Faculty Bibliography

PURPOSE: Documenting surgical complications is limited by multiple barriers and is not fostered in the electronic health record. Tracking complications is essential for quality improvement (QI) and required for board certification. Current registry platforms do not facilitate meaningful complication reporting. We developed a novel web application that improves accuracy and reduces barriers to documenting complications. METHODS: We deployed a custom web application that allows pediatric surgeons to maintain case logs. The program includes a module for entering complication data in real time. Reminders to enter outcome data occur at key postoperative intervals to optimize recall of events. Between October 1, 2014, and March 31, 2015, frequencies of surgical complications captured by the existing hospital reporting system were compared with data aggregated by our application. RESULTS: 780 cases were captured by the web application, compared with 276 cases registered by the hospital system. We observed an increase in the capture of major complications when compared to the hospital dataset (14 events vs. 4 events). CONCLUSIONS: This web application improved real-time reporting of surgical complications, exceeding the accuracy of administrative datasets. Custom informatics solutions may help reduce barriers to self-reporting of adverse events and improve the data that presently inform pediatric surgical QI. TYPE OF STUDY: Diagnostic study/Retrospective study. LEVEL OF EVIDENCE: Level I

Appendicitis remains the most common cause for emergency abdominal surgery in children. Immediate appendectomy in complicated, perforated appendicitis can be hazardous and nonoperative therapy has been gaining use as an initial therapy in children. Previous studies have reported failure rates in nonoperative therapy in such cases ranging from 10% to 41%. Factors leading to treatment failures have been studied with various and disparate results. We reviewed our institutional experience in treated complicated appendicitis, with focus on those initially managed nonoperatively. METHODS: Records of all children admitted with the diagnosis of perforated appendicitis to NYU Langone Medical Center and Bellevue Hospital Center from January 1, 2003 to December 31, 2013 were reviewed. The diagnosis was made with ultrasound and/or computed tomography scan. Those with abscesses amenable to drainage underwent aspiration and drain placement by an interventional radiologist. Broad spectrum intravenous (IV) antibiotics were given until the patient became afebrile, pain free and tolerating a regular diet. Oral antibiotics were continued for an additional week and interval appendectomy was done eight weeks later. The primary outcome measure was treatment response with failure defined as those who did not improve or required readmission for additional IV antibiotics and/or early appendectomy. Multiple patient and treatment related variables, including those previously reported as predicting failure in nonoperative therapy, were studied. Continuous variables were reported as means +/- standard error and compared using 2-tailed unpaired t tests; nonparametric variables were analyzed by Mann-Whitney U tests. Categorical variables were reported as medians +/- interquartile ranges and compared using Chi-square testing. Statistical significance was accepted for p<.05. RESULTS: Sixty-four patients were identified as undergoing initial nonoperative therapy. Fifty-two (81%) were categorized as treatment successes being treated nonoperatively and 12 (19%) were failures. Variables showing no significance in predicting treatment failures included duration of symptoms, presence of appendicolith, presence of phlegmon, presence of abscess, initial white blood cell count, and SIRS (Systemic Inflammatory Response Syndrome) positive. The variables that predicted failure of nonoperative therapy vs. successes were presence of bandemia (75% vs. 40%, p=0.052) and small bowel obstruction on imaging (42% vs. 15%, p=0.052) and presence of bandemia >/=15% which was highly predictive of failure (67% vs. 4%, p<0.01). CONCLUSIONS: Predicting which patients with complicated perforated appendicitis will respond well to nonoperative therapy may allow us to more effectively treat patients with complicated perforated appendicitis. In our study the presence of small bowel obstruction and bandemia, especially >/=15% correlated with treatment failure; this suggests that these select patients may need a modified treatment strategy.

PURPOSE: Quality improvement (QI) bundles have been widely adopted to reduce surgical site infections (SSI). Improvement science suggests when organizations achieve high-reliability to QI processes, outcomes dramatically improve. However, measuring QI process compliance is poorly supported by electronic health record (EHR) systems. We developed a custom EHR tool to facilitate capture of process data for SSI prevention with the aim of increasing bundle compliance and reducing adverse events. METHODS: Ten SSI prevention bundle processes were linked to EHR data elements that were then aggregated into a snapshot display superimposed on weekly case-log reports. The data aggregation and user interface facilitated efficient review of all SSI bundle elements, providing an exact bundle compliance rate without random sampling or chart review. RESULTS: Nine months after implementation of our custom EHR tool, we observed centerline shifts in median SSI bundle compliance (46% to 72%). Additionally, as predicted by high reliability principles, we began to see a trend toward improvement in SSI rates (1.68 to 0.87 per 100 operations), but a discrete centerline shift was not detected. CONCLUSION: Simple informatics solutions can facilitate extraction of QI process data from the EHR without relying on adjunctive systems. Analyses of these data may drive reductions in adverse events. Pediatric surgical departments should consider leveraging the EHR to enhance bundle compliance as they implement QI strategies.

BACKGROUND: The effect of perforated appendicitis on the adnexa is an issue of concern and controversy. Long-term fertility studies have been conflicting. CASE: We present the case of a patient with chronic pelvic infections, salpingitis, and hydrosalpinx after perforated appendicitis. SUMMARY AND CONCLUSION: Magnetic resonance imaging was helpful in diagnosing a chronically obstructed fallopian tube, likely secondary to the dense adhesions from her previously treated perforated appendicitis. Salpingectomy relieved her symptoms of chronic pain and recurrent infections.

BACKGROUND: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. CASE REPORT: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations.

Background: PNETs (Pancreatic Neuroendocrine tumors) are infrequent in the context of tuberous sclerosis complex (TSC) in children. There is marked disease heterogeneity, challenging clinical presentation and a limited knowledge of underlying molecular mechanisms. Inactivating mutations in the two genes TSC1 and TSC2, which correspondingly encode for hamartin and tuberin, are pathognomonic for the disease. The upregulation of the phosphoinositide 3-kinase (PI3K)/AKT (protein kinase B) with cascade activation of mitogen-activated protein kinase (MAPK) and the mammalian target of rapamycin (mTOR) leads to uncontrolled cell proliferation and tumorigenesis. The association of TSC and PNET is not clearly defined. We describe a case of PNET in a toddler with TSC1. Case presentation: An asymptomatic male aged 3 years 10 months with a TSC1 was identified with a pancreatic mass. Clinical sequence of events: diagnosed at 3 months with epilepsy and 3 hypomelanotic lesions on trunk; delayed speech development; at 3 years: kidney angiomyolipomas/left cortical cyst; at 3 years 7 months: multiple small rhabdomyomas in the right/left ventricles, at 3 years 9 months: a subependymal giant cell astrocytoma (SGCA)/excision and at 4 years of age open enucleation of 1 cm pancreatic mass located near junction of body and tail. Endocrine study: Test NameValue Reference Range Gastrin, pg/mL 83 Fasting 3-4 hrs: 2-168 Neuron-Specific Enolase (NSE), Serum, ng/mL 8.9 0.0-12.5 Chromogranin A, nmol/L 2 0-5 Glucose, plasma, mg/dL 81 65-99 Insulin, ulU/mL 4 2.6-24.9 IGF-1, ng/mL 59 20-141 IGFBP3, ng/mL 1960 972-4123 Diagnostic study: Molecular study: exon 10 of the TSC1 gene has a heterozygous basechange mutation (c.989dupT, an abnormal TSC1 protein, hamartin - p.Ser331fs). Brain MRI: SGCA (2.3 cm). Histology: Grade I, single mitoses, immunostains (+) for GFAP (glial fibrillary acidic protein) and synaptophysin (neuroendocrine marker), increased MIB-1 proliferation index (10%) indicative of high activity of cell proliferation. SGCA in the setting of TSC1 is able to express GFAP. MRI abdomen with contrast: pancreatic body lesion 1.1 cm in diameter (interval change from 4 mm in 5 months). Pathology: 1.0 x 0.8 x 0.6 cm; pale tan-pink tumor. Histology: PNET, grade 2; 2 mitotic figures/10 hpf, the Ki-67 proliferation index is about 20%; diffuse positivity with chromogranin, synaptophysin and CD56 (membranous). Conclusions: Our case demonstrates that patients with TSC1 may develop SGCA and pancreatic nonsecretory tumor at an early age along with the typical clinical stigmata of this entity. PNETs express neuroendocrine markers, which are useful to differentiate functional vs nonfunctional tumors. Semi-annual/annual evaluation with abdominal MRI will be beneficial for identification of PNETs. Some evidence exists to support that PNETs are an associated feature of TSC and require further investigation

PURPOSE: To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children. METHODS: A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate. RESULTS: Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%). CONCLUSIONS: US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.

The omphalomesenteric duct (OMD), a temporary structure essential to fetal development, normally involutes completely by week 8 or 9 of gestation. On occasion, the OMD persists, the clinical presentations of which vary widely. We describe a case of a 6-week-old male with a patent OMD remnant that was initially treated as an umbilical granuloma, which then potentially allowed for prolapse of the small bowel through the umbilical ring. The patient required resection of the incarcerated bowel but had an otherwise uneventful and complete recovery.