Postoperative Outcomes in Exploratory Laparotomy and Intestinal Resection in Children: A Secondary Descriptive Observational Analysis

Background: We previously reported independent predictors of intraoperative and postoperative morbidity. These were age, American Society of Anesthesiologists Score (ASA), emergency situations, surgery and transfusion. ASA was the independent predictor of mortality. We conducted a secondary analysis of this previous retrospective study in patients who underwent exploratory laparotomy and intestinal resection. Objectives: The objective was to describe intraoperative and postoperative outcomes in patients who underwent exploratory laparotomy and intestinal resection in the initial study and to present a research protocol for intraoperative and postoperative optimization. Methods: Secondary analysis of the initial study was used. The Ethics Committee approved the study. Results: There were 54 patients with a median age of 15.5 [0 - 172] months. Thirty-seven (68.5%) patients underwent intestinal resection, nine (16.7%) underwent exploratory laparotomy, and eight (16.8%) underwent laparotomy for volvulus. Fourteen (25.9%) patients had intraoperative and/or postoperative complications. Two (3.7%) patients had an intraoperative hemorrhagic shock. Two (3.7%) patients had a postoperative cardio-circulatory failure. Three (5.6%) had postoperative respiratory failure. One (1.8%) of patients with postoperative complications in this cohort was not negligible. We, therefore, elaborated a research protocol where intraoperative patient management will be guided with transthoracic echocardiography for fluid and hemodynamic therapy optimization. The objective of this study protocol is to clarify the impact of intraoperative goal-directed fluid and hemodynamic therapy with transthoracic echocardiography on postoperative outcomes in terms of complications in pediatric surgical patients.

ASA was the independent predictor of mortality [1].
Intraoperative and postoperative complications in pediatric surgical settings with regard to age have been described previously [5]- [10]. When considering the entire initial cohort of 594 patients, the overall rate of patients with intraoperative and/or postoperative complications was 23.9% [1]. The most-reported intraoperative complication was hemorrhagic shock, with an overall rate of 3.9% [1]. The most commonly reported postoperative organ failure was neurologic, followed by respiratory, cardio-circulatory and multiple organ failure, with overall rates of 4.2%, 3.5%, 3% and 1.5%, respectively [1]. The most commonly reported postoperative infection was septicemia, followed by pulmonary sepsis, abdominal sepsis, surgical wound sepsis and urinary sepsis, with overall rates of 3.7%, 2.9%, 2.7%, 2% and 1.3%, respectively [1]. Overall transfusion rate was 49.2%. Overall rate of reoperation was 7.2%. The rate of emergency interventions was 22.9%. Overall in-hospital mortality rate was 1.9%.
We conducted a secondary analysis of this initial cohort with the primary objective of describing intraoperative and postoperative outcomes in patients who underwent exploratory laparotomy and intestinal resection. The secondary objective was to propose and implement intraoperative optimization management research protocols for postoperative outcome improvement in these pediatric surgical settings.

Methods and Materials
A secondary analysis of patients who underwent exploratory laparotomy and intestinal resection was included in the initial study [1]. In the initial study, we emphasized on determining predictors of intraoperative and postoperative out-C. Kumba Open Journal of Pediatrics comes. In this secondary analysis we aimed to emphasize on the specific intraoperative and postoperative outcomes in a specific surgery, namely laparotomy.
Outcomes were defined in terms of organ dysfunction, infection or sepsis, length of stay in the intensive care unit, length of hospital stay, length of total hospital stay (length of intensive care unit stay and length of stay in the standard hospitalization ward), duration of mechanical ventilation and transfusion.
Organ dysfunction and sepsis were defined per system with clinical, laboratory and imaging findings as a state of organ alteration not present in the preoperative period or present preoperatively with postoperative majoration or increase.
Multiple organ dysfunction or multiple organ sepsis was defined as a state of more than one organ alteration with clinical, laboratory, and/or imaging findings. The inclusion criteria were patients who underwent exploratory laparotomy or intestinal resection and those aged less than 18 years old included in the initial study.
The exclusion criteria were patients who did not undergo exploratory laparotomy or intestinal resection and were aged more than 18 years old.
Patients were included retrospectively from 1 January 2014 to 17 May 2017.
Statistics were analyzed with XLSTAT 2020.4.1. software. Continuous variables were expressed as medians with ranges or means with standard deviations. Category variables were described in proportions. Table 1  Seventeen patients had intraoperative transfusion. There were two in-hospital deaths. All patients with fatal outcomes had comorbidity, namely, congenital heart disease and all were managed on an emergency basis. Table 2 illustrates the characteristics of patients with fatal outcomes. Table 3 illustrates surgery. Re-operation n (%) 6 (11.1)

Discussion
The rate of patients with intraoperative and/or postoperative complications in this secondary analysis was comparable to that of the initial cohort [ [24]. In adults, goal-directed fluid and hemodynamic therapy has been shown to reduce postoperative morbidity, mortality and length of hospital stay in surgical patients [25]. In children, the impact of goal directed-fluid and hemodynamic therapy has not yet been demonstrated. Our hypothesis is that goal C. Kumba Open Journal of Pediatrics Pre-term + Necrotizing enterocolitis 2 (3.   [24]. Transfusion protocols guided with point-of-care tests have the objective of optimizing blood product administration in order to transfuse the right product at the right time. Optimal hemoglobin levels are necessary for an optimal oxygen consumption-oxygen delivery relation [23] [24]. Our hypothesis is that intraoperative optimization with goal-directed therapies could contribute to upgrading postoperative outcomes in these major surgical settings. To date, goal-directed therapies are not well developed in children. A systematic review and meta-analysis in children revealed that indirect non-optimal biomarkers of oxygen consumption-oxygen delivery relation namely lactate levels, regional oxygen saturation, mixed venous oxygen saturation were predictors of adverse postoperative outcomes in major pediatric surgical patients in terms of morbidity; mortality and length of hospital stay [27]. We have elaborated a study protocol with transthoracic echocardiography for intraoperative fluid and hemodynamic therapy optimization. This protocol will clarify the impact of this validated tool on postoperative outcome in pedia-

Conclusion
The number of patients with postoperative complications in this cohort was 25.9%. To improve these outcomes, we have elaborated a research protocol with transthoracic echocardiography. Intraoperative goal-directed therapies need to be developed in research protocols in these major pediatric surgical settings to determine their impact on intraoperative and postoperative outcomes.

Author' Contributions
Claudine Kumba conceptualized and designed the study and drafted the initial manuscript. She designed the data collection instruments, collected data, carried out initial and final analyses.