Postoperative Outcomes In Pediatric Patients Research Articles

Impact of preoperative nutritional status on surgical outcomes in patients with pediatric gastrointestinal surgery.

BackgroundMalnutrition has a high incidence among pediatric surgical patients and contributes to increased risks of postoperative complications and extended hospital stays.PurposeThe present study aimed to determine the influence of preoperative nutritional status on the postoperative outcomes of pediatric patients who underwent elective gastrointestinal (GI) surgery.MethodsThis prospective observational study was conducted at Cairo University Specialized Pediatric Hospital. According to the designated inclusion criteria, 75 surgical cases of both sexes were included. A structured questionnaire was developed and administered. This questionnaire included 3 main sections: demographic data and nutritional status parameters at admission and discharge. Pre- and postoperative nutritional statuses were compared.ResultsAccording to both the subjective global nutritional assessment and STRONGKIDS score Questioner, more than 60% of patients in the upper GI patient group were at risk of malnutrition. Wasting status was most common in the upper GI patient group (67%; vs. 39.1% in the lower GI group). Underweight status was more common in the hepatobiliary and upper GI patient groups (nearly 50% for each group) than in the lower GI group (30.4%). On the other hand, stunted patients had a higher incidence of complications and a prolonged hospital stay (P=0.003 and P=0.037, respectively), while underweight lower GI patients experienced a prolonged hospital stay (P=0.02). A higher proportion of patients with preoperative anemia than those without preoperative anemia required a blood transfusion (P=0.003).ConclusionNutritional assessment is a crucial component of pediatric surgical patient management. Both underweight and wasting statuses were more common among hepatobiliary and upper GI patients. Postoperative complications and a long hospital stay were more common among stunted patients.

Acute histologic inflammatory activity and postoperative outcomes in pediatric patients with ulcerative colitis

BackgroundThe aim of this study was to determine whether acute histologic inflammatory activity at the rectal margin predicts postoperative complications in children with ulcerative colitis following ileal pouch-anal anastomoses (IPAA). MethodsPatients who underwent IPAA following previous total abdominal colectomy for ulcerative colitis between 2006 and 2014 were included. Data collected included demographics, operative and postoperative data, histologic grading of the rectal margin at time of IPAA, and stooling outcomes at one, six and 12 months following ileostomy closure. ResultsTwenty-seven patients were included. Acute inflammation scores ranged between 2 and 13. Unadjusted and adjusted models showed no statistically significant relationship between inflammation and presence of any postoperative complications, number of daily stools, nighttime stooling, soiling, or stool-altering medication usage. ConclusionAcute histologic inflammatory activity at the rectal margin is not associated with increased rates of postoperative complications following IPAA creation in children, nor with poorer continence outcomes following ileostomy closure.

Fluid Overload in Special Pediatric Cohorts With Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery Following Surgical Repair

To investigate the prevalence, risk factors, and clinical outcomes associated with early fluid overload (FO) in a special group of pediatric patients undergoing repair of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). It was a retrospective study performed with multiple variable regression analysis. A single cardiac surgical institution. Eighty-eight patients younger than 18 years of age undergoing ALCAPA surgical repair with cardiopulmonary bypass were recruited at the authors' institution from June 2010 to September 2017. None. Of 88 pediatric patients with ALCAPA after surgical repair, 37.5% developed early FO, defined as fluid accumulation ≥5% within the period from surgery until midnight of postoperative day 1. Patients with early FO were younger, weighed less, and had worse preoperative cardiac dysfunction. With logistic regression analysis, being underweight was confirmed to be a risk factor for FO development (odds ratio, 8.66; 95% confidence interval, 2.83-26.52; p < 0.001). Early FO also predicted severe acute kidney injury, respiratory morbidity, and low cardiac output syndrome after reimplantation procedure. Patients with early FO also had significantly longer mechanical ventilation hours (p < 0.001), intensive care unit length of stay (p = 0.003), and hospital length of stay (p = 0.009). Early FO ≥5% has been linked to adverse postoperative outcomes in pediatric patients undergoing repair for ALCAPA. The use of restrictive fluid management is crucial for patients who have lower weight and poor myocardial function before and after complex surgical procedures such as in ALCAPA settings.

Low Muscle Mass as a Prognostic Factor for Early Postoperative Outcomes in Pediatric Patients Undergoing the Fontan Operation: A Retrospective Cohort Study

The impact of low muscle mass on pediatric cardiac patients remains unclear. We investigated the impact of low muscle mass on early postoperative outcomes in patients undergoing the Fontan operation. The electronic medical records of 74 patients (aged <18 years) who underwent the Fontan operation were retrospectively reviewed. The cross-sectional areas of the erector spinae and pectoralis muscles were measured using preoperative chest computed tomography (CT), normalized to the body surface area, and combined to obtain the total skeletal muscle index (TSMI). Low muscle mass was defined as a TSMI value lower than the median TSMI for the second quintile. The incidence of major postoperative complications was higher in patients with low muscle mass than in those with high muscle mass (48% (15/31) versus 14% (6/43); P = 0.003). Multivariable analyses revealed that a higher TSMI was associated with a lower likelihood of an increased duration of intensive care unit (>5 days) and hospital stay (>14 days) (odds ratio (OR) 0.86; 95% confidence interval (CI) 0.77–0.96; P = 0.006 and OR 0.92; 95% CI 0.85–0.99; P = 0.035 per 1 cm2/m2 increase in TSMI) and incidence of major postoperative complications (OR 0.90; 95% CI 0.82–0.99; P = 0.039 per 1 cm2/m2 increase in TSMI). Preoperative low muscle mass was associated with poor early postoperative outcomes in pediatric patients undergoing the Fontan operation.

Impact of Left-sided Lesions in Pediatric Patients Having Surgery for Ebstein Anomaly

Purpose: Pediatric patients undergoing tricuspid valve intervention for Ebstein anomaly (EA) are at risk for post-operative morbidity and mortality. The impact of left-sided abnormalities (LSA), including left ventricular non-compaction (LVNC) as well as abnormalities of the mitral and aortic valves, on early cardiac post-operative outcomes is unknown. We sought to determine factors that impact early post-operative outcomes in pediatric patients undergoing cone repair (CR) for EA. Methods: We performed a retrospective review …

Liver Transplantation for Wilson's Disease in Non-adult Patients: A Systematic Review

IntroductionWilson's disease (WD) is a rare autosomal recessive disorder transmitted through a gene located on chromosome 13. Liver transplantation (LT) provides a therapeutic option for patients with WD presenting fulminant liver failure or drug resistance. LT in patients with WD has a twofold aim: to save the patient's life when the disorder has progressed to hepatic (or other organ) failure and to cure the underlying metabolic defect. The aim of our study was to investigate the indications, aspects and post-operative outcomes in pediatric patients (< 18 years old) with WD who underwent LT. MethodsA meticulous search of the literature since 1971 was performed. A retrospective analysis of all the studies, presenting cases of LT in children due to WD, was conducted. Studies that did not report patients' characteristics, transplantation indications, post-operative outcomes, and complications, as well as those with small study populations (< 10 patients), were excluded. ResultsSix studies were included in the present review, which involved 290 children. The main indications for LT included chronic liver failure and fulminant liver failure. The average 1-year survival rate was 91.9%, while the average 5-year survival rate was 88.2%. Retransplantation was performed in 16 patients due to transplant rejection. In general, patients transplanted for WD displayed an excellent quality of life after LT. ConclusionLT is a safe and efficient procedure in selected pediatric patients with WD, demonstrating excellent long-term outcomes and quality of life.

Opioid prescription and postoperative outcomes in pediatric patients.

To determine if the amount of opioid prescribed and postoperative outcomes after adenotonsillectomy changed following implementation of mandated opioid consent forms. Retrospective cohort study. Patients undergoing adenotonsillectomy 6 months before and after implementation of mandated opioid consent forms at a tertiary-care pediatric hospital were studied. Demographics, operative data, weight-based opioid dosage, and postoperative outcome measures, including nursing calls, emergency department (ED) visits, hospital readmission, and bleed rates, were collected and analyzed. Of 300 patients, opioid prescription was provided for 211 patients (70.3%), 112 preconsent (74.7%) and 99 postconsent (66.0%). Mean (standard deviation) total opioid prescribed (milligrams/kilogram) was significantly higher preconsent 4.8 (5.6) than postconsent 3.2 (4.7), (P = .003). There were no differences between number of nursing calls (P = .134) or ED visits (P = .083). Interestingly, preconsent patients had more hospital readmission for pain/dehydration (odds ratio OR: 368, P = .016) and bleeding concerns (OR: 244, P = .003). A mandated consent form prior to opioid prescription was associated with decreased overall opioid prescription without resultant increase in postoperative complications in pediatric patients. These data provide support for minimizing opioid prescription on a systems-based level. 4 Laryngoscope, 129:1477-1481, 2019.

Caregiver Appraisals of Anxiety, Pain, and Behavioral Changes Among Children After Ambulatory Surgery

Background: Preoperative anxiety is very common across the age continuum; however, for children who experience anxiety, it can be especially challenging. On the basis of the report of caregivers, this anxiety can sometimes lead to negative behaviors postoperatively. Purpose: The purpose of this study was to examine the relationship between pediatric trait anxiety and postoperative outcomes in pediatric patients who undergo ambulatory surgery. Methods: A quantitative cross-sectional descriptive research design study of 64 caregivers was conducted. Inclusion criteria consisted of caregivers of children aged 1–8 years who underwent ambulatory surgery and provided informed consent. Measures administered included the Post Hospitalization Behavioral Questionnaire to evaluate postoperative behavior of patients after discharge from the hospital, Parents' Postoperative Pain Measure-Short Form to evaluate pain of a child after surgery, and Screen for Child Anxiety Related Emotional Disorders to evaluate children's anxiety. Data were analyzed using measures of central tendencies and bivariate correlational analysis. Results: Caregivers' appraisals of trait anxiety in children undergoing ambulatory surgery were low, whereas negative postoperative behaviors and pain levels were high. The only statistically significant relationship was a negative correlation between trait anxiety and postoperative pain of children who underwent ambulatory surgery. Conclusions: Central to this finding is the importance of developing adaptive skills of children to improve postoperative outcomes such as pain management. However, this study showed that trait anxiety is not related to postoperative negative behaviors.

Assessing Caudal Block Concentrations of Bupivacaine With and Without the Addition of Intravenous Fentanyl on Postoperative Outcomes in Pediatric Patients: A Retrospective Review.

Caudal blocks are a significant and efficacious aspect of pediatric anesthesia, especially in urologic and many general surgery cases. This type of regional anesthesia is common because it has a high success rate and provides between 6 and 8 hours of postoperative pain control. The aim of this study was to determine whether the concentration of bupivacaine or the addition of intravascular (i.v.) fentanyl affected the postanesthesia care unit (PACU) discharge time. A retrospective cohort study comparing the outcomes in pediatric patients who have received varying caudal concentrations with and without the addition of i.v. fentanyl was performed. A total of 849 consecutive patients undergoing hypospadias repairs or circumcisions were reviewed and placed in one of the following 3 groups: 0.125% bupivacaine (group 1), 0.25% bupivacaine (group 2), or one of these concentrations of bupivacaine + i.v. fentanyl intraoperatively (group 3). Total PACU time for each group was 46.1 minutes (group 1), 48.9 minutes (group 2), and 49.7 minutes (group 3). Our results revealed that there is no statistically significant difference between concentrations of bupivacaine administered in a caudal block with or without i.v. fentanyl with regard to the outcome of PACU duration (P = 0.16). Overall, based on the retrospective cohort design, there is no difference in primary and secondary outcomes based on the concentration of bupivacaine, when administered at a volume of 1 mL/kg.

Utility of Inferior Turbinoplasty for the Treatment of Nasal Obstruction in Children: A 10-Year Review.

Inferior turbinoplasty (IT) in pediatric patients is a common procedure used to treat childhood nasal obstruction. Most of the published IT studies in this population did not control for concurrent airway procedures. To assess postoperative outcomes in pediatric patients undergoing isolated IT. Ten-year retrospective review of the medical records of 1770 children (aged <18 years) undergoing an IT procedure at Children’s Hospital Colorado from August 1, 2003, through August 1, 2013. Patients with simultaneous procedures involving the upper airway were excluded. The review identified demographic and clinical information, operative technique, and postprocedural follow-up data. The last follow-up was completed on April 21, 2014. A telephone questionnaire was administered to parents to obtain long-term outcome data. Data were analyzed from March 10 to July 23, 2014. Demographics, complications, postoperative outcomes, the need for revision surgery and continued use of medication, and overall parent satisfaction with the procedure. Outcomes were assessed with a 5-point Likert scale of parental perception of their child’s ability to breathe through the nose (nasal patency) preoperatively and currently (1 indicates extremely poor; 5, extremely well) and their overall satisfaction rating for the procedure (1 indicates extremely dissatisfied; 5, extremely satisfied). Of the 1770 children, 107 underwent isolated IT. The mean age of the cohort was 10.5 (range, 1.2-17.9) years. The IT procedures included radiofrequency ablation (72 [67.3%]), microdebridement (19 [17.8%]), and partial turbinate resection (21 [19.6%]). No major complications were observed. Eight revision ITs for persistent nasal symptoms were performed independently of the initial surgical procedure, including 4 of 72 radiofrequency ablations (5.6%), 1 of 19 microdebridements (5.3%), and 3 of 21 partial turbinate resections (14.3%), with no difference among the 3 techniques (P = .10). The parents of 63 patients completed the telephone questionnaire with a mean follow-up of 4.55 (range, 0.63-10.68) years. The combined parental satisfaction on a 5-point Likert scale for the extremely satisfied and satisfied categories was 44 (69.8%), and the nasal patency score improved significantly from 2.0 to 3.4 (95% CI, 1.03-1.65; P < .001), independently of surgical techniques. Thirty-four patients (54.0%) continued to require medical management owing to persistent nasal symptoms. Patients with a history of allergic rhinitis had a greater improvement of nasal patency (2.1 to 3.9; P = .02) and a higher postoperative use of medical therapy (13 of 34 patients [38.2%] vs 21 of 73 [28.8%]; P = .01). Inferior turbinoplasty showed overall utility and was safe and effective in the treatment of nasal obstruction in children for whom medical management had failed. No differences between surgical techniques were found in patient satisfaction, improvement of nasal patency, and recurrence, likely related to sample size. More than half of the patients continued to use medical therapy postoperatively, suggesting that inferior turbinate hypertrophy should not be considered solely as a surgical disease. Allergic rhinitis was identified as a significant comorbidity.

Functional Endoscopic Sinus Surgery Versus Balloon Sinuplasty with Ethmoidectomy: A 2-year Analysis in Pediatric Chronic Rhinosinusitis.

To evaluate the 2-year post-operative outcomes of pediatric patients with chronic rhinosinusitis (CRS) treated with balloon catheter sinuplasty (BCS) and ethmoidectomy compared to functional endoscopic sinus surgery (FESS). Two-group, retrospective cohort study of 28 children with CRS was performed. Of these 28 participants, 15 were treated with traditional FESS (53.6%) and 13 (46.4%) underwent traditional ethmoidectomy with balloon sinuplasty. Pre-operative and 2-year postoperative total symptom scores and medications were compared. To examine the potential long-term differences in surgical outcomes and surgical procedure on symptom outcome, one-tailed Chi square analyses were employed. The mean age of the children examined was 9.3 (SD=SD=4.1; range 3-18) and 61.9% were male. Pre-operative symptomatology, medication and Lund Mackay scores were evaluated for both groups and no significant differences were identified. Overall, 73.3% of children that underwent traditional FESS and 76.9% of those who had BCS with ethmoidectomy reported significant long-term improvement in at least one of their pre-operative sinus complaints. Our data suggests that both BCS with ethmoidectomy and traditional FESS are effective treatment options for uncomplicated CRS and result in long-term alleviation of core sinus complaints, as well as decreased sinus related medication use. Larger prospective studies are needed to further evaluate these procedures.

Morbidity of peripherally inserted central catheters in pediatric complicated appendicitis

BackgroundThe purpose of this study was to compare postoperative outcomes of pediatric patients with complicated appendicitis managed with or without a peripherally inserted central catheter (PICC). MethodsPatients aged ≤18 y in the Pediatric Health Information System database with complicated appendicitis that underwent appendectomy during their index admission in 2000–2012 were grouped by whether they had a PICC placed using relevant procedure and billing codes. Rates of subsequent encounters within 30 d of discharge along with associated diagnoses and procedures were determined. A propensity score–matched (PSM) analysis was performed to account for differences in baseline exposures and severity of illness. ResultsWe included 33,482 patients with complicated appendicitis; of whom, 6620 (19.8%) received a PICC and 26,862 (80.2%) did not. The PICC group had a longer postoperative length of stay (median 7 versus 5 d, P < 0.001) and were more likely to undergo intra-abdominal abscess drainage during the index admission (14.4% versus 2.1%, P < 0.001), and have a reencounter (17.5% versus 11.4%, P < 0.001) within 30 d of discharge. However, in the PSM cohort (n = 4428 in each group), outcomes did not differ between treatment groups, although the PICC group did have increased odds for the development of other postoperative complications (odds ratio = 3.95, 95% confidence interval: 1.45, 10.71). ConclusionsAfter accounting for differences in severity of illness by PSM, patients managed with PICCs had a similar risk for nearly all postoperative complications, including reencounters. Postoperative management of pediatric complicated appendicitis with a PICC is not clearly associated with improved outcomes.

Intraoperative Use of FloSeal with Adenotonsillectomy to Prevent Adverse Postoperative Outcomes in Pediatric Patients

The purpose of this study was to compare postoperative complications associated with monopolar dissection adenotonsillectomy, with and without the application of FloSeal at the completion of the procedure. Retrospective cohort study. Tertiary care pediatric hospital. This was a retrospective cohort study of 800 cases of adenotonsillectomy. Two cohorts of patients were identified based on whether or not FloSeal was used intraoperatively during the completion of the monopolar dissection adenotonsillectomy. Outcomes that were measured included: (1) age, (2) sex, (3) diagnosis, (4) primary hemorrhage, (5) secondary hemorrhage, (6) return to operating room, and (7) dehydration. All binomial outcomes measured were subjected to chi-square and t tests. Age and gender were similar between the 2 groups. Chronic tonsillitis was the primary indication more often in the control group; this was statistically significant. Primary hemorrhage occurred in 1 subject from each group (0.28%); secondary hemorrhage occurred in 11 subjects from the FloSeal group (3.22%) and 7 from the control group (1.87%). Both outcomes were not statistically different between the 2 groups. Return to operating room showed no statistically significant difference between groups. The need for postoperative admission for dehydration failed to show statistical significance between groups. In our experience, the application of FloSeal hemostatic matrix after monopolar adenotonsillectomy demonstrates no additional reduction in postoperative adverse events encountered in the pediatric population. Specifically, our data failed to demonstrate statistically significant reduction of: (1) primary hemorrhage, (2) secondary hemorrhage, (3) return to operating theatre, or (4) dehydration.

Warm, Humidified Carbon Dioxide Gas Insufflation for Laparoscopic Appendicectomy in Children

To investigate clinical benefits of warm, humidified carbon dioxide (CO(2)) insufflation for acute laparoscopic appendicectomy on postoperative pain and recovery in children (age 8-14 years). Conventional CO(2) insufflation leads to desiccation-related peritoneal inflammation and injury, which is preventable with warm, humidified CO2 gas. We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy. A double-blinded, randomized controlled trial was conducted. Intervention group participants received warm (37°C), humidified (98% relative humidity) CO(2) gas insufflation, whereas control participants received standard room temperature (20°C) gas with 0% relative humidity. Perioperative analgesia and anesthesia were standardized. Postoperative opiate usage was converted to morphine equivalent daily dosages (MEDD) for comparison, and pain intensity at rest and on moving was rated by participants using visual analog scales. Postoperative recovery and return to normal activities was assessed using a questionnaire on day 10. Between February 2010 and March 2011, a total of 190 participants were randomized. Both intervention and control groups were matched at baseline. Postoperative MEDD and pain scores were also similar. There were no differences in postoperative recovery parameters. Warm, humidified CO(2) insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients (ClinicalTrials.gov trial identifying code: NCT01027455).

Postsurgical Outcome in Pediatric Patients with Epilepsy: A Comparison of Patients with Intellectual Disabilities, Subaverage Intelligence, and Average‐Range Intelligence

Intellectual disabilities are often associated with bilateral or diffuse morphologic brain damage. The chances of becoming seizure free after focal surgery are therefore considered to be worse in patients with intellectual disabilities. The risk of postoperative cognitive deficits could increase because diffuse brain damage lowers the patient's ability to compensate for surgically induced deficits. Several studies in adult patients have indicated that IQ alone is not a good predictor of postoperative cognitive and seizure outcome. Our study evaluated this subject in children and adolescents. Pediatric patients with intellectual disabilities (IQ < or = 70), subaverage intelligence (IQ between 71 and 85), or average-range intelligence (IQ > 85) were matched according to several clinical and etiologic criteria to determine the influence of IQ (N = 66). No dependency of seizure outcome, postoperative cognitive development, and behavioral outcome on the IQ level was found. All groups slightly improved in attention while memory functions tended to decrease and executive functions were stable. School placement remained unchanged for the majority of patients. Between 67 and 78% were seizure free 1 year after surgery (Engel outcome class I). IQ alone is not a good predictor of postoperative outcome in pediatric patients with epilepsy. As with patients of average-range intelligence, the decision to operate on patients with a low level of intelligence should depend on the results of the presurgical diagnostics. If the results of the neuropsychological examination indicate diffuse functional impairment, this should not hinder further steps, if all other findings are consistent.

Pediatric myocardial protection: a cardioplegic strategy is the “solution”

This article describes the experimental infrastructure and subsequent successful clinical application of a comprehensive cardioplegic strategy that limits intraoperative injury and improves postoperative outcomes in pediatric patients. The infant heart is at high risk of damage from poor protection as a result of preoperative hypertrophy, cyanosis, and ischemia. These factors may also make the immature (pediatric) heart more sensitive to cardioplegic arrest compared with the mature (adult) heart. The preoperative factors of cyanosis and pressure volume overload are discussed, followed by the infrastructure of the strategies of warm induction and reperfusion with substrate enhancements, multidose cardioplegia, and a “modified” integrated approach to allow ischemia only when visualization is needed in pediatric surgeries. The importance of using a blood cardioplegia solution, with reduced calcium, increased magnesium, and low perfusion pressure are also shown. A practical clinical framework based on these experimentally proven principles is then presented to allow the surgeon to apply these strategies clinically. The results of using these principles are depicted in a series of 567 patients, including 93 patients with hypoplastic left heart syndrome. Applications of these concepts should improve the safety of protection of the infant heart and reduce postoperative morbidity and mortality.

Pediatric myocardial protection: an overview.

This article describes the experimental infrastructure and subsequent successful clinical application of a comprehensive bypass and cardioplegic strategy that limits intraoperative injury and improves postoperative outcomes in pediatric patients. The infant heart is at high risk of damage from poor protection because of preoperative hypertrophy, cyanosis, and ischemia. The background factors of vulnerability to damage caused by cyanosis and ischemia are discussed, together with studies of the infrastructure of strategies to use normoxia versus hyperoxia as bypass starts, white blood cell filtration, warm induction and reperfusion with substrate enhancements, multidose blood cardioplegia, and an integrated approach to allow ischemia only when vision is needed in pediatric surgeries. Data on cardioplegic management, including reducing calcium, increasing magnesium, and reducing perfusion pressure are shown, as used during this technique. These principles were applied to a consecutive series of 567 patients at the Heart Institute for Children and University of Illinois hospital over a 2-year period. Included also were 72 patients with hypoplastic left heart over a 4-year period with this myocardial management strategy. Application of these concepts may improve the safety of protection in infant hearts.