American Pediatric Surgical Association (APSA): Annual Meeting

PALM DESERT, CALIF. – Providing quality surgical care in resource-poor settings is challenging, but participants in the Paul Farmer Global Surgery Fellowship have found it to be a worthwhile endeavor.

The fellowship, founded by Dr. John Meara, plastic surgeon-in-chief at Children’s Hospital Boston, in conjunction with Dr. Paul Farmer of Partners in Health (PIH), was designed "to build surgical capacity internationally," according to Dr. Shahram Aarabi. Between June 2009 and June 2010, Dr. Aarabi served as a visiting surgeon in Haiti for 2 weeks every 2 months alongside Dr. Jason Smithers, a Paul Farmer Global Surgery Fellow with Children’s Hospital Boston.

Photos courtesy of Shahram Aarabi

"It’s also a model for how to help meet the global surgical burden in disease. The fellowship brings individual surgeons from abroad to work in specific PIH sites over the course of one or more years in order to provide continuity of care and teaching," Dr. Aarabi said at the annual meeting of the American Pediatric Surgical Association, where he reported on the work he did in Haiti.

Dr. Aarabi, a general surgery resident at the University of Washington, Seattle, spent most of his time in Cange, Haiti, at a 104-bed full-service hospital that includes four operating rooms. This facility was the first to be founded by PIH in 1985.

"The hospital and satellite clinics in the valley provide free care to patients over a catchment area of about 1.2 million people," he said, noting that there are now more than 11 PIH health care facilities nationwide. "There are two or three full-time Haitian general surgeons who work for PIH at these facilities, and one full-time orthopedic surgeon."

Dr. Aarabi also assisted in the temporary staffing of University Hospital in Port-au-Prince after the devastating earthquake of January 2010.

Photos courtesy of Shahram Aarabi

He reported on 147 operations that were performed on 131 patients at the two hospitals over a 12-week period. More than three-quarters (78%) of the procedures were elective, and 22% were emergent. Hernia repairs, imperforate anus/Hirschprung’s disease repairs, and bowel resections were the most commonly performed operations.

Nearly one-third of the operative patients (32%) were adults and the rest were children, including 15 under 1 year of age and five who were less than 2 months old. A minority of patients (29%) lived locally, while 71% came from various locations across the country, usually by foot.

"Some Haitians spent days to a week trying to get to PIH facilities for care," Dr. Aarabi said. "Our patients received regular follow-up at weekly clinics staffed either by ourselves or by Haitian general surgeons. Limits to follow-up were primarily due to social factors for our patients, not from a lack of surgical staffing."

Dr. Smithers, who is now a pediatric surgeon at Children’s Hospital Boston, said that he found it helpful to have an understanding of surgical history, because in many cases he and his associates relied on strategies used by surgeons 20 years ago, "when the equipment and capabilities that we had in the United States were similar to what Haiti currently has," he said.

For example, in the United States most Hirschprung’s disease repairs can be performed with a single surgical procedure in the neonatal period, while the same procedure in Haiti requires multiple stages.

"When it comes down to it, a lot of what surgeons need are just a scalpel and scissors, and some suture," Dr. Smithers added. "Even though we may have a variety of complex instruments at home, you can get by without those."

Dr. Aarabi said that most cases (91%) involved training of an American medical student or resident with an interest in international medicine, a Haitian resident, or a Haitian staff surgeon.

"We feel that one of the major strengths of the fellowship was that training of Haitian students and surgeons was integrated into the program. The infant cases in particular were valuable to the Haitian surgeons because there are no pediatric surgeons in Haiti," Dr. Aarabi said.

"Our nonoperative time was spent seeing patients in clinic, taking care of our inpatients, seeing new consults on the wards and in the emergency room, and working on site development and planning," he added.

The Paul Farmer Global Surgery Fellowship’s planned expansion to other sites around the world "holds promise as a way to provide a lasting collaboration of developing local surgical infrastructure and training local surgeons," he concluded.

Dr. Aarabi said that he had no relevant financial disclosures to make. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Providing quality surgical care in resource-poor settings is challenging, but participants in the Paul Farmer Global Surgery Fellowship have found it to be a worthwhile endeavor.

The fellowship, founded by Dr. John Meara, plastic surgeon-in-chief at Children’s Hospital Boston, in conjunction with Dr. Paul Farmer of Partners in Health (PIH), was designed "to build surgical capacity internationally," according to Dr. Shahram Aarabi. Between June 2009 and June 2010, Dr. Aarabi served as a visiting surgeon in Haiti for 2 weeks every 2 months alongside Dr. Jason Smithers, a Paul Farmer Global Surgery Fellow with Children’s Hospital Boston.

Photos courtesy of Shahram Aarabi

"It’s also a model for how to help meet the global surgical burden in disease. The fellowship brings individual surgeons from abroad to work in specific PIH sites over the course of one or more years in order to provide continuity of care and teaching," Dr. Aarabi said at the annual meeting of the American Pediatric Surgical Association, where he reported on the work he did in Haiti.

Dr. Aarabi, a general surgery resident at the University of Washington, Seattle, spent most of his time in Cange, Haiti, at a 104-bed full-service hospital that includes four operating rooms. This facility was the first to be founded by PIH in 1985.

"The hospital and satellite clinics in the valley provide free care to patients over a catchment area of about 1.2 million people," he said, noting that there are now more than 11 PIH health care facilities nationwide. "There are two or three full-time Haitian general surgeons who work for PIH at these facilities, and one full-time orthopedic surgeon."

Dr. Aarabi also assisted in the temporary staffing of University Hospital in Port-au-Prince after the devastating earthquake of January 2010.

Photos courtesy of Shahram Aarabi

He reported on 147 operations that were performed on 131 patients at the two hospitals over a 12-week period. More than three-quarters (78%) of the procedures were elective, and 22% were emergent. Hernia repairs, imperforate anus/Hirschprung’s disease repairs, and bowel resections were the most commonly performed operations.

Nearly one-third of the operative patients (32%) were adults and the rest were children, including 15 under 1 year of age and five who were less than 2 months old. A minority of patients (29%) lived locally, while 71% came from various locations across the country, usually by foot.

"Some Haitians spent days to a week trying to get to PIH facilities for care," Dr. Aarabi said. "Our patients received regular follow-up at weekly clinics staffed either by ourselves or by Haitian general surgeons. Limits to follow-up were primarily due to social factors for our patients, not from a lack of surgical staffing."

Dr. Smithers, who is now a pediatric surgeon at Children’s Hospital Boston, said that he found it helpful to have an understanding of surgical history, because in many cases he and his associates relied on strategies used by surgeons 20 years ago, "when the equipment and capabilities that we had in the United States were similar to what Haiti currently has," he said.

For example, in the United States most Hirschprung’s disease repairs can be performed with a single surgical procedure in the neonatal period, while the same procedure in Haiti requires multiple stages.

"When it comes down to it, a lot of what surgeons need are just a scalpel and scissors, and some suture," Dr. Smithers added. "Even though we may have a variety of complex instruments at home, you can get by without those."

Dr. Aarabi said that most cases (91%) involved training of an American medical student or resident with an interest in international medicine, a Haitian resident, or a Haitian staff surgeon.

"We feel that one of the major strengths of the fellowship was that training of Haitian students and surgeons was integrated into the program. The infant cases in particular were valuable to the Haitian surgeons because there are no pediatric surgeons in Haiti," Dr. Aarabi said.

"Our nonoperative time was spent seeing patients in clinic, taking care of our inpatients, seeing new consults on the wards and in the emergency room, and working on site development and planning," he added.

The Paul Farmer Global Surgery Fellowship’s planned expansion to other sites around the world "holds promise as a way to provide a lasting collaboration of developing local surgical infrastructure and training local surgeons," he concluded.

Dr. Aarabi said that he had no relevant financial disclosures to make. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Providing quality surgical care in resource-poor settings is challenging, but participants in the Paul Farmer Global Surgery Fellowship have found it to be a worthwhile endeavor.

The fellowship, founded by Dr. John Meara, plastic surgeon-in-chief at Children’s Hospital Boston, in conjunction with Dr. Paul Farmer of Partners in Health (PIH), was designed "to build surgical capacity internationally," according to Dr. Shahram Aarabi. Between June 2009 and June 2010, Dr. Aarabi served as a visiting surgeon in Haiti for 2 weeks every 2 months alongside Dr. Jason Smithers, a Paul Farmer Global Surgery Fellow with Children’s Hospital Boston.

Photos courtesy of Shahram Aarabi

"It’s also a model for how to help meet the global surgical burden in disease. The fellowship brings individual surgeons from abroad to work in specific PIH sites over the course of one or more years in order to provide continuity of care and teaching," Dr. Aarabi said at the annual meeting of the American Pediatric Surgical Association, where he reported on the work he did in Haiti.

Dr. Aarabi, a general surgery resident at the University of Washington, Seattle, spent most of his time in Cange, Haiti, at a 104-bed full-service hospital that includes four operating rooms. This facility was the first to be founded by PIH in 1985.

"The hospital and satellite clinics in the valley provide free care to patients over a catchment area of about 1.2 million people," he said, noting that there are now more than 11 PIH health care facilities nationwide. "There are two or three full-time Haitian general surgeons who work for PIH at these facilities, and one full-time orthopedic surgeon."

Dr. Aarabi also assisted in the temporary staffing of University Hospital in Port-au-Prince after the devastating earthquake of January 2010.

Photos courtesy of Shahram Aarabi

He reported on 147 operations that were performed on 131 patients at the two hospitals over a 12-week period. More than three-quarters (78%) of the procedures were elective, and 22% were emergent. Hernia repairs, imperforate anus/Hirschprung’s disease repairs, and bowel resections were the most commonly performed operations.

Nearly one-third of the operative patients (32%) were adults and the rest were children, including 15 under 1 year of age and five who were less than 2 months old. A minority of patients (29%) lived locally, while 71% came from various locations across the country, usually by foot.

"Some Haitians spent days to a week trying to get to PIH facilities for care," Dr. Aarabi said. "Our patients received regular follow-up at weekly clinics staffed either by ourselves or by Haitian general surgeons. Limits to follow-up were primarily due to social factors for our patients, not from a lack of surgical staffing."

Dr. Smithers, who is now a pediatric surgeon at Children’s Hospital Boston, said that he found it helpful to have an understanding of surgical history, because in many cases he and his associates relied on strategies used by surgeons 20 years ago, "when the equipment and capabilities that we had in the United States were similar to what Haiti currently has," he said.

For example, in the United States most Hirschprung’s disease repairs can be performed with a single surgical procedure in the neonatal period, while the same procedure in Haiti requires multiple stages.

"When it comes down to it, a lot of what surgeons need are just a scalpel and scissors, and some suture," Dr. Smithers added. "Even though we may have a variety of complex instruments at home, you can get by without those."

Dr. Aarabi said that most cases (91%) involved training of an American medical student or resident with an interest in international medicine, a Haitian resident, or a Haitian staff surgeon.

"We feel that one of the major strengths of the fellowship was that training of Haitian students and surgeons was integrated into the program. The infant cases in particular were valuable to the Haitian surgeons because there are no pediatric surgeons in Haiti," Dr. Aarabi said.

"Our nonoperative time was spent seeing patients in clinic, taking care of our inpatients, seeing new consults on the wards and in the emergency room, and working on site development and planning," he added.

The Paul Farmer Global Surgery Fellowship’s planned expansion to other sites around the world "holds promise as a way to provide a lasting collaboration of developing local surgical infrastructure and training local surgeons," he concluded.

Dr. Aarabi said that he had no relevant financial disclosures to make. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Single-incision laparoscopic surgical appendectomy is both feasible and safe across a wide range of pediatric patient ages, results from a single-center study showed.

"Single-incision laparoscopic surgery is an exciting area of minimally invasive surgery," Dr. Eduardo A. Perez said at the annual meeting of the American Pediatric Surgical Association. "There are known disadvantages, including limited lateral movement and dueling instruments, but industry is working hard to improve these platforms. This includes articulating instruments, flexible laparoscopes, multichannel ports, and robotic platforms."

Dr. Perez, of the division of pediatric surgery at Children’s Medical Center, Dallas, and his associates randomized 50 patients equally to either single-incision laparoscopic surgery (SILS) or conventional laparoscopy (LAP) for appendectomy and followed them for a median of 14 months. The technique for SILS involved a single supraumbilical curvilinear incision with three fascial incisions placed in a triangular fashion. To make SILS technically comparable to the LAP procedure, the researchers used a stapler device that required upsizing a 5-mm port to a 12-mm size. Cosmesis was not studied.

The children ranged in age from 3 to 15 years, and there were no significant age differences between the two treatment groups. Half of the patients were under age 8, 50% were male, and 67% were Hispanic.

The overall mean OR time was 46.8 minutes for the SILS procedure, compared with 34.8 minutes for the LAP procedure, a difference that was significant (P = .010). However, the OR time between groups became more similar as the number of cases increased. For example, after the first 25 patients were treated, the mean OR time for the SILS procedure was 49.3 minutes, compared with 33.5 minutes for the LAP procedure, a difference that remained significant (P = .049). After the last 25 patients were treated, the mean OR times were no longer significantly different between the two groups (a mean of 44.1 vs. 36 minutes, respectively).

There were no conversions and no differences in hospital length of stay between the two groups (a median of 40.3 hours for SILS vs. 36.7 hours for LAP).

The only complication was a wound seroma in the SILS group, and no hernias were observed. In addition, no differences were noted between the two groups in terms of hospital readmissions, diet tolerance, fever, or postoperative pain.

Operative times between SILS and LAP appendectomy "are similar once experience is gained," Dr. Perez concluded. "OR cost is similar when using standard instruments, but this will increase [in SILS] with the use of newer, more advanced instruments."

Dr. Perez said that he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Single-incision laparoscopic surgical appendectomy is both feasible and safe across a wide range of pediatric patient ages, results from a single-center study showed.

"Single-incision laparoscopic surgery is an exciting area of minimally invasive surgery," Dr. Eduardo A. Perez said at the annual meeting of the American Pediatric Surgical Association. "There are known disadvantages, including limited lateral movement and dueling instruments, but industry is working hard to improve these platforms. This includes articulating instruments, flexible laparoscopes, multichannel ports, and robotic platforms."

Dr. Perez, of the division of pediatric surgery at Children’s Medical Center, Dallas, and his associates randomized 50 patients equally to either single-incision laparoscopic surgery (SILS) or conventional laparoscopy (LAP) for appendectomy and followed them for a median of 14 months. The technique for SILS involved a single supraumbilical curvilinear incision with three fascial incisions placed in a triangular fashion. To make SILS technically comparable to the LAP procedure, the researchers used a stapler device that required upsizing a 5-mm port to a 12-mm size. Cosmesis was not studied.

The children ranged in age from 3 to 15 years, and there were no significant age differences between the two treatment groups. Half of the patients were under age 8, 50% were male, and 67% were Hispanic.

The overall mean OR time was 46.8 minutes for the SILS procedure, compared with 34.8 minutes for the LAP procedure, a difference that was significant (P = .010). However, the OR time between groups became more similar as the number of cases increased. For example, after the first 25 patients were treated, the mean OR time for the SILS procedure was 49.3 minutes, compared with 33.5 minutes for the LAP procedure, a difference that remained significant (P = .049). After the last 25 patients were treated, the mean OR times were no longer significantly different between the two groups (a mean of 44.1 vs. 36 minutes, respectively).

There were no conversions and no differences in hospital length of stay between the two groups (a median of 40.3 hours for SILS vs. 36.7 hours for LAP).

The only complication was a wound seroma in the SILS group, and no hernias were observed. In addition, no differences were noted between the two groups in terms of hospital readmissions, diet tolerance, fever, or postoperative pain.

Operative times between SILS and LAP appendectomy "are similar once experience is gained," Dr. Perez concluded. "OR cost is similar when using standard instruments, but this will increase [in SILS] with the use of newer, more advanced instruments."

Dr. Perez said that he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Single-incision laparoscopic surgical appendectomy is both feasible and safe across a wide range of pediatric patient ages, results from a single-center study showed.

"Single-incision laparoscopic surgery is an exciting area of minimally invasive surgery," Dr. Eduardo A. Perez said at the annual meeting of the American Pediatric Surgical Association. "There are known disadvantages, including limited lateral movement and dueling instruments, but industry is working hard to improve these platforms. This includes articulating instruments, flexible laparoscopes, multichannel ports, and robotic platforms."

Dr. Perez, of the division of pediatric surgery at Children’s Medical Center, Dallas, and his associates randomized 50 patients equally to either single-incision laparoscopic surgery (SILS) or conventional laparoscopy (LAP) for appendectomy and followed them for a median of 14 months. The technique for SILS involved a single supraumbilical curvilinear incision with three fascial incisions placed in a triangular fashion. To make SILS technically comparable to the LAP procedure, the researchers used a stapler device that required upsizing a 5-mm port to a 12-mm size. Cosmesis was not studied.

The children ranged in age from 3 to 15 years, and there were no significant age differences between the two treatment groups. Half of the patients were under age 8, 50% were male, and 67% were Hispanic.

The overall mean OR time was 46.8 minutes for the SILS procedure, compared with 34.8 minutes for the LAP procedure, a difference that was significant (P = .010). However, the OR time between groups became more similar as the number of cases increased. For example, after the first 25 patients were treated, the mean OR time for the SILS procedure was 49.3 minutes, compared with 33.5 minutes for the LAP procedure, a difference that remained significant (P = .049). After the last 25 patients were treated, the mean OR times were no longer significantly different between the two groups (a mean of 44.1 vs. 36 minutes, respectively).

There were no conversions and no differences in hospital length of stay between the two groups (a median of 40.3 hours for SILS vs. 36.7 hours for LAP).

The only complication was a wound seroma in the SILS group, and no hernias were observed. In addition, no differences were noted between the two groups in terms of hospital readmissions, diet tolerance, fever, or postoperative pain.

Operative times between SILS and LAP appendectomy "are similar once experience is gained," Dr. Perez concluded. "OR cost is similar when using standard instruments, but this will increase [in SILS] with the use of newer, more advanced instruments."

Dr. Perez said that he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Nitric oxide use in neonates with diaphragmatic hernia remains widespread even though its efficacy remains to be proven, results from a large national analysis demonstrated.

"Nitric oxide has been studied extensively in newborns with hypoxemic respiratory failure," Dr. Brendan T. Campbell said at the annual meeting of the American Pediatric Surgical Association. "There have been 14 randomized, controlled trials done in term newborns with respiratory failure, and two of these studies enrolled significant numbers of patients with congenital diaphragmatic hernia. Both studies demonstrated conclusively that treatment with nitric oxide does not improve outcomes in newborns with congenital diaphragmatic hernia."

The first of these studies, he said, found that patients treated with nitric oxide were actually 30% more likely to require extracorporeal membrane oxygenation than were those who did not receive nitric oxide (Pediatrics 1997;99:838-45).

In an effort to describe national trends, interhospital variability in use, and costs associated with nitric oxide use in neonates with congenital diaphragmatic hernia (CDH), a health services research team led by Dr. Campbell analyzed records in the Pediatric Health Information System (PHIS) database. For the years 2003-2010, they identified all patients with a diagnostic code of CDH and a procedural code for CDH repair at 40 children’s hospitals that contribute data to the PHIS. Patients with congenital cardiac anomalies and inaccurate nitric oxide discharge data were excluded from analysis, said Dr. Campbell, a pediatric surgeon at Connecticut Children’s Medical Center, Hartford, who is also with the departments of surgery and pediatrics at the University of Connecticut, Storrs.

A total of 3,651 infants with CDH were identified in the analysis, and 514 with cardiac anomalies and missing or inaccurate data were excluded. The overall mortality rate was 15%, but the mortality rate for the 761 patients treated with nitric oxide was 47%, compared with roughly 5% for the 2,376 patients who were not treated with nitric oxide.

Patients treated with nitric oxide had a significantly longer median length of stay, compared with their counterparts (a median of 31 days vs. 6 days, respectively), and significantly higher median total charges billed (a median of $456,473 vs. $36,270).

Dr. Campbell estimated that the 761 patients treated with nitric oxide generated nearly $34 million in unnecessary hospital charges. "Reducing nitric oxide use in these patients would significantly lower costs without adversely affecting outcomes," he said.

Wide variation in the use of nitric oxide in neonates with CDH existed among the 40 PHIS hospitals. At one hospital, for example, more than 50% were treated with nitric oxide, while the rate was 10% or less at two other PHIS hospitals.

Limitations of the study included its retrospective design and the potential for coding errors and missing data.

Dr. Campbell said that he had no relevant financial conflicts to disclose.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Compared with portosystemic shunting in the management of extrahepatic portal vein obstruction, mesenterico-left portal vein bypass restores portal circulation and achieves superior relief of thrombocytopenia and certain metabolic symptoms, results from a single-center study showed.

"For surgeons who still perform portosystemic shunts as a first-line operation for extrahepatic portal vein obstruction, we hope that this evidence provides further proof of the advantages of doing the mesenterico-left portal vein bypass," Dr. Timothy B. Lautz said at the annual meeting of the American Pediatric Surgical Association.

Modern surgical options for extrahepatic portal vein obstruction include the distal splenorenal shunt and the mesenterico-left portal vein bypass (meso-Rex). "The distal splenorenal shunt preserves the spleen but diverts the splenic portion of portal flow into the systemic circulation," said Dr. Lautz of the department of surgery at Children’s Memorial Hospital, the primary pediatric teaching hospital of Northwestern University, Chicago.

"The meso-Rex bypass, on the other hand, is a totally restorative procedure that diverts all portal flow around the area of obstruction and into the intrahepatic left portal vein," he said.

In an effort to compare the two procedures, Dr. Lautz and senior author Dr. Riccardo A. Superina evaluated 91 consecutive patients who underwent an operation for extrahepatic portal vein obstruction at the hospital between 1998 and 2009. Their mean age was 7 years, and 58% were male. Meso-Rex bypass was the treatment of choice in all cases, but portosytemic shunts were reserved for those with anatomic or technical constraints that prevented meso-Rex. Analysis was limited to patients with at least 1 year of postoperative follow-up.

Dr. Lautz reported that 72 patients underwent the meso-Rex procedure (group 1) and 19 underwent portosystemic shunts (group 2). Prior to surgery, patients in both groups experienced growth retardation, thrombocytopenia, hyperammonemia, and impaired synthetic function.

Following surgery, variceal bleeding resolved in 59 of the group-1 patients and in 13 group-2 patients who manifested this symptom preoperatively. In addition, group-1 patients had significantly better improvements compared with group-2 patients in weight for age z-score (+0.76 vs. +0.13, respectively; P = .048), platelet count (+77,700 vs. +29,000 per mL; P = 0.006), international normalized ratio (-0.23 vs. +0.22; P = .002), and serum ammonia (-25.5 vs. +18 micromol/L; P = .002).

"The meso-Rex bypass and portosystemic shunts are both effective at relieving portal hypertensive bleeding," Dr. Lautz concluded. "By restoring normal physiologic portal venous circulation, the meso-Rex bypass better relieves hypersplenism, liver dysfunction, and growth impairment."

Dr. Lautz said he had no relevant financial disclosures to make.

The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Children treated with infliximab prior to ileal pouch anal anastomosis for chronic ulcerative colitis experienced nearly twice as many postoperative complications, compared with controls, but the long-term outcomes were similar between the two groups, results from a single-center study showed.

Infliximab, an anti–tumor necrosis factor–alpha antibody, has become increasingly popular for the treatment of ulcerative colitis and was approved by the Food and Drug Administration for use in moderate and severe disease in 2005. "Since that time, there have been a multitude of conflicting reports regarding infliximab’s potential to cause postoperative infections," Dr. Raelene Kennedy said at the annual meeting of the American Pediatric Surgical Association. "However, there has been a lack of data specific to the pediatric population."

Dr. Kennedy of the Mayo Clinic, Rochester, Minn., and her pediatric surgery associates retrospectively studied 38 patients aged 18 years and younger who underwent ileal pouch anal anastomosis (IPAA) for chronic ulcerative colitis at the Mayo Clinic in 2003-2008. Of these, 11 patients received infliximab within 8 weeks prior to surgery. The control group included 27 patients who were well matched in terms of age and sex. "However, preoperative albumin levels were slightly lower in the infliximab group (3.4 vs. 4 g/dL)," she said. "This may suggest that our infliximab group had more severe disease."

Use of other medications was similar between the two groups, except that a significantly greater proportion of patients in the infliximab group vs. the control group used thiopurines (91% vs. 41%, respectively).

Operative technique for the groups varied. Overall, most patients underwent a two-stage procedure, but 33% of control group patients underwent three-stage procedures, whereas none in the infliximab group did. Additionally, a laparoscopic approach was used for all patients in the infliximab group, compared with 63% of the control group.

Overall complications following IPAA were more frequent in the infliximab group than in the control group (55% vs. 26%, respectively), but this did not reach statistical significance. Small-bowel obstruction was significantly higher in the infliximab group, compared with the control group (55% vs. 7%), as was the rate of wound infections (18% vs. 7%). The rate of postoperative leaks between the two groups was similar (9% vs. 7%, respectively).

Compared with controls, a greater proportion of patients in the infliximab group had leak/abscess, small-bowel obstruction, wound infection, or pouchitis 30 days after ileostomy closure (36% vs. 19%), but there were no differences in the rates of complications between the two groups at postoperative year 1 (64% in the infliximab group vs. 62% in the control group). Pouchitis accounted for nearly all of the late complications in both groups.

"From this, we can conclude that children treated with infliximab prior to surgery are at increased risk for postoperative complications following their pouch procedures," Dr. Kennedy said. "Specifically, these children are at increased risk for small-bowel obstruction and wound infection. However, long-term outcomes remain similar to [those of] children who were not treated with infliximab."

She acknowledged certain limitations of the study, including its small sample size. "Larger pediatric studies are required to further evaluate these findings," she said.

Currently, Dr. Kennedy and her associates recommend discontinuing infliximab at least 8 weeks prior to IPAA when possible. "For patients who are currently being treated with infliximab, we recommend total abdominal colectomy with temporary end ileostomy followed by IPAA at a later date," she said.

Dr. Kennedy said that she had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.

PALM DESERT, CALIF. – Venoarterial extracorporeal circulation membrane oxygenation appears to be the primary mode of treatment for septic patients, but new research suggests that venovenous ECMO confers a significant survival benefit in select noncardiac pediatric patients with sepsis.

"ECMO is used as a last resort in sepsis, but to date there is really no consensus on the best mode of ECMO to be used" in these patients," Dr. Sean C. Skinner said at the annual meeting of the American Pediatric Surgical Association.

To compare venoarterial (VA) with venovenous (VV) ECMO in septic pediatric patients, Dr. Skinner and his associates analyzed Extracorporeal Life Support Organization (ELSO) registry data from 1990 to 2008 in patients younger than age 18 years with a primary, secondary, or discharge diagnosis of sepsis. Patients with congenital heart diagnoses were excluded. The primary outcome was survival.

Patients were grouped by modality (VA vs. VV ECMO) and by three age categories: neonates to 1 month of age, children aged 1 month to 12 years of age, and adolescents older than age 12 years. To assess the patients’ severity of illness, the investigators examined pre-ECMO vasoactive medication and any advanced respiratory support that was provided. Univariate and multivariate analyses were performed.

Of the 4,332 ECMO runs that were analyzed during the study period, 3,256 (75%) were VA and 1,076 (25%) were VV, said Dr. Skinner, a pediatric surgeon at the University of Kentucky, Lexington. Overall survival was 68% and was significantly higher in the VV group, compared with the VA group (79% vs. 64%, respectively). Survival also decreased significantly with age, from 75% of neonates to 40% of children aged 1 month–12 years and 31% of adolescents.

Dr. Skinner reported that there was survival benefit favoring VV in all three age groups. The rate of survival was 83% in neonates who underwent VV vs. 70% in neonates who underwent VA. Survival rates were 64% vs. 37%, respectively, in children 1 month–12 years of age, and were 43% vs. 29%, respectively, in adolescents.

After adjusting for age group, vasoactive medication use, and any advanced respiratory support provided, the investigators found a significant survival benefit to VV ECMO, with an odds ratio for mortality of 2.06 in VA ECMO patients. Advanced age and use of vasoactive medications remain independent mortality risk factors after adjustment (OR, 4.07 for children vs. neonates; OR, 5.84 for adolescents vs. neonates; and OR, 1.28 for those on vasoactive medications vs. those who were not).

Dr. Skinner acknowledged certain limitations of the study: The ELSO registry consists of retrospective data, it was not possible to control for selection bias, and there was limited adjustment for severity of illness.

"We believe that there is a survival benefit in VV vs. VA ECMO in select septic pediatric patients who do not have any underlying congenital heart disease," he concluded. "Patients who have severe cardiac depression may benefit from VA ECMO, but when possible, septic patients can be tried on VV ECMO as a primary modality in a safe manner."

Dr. Skinner said that he had no relevant financial conflicts to disclose. The meeting was supported by a grant from Elsevier, which owns this news organization.