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Objective: Considerable variation in primary spontaneous pneumothorax (PSP) management exists in the pediatric population. This study aims to compare nationwide outcomes of children with PSP. Methods: The Nationwide Readmissions Database (2016 to 2018) was used to identify patients 1 to 18 years old with PSP. Trauma, secondary pneumothoraces, and elective admissions were excluded. Demographics and complications were compared among patients undergoing initial nonoperative management (NOM; observation or percutaneous drainage) or operative resection using standard statistical tests. Results: A total of 3,890 patients were identified with PSP (median age, 16 [interquartile range 14 to 17] years). Most (78%) underwent NOM, of which 17% failed requiring operative resection. Of the intent-to-treat cohort, 28% failed NOM during index admission or required repeat percutaneous drainage or operative resection on readmission. Patients treated by NOM had higher 30-day and overall readmission rates compared with operative resection (all P < 0.001). Ipsilateral recurrent pneumothorax was higher in those receiving NOM (13% vs 3%, P < 0.001). Patients from the lowest median household income quartile more frequently received NOM compared with the highest income quartile (82% vs 76%) with more readmissions. Conclusions: Patients with PSP who underwent initial NOM experienced higher readmission rates than those receiving operative resection. Furthermore, socioeconomic status was associated with the utilization of nonoperative versus operative management.

Gastrostomy tube (GT) placement for enteral access is one of the most common procedures for infants with numerous conditions such as congenital heart disease (CHD). Discrepancies in the literature exist regarding outcomes of newborns with CHD undergoing GT placement. This study sought to characterize postoperative outcomes and readmission complications in this patient population.The Nationwide Readmission Database was queried from 2010 to 2014 for all newborns who underwent GT placement during their index hospitalization. Newborns with or without CHD other than an isolated atrial or ventricular septal defect were compared using standard statistical tests. A propensity score-matched analysis was performed among newborns with or without CHD using100 covariates.Seven thousand seven hundred thirty six patients underwent GT placement. Newborns with CHD (27%) more frequently underwent open GT (59% versus 55%) and less frequently underwent laparoscopic (17% versus 19%) or percutaneous (24% versus 26%) GT placement compared to those without CHD, P = 0.043. GT-related complications on index admission were similar between groups (7% versus 7%, P = 0.770). Newborns with CHD had higher overall readmission rates (39% versus 31%), more GT-related readmission complications (7% versus 3%), and higher readmission costs ($35,787 versus $20,073) compared to newborns without CHD, all P 0.001. Laparoscopic GT was associated with the lowest rate of GT-related complications (0%) and overall readmission rates (27%) compared to open or percutaneous endoscopic gastrostomy (all P 0.001).Compared to newborns without CHD, newborns with CHD had higher rates of overall readmissions, readmission costs, and GT-related complications on readmission. The laparoscopic GT approach was underused despite fewer complications and readmissions.

Pyloromyotomy for hypertrophic pyloric stenosis (HPS) is one of the most common non-elective operations performed in the neonatal period. This project aims to explore outcomes of pyloromyotomy and compare differences between laparoscopic versus open pyloromyotomies in newborns diagnosed with HPS.The Nationwide Readmissions Database (NRD) from 2010 to 2014 was queried to identify patients diagnosed with HPS that underwent repair.In total, 30,915 children (18% female) underwent pyloromyotomy for HPS. Median length of stay for index admission was 2 days. A total of 212 (0.7%) patients required a redo pyloromyotomy. 127 (60%) were performed during index admission. Readmission rate at 30 days was 3% and 5% at one year, and 22% presented to a different hospital. The most common indications for readmission were feeding intolerance (24%), dehydration (10%), and malnutrition (10%). Patients from low-income households were more likely to present with malnutrition and weight loss (9% vs 4%, p0.001) and had higher readmission rates (8% vs 4%, p0.001). Laparoscopic pyloromyotomies accounted for 10% (n = 2951) of cases. Those undergoing laparoscopy were less likely to have electrolyte disturbances (41% vs 54%, p0.001) or weight loss (2% vs 11%, p0.001) on admission. The rate of open conversion was 1%. Intraoperative perforation was not more common in laparoscopic than open cases. Open pyloromyotomies had higher 30-day readmission rates and more surgical site infections.Complications from pyloromyotomies are rare. Although infrequent, the incidence of incomplete pyloromyotomy is higher than previously reported and more common with open approaches. Newborns from low-income households are more likely to present with advanced symptoms and have disproportionately higher rates of readmission.Level III TYPE OF STUDY: Treatment Study, retrospective.

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

Malrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent with timely diagnosis and treatment, but the development of bowel ischemia is associated with many negative consequences.The Nationwide Readmissions Database was used to identify patients 0-18 years (excluding newborns) with malrotation and midgut volvulus from 2010 to 2014. Demographics, procedures, and outcomes were compared by income group (highest quartile vs. lowest quartile) using standard statistical tests. Results were weighted for national estimates.Emergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd's procedure, while 14% required bowel resection and/or ostomy. Patients in the lowest income quartile were more likely to require bowel resection (18% vs. 8%, p = 0.03) or ostomy (9% vs. 2%, p = 0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged hospital stay (8 [5-13] days vs. 6 [4-8] days, p0.001) and experience complications including infections (19% vs. 5%, p = 0.002), endotracheal intubation (18% vs. 4%, p0.001), and blood transfusions (13% vs. 3%, p = 0.003).Income disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists. Patients from lower-income communities are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigations of practices to mitigate risk for low-income patients.Level III: Retrospective comparative study.

PURPOSE Pyloric atresia is an uncommon congenital anomaly that may present with emesis and dehydration early in infancy. Definitive therapy consists of pyloroplasty or gastroduodenostomy depending on the subtype of atresia involved. CASE PRESENTATION We report the case of a 2-day-old girl infant who presented with nonbilious emesis with feeds. Abdominal ultrasound and upper gastrointestinal series were performed and demonstrated a dilated, air-filled stomach with no distal air or passage of contrast. The patient was successfully treated by laparoscopic-assisted open pyloroduodenostomy of a type 2 pyloric atresia. CONCLUSION Type 2 pyloric atresia is a rare clinical entity that can present with symptoms of gastric outlet obstruction. The patient described was treated by laparoscopic-assisted open pyloroduodenostomy, which has not been previously described for pyloric atresia. This work demonstrates an example of the safety and efficacy of laparoscopic surgery for infants with this anomaly.

Down syndrome (DS) is the most common abnormality associated with Hirschsprung disease (HD). It has been suggested patients with HD and DS have worse outcomes, however the literature is controversial.The Kids' Inpatient Database (KID) from 2003 to 2012 was used to identify newborns with HD. Demographics, hospital characteristics, and outcomes were compared among patients with and without DS using standard statistical tests.There were 481 patients identified with HD, of which 45 (9%) had DS. Patients with DS were older at the time of first rectal biopsy (6 [3-11] days vs. 4 [3-6] days, p = 0.012). There were no differences in operative versus non-operative management in patients with and without DS (p = 0.706). Hospital length of stay was longer in the DS cohort (22 [13-33] days vs. 15 [10-24] days, p = 0.019), and patients with DS were more likely to have a concomitant diagnosis of wound infection (12% vs. 3%, p = 0.002) and necrotizing enterocolitis (14% vs. 5%, p = 0.018). The mortality rate for patients with DS was four times higher than those without DS (5% vs.0.8%, p = 0.018).In this nationwide cohort of patients with Hirschsprung disease, those with Down syndrome experienced delays in diagnosis and worse outcomes.Level III.Treatment study, retrospective comparative study.

Pediatric patients with Crohn's disease often require colectomies. The laparoscopic approach is considered safe, but there is little national data on outcomes and readmissions in this population.The Nationwide Readmissions Database was queried from 2010 to 2014 for patients ≤ 18 years who underwent colectomy for Crohn's disease during index admission. Patients were stratified by operative approach: laparoscopic versus open. Outcomes were compared with standard statistical methods.There were 2833 patients (47% female) who underwent a colectomy via laparoscopic (58%) vs. open (42%) approach. Index admissions were elective 55% of the time. Most operations were right hemicolectomy (86%), followed by total colectomy (8%). Of the study population, 489 (17%) were diverted with an ostomy. Readmission rates at 30 days and 1 year were 9% and 18%, respectively. The most common diagnoses at readmission were intra-abdominal infection (16%), small bowel obstruction (16%), and surgical site infection (9%). Laparoscopy was more commonly performed during elective admissions (63% vs. 44%), for patient with private insurance (72% vs. 39%), and for patients in the highest income quartile (66% vs. 48% in the lowest income quartile), all p0.001. Length of stay was longer on index admission for open colectomy (8[5-12] days vs. 6[4-11] days, p0.001), while cost was similar ($17,754[$12,375-$30,625] vs. $17,017[$11,219-$27,336], p = 0.104). There were no differences in readmission rate, intraabdominal infection or small bowel obstruction.In pediatric patients, laparoscopic colectomy for Crohn's disease is safe and is associated with shorter hospitalization and equivalent hospital costs compared to the open procedure. Socioeconomic disparities in laparoscopic utilization exist and warrant future investigation.Level III.

This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.The 2010-2014 Nationwide Readmissions Database was used to identify patients18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs.7%, p = 0.017) settings.In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.