Variation in resource utililization associated with the management of appendicitis in children (APSA2011)

This presentation shed light on the spectrum of hospital costs entailed by different institutions for a somewhat uniform disease process, simple appendicitis, and the more heterogenous form, complicated or perforated appendicitis.

Not surprizingly, the authors found a significan variation in resourse utilization between institutions. This included the use of imaging studies and laboratory tests, readmission rates for both simple and complicated appendicitis, and hospital costs. Most strikingly, the authors noted an adjusted, case-related hospital cost for simple appendicitis that ranged from $4,000 to $10,000. As to complicated appendicitis, the cost ranged from $6,000 to $27,000.

Despite the limitation of studies obtained from databases, and the lack of correlatio between resource utilization and outcome, this study highlights the marked variability in management of a common condition that results in substantial resource utilization.

Why does simple appendicitis cost $4K in one hospital and $10K in another. Is the answer as simple as using cheaper but equally effective instruments? And if so, should we not all be standardizing this operation to help save what seems to me to be a lot of money?

Reference:
Variation of resource utilization associated with the management of appendicitis in children: implications for quality improvement through comparative analysis and collaborative networking.
Rangel SJ, Baxter J, Barnes J.

A bowel prep is not necessary before colosotmy reversal in kids (APSA 2011)

In this retrospective study looking at data from three institutions, the authors compared LOS and complication rates after colostomy takedown between pediatric patients who underwent a mechanical bowel prep and those who did not.

When they reviewed the data from 272 children (187 underwent a prep) they noted a longer hospital LOS for the prep group (5.6 vs 4.4 days); 122 of them had been pre-admitted for the prep. They also noted a higher rate of wound infections for the prep group (14.4 vs 5.8%). No significant difference was noted in the rate of abdominal abscess formation, anastomotic leaks, or C-diff infections.

Despite the limitations of this retrospective study, which may be comparing individual surgeon outcomes rather than the effect of bowel preps, this is another nail in the coffin of the pre-op bowel prep dogma that will hopefully be sealed by a PRS by the same group.

Reference:
A multi-center evaluation of the role of mechanical bowel preparation in pediatric colostomy takedown.
Serrurier K, Liu j, Breckler F, et al.

What's the Pediatric Appendicitis Score (PAS) and is it actually helpful?

So who hasn't received the call for a kiddo with 'classic' appendicitis only to see the kid and send him home because he's constipated.

What if there was a consistent and reliable way of communicating the "classic'ness" of someone's abdominal pain between healthcare workers; NP from an outside hospital calling for a transfer or ED physician calling for a surgical consult.

Enter PAS.

The PAS was introduced by Maden Samuel in 2002 as a way to stratify children's risk of having appendicitis when they present with abdominal pain. The scoring system consists of 8 findings (6 worth 1 point, and 2 worth 2 points for a total score of 10 points). Since Samuel's inception, several studies have addressed the sensitivity and specificity of this scoring system and attempted to develop strategies for it's use, mostly in deciding whom to take to the OR without imaging, whom to image, and whom to send home.

Goldman et al from Sick Kids in Toronto prospectively tested the PAS on unselected children with abdominal pain. Based on the scoring system, they noted that if they had sent kids with a score less than or equal to 2 home, there would have been a 2.5% missed appendicitis rate. on the other hand, if they took anyone with a score greater or equal to 7 to the OR, the rate of negative appendectomies would have been 4%.

Another study by Bhatt et al looked at the use of PAS on children suspected of having appendicitis and noted that sending home children with a PAS of 4 or less would have resulted in a missed appendicitis rate of 2.4%, while operating on those with a PAS greater or equal to 8 would have resulted in a negative appendectomy rate of 8.8%.

Reading through the papers, it is clear that the PAS is not perfect. What about the female who is mid cycle and has severe, sudden onset abdominal pain, nausea, and right lower quadrant tenderness. I wouldn't take her to the OR without imaging even if her score was 10/10. Clearly there's an important role of the "intangible ingredient" in patient evaluation, and no scoring system could take the place of a thorough history, exam, and experience. What the PAS does do is help standardize the way we communicate the level of suspicion for appendicitis, and may have a role in developing pathways to help physicians decide on whom to image, and whom not to, before a surgical consult is called.

So instead of 'classic' appendicitis (which clearly means different things to different people), a phone call about a patient with PAS of 8 would probably be much more meaningful to all parties involved.

References:

Maden S. Pediatric appendicitis score. Journal of Pediatric Surgery 2002;37:877

Goldman et al. Prospective validation of the pediatric appendicitis score. Journal of Pediatrics 2008;153:278

Bhatt et al. Prospective validation of the pediatric appendicitis score in a Canadian pediatric emergency department. Academic Emergency Medicine 2009;16:591

What to do with a 2 YO in a C-collar?

Again, I find myself in the situation where I have to call the neurosurgery resident to evaluate a toddler in a C-collar because she keeps crying every time I touch her; making her exam unreliable. Thinking he's going to get a flex-ex, I find out that he cleared her clinically. Am I missing something?

Some basic questions to help solve this problem. First, what's the rate of C-spine injury (CSI) with or without spinal cord (SC) involvement in the setting of blunt trauma in this age group? Second,in which kids should I be worried about a CSI? Third, when are imaging studies indicated? Finally how do we clear the c-spine in a non-verbal child (whether imaging done or not)?

Polk-Williams et al reviewed the National Trauma Data Bank and identified over 95 thousand children younger than 3 years who sustained blunt trauma. The overall rate of CSI was 1.6%, with most injuries occurring in the setting of MVC's (rate of CSI doubles to 3.2%). Overall rate of SC injury (with or without a spinal column injury) was 0.4%. As expected most CSI (66%) occurred in the setting of MVC's, the second most common mechanism was falls (15%).

Ok, so CSI are uncommon, but occur more frequently with MVC (logical). But what do I do with this girl who fell off a trampoline? She has a GCS of 15, no distracting injuries, a relatively non-worrisome mechanism, but still cries every time I get close?

A multi center study of the American Association for the Surgery of Trauma looked at children younger than 3 years of age who sustained blunt trauma to clarify the approach to C-spine clearance (rate of CSI in that study was 0.66%). Based on predictors of CSI, they devised a weighted score that can be used to stratify kids based on risk for CSI and thus help determine who needs imaging and who doesn't. The score includes GCS<14 (3 points), GCSeye=1 (2 points), MVC (2 points), age 2 years or older (1 point). Based on the study, a score of 0 or 1 corresponded to a negative predictive value for CSI injury of 99.9%, and these children may be cleared without imaging studies. 70 percent of the population they studies fell into this category. Importantly, the few who escaped capture by this scoring system had other signs that prompted radiologic evaluation (splinting of neck and evidence of substantial head trauma). So based on that data, my girl in the ED, who had her eyes (and lungs) spontaneously wide open, could have been cleared without C-spine xrays. Which is fine, but I still needed to do an exam. Which is where I still am not sure that a screaming kid could have been cleared clinically. So, although based on these numbers, the chance of this girl having a CSI is minute, I'm not sure I would be comfortable clearing her C-spine without a good physical exam. References:

Polk-Williams A. et al. Cervical spine injury in young children: a National Trauma Data Bank review. Journal of Pediatric Surgery (2009). 43(9):1718-21

Pieretti-Vanmarcke R. et al. Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: A multi-center study of the American Association for the Surgery of Trauma. The Journal of Trauma (2009). 67(3):543-550

Laparoscopic repair of inguinal hernias in female children: the Inversion/ligation technique

The open repair for inguinal hernias in children is a time honored technique used by most pediatric surgeons. Different variations of laparoscopic repair techniques have been adopted by some pediatric surgeons, with the main criticism of those techniques being a high rate of recurrence (4% compared to 1% with the open repair).

Despite my overall skepticism with laparoscopic repair techniques and their outcome, one particular version used for repair of hernias in females is quite appealing.

The inversion-ligation technique for repair entails passing a laparoscopic grasper into the inguinal canal through the internal ring, grasping the distal aspect of the sac, and inverting it into the abdomen. The inverted sac is then twisted and doubly ligated with an endo-loop.

Lipskar et al looked at the outcome of 173 girls who underwent a total of 241 hernia repair operations. The mean age was 5 years. One third of patients were found to have a contralateral patent processus vaginalis/hernia. All were successfully repaired in an average time of 40 minutes and 90% were discharged home the same day. Recurrence rate was 0.8%.

The appealing part of this operation is that, unlike other laparoscopic hernia repair techniques, the hernia sac is not left within the canal, which may be a major contributor to the reported high recurrence rate in other techniques. Because of the absence of any important structures (vas etc..), the hernia sac in girls can be bluntly pulled off the round ligament and inverted.

Lipskar et al. Laparosocpic inguinal hernia inversion and ligation in female children: a review of 173 consecutive cases at a single institution. Journal of Pediatric Surgery (2010) 45,1370-1374

Which babies "sink" after PDA ligation?

30% of preemies who are over 32 weeks GA, and 60% who are under 28 weeks GA have a PDA.

Ligating a symptomatic PDA in a fragile premature infant can have substantial (but usually transient) unwanted hemodynamic consequences. The sudden ligation of the PDA causes an instantaneous rise in afterload, resulting from the obliteration of the the pop-off circuit into the low resistance pulmonary circulation, and an associated drop in preload. This sudden change may not be tolerated well by preemies, most likely due to underlying cardiac dysfunction. So how can we predict which infant is going to fare worse after ligation?

Moin et al, in a study that evaluated 100 premature infants who underwent PDA ligation, noted that 32% of preemies required vasopressor support (either starting pressors or increasing the dose of preexisting pressor support) within 72 hours of PDA ligation. Risk factors associated with need for vasopressor support were a lower gestational age (25 vs 26 weeks), lower birth weight (714 vs 870 grams), and relatively high ventilatory support (RIS>6).

Additionally, those infants who required pressor support after ligation had an increased risk of death before 36 week adjusted gestational age.

The authors cautioned that the study had several limitations by virtue of it's design and that further studies are needed to confirm their observations.

References:

Moin F et al. Risk factors predicting vasopressor use after patent ductus arteriosus ligation. American Journal of Perinatology;20(6)2003:313-320

Laparoscopic inguinal hernia repair in children. Why?

Inguinal hernia repair with high ligation of the hernia sac through an inguinal approach is one of the most commonly performed operations in the pediatric population. The laparoscopic approach to IH repair in children is certainly an attractive option, given that it entails no manipulation of cord structures, allows for the repair of recurrent hernias (initially repaired by an inguinal approach) through fresh tissue, and allows for the inspection of the contralateral internal ring (whatever implications that my have!). However, the fact that an intact hernia sac is left behind within the inguinal canal when hernias are repaired laparosocopically makes me wonder about recurrence.

Two main techniques for the closure of the internal ring from a peritoneal approach are described; the lap assisted/percutaneous closure (SEAL) and the totally laparoscopic approach. Both entail closing the internal ring (using a "purse string" or "N"-shaped type of suture) while avoiding the vas and vessels.

A recent series out of Mainz, Germany looked at over 500 patients who underwent a totally laparoscopic repair with a suture used in an "N"-shaped fashion. After a median follow up of 40 months, the recurrence rate was 4%. This dropped to 2% with the last 100 patients; an improvement that the author attributed to a refinement of the technique of internal ring closure.

Understandably, the concept of laparoscopic repair is very attractive, particularly in the setting of recurrent hernias. However, one must keep in mind that even in the most experienced hands, the recurrence rate of laparoscopic hernia repair is still 4 times higher than the classic repair.


References

Harrison et al. The subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique. Journal of Pediatric Surgery (2005) 1177-1180

Schier F. Laparoscopic inguinal hernia repair-a prospective personal series of 542 children. Journal of Pediatric Surgery (2006) 41, 1081-84