleft lip (CL) and cleft palate (CP) repair. Cross-sectional analysis of the National Surgical Quality Improvement Program Pediatric (NSQIP-P) database from 2013 to 2018. Patients under 2 years of age who underwent primary CL or CP repair were identified in the NSQIP-P. Outcomes were the timing of surgery and 30-day readmission and reoperation rates stratified by race and ethnicity. In total, 6021 children underwent CL and 6938 underwent CP repair. Adjusted rates of CL repair over time were 10% lower in Hispanic children (95%CI: 0.84-0.96) and 38% lower for Asian children (95%CI: 0.55-0.70) compared with White infants. CP repair rates over time were 13% lower in Black (95%CI: 0.79-0.95), 17% lower in Hispanic (95%CI: 0.77-0.89), and 53% lower in Asian children (95%CI: 0.43-0.53) than in White infants. Asian patients had the highest rates of delayed surgical repair, with 19.3% not meeting American Cleft Palate-Craniofacial Association (ACPA) guidelines for CL (P < .001) and 28.2% for CP repair (P< .001). Black and Hispanic children had 80% higher odds of readmission following primary CL repair (95%CI: 1.16-2.83 and 95%CI: 1.27-2.61, respectively). This study of a national database identified several racial/ethnic disparities in primary CL and CP, with reduced receipt of cleft repair over time for non-White children. Asian patients were significantly more likely to have delayed cleft repair per ACPA guidelines. These findings underscore the need to better understand disparities in cleft repair timing and postoperative outcomes.