Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review.

INTRODUCTION: The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. MATERIALS AND METHODS: We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval. RESULTS: Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. CONCLUSION: Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.

Single-visit surgery: An evaluation from an institutional perspective.

BACKGROUND/PURPOSE: Elective ambulatory surgical care traditionally involves three independent visits. Single-Visit Surgery (SVS) is an alternative surgical model that consolidates care into one visit. Evaluation of the effect of this novel program on hospital operations is limited. The objective of this study was to analyze SVS from an institutional perspective. METHODS: We retrospectively reviewed patients scheduled for SVS at a freestanding children's hospital between January 2016 and August 2017. Data collected included clinic "no show" rates, operating room (OR) utilization, reimbursement rates, and postoperative visits. RESULTS: There were 89 patients scheduled for SVS, of which 63% (n=56) were male, and the median age was 6 years [IQR, 4-9]. The SVS clinic "no show" rate was 2% (n=2) compared to the pediatric surgery clinic "no show" rate of 11% (p=0.01). The SVS OR block utilization rate was 90%. Payment was received from third-party payors for 92% of consultations and 100% of operative procedures without securing prior authorization. Postoperatively 25% (n=17) of patients presented to clinic for follow-up, and one child presented to the emergency department for vomiting. There were no hospital admissions. CONCLUSION: Single-Visit Surgery is an alternative model of ambulatory surgical care that improves institutional efficiency while also enhancing the patient experience. TYPE OF STUDY: Retrospective cohort review LEVEL OF EVIDENCE: III.

Single-Visit Surgery Offers Added Convenience and Excellent Family Satisfaction.

BACKGROUND: The traditional model for elective ambulatory surgical care includes three separate visits to the surgeon: an initial consultation, a second for outpatient surgery, and a third for postoperative follow-up. Single-Visit Surgery (SVS) is an alternative model of ambulatory surgical care that consolidates care into a single appointment where patients with straightforward surgical problems are evaluated in the morning and undergo a surgical procedure later that same afternoon. In April 2016, SVS was introduced at a tertiary-care freestanding children's hospital. Our objective for this study was to evaluate our early experience and conduct a survey of our patient's caregivers to evaluate their satisfaction with SVS. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients that were seen as part of SVS from April 2016 through December 2016. Data collected included demographics, diagnoses, procedures performed, clinical outcomes, and distance traveled to the hospital. In addition, adult caregivers of SVS patients were asked to participate in a telephone survey. RESULTS: There were 43 patients seen through SVS during the study period. The median age was 7 y. Of the 43 patients evaluated through SVS, 40 (93%) of them underwent surgery. Of the 40 patients that had surgery, 27 (68%) of the families participated in the telephone survey. Of those responding, 93% were strongly satisfied, and 7% were satisfied with the care through SVS. All families said they would recommend the SVS program to a friend. CONCLUSIONS: SVS is an alternative model of ambulatory surgical care that adds convenience to the patient experience and results in excellent family satisfaction.

Activity-Based Costing.

Cost allocation for health care professionals can be an enigma within the health care system. Activity-based costing (ABC) is an accounting tool that allocates costs incurred through a company's practice of providing goods and services to the consumer. ABC can provide insight into inefficiencies across the supply chain and unlock excess capacity. This, in turn, can drive services provided toward generating more value for the hospital system. ABC can be tailored to focus upon a unit of measurement that holds value as it pertains to production. With time-driven ABC (Td-ABC), we look to use the advantages of both the fee-for-service and capitation model to transition to a value-based system. Providers are rewarded based on efficiencies and successful outcomes in patient care while disincentivizing poor outcomes and superfluous volume/expenditures. ABC, however, does not come without its own risks and disadvantages, and the user must exercise caution in applying this cost-allocating tool to avoid detriment to its practice. A review of the literature was conducted to analyze the implementation, medical application, and advantages and disadvantages of Td-ABC.

Diffuse and uncontrolled vascular smooth muscle cell proliferation in rapidly progressing pediatric moyamoya disease.

Moyamoya disease is a rare stroke syndrome of unknown etiology resulting from stenosis or occlusion of the supraclinoid internal carotid artery (ICA) in association with an abnormal vascular network in the basal ganglia. Although the highest incidence of moyamoya disease is in pediatric patients, pathology reports have been primarily limited to adult samples and describe occlusive fibrocellular lesions in the intimae of affected arteries. We describe the case of a young girl with primary moyamoya disease who presented at 18 months of age with right hemiparesis following an ischemic stroke. Angiography showed stenosis of the distal left ICA, left middle cerebral artery, and right ICA. An emergent left-sided dural inversion was performed. Recurrent strokes and alternating hemiplegia necessitated a right dural inversion 6 months later. Nonetheless, her aggressive disease proved uniquely refractory to surgical revascularization, and she succumbed to recurrent strokes and neurological deterioration at 2.5 years of age. Pathological specimens revealed a striking bilateral occlusion of the anterior carotid circulation resulting from intimal proliferation of smooth muscle cells (SMCs). Most strikingly, the ascending aorta and the superior mesenteric artery demonstrated similar intimal proliferation, along with SMC proliferation in the media. The systemic pathology involving multiple arteries in this extremely young child, the first case of its kind available for autopsy, suggests that globally uncontrolled SMC proliferation, in the absence of environmental risk factors and likely resulting from an underlying genetic alteration, may be a primary etiologic event leading to moyamoya disease.