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Abstract Background/Purpose Achalasia is an extremely rare disease in children (0.1 per 100,000 individuals). Standard treatments for this include pneumatic dilation and esophagomyotomy. Minimally invasive esophagomyotomies have increasingly been used owing to improved postoperative pain and length of stay. We describe our experience with thoracoscopic esophagomyotomy in this population. Methods This is a retrospective cohort study of all patients at our institution who underwent thoracoscopic esophagomyotomy for achalasia from 1995 to 2016. We used endoscopic guidance during all procedures. No fundoplication was performed. Results Thirty-one patients were included in this study. Thirteen patients underwent pneumatic dilations prior to their operation with a median of 3 dilations. Two patients had a mucosal injury during the case. There were no conversions to an open procedure. Median length of stay was 2 days. After the procedure, 97% of patients had initial symptom relief. Eight patients (26%) required postoperative pneumatic dilations for recurrent symptoms; there was a greater chance of this (OR 8.5) if they had a preoperative dilation. No patients required a fundoplication for reflux postoperatively. Conclusions Thoracoscopic esophagomyotomy is a safe and effective procedure for achalasia in the pediatric population. It should be considered as an alternative to the laparoscopic approach for these patients. Level of evidence IV [ABSTRACT FROM AUTHOR]

Background There has been an increased focus on transition of pediatric and adolescent patients to adult centered care. For patients with rare and complex conditions, such as anorectal malformations (ARM), difficulties are compounded by the absence of structured transition protocols and lack of adult provider expertise. We sought to explore the actual experiences of adult patients with ARM and distinguish if there are factors that influence the ability to achieve satisfactory transition to adult centered medical care. Methods Patients older than 18 years with ARM were identified through a hospital database and social support networks, and invited to participate in an anonymous questionnaire. Patients were asked to describe their transition experience as well as report their demographics, and functional outcomes (bowel and bladder function). Results Twenty-six surveys were completed. Comparison of those respondents (53%) who had transitioned to adult providers to those that had not yet transferred care demonstrated no difference in satisfaction with bowel and bladder function, presence of ostomy, and education level. There was a slight trend for patients with more complex malformations to seek further medical care with adult providers. Of those who transitioned, 67% reported no discussion prior to their transition and 71% received no recommendations for follow-up providers. Conclusions This pilot project suggests that a significant number of adult patients with ARM lack transition preparation and fail to find adult providers with expertise. Future studies will need to find optimal ways to address these issues. Type of Study Survey. Retrospective Study Levels of Evidence Level II. [ABSTRACT FROM AUTHOR]

Background/Purpose The purpose of this project was to examine the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACSNSQIP-P) Participant Use File (PUF) to compare risk-adjusted outcomes of neonates versus other pediatric surgical patients. Methods In the ACS-NSQIP-P 2012–2013 PUF, patients were classified as preterm neonate, term neonate, or nonneonate at the time of surgery. The primary outcomes were 30-day mortality and composite morbidity. Patient characteristics significantly associated with the primary outcomes were used to build a multivariate logistic regression model. Results The overall 30-day mortality rate for preterm neonates, term neonate, and nonneonates was 4.9%, 2.0%, 0.1%, respectively (p < 0.0001). The overall 30-day morbidity rate for preterm neonates, term neonates, and nonneonates was 27.0%, 17.4%, 6.4%, respectively (p < 0.0001). After adjustment for preoperative and operative risk factors, both preterm (adjusted odds ratio, 95% CI: 2.0, 1.4–3.0) and term neonates (aOR, 95% CI: 1.9, 1.2–3.1) had a significantly increased odds of 30-day mortality compared to nonneonates. Conclusion Surgical neonates are a cohort who are particularity susceptible to postoperative morbidity and mortality after adjusting for preoperative and operative risk factors. Collaborative efforts focusing on surgical neonates are needed to understand the unique characteristics of this cohort and identify the areas where the morbidity and mortality can be improved. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD). Methods Patients with CHD who underwent cardiac surgery by 1 year of age and had malrotation diagnosed during their initial admission at 34 hospitals contributing to the Pediatric Health Information System in 2004–2009 were included. Ladd’s procedures performed during the first admission were considered early correction, and those at a subsequent admission were considered delayed. Interhospital variability in the proportion of patients undergoing delayed correction was assessed, and outcomes were compared between the groups. Results Of the 324 patients identified, 85.2% underwent early correction. Significant variability existed in the proportion of patients undergoing delayed correction across hospitals (p<0.0001). Baseline characteristics, including severity of CHD, were similar between the groups. In the delayed group, 27% of patients underwent a Ladd’s procedure during an urgent or emergent admission, but none had volvulus or underwent intestinal resection. Rates of mortality and readmission within 1 year of malrotation diagnosis were similar in both groups. Chart validation confirmed 100% accuracy of diagnosis and treatment group assignment. Conclusions In patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative. [ABSTRACT FROM AUTHOR]

Purpose The purpose of this study was to examine practice variability and compare outcomes between early and delayed neonatal inguinal hernia repair (IHR). Methods Patients admitted to neonatal intensive care units with a diagnosis of IH who underwent IHR by age 1 year in the Pediatric Health Information System from 1999 to 2011 were included. IHR after the index hospitalization was considered delayed. Inter-hospital variability in the proportion of delayed repairs and differences in outcomes for each group were compared. A propensity score matched analysis was performed to account for baseline differences between treatment groups. Results Of the 2030 patients identified, 32.9% underwent delayed IHR with significant variability in the proportion of patients having delayed repair across hospitals (p < 0.0001). More patients in the delayed group had a congenital anomaly or received life supportive measures prior to IHR (all p < 0.01), and 8.2% of patients undergoing delayed repair had a diagnosis of incarceration at repair. More patients in the early group underwent reoperation for hernia within 1 year (5.9% vs. 3.7%, p = 0.02). Results were similar after performing a propensity score matched analysis. Conclusions Significant variability in practice exists between children’s hospitals in the timing of IHR, with delayed repair associated with incarceration and early repair with a higher rate of reoperation. [ABSTRACT FROM AUTHOR]

Purpose Neonates placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) undergo either carotid repair or ligation at decannulation. Study aims were to evaluate carotid patency rates after repair and to compare early neurologic outcomes between repaired and ligated patients. Methods A retrospective study of all neonates without congenital heart disease (CHD) who had VA-ECMO between 1989 and 2012 was completed using our institutional ECMO Registry. Carotid patency after repair, neuroimaging studies, and auditory brainstem response (ABR) testing at time of discharge were examined. Results 140 neonates were placed on VA-ECMO during the study period. Among survivors, 84% of carotids repaired and imaged remained patent at last study. No significant differences were observed between infants in the repaired and ligated groups regarding diagnosis, ECMO duration, or length of stay. A large proportion (43%) developed a severe brain lesion after VA-ECMO, but few failed their ABR testing. Differences in early neurologic outcomes between the two groups of survivors were not significant. Conclusions At this single institution, carotid patency is excellent following repair at ECMO decannulation. No increased incidence of severe brain lesions or greater neurosensory impairment in the repair group was observed. Further studies are needed to investigate the effects of ligation on longer-term neurocognitive outcomes. [ABSTRACT FROM AUTHOR]

Purpose Babies born in the hospital where they obtain definitive surgical care do not require transportation between institutions and may have shorter time to surgical intervention. Whether these differences result in meaningful improvement in outcomes has been debated. A multi-institutional retrospective study was performed comparing outcomes based on birthplace. Methods Six institutions within the PedSRC reviewed infants born with gastroschisis from 2008 to 2013. Birthplace, perinatal, and postoperative data were collected. Based on the P-NSQIP definition, inborn was defined as birth at the pediatric hospital where repair occurred. The primary outcome was days to full enteral nutrition (FEN; 120 kcal/kg/day). Results 528 patients with gastroschisis were identified: 286 inborn, 242 outborn. Days to FEN, time to bowel coverage and abdominal wall closure, primary closure rate, and length of stay significantly favored inborn patients. In multivariable analysis, birthplace was not a significant predictor of time to FEN. Gestational age, presence of atresia or necrosis, primary closure rate, and time to abdominal wall closure were significant predictors. Conclusions Inborn patients had bowel coverage and definitive closure sooner with fewer days to full feeds and shorter length of stay. Birthplace appears to be important and should be considered in efforts to improve outcomes in patients with gastroschisis. [ABSTRACT FROM AUTHOR]

Summary: Background: Composite tissue allotransplantation of hand, facial and other tissues is now a clinical reality. The terminology, treatment principles, drug combinations, dosage schedules and mechanisms of the immunosuppression medications on which contemporary transplant surgery is based are unfamiliar to plastic surgeons and most healthcare providers outside the field of transplantation medicine. With this in mind, the purpose of this manuscript is to provide plastic surgeons with a comprehensive and understandable review of key immunological principles relevant to composite tissue allotransplantation. Methods: We present an overview of the immunological basis of composite tissue allotransplantation aimed at the plastic surgery readership, based on our own experience plus manuscripts sourced from MEDLINE, EMBASE, text books, ancient manuscripts and illustrations. Results: In this manuscript we provide the reader with a brief history of composite tissue allotransplantation (CTA), a concise description of the immunological terminology, treatment approaches, risks associated with immunosuppressive therapy, risk acceptance, and current research avenues relating to contemporary CTA. Conclusion: Today, as transplant and reconstructive surgeons join forces to move hand and facial tissue allotransplantation into the clinical arena, it is important that plastic surgeons have an understanding of the major immunological principles upon which this new treatment is based. [Copyright &y& Elsevier]

Background/purpose NSQIP Pediatric (NSQIP-P) is a robust quality improvement effort. A limitation of the NSQIP process lies in capturing a small proportion of the total case volume. This study examines whether appendectomies captured by NSQIP-P are concordant with all appendectomies, the most commonly captured procedure in 2011. Methods We compared case mix and 30-day outcomes between children undergoing an appendectomy who were included in NSQIP (n = 80) and children not captured by NSQIP (n = 276) during 2011 at a tertiary referral children's hospital. A single surgical case reviewer reviewed all cases using NSQIP-P methodology. Results NSQIP-P captured 80 of a total of 356 appendectomies (22%). The case mix was similar between NSQIP and non-NSQIP groups (e.g., 31% of each group had complicated appendicitis). Outcomes were also similar; post-operative occurrences, readmissions and return to the operation room occurred at rates of 7.5% vs. 7.6%, 5% vs. 4.7%, and 3.8% vs. 4.3% respectively. Conclusion Although NSQIP-P captured a minority of the total patient population that had an appendectomy, the case mix and outcomes were similar. Our results offer reassurance that NSQIP-P data are representative of the larger population for this procedure. Whether this concordance exists for procedures less commonly performed is unknown and a focus of ongoing work. [ABSTRACT FROM AUTHOR]