The Northeastern Society of Plastic Surgeons

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Development of a Post-Operative Care Pathway for Children with Renal Tumors
Amanda F. Saltzman, MD, Jason C. Warncke, MD, Alonso Carrasco, Jr., MD, Alexandra N. Colvin, BS, Nicholas G. Cost, MD.
University of Colorado, Department of Surgery, Division of Urology, Aurora, CO, USA.

Background: Protocol driven post-operative care pathways (e.g. enhanced recovery after surgery [ERAS] protocol) can standardize peri-operative treatment and have been shown to improve short term outcomes. This is important in pediatric renal tumor surgery as initiating outpatient adjuvant therapy in a timely manner is associated with improved oncologic outcomes. As an initial step to develop our own post-nephrectomy pathway, we designed this study to identify factors associated with a shorter post-operative stay.
Methods: We retrospectively reviewed patients at a pediatric tertiary care facility managed with upfront open radical nephrectomy for renal tumors between 2005-2016. Patients with bilateral tumors or who received pre-operative chemotherapy were excluded. Demographic and clinical information were abstracted and analyzed. Univariate and multivariate logistic regression was performed to identify factors associated with discharge by post-operative day (POD) 4.
Results: A total of 84 patients met inclusion criteria. Median age was 28.1 months (range 1.8-193.1) and 41 (48.8%) were female.
Preoperatively, 3 (3.9%) patients underwent bowel preparation. All but one of the patients had an epidural placed for regional pain control. 63 (75%) patients were operated on by the surgery service alone, 15 (17.9%) by the urology service alone, and 6 (7.1%) by a combined surgery and urology team. 65 (77.4%) patients had synchronous central venous access placed at the time of nephrectomy and 75 (89.3%) had malignant histology. Median tumor size was 10.5 cm (range 3.6-24) and median number of lymph nodes examined was 7 (range 0-29). Median blood loss was 30 mL (range 5-1000). Stage distribution was 25 (29.8%) stage I, 26 (31%) stage II, 24 (28.6%) stage III and 9 (10.7%) stage IV. Median total OR time was 176 mins (range 66-400) with median nephrectomy time of 150 mins (range 66-318).
34 (40.5%) patients had a nasogastric tube in place postoperatively. The median POD the patient was advanced to a clear liquid diet was 2 (range 0-7) and regular diet was 3 (range 1-8). 20 (23.8%) patients received a blood transfusion and 22 (26.2%) received their first dose of chemotherapy before discharge. Median time from surgery to discharge was 5 days (range 2-12), with 38 (45.2%) discharged by POD 4. There was a single complication during the first 30d postoperatively (pneumonia).
Univariate and multivariate logistic regression analyses are summarized in table 1. Timing of regular diet (OR 0.523, p=0.028) was positively associated with to discharge by POD 4. Other factors analyzed were not significant.
Conclusion: For children with unilateral renal tumors undergoing radical nephrectomy, early refeeding is associated with a shorter time to discharge, while stage, extent of lymphadenectomy are not influential, use of bowel prep and nasogastric tube do not appear to shorten time to discharge. These data are important as we develop a post-operative care pathway for these patients which will be studied prospectively.
Table 1 Logistic regression for post-operative discharge by POD 4

UnivariateMultivariate
OR95% CIp-value OR95% CIp-value
Age0.9920.98-1.0050.209
Gender
Male
Female
1
1.323
0.559-3.130.525
Laterality
Right
Left
1.26
1
0.53-2.9950.6
Simultaneous Venous Access0.6810.244-1.90.463
Malignant Histology0.3720.0861.6010.184
Tumor Diameter (cm)0.910.809-1.0240.118
Number of LNs Examined1.0721.003-1.1450.0391.0630.977-1.1570.157
Number of LNs Positive0.6660.347-1.280.232
Stage
I
II
III
IV
1
0.209
0.336
0.235
0.064-0.683
0.105-1.081
0.047-1.19
0.01
0.067
0.08
1
0.323
0.4
0.277
0.085-1.223
0.106-1.513
0.039-1.987
0.096
0.177
0.201
OR Time
Overall
Nephrectomy only
1
0.997
0.993-1.006
0.99-1.006
0.919
0.536
EpiduralNA
POD Clears Started0.4510.267-1.7640.003
POD Regular Diet Started0.4350.264-0.7150.0010.5230.293-0.9340.028
Preop Bowel Prep0.5950.052-6.8210.676
Postop NG Tube0.4070.164-1.0110.053
EBL0.9930.0985-1.0010.095
Intraop or Postop ComplicationNA
Transfusion (any time during hospitalization)0.2210.066-0.7330.0140.4610.12-1.7630.258
Surgical Service
Pediatric Urology
Pediatric Surgery
Combo Case
1
0.224
0.364
0.064-0.783
0.051-2.601
0.019
0.314
1
0.882
0.588
0.181-4.299
0.053-6.587
0.877
0.667
Chemotherapy Prior to Discharge0.3520.122-1.0170.054


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