Establishment of a successful robotic pediatric general surgery practice.

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

Costs and Complications: Delayed Gastric Emptying after Pancreaticoduodenectomy.

Postoperative delayed gastric emptying (DGE) is a very common complication after a pancreaticoduodenectomy (PD). This along with other complications can lead to increased health-care costs. This study investigates the costs and length of stay (LOS) associated with these. A retrospective study of 131 patients undergoing PD between 2000 and 2016 at Loma Linda University Health was performed. Chi-squared test was used to determine statistically significant differences between patients with and without DGE (according to the definition of the International Study Group of Pancreatic Surgery). Multiple logistic and linear regression analyses were performed to obtain adjusted odds ratios for variables of interest in association with DGE and relationship to LOS. Of 150 patients undergoing PD, 131 patients with tumors were analyzed. The overall incidence of DGE was 56 per cent. No pre- or postoperative factors were associated with increased risk of DGE. The median LOS for patients with DGE was 15 days versus 9 days for patients without DGE. Patients with DGE added $21,198 to the overall cost of hospitalization. Fourteen patients (10.7%) were readmitted, of whom 11 were because of DGE. Further studies assessing the utility of intraoperative G-tube placement in decreasing hospital costs and readmissions are needed.

Effectiveness of a 1-Hour Extended Focused Assessment With Sonography in Trauma Session in the Medical Student Surgery Clerkship.

OBJECTIVE: To demonstrate the effectiveness of incorporating 1 hour of ultrasound training on the extended focused assessment with sonography in trauma (eFAST) into the year-3 medical student surgical clerkship. DESIGN: A prospective cohort study where participants served as self-controls. One hour of instruction in the eFAST examination, along with 3 required observed examinations, was incorporated into the year-3 surgery clerkship. Effectiveness of the training was evaluated by a preliminary and posttraining assessment. An online survey was used assessing comfort based on a 5-point Likert scale. An online quiz was used assessing knowledge, and a 2-part objective structured clinical examination (OSCE) was used assessing skill and speed. Participants also logged 3 eFAST examinations during the 10-week clerkship where they reported their comfort in performing and interpreting the eFAST on a 5-point Likert scale. Postassessment was held during the last week of the clerkship and included the same online quiz, survey, and 2-part OSCE. SETTING: The study was performed at Loma Linda University and affiliated hospitals where surgical clerkship students rotate. PARTICIPANTS: A total of 148 year-3 medical students completed the study. RESULTS: All testing modalities showed improvement. The mean average of the OSCE improved from 46% ± 27% to 81% ± 18%. The percentage of participants able to perform the examination in less than 6 minutes increased from 18% ± 27% to 84% ± 36%. Participants' comfort level in recognizing eFAST pathology increased from a mean of 2.40 ± 0.94 to 3.55 ± 0.87 out of 5. Comfort in performing the eFAST examination improved from 2.81 ± 0.79 to 3.77 ± 0.68. Comfort in interpreting the eFAST examination improved from 2.88 ± 0.87 to 3.65 ± 0.72. CONCLUSIONS: This study demonstrates that incorporating 1 hour of eFAST training into the general surgery clerkship is feasible and may lead to improved competency in performing and interpreting the eFAST examination.

Outcomes in the management of appendicitis and cholecystitis in the setting of a new acute care surgery service model: impact on timing and cost.

BACKGROUND: The acute care surgery model is a novel notion in the provision of emergency general surgery. To date, several studies have analyzed the effects on patient health outcomes and timeliness of care for nontrauma patients within the scope of acute general surgery and emergencies, but none have assessed the cost benefits of this model. STUDY DESIGN: A retrospective analysis of patients undergoing appendectomy or cholecystectomy in the setting of acute abdomen was performed to compare data from 2 cohorts, the traditional model from July 2009 to June 2010 and the acute care surgery model from July 2010 to June 2011. Categorical variables and comparison means were examined using chi-square and independent 2-tailed sample t-tests. RESULTS: One hundred and seventy-five patients underwent appendectomy and 113 underwent cholecystectomy. The traditional model team staffed 82 appendectomies and 51 cholecystectomies, and the acute care surgery team staffed 93 and 62, respectively. In the appendectomy group, there was a statistically significant mean reduction of time to surgical evaluation (2.19 hours; p < 0.001) and time to the operating room (5.38 hours, p = 0.006), there were 7 fewer patients with complications (p = 0.06) and a reduced length of stay (1 day, p = 0.002) for the acute care surgery cohort. Similar statistically significant differences were observed in the cholecystectomy group in the acute care surgery cohort: surgical evaluation difference = 5.84 hours (p = 0.03), time to operating room difference = 25.37 hours (p = 0.002), 8 fewer patients with complications (p = 0.01), and length of stay difference was 2 days (p = 0.03) compared with the traditional model cohort. CONCLUSIONS: The newly implemented acute care surgery model in our institution accomplished earlier treatment and shorter length of stay for the 2 most common causes of acute abdomen in our setting. Overall, the new model translated to better outcomes for patients and savings per case for the hospital.

Tumor size and presence of calcifications on ultrasonography are pre-operative predictors of lymph node metastases in patients with papillary thyroid cancer.

BACKGROUND AND OBJECTIVES: Lymph node metastases in papillary thyroid cancer (PTC) are common and their presence can significantly alter the treatment for patients with PTC. We therefore sought to identify pre-operative predictors of lymph node metastases in patients with PTC. METHODS: A thyroid tumor database was queried to identify patients with a pre-operative diagnosis of PTC and underwent thyroidectomy between January 2006 and August 2009. One hundred and three patients who had a pre-operative ultrasound and had lymph nodes surgically resected were identified. Clinical factors and tumor ultrasound characteristics were recorded. The pre-operative ultrasound results, type of operation, and final pathology results were also recorded. RESULTS: Of the 103 patients, 74 (72%) were women and 29 (28%) were men with an age range of 15-78 years (median age of 43). Of the ultrasound characteristics evaluated only calcifications (P = 0.007) and size (P = 0.003) were statistically associated with positive cervical lymph nodes. None of the other demographic or clinical factors were significantly associated with lymph node metastases. CONCLUSIONS: Thyroid nodule size and presence of calcifications on ultrasound were found to have a statistically significant association with lymph node metastases in patients with PTC. This information could be used to guide the surgical management of these patients.

A prospective analysis of critical limb ischemia: factors leading to major primary amputation versus revascularization.

In our aging population, primary major amputations (AMP, below-knee or above-knee) continue to be performed despite advances in revascularization. We hypothesized that not only patient comorbidities but also the system of health-care delivery affected the treatment of patients with critical limb ischemia (CLI). A prospective analysis of patients presenting with CLI was undertaken to determine whether patient-specific factors or healthcare delivery factors (system-related) influenced treatment with primary AMP versus lower extremity revascularization (LER). The patient-specific factors age, gender, race/ethnicity, presence of coronary artery disease, cerebrovascular disease, tobacco use, diabetes mellitus (DM), dialysis dependence (end-stage renal disease, ESRD), hypertension, hyperlipidemia, stage of CLI (rest pain, minor or major tissue loss), history of revascularization, and functional status (living situation and ambulatory status) were recorded. The system-related factors time from onset of CLI to vascular surgery evaluation and type of insurance (managed care/other insurance) were also noted. The influence of patient-specific and system-related factors on the primary treatment modality (AMP versus LER) was determined with univariate and multivariate analyses. A total of 224 patients presented with CLI between March 1, 2001, and March 1, 2005. Patients were treated with primary major AMP in 97 cases (43%) and revascularization in 127 cases (57%). On univariate analysis, nonwhite race/ethnicity, DM, ESRD, major tissue loss, dependent living situation, and nonambulatory status were all significant predictors of AMP versus LER (all P < 0.01). On multivariate analysis, major tissue loss, ESRD, DM, and nonambulatory status remained independent predictors of AMP versus LER (all P < 0.05). The system-related factors of time to vascular surgery evaluation (mean 8.6 weeks, 7.1 vs. 9.3 weeks AMP versus LER, P = 0.60) and type of insurance (managed care, 17% vs. 24% AMP vs. LER, P = 0.15) had no influence on treatment. Fifty-four percent of all primary major AMPs were performed due to extensive gangrene or infection present at initial vascular evaluation which precluded limb salvage. Major tissue loss, ESRD, DM, and nonambulatory status are all independent predictors of treatment with primary AMP as opposed to revascularization. Treatment of CLI is determined by patient-specific factors and does not appear to be adversely influenced by system-related factors. Efforts toward improving limb salvage may be best directed at aggressive treatment of medical comorbidities to prevent the late complications of CLI. Earlier recognition of tissue loss and referral to the vascular specialist may lead to improved limb salvage.