Faculty Bibliography

BACKGROUND:There is little consensus regarding the use of postoperative antibiotics in the management of perforated appendicitis in children. Patients are commonly discharged with oral antibiotics after a course of intravenous antibiotics; however, recent literature suggests that patients can be safely discharged without any oral antibiotics. To further evaluate this protocol, we conducted a multicenter retrospective preimplementation/postimplementation study comparing rates of abscess formation and rehospitalization between patients discharged with and without oral antibiotics. MATERIALS AND METHODS/METHODS:We reviewed the records of all pediatric patients who underwent appendectomies for perforated appendicitis at NYU Tisch Hospital, Bellevue Hospital, and Hackensack University Medical Center from January 2014 to June 2019. Data pertaining to patient demographics, hospital course, intraoperative appearance of the appendix, antibiotic treatment, abscess formation, and rehospitalization were collected. RESULTS:A total of 253 patients were included: 162 received oral antibiotics and 91 did not. The median length of antibiotic treatment (oral and intravenous) was 11 (10-14) d for patients on oral antibiotics and 5 (3-6) d for patients without oral antibiotics (P < 0.01). The median leukocyte count at discharge was 9.5 (7.4-10.9) and 8.1 (6.8-10.4) for these groups, respectively (P = 0.02). Postoperative abscesses occurred in 22% of patients receiving oral antibiotics and 15% of patients on no antibiotics (P = 0.25). Rates of rehospitalization for these groups were 10% and 11%, respectively (P = 0.99). CONCLUSIONS:Children who have undergone appendectomy for perforated appendicitis can be safely discharged without oral antibiotics on meeting clinical discharge criteria and white blood cell count normalization.

BACKGROUND:Congenital diaphragmatic hernia (CDH) occurs in 1 out of 2500-3000 live births. Right-sided CDHs (R-CDHs) comprise 25% of all CDH cases, and data are conflicting on outcomes of these patients. The aim of our study was to compare outcomes in patients with right versus left CDH (L-CDH). METHODS:We analyzed a multicenter prospectively enrolled database to compare baseline characteristics and outcomes of neonates enrolled from January 2005 to January 2019 with R-CDH vs. L-CDH. RESULTS:A total of 588, 495 L-CDH, and 93 R-CDH patients with CDH were analyzed. L-CDHs were more frequently diagnosed prenatally (p=0.011). Lung-to-head ratio was similar in both cohorts. R-CDHs had a lower frequency of primary repair (p=0.022) and a higher frequency of need for oxygen at discharge (p=0.013). However, in a multivariate analysis, need for oxygen at discharge was no longer significantly different. There were no differences in long-term neurodevelopmental outcomes assessed at two year follow up. There was no difference in mortality, need for ECMO, pulmonary hypertension, or hernia recurrence. CONCLUSION/CONCLUSIONS:In this large series comparing R to L-CDH patients, we found no significant difference in mortality, use of ECMO, or pulmonary complications. Our study supports prior studies that R-CDHs are relatively larger and more often require a patch or muscle flap for repair. TYPE OF STUDY/METHODS:Prognosis study LEVEL OF EVIDENCE: Level II.

Introduction: Abdominal compartment syndrome (ACS) in children carries a mortality rate of 40% to 60%. Definitive treatment for ACS traditionally involves decompressive laparotomy. Although percutaneous catheter drainage (PCD) is an accepted therapy for neonates with intestinal perforation, its adoption for ACS remains low, due to uncertainty concerning its efficacy and concerns about complications. We explored whether PCD safely and successfully reversed ACS physiology in a cohort of children with intra-abdominal fluid.
Method(s): We reviewed records of all children undergoing PCD for ACS from 2014 to 2018 at a single institution. Bedside sonogram-guided PCD was performed by the surgical service using the Seldinger technique, with catheters removed on resolution of ACS physiology and fluid output of <10 mL/d. Clinical variables were explored using descriptive statistics and reported as median with interquartile range (IQR). Physiologic improvements over 24 hours were compared using paired Wilcoxon signed-rank tests.
Result(s): A total of 11 infants with a median age of 11 days (IQR 4 to 273 days) and weight of 4.2 kg (IQR 2.3 to 9.2 kg) underwent PCD for ACS secondary to ascites (n = 6), hemoperitoneum (n = 4), and pneumoperitoneum with ascites (n = 1). Catheters remained in place for a median of 8 days (IQR 5 to 9 days), with a median of 359 mL of fluid (IQR 165 to 1,588 mL) drained in the first 24 hours. Percutaneous catheter drainage resulted in significant physiologic improvement across multiple variables (Table). No catheter-related complications occurred, with only 1 patient requiring subsequent laparotomy.
Conclusion(s): Percutaneous catheter drainage is efficacious in reversing ACS physiology in children with intra-abdominal fluid, and should be considered a safe intervention that can obviate decompressive laparotomy. [Figure presented]
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