Aim: To evaluate factors associated with excellent correction in pectus excavatum patients undergoing vacuum bell therapy (VBT). Methods: A single-institution retrospective chart review was performed November 2012-April 2023 to assess corrections of patients who underwent VBT. Patient demographics, presentation, and results were collected. Excellent correction was defined as complete correction or >100 % improved from an average standard chest depth of 0.51 cm. Data are reported using odds ratio & confidence intervals; and paired t-test comparison. A p-value of <0.05 was regarded as significant. Results: VBT was utilized in 431 patients with 278 patients included and 153 excluded due to loss of follow-up or incomplete data. Of those included, 89 % were male. There were 31 patients with excellent corrections (11 %) and 247 non-excellent corrections. Initial chest depth < 1.5 cm and chest wall flexibility remain important predictors of positive outcome (p=0.0 08 and < 0.001, respectively). Excellent correction was statistically more likely in patients aged 8 to 12.9 (OR = 2.2, p = 0.039). Surgical correction following VBT was performed in only 15.5% (42 of 278) of our patients, none of which were in the group with an excellent correction. Conclusion: Excellent correction for pectus excavatum via VBT was achieved in a small proportion of patients, with improved outcomes in those initiating therapy at a younger age, with a mild defect, and with increased chest wall flexibility. These data may be used to help determine those more likely to achieve complete correction from a nonsurgical approach and guide decisions towards treatment methods.

Importance:Postoperative antimicrobial prophylaxis (PAP) is frequently used following pectus excavatum repair and accounts for the highest relative burden of potentially avoidable postoperative antibiotic days among pediatric general surgical procedures. Objective:To evaluate the association of postoperative antibiotic prophylaxis with postoperative rates of surgical site infections, reoperation, and readmission in children undergoing pectus excavatum repair who did and did not receive postoperative antibiotic prophylaxis. Design, Setting, and Participants:This cohort study included children aged younger than 18 years undergoing pectus excavatum repair from January 2021 to December 2023 at 141 hospitals participating in the National Surgical Quality Improvement Program-Pediatric. Exposures:Continuation of prophylactic antibiotics after incision closure. Main Outcomes and Measures:Primary outcomes included 30-day postoperative rates of surgical site infections (SSIs), reoperation, and readmission. Propensity score matching was used to balance groups (without PAP or with PAP) on patient and operative characteristics plausibly associated with PAP use and outcomes. Mixed-effects models were used to compare outcomes between matched groups, with a random effect used to account for hospital clustering. A complementary hospital-level analysis was used to explore the correlation between rates of PAP use and observed to expected (O/E) rate ratios for each outcome after adjusting for differences in patient and procedural characteristics among hospitals. Results:A total of 3552 patients were included (median [IQR] age, 15.4 [14.5-16.4] years; 3099 males [87.3%]). Postoperative prophylaxis was used in 1949 patients (54.9%) for a median (IQR) duration of 21.6 (14.6-24.0) hours. In the matched cohort of 3168 patients, outcomes were similar in children receiving PAP compared with those who did not, with 26 of 1584 (1.6%) of children who received PAP developing an SSI compared with 29 of 1584 (1.8%) of children who did not receive PAP (odds ratio [OR], 0.90; 95% CI, 0.50-1.61). For children requiring reoperation, 25 of 1584 (1.6%) received PAP compared with 27 of 1584 (1.7%) who did not (OR, 0.98; 95% CI, 0.52-1.83). For readmission, 41 of 1584 (2.6%) children received PAP compared with 57 of 1584 (3.6%) who did not (OR, 0.81; 95% CI, 0.48-1.34). In the hospital-level analysis, no correlation was found between rates of postoperative prophylaxis use and O/E rate ratios for SSIs (Spearman ρ, -0.07; P = .43), reoperation (Spearman ρ, -0.01; P = .93), or readmission (Spearman ρ, -0.03; P = .65). Conclusions and Relevance:In this cohort study of 3552 pediatric patients undergoing pectus excavatum repair, postoperative antibiotic use was not associated with improved outcomes, challenging the routine use of postoperative prophylaxis in the operative management of this condition.

PURPOSE:Pediatric Surgery Quality Collaborative (PSQC) implemented a colon bundle checklist pilot study in 2023 using the NSQIP-P platform. This study aims to analyze bundle compliance in a multicenter surgical quality initiative and identify checklist item specific compliance rates. METHODS:A 7-item perioperative colon bundle checklist was implemented. Custom variables for the checklist items were created on the NSQIP-P platform. Compliance for pediatric colorectal cases between January 2023-September 2024 was analyzed between implementation and control cases and over time. RESULTS:361 cases were analyzed: 62.3 % were controls and 37.7 % were implementation cases. The cohorts were similar in demographics characteristics. Implementation cases significantly outperformed controls in all colon bundle components except pre-operative antibiotics and intraoperative normothermia. Implementation cases adhered to administering preoperative antibiotics (90 %) the most and intraoperative anastomotic leak testing (62 %) the least. Despite being the least compliant bundle item, implementation cases outperformed control cases (44.7 %) in anastomotic leak testing. Implementation cases' mean bundle compliance score increased significantly over time (4.07 vs 5.14, p = 0.010). From 2023 to 2024, implementation cases significantly improved adherence to preoperative umbilical cleansing, antibiotic administration, and glove change prior to closure. Although not statistically significant, superficial surgical site infection occurred more frequently in control cases compared to implementation cases (5.8 % vs. 3.7 %, p = 0.390). CONCLUSIONS:We present the largest multicenter initiative using the NSQIP-Pediatric platform to assess the utilization of a colon bundle checklist for pediatric colorectal surgeries. Significant compliance improvement, albeit imperfect, over 21 months reflects a realistic adoption rate of a multicenter initiative using NSQIP. LEVEL OF EVIDENCE:III.

AIM:Evaluation of ultra-low dose chest CT imaging for the assessment of pectus excavatum severity as determined by pediatric radiologists and pediatric surgeons using Haller (HI) and Correction indices (CI). METHODS:A single institution, prospective evaluation of patients being evaluated for pectus excavatum were scanned with a standard low-dose chest CT protocol (CARE) followed by a consecutive ultra-low dose CT scan (ULTRA). 3 surgeons and 4 radiologists were instructed to determine HI and CI in each series. The Intraclass Correlation Coefficient (ICC) was used to calculate the agreement level between CARE and ULTRA. Bland-Altman (BA) and scatter plots were also performed to determine bias of each approach. RESULTS:32 patients had CARE and ULTRA consecutively. The ICC for HI demonstrated good reliability with a value of 0.89 and excellent reliability for CI with a value of 0.91. The reliability for HI was greater in the surgeon group (0.89) compared to the radiologist group (0.88). The reliability for CI was greater in the radiologist group (0.92) compared to the surgeon group (0.90). The Bland Altman plots for the HI and CI demonstrate no consistent bias for CARE or ULTRA approach when evaluating HI and CI. CONCLUSION:Ultra-low dose CT scan imaging compared to standard low-dose CT appears to be a reliable alternative for evaluating PE severity as assessed by HI and CI. This work supports the evaluation and potential development of a standardized CT imaging protocol capable of reducing radiation exposure without sacrificing imaging for PE patients. LEVEL OF EVIDENCE: 2:

Objective:To establish surgical site infection (SSI) performance benchmarks in pediatric surgery and to develop a prioritization framework for SSI prevention based on procedure-level SSI burden. Background:Contemporary epidemiology of SSI rates and event burden in elective pediatric surgery remain poorly characterized. Methods:Multicenter analysis using sampled SSI data from 90 hospitals participating in NSQIP-Pediatric and procedural volume data from the Pediatric Health Information System (PHIS) database. Procedure-level incisional and organ space SSI (OSI) rates for 17 elective procedure groups were calculated from NSQIP-Pediatric data and estimates of procedure-level SSI burden were extrapolated using procedural volume data. The relative contribution of each procedure to the cumulative sum of SSI events from all procedures was used as a prioritization framework. Results:A total of 11,689 nonemergent procedures were included. The highest incisional SSI rates were associated with gastrostomy closure (4.1%), small bowel procedures (4.0%), and gastrostomy (3.7%), while the highest OSI rates were associated with esophageal atresia/tracheoesophageal fistula repair (8.1%), colorectal procedures (1.8%), and small bowel procedures (1.5%). 66.1% of the cumulative incisional SSI burden from all procedures were attributable to 3 procedure groups (gastrostomy: 27.5%, small bowel: 22.9%, colorectal: 15.7%), and 72.8% of all OSI events were similarly attributable to 3 procedure groups (small bowel: 28.5%, colorectal: 26.0%, esophageal atresia/tracheoesophageal fistula repair: 18.4%). Conclusions:A small number of procedures account for a disproportionate burden of SSIs in pediatric surgery. The results of this analysis can be used as a prioritization framework for refocusing SSI prevention efforts where they are needed most.

The Nuss repair has revolutionized the care of the patient with pectus excavatum. As with all surgical procedures, complications can occur, and all efforts to strive to 0% should be made. After years of experience and procedural modifications, severe and life-threatening complications with both bar insertions and bar removals should be very rare. Most Nuss repairs are performed in teenagers and young adults. As more and more surgeons, including both pediatric and thoracic surgeons, embrace the Nuss procedure, the age limits continue to expand. Many articles have demonstrated equally successful results even through middle age and older age. Questions have remained on whether the older patient has more complications with the Nuss procedure. Equally important is the safe removal of the pectus hardware after successful repair. Risk Factors and Techniques for Safe Pectus Bar Removal in Adults After Modified Nuss RepairThe Annals of Thoracic SurgeryVol. 116Issue 4PreviewThe Nuss repair involves implants designed for removal after 2 to 3 years. Although rare, significant complications can occur with bar removal, and the incidence of these complications may be higher in adults. This study was performed to review complications and risk factors associated with bar removal and discuss strategies to improve operative safety. Full-Text PDF

Quality and process improvement (QI/PI) in children's surgical care require reliable data across the care continuum. Since 2012, the American College of Surgeons' (ACS) National Surgical Quality Improvement Program-Pediatric (NSQIP-Pediatric) has supported QI/PI by providing participating hospitals with risk-adjusted, comparative data regarding postoperative outcomes for multiple surgical specialties. To advance this goal over the past decade, iterative changes have been introduced to case inclusion and data collection, analysis and reporting. New datasets for specific procedures, such as appendectomy, spinal fusion for scoliosis, vesicoureteral reflux procedures, and tracheostomy in children less than 2 years old, have incorporated additional risk factors and outcomes to enhance the clinical relevance of data, and resource utilization to consider healthcare value. Recently, process measures for urgent surgical diagnoses and surgical antibiotic prophylaxis variables have been developed to promote timely and appropriate care. While a mature program, NSQIP-Pediatric remains dynamic and responsive to meet the needs of the surgical community. Future directions include introduction of variables and analyses to address patient-centered care and healthcare equity.

Background: The objective of this study was to quantify prophylaxis misutilization to identify high -priority procedures for improved stewardship and SSI prevention.Methods: This was a multicenter analysis including 90 hospitals participating in the NSQIP-Pediatric Antibiotic Prophylaxis Collaborative from 6/2019 to 6/2020. Prophylaxis data were collected from all hospitals and misutilization measures were developed from consensus guidelines. Overutilization included use of overly broad-spectrum agents, continuation of prophylaxis >24 h after incision closure, and use in clean procedures without implants. Underutilization included omission (clean-contaminated cases), use of inappropriately narrow-spectrum agents, and administration post-incision. Procedure-level misutilization burden was estimated by multiplying NSQIP-derived misutilization rates by case volume data obtained from the Pediatric Health Information System database.Results: 9861 patients were included. Overutilization was most commonly associated with overly broad-spectrum agents (14.0%), unindicated utilization (12.6%), and prolonged duration (8.4%). Procedure groups with the greatest overutilization burden included small bowel (27.2%), cholecystectomy (24.4%), and colo-rectal (10.7%). Underutilization was most commonly associated with post-incision administration (6.2%), inappropriate omission (4.4%), and overly narrow-spectrum agents (4.1%). Procedure groups with the greatest underutilization burden included colorectal (31.2%), gastrostomy (19.2%), and small bowel (11.1%). Conclusion: A relatively small number of procedures account for a disproportionate burden of antibiotic misutilization in pediatric surgery. Type of Study: Retrospective Cohort. Level of Evidence: III. (c) 2023 Elsevier Inc. All rights reserved.

ImportanceUse of postoperative antimicrobial prophylaxis is common in pediatric surgery despite consensus guidelines recommending discontinuation following incision closure. The association between postoperative prophylaxis use and surgical site infection (SSI) in children undergoing surgical procedures remains poorly characterized.ObjectiveTo evaluate whether use of postoperative surgical prophylaxis is correlated with SSI rates in children undergoing nonemergent surgery.Design, Setting, and ParticipantsThis is a multicenter cohort study using 30-day postoperative SSI data from the American College of Surgeons' Pediatric National Surgical Quality Improvement Program (ACS NSQIP-Pediatric) augmented with antibiotic-use data obtained through supplemental medical record review from June 2019 to June 2021. This study took place at 93 hospitals participating in the ACS NSQIP-Pediatric Surgical Antibiotic Prophylaxis Stewardship Collaborative. Participants were children (<18 years of age) undergoing nonemergent surgical procedures. Exclusion criteria included antibiotic allergies, conditions associated with impaired immune function, and preexisting infections requiring intravenous antibiotics at time of surgery.ExposuresContinuation of antimicrobial prophylaxis beyond time of incision closure.Main Outcomes and MeasuresThirty-day postoperative rate of incisional or organ space SSI. Hierarchical regression was used to estimate hospital-level odds ratios (ORs) for SSI rates and postoperative prophylaxis use. SSI measures were adjusted for differences in procedure mix, patient characteristics, and comorbidity profiles, while use measures were adjusted for clinically related procedure groups. Pearson correlations were used to examine the associations between hospital-level postoperative prophylaxis use and SSI measures.ResultsForty thousand six hundred eleven patients (47.3% female; median age, 7 years) were included, of which 41.6% received postoperative prophylaxis (hospital range, 0%-71.2%). Odds ratios (ORs) for postoperative prophylaxis use ranged 190-fold across hospitals (OR, 0.10-19.30) and ORs for SSI rates ranged 4-fold (OR, 0.55-1.90). No correlation was found between use of postoperative prophylaxis and SSI rates overall (r = 0.13; P = .20), and when stratified by SSI type (incisional SSI, r = 0.08; P = .43 and organ space SSI, r = 0.13; P = .23), and surgical specialty (general surgery, r = 0.02; P = .83; urology, r = 0.05; P = .64; plastic surgery, r = 0.11; P = .35; otolaryngology, r = -0.13; P = .25; orthopedic surgery, r = 0.05; P = .61; and neurosurgery, r = 0.02; P = .85).Conclusions and RelevanceUse of postoperative surgical antimicrobial prophylaxis was not correlated with SSI rates at the hospital level after adjusting for differences in procedure mix and patient characteristics.

Objective: To establish surgical site infection (SSI) performance benchmarks in pediatric surgery and to develop a prioritization framework for SSI prevention based on procedure-level SSI burden. Background: Contemporary epidemiology of SSI rates and event burden in elective pediatric surgery remain poorly characterized. Methods: Multicenter analysis using sampled SSI data from 90 hospitals participating in NSQIP-Pediatric and procedural volume data from the Pediatric Health Information System (PHIS) database. Procedure-level incisional and organ space SSI (OSI) rates for 17 elective procedure groups were calculated from NSQIP-Pediatric data and estimates of procedure-level SSI burden were extrapolated using procedural volume data. The relative contribution of each procedure to the cumulative sum of SSI events from all procedures was used as a prioritization framework. Results: A total of 11,689 nonemergent procedures were included. The highest incisional SSI rates were associated with gastrostomy closure (4.1%), small bowel procedures (4.0%), and gastrostomy (3.7%), while the highest OSI rates were associated with esophageal atresia/tracheoesophageal fistula repair (8.1%), colorectal procedures (1.8%), and small bowel procedures (1.5%). 66.1% of the cumulative incisional SSI burden from all procedures were attributable to 3 procedure groups (gastrostomy: 27.5%, small bowel: 22.9%, colorectal: 15.7%), and 72.8% of all OSI events were similarly attributable to 3 procedure groups (small bowel: 28.5%, colorectal: 26.0%, esophageal atresia/tracheoesophageal fistula repair: 18.4%). Conclusions: A small number of procedures account for a disproportionate burden of SSIs in pediatric surgery. The results of this analysis can be used as a prioritization framework for refocusing SSI prevention efforts where they are needed most.

OBJECTIVE:To review standardized Nuss correction of pectus excavatum and vacuum bell treatment over the last 10 years. SUMMARY OF BACKGROUND DATA:In 2010, we reported 21 years of the Nuss procedure in 1215 patients. METHODS:Over the last 10 years, 2008-2018, we evaluated 1885 pectus excavatum patients. Surgery was indicated for well-defined objective criteria. A consistent operation was performed by 8 surgeons in 1034 patients, median 15 years, (range 6-46); 996 were primary, and 38 redo operations. Surgical patients' mean computed tomography index was 5.46. Mitral valve prolapse was present in 5.4%, Marfan syndrome in 1.1% and scoliosis in 29%. Vacuum bell treatment was introduced for 218 patients who did not meet surgical criteria or were averse to surgery. RESULTS:At primary operation, 1 bar was placed in 49.8%; 2 bars, 49.4%; and 3 bars, 0.7%. There were no deaths. Cardiac perforation occurred in 1 patient who had undergone previous cardiac surgery. Paraplegia after epidural catheter occurred once. Reoperation for bar displacement occurred in 1.8%, hemothorax in 0.3%, and wound infection in 2.9%; 1.4% required surgical drainage. Allergy to stainless steel was identified in 13.7%. A good anatomic outcome was always achieved at bar removal. Recurrence requiring reoperation occurred in 3 primary surgical patients. Two patients developed carinate overcorrection requiring reoperation. Vacuum bell treatment produced better results in younger and less severe cases. CONCLUSIONS:A standardized Nuss procedure was performed by multiple surgeons in 1034 patients with good overall safety and results in primary repairs. Vacuum bell treatment is useful.

Introduction: We report pectus carinatum management over a 10+year period.Methods: Staged management, with initial bracing and operation for failure or special circumstances, was employed. A newer brace and a minimally invasive operation for PC (the Abramson procedure) were introduced during the study period.Results: Of 695 consenting patients from 2008 to 2018, 265 (38%) were observed. Of 430 treated, 339 (79%) had bracing only; 65 (15%) underwent surgery without a trial of bracing, while 26(5%) underwent surgery after a failed attempt at bracing. Of 364 bracing patients, 144 (40%) were successful, 77 (21%) are ongoing, 25 (7%) failed, and 118 (32%) dropped out. Recurrence was noted in 17 (5%), an average 5.4 months later. Two (0.4%) overcorrected to pectus excavatum (PE). Successful patients experienced a 50% decrease in pressure of correction (POC) beginning one month after starting treatment. Brace failure patients did not. Reported compliance with brace utilization (hours/day) was similar. Surgery was required in 91 patients. Open operations were performed in 61 (67%), Abramson operations in 23 (25%), and Nuss procedure in 7 (8%) who developed excavatum over correction following bracing or who had mixed deformity, with excavatum one side of the sternum and carinatum on the other. Twenty-four (36%) of the surgeries for PC occurred after an attempt at bracing. All obtained good initial results by operation. No recurrence was noted after open operation and 3 (13%) after Abramson. Open complications included 1 (2%) infection. Abramson's operation required 11 (48%) revisions, 6 (26%) early bar removals, and had 3 (13%) infections.Conclusion: Brace treatment for PC can be guided by pressure of correction, which fell by more than half in successfully treated patients. POC did not fall in patients who failed. If POC does not fall, surgery should be considered. Open repair of Pectus Carinatum is generally successful, while the Abramson operation has a significant rate of complications with the implants currently available in the U.S.Levels of Evidence: Level III – Retrospective comparative study.

Background/purpose: Evaluate the safety of sternal elevation (SE) used selectively before creating the substernal tunnel during the Nuss procedure. Methods: An IRB-approved (01-05-EX-0175-HOSP), single institution, retrospective review was performed (1/1/1997-11/20/2017). Primary and secondary Nuss repairs (i.e., previous Nuss, Ravitch, thoracotomy, or stemotomy) are included. SE use, cardiac injuries, and pectus bar infections are reported. Chi square and Fisher's exact test (FE) were used (critical p < .05). Results: 2037 patients [(80% male; mean age 15.2 years (SD = 4.4, range 3-46); mean Haller index (HI) 5.3 (SD = 5.7, range 1.73-201)] underwent Nuss repair. SE was used before creating the substernal tunnel in 171 (8.4%): 160 (8.2%) of 1949 primary and 11 (12.5%) of 88 secondary repairs. SE use increased significantly [chi(2)(2) = 118.93; p < .001] over time and with increasing HI [chi(2)(3) = 59.9; p < .001]. No cardiac injuries occurred in primary repairs but two occurred in patients with previous stemotomy. Infection rates were not different with (2.9%) or without SE (1.8%) (chi(2)(1) = 1.14; p = .285] and not higher with off-label VB (1.5%) versus other SE techniques (3.8%) [FE, p = .65)]. Conclusion: Selective use of sternal elevation before substernal dissection during the Nuss procedure is safe but may not prevent cardiac injuries in patients with previous sternotomy. Infection rates were not increased with SE. (C) 2020 Elsevier Inc. All rights reserved.

The minimally invasive pectus excavatum repair (Nuss repair) is performed by pediatric general surgeons and pediatric and adult thoracic surgeons around the world. Complications related to pediatric surgical procedures are always a major concern for surgeons and their patients, and as with all surgery, especially pectus surgery, complications can be life-threatening. The purpose of this article is to discuss early and late complications of pectus excavatum surgery and potential preventive strategies to minimize them.

Background: Hemorrhage during Nuss bar removal is an uncommon but feared complication that can be life threatening if not controlled rapidly. This study aims to identify the incidence and sources of large volume hemorrhage, discuss successful management strategies, and provide patient care recommendations. Methods: An IRB approved (#15-11-WC-0214), single institution retrospective chart review was performed on patients who underwent Nuss bar removal over a 15-year interval. Estimated blood loss (EBL), source of hemorrhage, management, and outcomes are reported. Results: One thousand six hundred twenty-eight Nuss bar removal procedures were reviewed. EBL >150mL occurred in 7 patients (0.43%), of whom 2 patients (0.12%) had EBL >2000mL. Bleeding sources included: lateral soft tissue, lateral ectopic calcium, medial ectopic calcification, and an intercostal vessel. Most bleeding could be controlled with pressure and electrocautery. Only 2 patients (0.12%) required transfusion. One of these had bleeding from an intercostal vessel, and the other bled from a large vein in the medial calcified substernal tract. No patients sustained heart injury or died. Conclusion: Large volume hemorrhage after Nuss bar removal is rare, but may require blood transfusion, thoracoscopic exploration, or open exploration through thoracotomy or sternotomy. Nuss bar removal should be performed in centers capable of these interventions. After bar removal, a chest X-ray and a period of postoperative observation up to 6 hours may be beneficial to detect occult hemorrhage.