Quality Improvement Program Pediatric Database Research Articles

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.

Risk Factors for Venous Thromboembolism in Children Undergoing Orthopedic Surgery.

Venous thromboembolism (VTE) is an uncommon but highly morbid and potentially preventable complication in children. This study aimed to characterize the incidence of, and risk factors for, VTE in children undergoing orthopedic surgery. A retrospective analysis was performed using the 2012 to 2017 American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database. Patient demographics, comorbidities, operative variables, and perioperative outcomes were compared between patients who did and did not develop a VTE. In total, 81,490 pediatric patients who underwent orthopedic surgery were identified. Of those, the mean±SD age was 9.7±4.8 years, and 50.1% were male. Sixty patients (0.07%) developed a postoperative VTE. On multivariate regression, demographic and surgical variables associated with a VTE were ages 16 to 18 years (P=.002; compared with ages 11 to 15 years), American Society of Anesthesiologists (ASA) classes III and V (P=.003; compared with ASA classes I and II), preoperative blood transfusion (P<.001), arthrotomy (P<.001), and femur fracture (P<.001). Postoperative adverse events occurring prior to a VTE were also assessed. Controlling for patient factors, independent risk factors for VTE included any adverse event (P<.001), major adverse events (P<.001), minor adverse events (P<.001), reoperation (P<.001), and readmission (P<.001). This study identified an incidence of VTE of 0.07% in a population of more than 80,000 children undergoing orthopedic surgery. The identification of risk factors for VTE in this patient population raises the issue of VTE prophylaxis for select high-risk subpopulations. [Orthopedics. 2022;45(1):31-37.].

Association of prematurity with complications and failure to rescue in neonatal surgery

BackgroundThe majority of failure to rescue (FTR), or death after a postoperative complication, in pediatric surgery occurs among infants and neonates. The purpose of this study is to evaluate the association between gestational age (GA) and FTR in infants and neonates. MethodsNational cohort study of 46,452 patients < 1 year old within the National Surgical Quality Improvement Program–Pediatric database who underwent inpatient surgery. Patients were categorized as preterm neonates, term neonates, or infants. Neonates were stratified based on GA. Surgical procedures were classified as low- (< 1% mortality) or high-risk (≥ 1%). Multivariable logistic regression and cubic splines were used to evaluate the association between GA and FTR. ResultsPreterm neonates had the highest FTR (28%) rates. Among neonates, FTR increased with decreasing GA (≥ 37 weeks, 12%; 33–36 weeks, 15%; 29–32 weeks, 30%; 25–28 weeks 41%; ≤ 24 weeks, 57%). For both low- and high-risk procedures, FTR significantly (trend test, p < 0.01) increased with decreasing GA. When stratifying preterm neonates by GA, all GAs ≤ 28 weeks were associated with significantly higher odds of FTR for low- (OR 2.47, 95% CI [1.38–4.41]) and high-risk (OR 2.27, 95% CI [1.33–3.87]) procedures. A lone inflection point for FTR was identified at 31–32 weeks with cubic spline analysis. ConclusionsThe dose-dependent relationship between decreasing GA and FTR as well as the FTR inflection point noted at GA 31–32 weeks can be used by stakeholders in designing quality improvement initiatives and directing perioperative care. Level of evidenceLevel IV, Retrospective cohort study

Early Adverse Events Following Pediatric Mandibular Advancement: Analysis of the ACS NSQIP-Pediatric Database.

This study aims to assess early adverse events and patient factors associated with complications following mandible distraction osteogenesis (MDO). The American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) database, years 2012 to 2019, was queried for patients undergoing mandible advancement via relevant Current Procedural Terminology and postoperative diagnosis codes. Thirty-day adverse events and co-morbidities are assessed. A total of 208 patients were identified with 17.3% (n = 36) experiencing an adverse event, reoperation (n = 14), and readmission (n = 11) being most common. Patients < 365 days old at the time of operation were more likely to experience an adverse event (26.1% vs 10.8%; P = .005). However, among patients less than 1 year of age, differences in the complication rates between patients ≤ 28 days and >28 days (30.2% vs 22.2%; P = .47) and those weighing ≤ 4 kg and >4 kg (31.7% vs 11.5%; P = .063) did not reach statistical significance. Adverse events following mandible advancement are relatively common, though often minor. In our analysis of the NSQIP-Pediatric database, neonatal age ( ≤ 28 days) or weight ≤ 4 kg did not result in a statistically significant increase in complications among patients less than 1 year of age. Providers should consider early intervention in patients who may benefit from MDO.

P61. Allogenic transfusion increases the risk for postoperative infectious complications in children undergoing spinal fusion

<h3>BACKGROUND CONTEXT</h3> Perioperative transfusion is thought to contribute to infectious complications in adolescent spinal fusion procedures, though low power, inconsistent findings, and uncontrolled potential confounders limit interpretation of the literature to date. <h3>PURPOSE</h3> Perioperative allogenic RBC transfusion is associated with 30-day postoperative infectious complications in pediatric spinal fusion patients. <h3>STUDY DESIGN/SETTING</h3> Retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP) database. <h3>PATIENT SAMPLE</h3> A total of 19,132 pediatric patients from the ACS-NSQIP database. <h3>OUTCOME MEASURES</h3> Postoperative infections. <h3>METHODS</h3> The multicenter NSQIP pediatric surgical database was queried for spinal fusion procedures in patients <18 years, from 2016-2019. Perioperative allogenic blood transfusion was defined as any transfusion of red blood cells (RBCs) from surgery start until 72h postoperative. Postoperative complications included surgical site infection (SSI), pneumonia (PNA), urinary tract infection (UTI), systemic sepsis, or septic shock up to 30 days postoperative. Logistic regression was performed comparing those who did and did not experience infectious complications. <h3>RESULTS</h3> Of 19,132 children undergoing spinal fusion, 693 (3.6%) patients. experienced ≥1 infectious complication postop: 393 (2.0%) with SSI, 192 (1.0%) with PNA, 155 (0.6%) with UTI, 120 (0.6%) with systemic sepsis, and 29 (0.2%) with septic shock. 4075 (21.3%) were transfused allogenic RBCs. In multiple logistic regression, after adjusting for comorbid conditions, periop RBC transfusion was independently associated with experiencing ≥1 infectious complication (OR 1.54, 95%CI 1.26-1.87), SSI (OR 1.35, 95%CI 1.04-1.75) and PNA (OR 1.91, 95%CI 1.34-2.72). In addition, age (OR 0.92, p<0.0001), weight (OR 1.01, p=0.0009), ASA status (OR 2.73 p<0.0001), neuromuscular disease (OR 1.83 p<0.0001), operative time >300 minutes (OR 1.35 p=0.0017), 13 or more levels fused (OR 1.67 p<0.0001), and antibiotic treatment of the surgical site (OR 0.75, p=0.0102), were also independently associated with infectious complications. <h3>CONCLUSIONS</h3> This is the largest cohort to date examining infectious outcomes following pediatric spinal fusion surgery, providing evidence for the association between transfusion and postoperative infections. After adjusting for patient and procedure-specific characteristics, transfusion increased the odds of any postoperative infection by 54%, SSI by 35%, and pneumonia by 91%. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Estimating perioperative outcomes after pediatric laryngotracheal reconstruction surgery in accordance with ACS-NSQIP-P reporting

BackgroundThe American College of Surgeons National Surgical Quality Improvement Program-Pediatric (ACS-NSQIP-P) database monitors quality outcomes in pediatric surgery. However, the registry might underreport low-volume procedures. This review describes complications after laryngotracheal reconstruction (LTR) based on ACS-NSQIP-P reporting standards. MethodsA case series with chart review at a tertiary children's hospital included consecutive LTR procedures between 2010 and 2018. Surgical procedures were grouped into single- or double-stage for comparison of thirty-day complication rates. ResultsEighty-four procedures were reviewed with 70% (59/84) double-stage and 30% (25/84) single-stage. Children requiring double-stage procedures were younger (3.3 vs. 6.0 years, P = .002) and more often Black or African American (51% vs. 24%, P = .03). Double-stage LTR was frequently performed on children with grade 3 or 4 subglottic stenosis (90% vs. 52%, P < 001), with a tracheostomy (97% vs. 68%, P = .001) and with gastroesophageal reflux disease (93% vs. 67%, P = .004). Airway-related complications occurred in 19% (16/84) of children and non-airway complications occurred in 16% (13/84) with similar rates between groups. Unplanned reintubation (20% vs. 0%, P = .002), ventilator support longer than 48 hours (12% vs. 0%, P = .02), and total hospitalization lengths (15.6 vs. 6.5 days, P < .001) were increased after single-stage LTR. Children with non-airway complications had more central nervous system disorders (46% vs. 10%, P = .004). ConclusionPostoperative complications after pediatric LTR occur in nearly 20% of children and single-stage procedures have higher unplanned reintubations, prolonged ventilator support and hospitalization lengths. Surgeons should recognize that these typically minor events should be consistently monitored and reported after surgical expansion of the pediatric airway.Level of evidence: IV

Obesity Increases the Risk of Hospital Readmission Following Intestinal Surgery for Children With Crohn Disease.

Obese habitus can lead to adverse outcomes for colorectal surgeries due to technical challenges and pro-inflammatory immune mediators associated with excess adipose tissue. Surgical planning, pre-operative risk stratification, and patient counseling of pediatric Crohn disease (CD) patients are limited by the scarcity of data on this topic. We sought to determine the association between obesity and hospital readmission in children with CD undergoing intestinal resection. We used the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify pediatric CD patients undergoing intestinal resection between 2012 and 2018. We calculated age- and sex-adjusted body mass index (BMI) z scores using CDC population statistics. We used logistic regression to evaluate the association between obesity and readmission compared to average-BMI patients adjusting for age, race, sex, steroid exposure, disease activity, and surgery type. We evaluated 1258 pediatric CD intestinal resections occurring between 2012 and 2018. Patients were predominantly adolescent (91%), white (84%), and male (56%). Those with average BMI comprised 50% of the cohort, 31% were underweight, 11% overweight, and 8% obese. The overall 30-day hospital readmission rate was 8.8%. Compared to those with average BMI, obese children had a 2-fold (adjusted odds ratio 1.9, 95% confidence interval 1.0-3.8) increase in risk of hospital readmission. Obese patients undergoing intestinal resection face a higher risk of 30-day hospital readmission compared to average-BMI patients. These results can inform pre-surgical risk counseling and underscore the need for long-term weight management strategies to aid in risk reduction for obese children with CD at risk of future surgery.

Appendectomy and Cholecystectomy Outcomes for Pediatric Cancer Patients with Leukopenia: A NSQIP-Pediatric Study

BackgroundChildren with cancer often develop leukopenia which may impair wound healing and increase surgical complication rates. When leukopenic children with cancer develop an acute surgical condition, the optimal management strategy remains unclear. This study examined the effect of preoperative leukopenia on postoperative outcomes in children with cancer who underwent an appendectomy or cholecystectomy. MethodsWe retrospectively identified cancer patients undergoing an appendectomy or cholecystectomy from the National Surgical Quality Improvement Program-Pediatric database from 2012-2018. Demographics and perioperative characteristics were compared by leukopenia status (WBC <4 vs. ≥4 × 10^3/mL). Postoperative length of stay (LOS) and 30-day composite complications, including infections, reoperations, and readmissions, were analyzed for each procedure using multivariate regression. ResultsThere were 227 children who underwent an appendectomy and 101 children who underwent a cholecystectomy. Leukopenia was seen in 93 (41.0%) appendectomy and 57 (56.4%) cholecystectomy cases. Nineteen (8.4%) appendectomy patients and six (5.9%) cholecystectomy patients developed a postoperative complication. The median postoperative LOS was 2 days (IQR 1-6 days) for appendectomy and 1 day (IQR 1-2.5 days) for cholecystectomy cases. After multivariate analyses, leukopenia was not associated with increased postoperative complications after an appendectomy (OR 0.55, P = 0.36) or cholecystectomy (OR 0.39, P = 0.37). There was no significant difference in postoperative LOS based on leukopenia status for children who underwent an appendectomy (P = 0.82) or cholecystectomy (P = 0.37). ConclusionIn pediatric cancer patients, leukopenia was not associated with increased short-term postoperative complications or longer postoperative LOS after either an appendectomy or cholecystectomy. These results support that operative management can be performed safely in pediatric appendicitis and cholecystitis in leukopenic cancer patients.

Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study.

Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM. Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures. Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures. The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients. Level III.

Association of same-day discharge with hospital readmission after pediatric thyroidectomy.

Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients. This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression. Of the 1125 patients (79% female, median age 15years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group. Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.

The Association Between Race and Adverse Postoperative Outcomes in Children With Congenital Heart Disease Undergoing Noncardiac Surgery.

The association between race and perioperative outcomes has been evaluated in adult cardiac surgical and in healthy pediatric patients but has not been evaluated in children with congenital heart disease (CHD) presenting for noncardiac procedures. This study compares the incidence of the primary outcome of 30-day mortality and adverse postoperative outcomes following noncardiac surgery between Black and White children with CHD, stratified by severity. This is a retrospective study. Comparison of outcomes between Black and White children was performed using the 2012-2018 American College of Surgeons National Surgical Quality Improvement Program Pediatric database and after stratification for severity of CHD and propensity score matching. A total of 55,859 patients were included, and divided into 28,601 minor, 23,839 major, and 3419 severe CHD. Black and White children in each category were matched and compared. Following matching in the overall CHD cohort, there were significantly higher rates of the following adverse postoperative outcomes among Black patients as compared to White patients: 30-day mortality (1.84% vs 1.49%; odds ratio [OR], 1.25; 95% confidence interval [CI], 1.05-1.48; P = .014), composite secondary outcomes (19.90% vs 17.88%; OR, 1.14; 95% CI, 1.08-1.21; P < .001), cardiac arrest (1.42% vs 0.98%; OR, 1.46; 95% CI, 1.19-1.79; P < .001), 30-day reoperation (7.59% vs 6.67%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), and reintubation (3.9% vs 2.95%; OR, 1.34; 95% CI, 1.19-1.52; P < .001). No significant statistical interaction between race and CHD severity was found. Following matching and within the minor CHD cohort, Black children had significantly higher rates of composite secondary outcome (17.44% vs 15.60%; OR, 1.15; 95% CI, 1.05-1.25; P = .002), cardiac arrest (1.02% vs 0.53%; OR, 1.94; 95% CI, 1.37-2.76; P < .001), 30-day reoperation (7.19% vs 5.77%; OR, 1.26; 95% CI, 1.11-1.43; P < .001), and thromboembolic complications (0.49% vs 0.23%; OR, 2.17; 95% CI, 1.29-3.63; P = .003) compared to White children. In the major CHD cohort, Black children had significantly higher rates of 30-day mortality (2.75% vs 2.05%; OR, 1.35; 95% CI, 1.08-1.69; P = .008) and reintubation (4.82% vs 3.72%; OR, 1.32; 95% CI, 1.11-1.56; P = .002). There were no statistically significant differences in outcomes in the severe CHD category for 30-day mortality (3.36% vs 3.3%; OR, 1.02; 95% CI, 0.60-1.73; P = .946), composite secondary outcome (22.65% vs 21.36%; OR, 1.08; 95% CI, 0.86-1.36; P = .517) nor the components of the composite secondary outcomes. Race is associated with postoperative mortality and complications in children with minor and major CHD undergoing noncardiac surgery. No significant association was observed between race and postoperative outcomes in patients with severe CHD. This is consistent with previous findings wherein in patients with severe CHD, residual lesion burden and functional status is the leading predictor of outcomes following noncardiac surgery. Nevertheless, there is no evidence that the relationship between race and outcomes differs across the CHD severity categories. Future studies to understand the mechanisms leading to the racial difference, including institutional, clinical, and individual factors are needed.

Pediatric cerebral cysts: comparison of early complications following fenestration versus shunting procedures

ABSTRACT Objective: Characterize practice patterns and acute (30-day) surgical complications following fenestration and shunt procedures for the treatment of cerebral cysts in pediatric patients. Methods: This study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients were identified by International Classification of Disease codes for cerebral cysts and Current Procedural Terminology codes for shunting or fenestration. Demographic data, preoperative comorbidities, and postoperative complications were compared between the two procedures. Results: 741 patients were included in the data analysis, with a majority aged 4 years or younger (55.9%) and a male predominance (62.6%). Fenestration was performed in 590 (79.6%) patients. Primary shunting was performed in 151 (20.4%) patients. Patients who received shunts were more commonly aged 0–4 years and had proportionately worse preoperative health status. No statistically significant differences in postoperative complications were detected. Reoperation rate was 7.9% and 8.6% in the shunt and fenestration groups, respectively. Common reasons for reoperation were shunt revision or replacement and shunt placement after fenestration. Patients requiring shunting after a failed fenestration tended to be younger with higher American Society of Anesthesiologists (ASA) classification. Discussion: Fenestrations are performed more often than shunting. Generally, children who receive shunts are younger than those who undergo fenestration. Acute surgical risk appears to be similar for both operations.

Postoperative outcomes of autologous rib graft for microtia repair in children: A NSQIP study

ObjectiveTo compare the effect of surgical specialty and patient factors on 30-day postoperative outcomes and complications for children undergoing autologous costochondral grafting for microtia reconstruction. MethodsThe American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) database was searched from 2012 through 2017 for patients who underwent autologous rib grafting (CPT 21230). The group was further filtered for coexisting ICD 9 or 10 code for microtia (744.23, Q17.2) as an indication for surgery. Outcomes analyzed included patient demographics, medical comorbidities, admission type (inpatient vs. outpatient), operative time, surgeon specialty, length of hospital stay (LOS), complications, and readmission. ResultsA total of 375 pediatric patients were identified of which 157 were female and 218 were male. Mean age at time of surgery was 9.6 years. Postoperative complications and readmission occurred in 5.6% and 3.5% of patients, respectively. Surgical site infection was the most common complication. Average operative time was 246.9 min. When comparing Otolaryngology to Plastic Surgery with multivariate analysis, there was no difference in admission type (OR 1.00, p = 0.993), complication rate (OR 0.91, p = 0.744), readmission (OR 0.68, p = 0.576), operative time (p = 0.471) or total LOS (p = 0.266). ConclusionThe present study demonstrated postoperative complications and readmission rates following microtia repair as reported by the NSQIP-P database. Overall complication and readmission rates were low. No significant risk factors were identified on multivariate analysis. There were no differences between surgical specialty for complication rate, operative time, hospital stay or readmission when accounting for demographic data and comorbidities.

Association of operative approach with outcomes in neonates with esophageal atresia and tracheoesophageal fistula

Purpose: We sought to evaluate the impact of thoracoscopic repair on perioperative outcomes in infants with esophageal atresia and tracheoesophageal fistula (EA/TEF).Methods: The American College of Surgeons National Surgical Quality Improvement Program pediatric database from 2014 to 2018 was queried for all neonates who underwent operative repair of EA/TEF. Operative approach based on intention to treat was correlated with perioperative outcomes, including 30-day postoperative adverse events, in logistic regression models.Results: Among 855 neonates, initial thoracoscopic repair was performed in 133 (15.6%) cases. Seventy (53%) of these cases were converted to open. Those who underwent thoracoscopic repair were more likely to be full-term (p = 0.03) when compared to those in the open repair group. There were no significant differences in perioperative outcome measures based on surgical approach except for operative time (thoracoscopic: 217 min vs. open: 180 min, p<0.001). A major cardiac comorbidity (OR 1.6, 95% CI 1.2–2.1; p = 0.003) and preoperative ventilator requirement (OR 1.4, 95% CI 1.0–1.9; p = 0.034) were the only risk factors associated with adverse events.Conclusions: Thoracoscopic neonatal repair of EA/TEF continues to be used sparingly, is associated with high conversion rates, and has similar perioperative outcomes when compared to open repair.Level of evidence: III

Cryoanalgesia enhances recovery from minimally invasive repair of pectus excavatum resulting in reduced length of stay: A case-matched analysis of NSQIP-Pediatric patients

PurposePain control is challenging after minimally invasive repair of pectus excavatum (MIRPE). Cryoanalgesia, which temporarily ablates peripheral nerves, improves pain control and may accelerate post-operative recovery. We hypothesized that cryoanalgesia would be associated with shorter length of stay (LOS) in children undergoing MIRPE. MethodsA matched cohort study was conducted of children (<18 years) who underwent MIRPE 2016–2018, using the National Surgical Quality Improvement Program-Pediatric database. Each patient who received cryoanalgesia during MIRPE was matched to four controls (no cryoanalgesia). Univariate and multilevel regression analyses were performed. ResultsThirty-five patients who received cryoanalgesia during MIRPE were matched to 140 controls. Patients who received cryoanalgesia had a LOS reduction with similar secondary outcomes (operative time, rates of complication, reoperation, and readmission). On multilevel regression adjusted for matched groups, cryoanalgesia was associated with a 1.3-day reduction in LOS (95% CI −1.8 to −0.8, p < 0.001). On sensitivity analysis excluding patients with complications, cryoanalgesia remained associated with a LOS reduction. ConclusionsCryoanalgesia is a promising adjunct in the care of pediatric patients undergoing MIRPE. Utilization is associated with a shorter LOS without an increase in operative time or complications. Cryoanalgesia should be considered for inclusion in enhanced recovery strategies for patients undergoing MIRPE.

Association of Race with Early Outcomes of Elective Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis: Propensity-Matched and Subgroup Analysis

To investigate the impact of race on 30-day postoperative complication rates of elective posterior spinal fusions (PSF) for adolescent idiopathic scoliosis (AIS). Patients who underwent PSF between 2012 and 2018 were reviewed from the American College of Surgeons National Surgical Quality Improvement Program pediatric database. Propensity score matching was utilized to evaluate whether patient race (i.e., black vs. white) was correlated with postoperative complications. A total of 4051 PSF for AIS cases met criteria for inclusion. Of these, 3221 (79.5%) patients were white and 830 (20.5%) were black. Several baseline characteristics significantly differed between cohorts. Patients in the black cohort had a significantly higher body mass index, a greater proportion of female patients, higher ASA scores, preoperative diagnosis of asthma or cardiac risk factors, and prior use of steroids. The total number of vertebral segments fused was also greater in the black cohort. After controlling for differences in baseline characteristics with propensity score matching analysis, the only significant difference in morbidity and mortality identified was a higher incidence of venous thromboembolism among the black cohort (2.8% vs. 0.1%; P < 0.001). In contrast to prior literature, our analysis did not identify black race as an independent risk factor for higher perioperative morbidity or mortality in patients of young age group undergoing elective PSF for AIS, except the higher incidence of venous thromboembolism. The findings of the present study suggest that previously reported perioperative morbidity and mortality outcomes in black patients may be secondary to baseline health characteristics, and not due to race itself.

The Effects of Pulmonary Risk Factors on Hospital Resource Use After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis Correction

The aim of this study was to determine the impact of preoperative pulmonary risk factors (PRFS) on surgical outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients with AIS undergoing PSF were identified. Patients were then categorized by whether they had recorded baseline PRF or no-PRF. Patient demographics, comorbidities, intraoperative variables, complications, length of stay, discharge disposition, and readmission rate were assessed. A total of 4929 patients were identified, of whom 280 (5.7%) had baseline PRF. Compared with the no-PRF cohort, the PRF cohort had higher rates of complications (PRF, 4.3% vs. no-PRF, 2.2%; P= 0.03) and longer hospital stays (PRF, 4.6 ± 4.3 days vs. no-PRF, 3.8 ± 2.3 days; P < 0.001), yet, discharge disposition was similar between cohorts (P= 0.70). Rates of 30-day unplanned readmission were significantly higher in the PRF cohort (PRF, 6.3% vs. no-PRF, 2.7%; P= 0.009), yet, days to readmission (P= 0.76) and rates of 30-day reoperation (P= 0.16) were similar between cohorts. On multivariate analysis, PRF was found to be a significant independent risk factor for longer hospital stays (risk ratio, 0.74; 95% confidence interval, 0.44-1.04; P < 0.001) but not postoperative complication or 30-day unplanned readmission. Our study showed that PRF may be a risk factor for slightly longer hospital stays without higher rates of complication or unplanned readmission for patients with AIS undergoing PSF and thus should not preclude surgical management.

Open Gastrostomy Tube Placement is Associated With Higher Complications in Infants: A National Surgical Quality Improvement Program Database Analysis

BackgroundThe purpose of this study was to compare outcomes between open versus laparoscopic gastrostomies in children aged ≤1 y. MethodsThe American College of Surgeons’ National Surgical Quality Improvement Program Pediatric database was reviewed between 2012 and 2017. Chi-square analysis was performed on children aged ≤1 y to compare complication rates between open and laparoscopic procedures. ResultsA total of 7940 patients were aged ≤1 y. Of which, 20% underwent open gastrostomy (OGT), and 80% received laparoscopic gastrostomy (LGT). There were no differences in sex or race. However, OGT patients were younger (119 d versus 134 d; P = 0.0001), smaller at birth (1.84 kg versus 1.85 kg; P = 0.03), and were smaller at operation (4.6 kg versus 5 kg; P = 0.0001). Also, patients were more likely to be inpatient at the time of surgery and had more congenital malformations. Complications (OGT 6% versus LGT 4%; P = 0.001) and mortality were significantly higher in the open group (OGT 2.3% versus LGT 0.6%; P = 0.001). However, matched control analysis demonstrated OGT patients have more complications. ConclusionsOGT patients are smaller and with more significant comorbidities in this data set. In fact, even after matched control analysis, these patients experience more complications.

Impact of Preoperative Anemia on Outcomes After Posterior Spinal Fusion for Adolescent Idiopathic Scoliosis

The aim of this study was to investigate the relationship of preoperative anemia and outcomes after posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS). A retrospective cohort study was performed using the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database from 2016 to 2018. All pediatric patients (age 10-18 years) with AIS undergoing PSF were identified. Two cohorts were categorized into anemic and nonanemic cohorts based on age-based and sex-based criteria for anemia. Thirty-day outcomes and readmission rates were evaluated. A total of 4929 patients were identified, of whom 592 (12.0%) were found to have preoperative anemia. The anemic cohort had a greater prevalence of comorbidities and longer operative times. Compared with the nonanemic cohort, the anemic cohort experienced significantly higher rates of perioperative bleed/transfusion (nonanemic, 67.4% vs. anemic, 73.5%; P= 0.004) and required a greater total amount of blood transfused (nonanemic, 283.2 ± 265.5 mL vs. anemic, 386.7 ± 342.6 mL; P < 0.001). The anemic cohort experienced significantly longer hospital stays (nonanemic, 3.8 ± 2.2 days vs. anemic, 4.2 ± 3.9 days; P= 0.001), yet discharge disposition (P= 0.58), 30-day complication rates (P= 0.79) and unplanned reoperation rates (P= 0.90) were similar between cohorts. On multivariate analysis, anemia was found to be an independent predictor of perioperative bleed/transfusion (odds ratio, 1.36; 95% confidence interval, 1.12-1.66; P= 0.002) as well as a longer length of hospital stay (relative risk, 0.46; 95% confidence interval, 0.25-0.67; P < 0.001) but was not an independent predictor for postoperative complications (P= 0.85). Our study suggests that preoperative anemia may be a risk factor for a greater perioperative bleed/transfusion event and slightly longer length of stay; however, it was not associated with greater 30-day complication and readmission rates in patients with AIS undergoing PSF.

Complications and Failure to Rescue After Inpatient Pediatric Surgery.

To describe the frequency and patterns of postoperative complications and FTR after inpatient pediatric surgical procedures and to evaluate the association between number of complications and FTR. FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. Although it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery. Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥ 1%) or low (< 1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression. Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least 1 postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (eg, low-risk- 9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥ 3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk [1 complication - odds ratio (OR) 3.34 (95% CI 2.62-4.27); 2 - OR 10.15 (95% CI 7.40-13.92); ≥3-27.48 (95% CI 19.06-39.62)] and high-risk operations [1 - OR 3.29 (2.61-4.16); 2-7.24 (5.14-10.19); ≥3-20.73 (12.62-34.04)]. There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, "minor" surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.