Emergency department (ED) visits and hospital readmissions are common after gastrostomy tube (GT) placement in children. We sought to characterize interhospital variation in revisit rates and explore the association between this outcome and hospital-specific GT case volume.We conducted a retrospective cohort study from 38 hospitals using the Pediatric Health Information System database. Patients younger than 18 years who had a GT placed in 2010 to 2012 were assessed for a GT-related (mechanical or infectious) ED visit or inpatient readmission at 30 and 90 days after discharge from GT placement. Risk-adjusted rates were calculated using generalized linear mixed-effects models accounting for hospital clustering and relevant demographic and clinical attributes, then compared across hospitals.A total of 15,642 patients were included. A median of 468 GTs were placed in all the 38 hospitals during 3 years (range: 83-891), with a median of 11.4 GT placed per 1000 discharges (range: 2.4-16.7). Median ED visit for each hospital at 30 days after discharge was 8.2% (range: 3.7%-17.2%) and 14.8% at 90 days (range: 6.3%-26.1%). Median inpatient readmissions for each hospital at 30 days after discharge was 3.5% (range: 0.5%-10.5%) and 5.9% at 90 days (range: 1.0%-18.5%). Hospital-specific GT placement per 1000 discharges (rate of GT placement) was inversely correlated with ED visit rates at 30 (P = 0.007) and 90 days (P = 0.020). The adjusted 30- and 90-day readmission rate and the adjusted 30- and 90-day ED return rates decreased with increasing GT insertion rate (P < 0.001).Higher hospital GT insertion rates are associated with lower ED revisit rates but not inpatient readmissions.
Patch repair of a congenital diaphragmatic hernia is associated with a much higher rate of recurrence than when primary repair is feasible. The biosynthetic options for the repair materials continue to expand. We therefore reviewed our experience to benchmark complication rates as we progress with the use of new materials.A retrospective review was conducted of all patients who underwent repair of congenital diaphragmatic hernia from January 1994 to May 2009.Of the 155 patients included in the study, 101 patients had primary closure and 54 received a diaphragmatic patch. The rates of recurrence, Small Bowel Obstruction (SBO), and subsequent abdominal operation were all significantly higher in the group of patients requiring patch repair. There were 3 types of patch repairs: 37 patients received a SIS patch, 12 had a nonabsorbable patch, and 5 received an AlloDerm patch. The incidence of SBO in patients with a nonabsorbable mesh was 17% and was associated with a 50% recurrence rate and 67% re-recurrence rate. SIS was associated with 19% incidence of SBO, a recurrence rate of 22% and a 50% re-recurrence rate, whereas AlloDerm had a 40% incidence of SBO, 40% recurrence rate, and 100% re-recurrence rate.As we move towards the next generation of materials, these data do not justify the continued comparison with nonabsorbable patches. We do not have enough comparative data to define a superior biosynthetic material, but we plan to use our data on SIS to benchmark our experience with future generation materials.
The experience with laparoscopic cholecystectomy in children trails the adult numbers and remains underreported. Therefore, we reviewed our experience with this approach.A retrospective review of our most recent 6-year experience with laparoscopic cholecystectomy at Children's Mercy Hospital (Kansas City, MO) between September 5, 2000, and June 1, 2006, was performed. Data points reviewed included patient demographics, indication for operation, operative time, complications, and recovery.During the study period, 224 patients underwent a laparoscopic cholecystectomy. The mean age was 12.9 years (range, 0-21) with a mean weight of 58.3 kg (range, 3-121). Indications for laparoscopic cholecystectomy were symptomatic gallstones in 166 children, biliary dyskinesia in 35, gallstone pancreatitis in 7, gallstones and an indication for splenectomy in 6, calculous cholecystitis in 5, choledocholithiasis in 1, gallbladder polyps in 1, acalculous cholecystitis in 1, and congenital cystic duct obstruction in 1. The mean operative time (excluding patients with concomitant operations) was 77 minutes (range, 30-285). An intraoperative cholangiogram was performed in 38 patients. Common bile duct (CBD) stones were cleared intraoperatively in 5 patients. Two patients required a postoperative endoscopy to retrieve CBD stones. One sickle-cell patient developed a postoperative hemorrhage, requiring a laparotomy. There were no conversions, ductal injuries, bile leaks, or mortality. Biliary dyskinesia was diagnosed in 10% of the first 30 patients in this series and 40% of the most recent 30 patients. The mean ejection fraction in these patients was 21%. All experienced an improvement in their symptoms after the cholecystectomy.Laparoscopic cholecystectomy is safe and effective in children. Biliary dyskinesia is becoming more frequently diagnosed in children, and these patients respond favorably to cholecystectomy. As opposed to the adult population, the incidence of complicated gallstone disease appears less common in children, as most present with symptomatic cholelithiasis without active inflammation, accounting for the very low rate of ductal complications.
