Journal of pediatric surgery最新文献

Background: The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide an algorithm to select patients with mild head trauma at highest risk for clinically important traumatic brain injury (ciTBI) in whom computed tomography (CT) would facilitate management. Failure to follow PECARN criteria exposes children to unnecessary radiation and contributes to increasing hospital costs, length of stay, and parental anxiety. We sought to evaluate the subsequent allocation of resources to low and intermediate risk group patients who underwent an initial Head CT - which was not indicated by PECARN guidelines but which identified cranial or intracranial injury.

Methods: We conducted a retrospective review of children ≤16 years old with head injury (GCS ≥14) between 2016 and 2021. Children with neurological deficits, penetrating head trauma, anticoagulation, or non-accidental trauma were excluded. Demographics, imaging results, PECARN risk category, and need for neurosurgical intervention were collected.

Results: There were 70 low risk patients who had positive findings on CT, however none demonstrated clinically significant progression on repeat imaging that necessitated medical or surgical intervention. Of 319 intermediate risk patients with evidence of skull fracture or intracranial injury on CT, only one required intervention. The decision to intervene was made based on clinical changes and was not influenced by repeat imaging.

Discussion: Despite PECARN guidelines, cross-sectional imaging remains overused. Identification of small foci of clinically non-actionable intracranial bleeding in patients who do not meet initial PECARN criteria frequently prompts further cross-sectional imaging without benefit. This suggests that routine interval imaging may not be necessary in the neurologically stable child with low-risk injury.

Type of study: Retrospective cohort study.

Level of evidence: Level III.

Introduction: Up to one-third of pediatric patients with acute appendicitis present with radiological evidence of appendicoliths. However, whether appendicolith presence influences prognosis under conservative management compared to non-appendicolith appendicitis remains uncertain.

Methods: We systematically searched PubMed, Cochrane, Embase, and Web of Science databases for studies comparing pediatric appendicolith and non-appendicolith appendicitis managed conservatively with antibiotics, fluids, and percutaneous drainage. Outcomes included the initial success of conservative management and recurrence rates. A random-effects model was applied for all analyses.

Results: Twelve observational studies with 814 patients were included. Of these, 282 (35 %) had appendicoliths, and 532 (65 %) did not. The average age ranged from 2 to 11 years, with follow-up between 1 week and 2 years. Overall, there is no significant difference in the initial success of conservative management was observed between the two groups (OR 0.70; 95 % CI 0.28-1.78; p = 0.46). Subgroup analysis revealed lower success rates for appendicolith-associated simple appendicitis (OR 0.42; 95 % CI 0.21-0.84; p = 0.01), but no difference in complicated appendicitis (OR 1.01; 95 % CI 0.24-4.31; p = 0.99). Recurrence rates were significantly higher in appendicolith appendicitis across both groups (OR 2.75; 95 % CI 1.05-7.20; p = 0.04).

Conclusion: Appendicolith presence reduces conservative management success in simple appendicitis, supporting early appendectomy. Although appendicoliths do not predict treatment failure in complicated appendicitis, interval appendectomy may be advisable due to the higher recurrence risk in both groups.

Type of study: Meta-analysis and systematic review.

Level of evidence: Level I.

Purpose: Pediatric health outcomes are often assessed using proxy reports, which may not fully capture children's experiences. Children with surgical conditions face unique, changing healthcare journeys, making accurate representation challenging. This review compares child-reported health status and treatment experiences from Patient-Reported Outcome Measures (PROMs) and Patient-Reported Experience Measures (PREMs) with parent reports.

Methods: A systematic search, designed by a librarian and adhering to PRISMA guidelines, was conducted across eight databases up to July 2023, targeting studies using PROMs and PREMs in pediatric surgery to capture both child and parent perspectives. Two reviewers independently screened abstracts, with conflicts resolved by senior authors. The Mixed Methods Appraisal Tool (MMAT) was used for quality assessment. A meta-analysis was also performed on Pediatric Quality of Life Inventory (PedsQL™) outcomes.

Results: Of 5415 screened studies, 53 met inclusion criteria: 50 used PROMs, two used PREMs, and one used both. PedsQL™ appeared in 30 studies, with 16 other quality of life measures used less frequently. Twenty-two studies with PedsQL™ data from 6691 child-parent pairs were included in the meta-analysis. The pooled effect size between child- and parent-reported PedsQL™ scores was 0.98 (95 % CI: [-0.81, 2.77]), with high heterogeneity (I² = 89 %).

Conclusion: This review revealed substantial variability but minimal systematic differences between child and parent reports, highlighting the need for future research to understand this variability and improve integration of child and parent perspectives in pediatric health assessments.

Level of evidence: I, Systematic Review or meta-analysis of RCTs (randomized control trials).

Background: Wait times for children's hospital-based surgical services are at unprecedented levels. Opportunities to increase most children's hospital-based service capacity are sparse, and community-based services are a potential patient-centered alternative. The aim of this study was to understand the current state of pediatric surgical outreach in Canada as an option to address these challenges.

Methods: An electronic survey was sent to all (n = 18) Canadian children's hospital surgical leaders inquiring about "outreach services" defined as inpatient/outpatient services provided by pediatric surgeons outside of children's hospitals. Descriptive analysis of outreach included facility type/location (by postal code), nature and frequency of service, and participation of other specialties.

Results: 18 survey respondents (100 %) reported that pediatric surgical outreach services were available in 7 out of 10 provinces, but only 8/18 (44 %) of Canadian children's hospitals. Services include: i) inpatient coverage at 2 sites in 2 provinces; ii) outpatient surgery at 6 sites in 3 provinces (median distance 69 km, range 6-1881 km from home children's hospital); and iii) outpatient ambulatory clinics at 19 sites in 4 provinces (median distance 18 km, range 4-1448 km from home children's hospital). Median frequencies of outreach surgical slates and clinics were 1 per week and 1 per month, respectively.

Conclusion: Less than half of Canadian children's hospitals have developed outreach programs as a strategy to increase capacity for children's surgical services. To promote improved surgical care for all Canadian children, efforts targeting expansion of outreach capacity could increase access for geographically remote children.

Type of study: Cross sectional Retrospective Survey.

Level of evidence: Level IV.

Introduction: Necrotizing enterocolitis (NEC) is a severe illness with high mortality. Traditional risk factors are prematurity and neonatal stress. Maternal risk factors have also been postulated but are often overlooked. We aimed to define parental and patient factors associated with NEC and their impact on outcomes.

Methods: Infants under 1 year old diagnosed with NEC were identified via the Pediatric Health Information System database between 2012 and 2022. The Childhood Opportunity Index (COI) was used to represent each family's household educational, environmental, and socioeconomic conditions. The COI was split into low, middle, and high levels and analyzed across demographics and mortality. Multivariable regression was used to determine the association between COI and in-hospital mortality, adjusting for gestational age, gender, race, primary payor, urban flag, and geographic region.

Results: Overall, 10,768 patients with a median gestational age of 29 weeks (IQR 25-34), and a median birthweight of 1,010 g (IQR 660-1,880 g) met inclusion criteria. The cohort was majority male (57 %), and White (46 %), and overall, had a mortality rate of 18 %. Low COI was associated with longer length of stay (56 vs. 53 days) and increased mortality (19 % vs. 15 %) when compared to high COI. On adjusted analysis, high COI was associated with decreased odds of death by time of discharge (OR 0.75, 95 % CI 0.65-0.86, p < 0.001) when compared to low COI.

Conclusion: NEC is a disease that disproportionately affects socially disadvantaged infants. The mortality rates of NEC are linked to parental social determinants of health, highlighting this unique population to target for risk assessment and additional prenatal resources.

Type of study: Cross Sectional Study.

Level of evidence: III.

Introduction: The physiologic benefits of the minimally invasive repair of pectus excavatum (MIRPE) on cardiopulmonary function are poorly understood in pediatrics. We sought to examine the effects of MIRPE on exercise response during cardiopulmonary exercise testing (CPET).

Methods: A prospective-pilot study was conduct of patients ≤18 years who presented for pectus bar removal. All patients had CPET prior to MIRPE and following bar removal. Paired sample T tests were used to compare pre- and post-MIRPE CPET results.

Results: Twenty-five patients completed post-MIRPE CPET (72 % male, median age 18.6 [IQR:17.5-19.8]). The median Haller and correction indices were 4.5 and 29.4 %, respectively. There was significant increase in O2Pulse, (10.3 vs 12.1 mL/beat, p = 0.004), and percent predicted O2Pulse (79.5% vs 84.4 %, p = 0.046) following MIRPE/bar removal. The peak-VO2/kg and did not change significantly following MIRPE/bar removal; however, peak-VO2 (ml/min) increased. Patients with decreased activity levels at time of bar removal compared to pre-MIRPE had decreased peak-VO2/kg and predicted peak-VO2/kg.

Conclusion: Following MIRPE, patients experience increased in O2Pulse, which is a surrogate measure of stroke volume response to exercise and may reflect relief of cardiac compression. Cardiopulmonary function is multifactorial and despite improvement in stroke volume, other factors may impact exercise capacity (VO2) following MIRPE.

Study type: Treatment Study.

Level of evidence: IV.

Purpose: This study evaluates the effectiveness of machine learning (ML) algorithms for improving the preoperative diagnosis of acute appendicitis in children, focusing on the accurate prediction of the severity of disease.

Methods: An anonymized clinical and operative dataset was retrieved from the medical records of children undergoing emergency appendectomy between 2014 and 2021. We developed an ML pipeline that pre-processed the dataset and developed algorithms to predict 5 appendicitis grades (1 - non-perforated, 2 - localized perforation, 3 - abscess, 4 - generalized peritonitis, and 5 - generalized peritonitis with abscess). Imputation strategies were used for missing values and upsampling techniques for infrequent classes. Standard classifier models were tested. The best combination of imputation strategy, class balancing technique and classification model was chosen based on validation performance. Model explainability was verified by a pediatric surgeon. Our model's performance was compared to another pediatric appendicitis severity prediction tool.

Results: The study used a retrospective cohort including 1980 patients (60.6 % males, average age 10.7 years). Grade of appendicitis in the cohort was as follows: grade 1-70 %; grade 2-8 %; grade 3-7 %; grade 4-7 %; grade 5-8 %. Every combination of 6 imputation strategies, 7 class-balancing techniques, and 5 classification models was tested. The best-performing combined ML pipeline distinguished non-perforated from perforated appendicitis with 82.8 ± 0.2 % NPV and 56.4 ± 0.4 % PPV, and differentiated between severity grades with 70.1 ± 0.2 % accuracy and 0.77 ± 0.00 AUROC. The other pediatric appendicitis severity prediction tool gave an accuracy of 71.4 %, AUROC of 0.54 and NPV/PPV of 71.8/64.7.

Conclusion: Prediction of appendiceal perforation outperforms prediction of the continuum of appendicitis grades. The variables our models primarily rely on to make predictions are consistent with clinical experience and the literature, suggesting that the ML models uncovered useful patterns in the dataset. Our model outperforms the other pediatric appendicitis prediction tools. The ML model developed for grade prediction is the first of this type, offering a novel approach for assessing appendicitis severity in children preoperatively. Following external validation and silent clinical testing, this ML model has the potential to enable personalized severity-based treatment of pediatric appendicitis and optimize resource allocation for its management.

Level of evidence: 3: