Estimating Length of Stay for Simple Gastroschisis.

BACKGROUND: Length of stay (LOS) is an important measure of quality; however, estimating LOS for rare populations such as gastroschisis is problematic. Our objective was to identify explanatory variables for LOS and build a model to estimate LOS in neonates with simple gastroschisis. METHODS: In 73 neonates with simple gastroschisis (47% female, 67% White), statistical correlations for 31 potential explanatory variables for LOS were evaluated using multivariate linear regression. Poisson regression was used to estimate LOS in predetermined subpopulations, and a life table model was developed to estimate LOS for simple gastroschisis. RESULTS: Female sex (-2.4 d), "time to silo placement" (0.9 d), total parenteral nutrition days (0.6 d), need for any nasogastric feedings (11.4 d) and at discharge (-7 d), "feeding tolerance" (0.4 d), days to first postoperative stool (-0.3 d), and human milk exposure (-3.4 d) associated with LOS in simple gastroschisis. Estimated LOS for preterm neonates was longer than term infants (5.4 versus 4.6 wk) but similar for estimates based on sex and race. Based on these associations, we estimate that >50% of neonates with simple gastroschisis will be discharged by hospital day 35. CONCLUSIONS: We identified several associations that explained variations in LOS and developed a novel model to estimate LOS in simple gastroschisis, which may be applied to other rare populations.

Management of Patients with Gastroschisis Requiring Extracorporeal Membrane Oxygenation for Concurrent Respiratory Failure.

Treatment of gastroschisis often requires multiple surgical procedures to re-establish abdominal domain, reduce abdominal contents, and eventually close the abdominal wall. In patients who have concomitant respiratory failure requiring extracorporeal membrane oxygenation (ECMO), this process becomes further complicated. This situation is rare and only five such cases have been reported in the ECMO registry database. Management of three of the five patients along with results and implications for future care of similar patients is discussed here. Two patients had respiratory failure due to meconium aspiration syndrome and one patient had persistent acidosis as well as worsening pulmonary hypertension leading to the decision of ECMO. The abdominal contents were placed in a spring-loaded silastic silo while on ECMO and primary closure was performed three to six days after the decannulation. All three patients survived and are developmentally appropriate. We recommend avoiding aggressively reducing the abdominal contents and using a silo to conservatively reducing the gastroschisis while the patient is on ECMO therapy. Keeping the intra-abdominal pressure below 20 mm Hg can possibly reduce ECMO days and ventilator time and has been shown to decrease morbidity and mortality. Patients with gastroschisis and respiratory failure requiring ECMO can have good outcomes despite the complexity of required care.

Venovenous Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure.

Conventional treatment of respiratory failure involves positive pressure ventilation that can worsen lung damage. Extracorporeal membrane oxygenation (ECMO) is typically used when conventional therapy fails. In this study, we evaluated the use of venovenous (VV)-ECMO for the treatment of severe pediatric respiratory failure at our institution. A retrospective analysis of pediatric patients (age 1-18) placed on ECMO in the last 15 years (1999-2014) by the pediatric surgery team for respiratory failure was performed. Five pediatric patients underwent ECMO (mean age 10 years; range, 2-16). All underwent VV-ECMO. Diagnoses were status asthmaticus (2), acute respiratory distress syndrome due to septic shock (1), aspergillus pneumonia (1), and respiratory failure due to parainfluenza (1). Two patients had severe barotrauma prior to ECMO initiation. Average oxygenation index (OI) prior to cannulation was 74 (range 23-122). No patients required conversion to VA-ECMO. The average ECMO run time was 4.4 days (range 2-6). The average number of days on the ventilator was 15 (range 4-27). There were no major complications due to the procedure. Survival to discharge was 100%. Average follow up is 4.4 years (range 1-15). A short run of VV-ECMO can be lifesaving for pediatric patients in respiratory failure. Survival is excellent despite severely elevated oxygen indices. VV-ECMO may be well tolerated and can be considered for severe pediatric respiratory failure.

Evaluation of soft tissue attachments to a novel intra-abdominal prosthetic in a rabbit model.

BACKGROUND: Laparoscopic ventral hernia repair requires placement of an intraperitoneal prosthetic. Composite mesh types have been developed to address the shortcomings of standard meshes. The authors evaluated the host reaction to intraperitoneal placement of a novel composite material. MATERIALS AND METHODS: A comparison of an innovative polypropylene/polylactide composite mesh was made to parietex composite (PCO), Proceed, and DualMesh. Eighteen meshes per group were implanted on intact peritoneum in New Zealand white rabbits. The main outcome measures included the formation of visceral adhesions, adhesion tenacity, tensiometric measurements, and histological analysis. Evaluations of adhesions were made at 1, 4, and 16 weeks using a 2-mm minilaparoscopy. RESULTS: There were no significant differences in the mean adhesion scores between the composite mesh types at week 1 (P = .15) and week 16 (P = .06). At 4 weeks, PCO had significantly fewer adhesions when compared with the other 3 mesh types (P = .02). Adhesion tenacity was also equivalent within the group at 16 weeks (P = .06). Tensiometry and histological analysis revealed no statistically significant differences between the mesh types. CONCLUSIONS: Four different composite mesh types had equivalent intra-abdominal soft tissue attachments in a rabbit model after a 16-week implantation period. PCO demonstrated the lowest mean adhesion score of each mesh type. Each mesh exhibited equivalent stiffness and energy to failure after explantation. The 4 composite mesh types demonstrated the successful formation of a neoperitoneum and comparable host biocompatibility as evidenced by similar degrees of inflammation.

Effect of bacterial exposure on acellular human dermis in a rat ventral hernia model.

BACKGROUND: Effectiveness of acellular human dermis (AHD) as an alternative to synthetic mesh in contaminated fields has been described. Cellular migration after implantation and corresponding strength of attachment is not well documented. Our aim is to correlate AHD vascularization, fibroblast migration, and strength of attachment with presence of inflammatory cells in clean and contaminated fields. MATERIALS AND METHODS: Lewis rats were randomized to a control and three experimental groups. AHD was placed as an onlay over the intact abdominal wall. Experimental groups (n=72) were exposed to Staphylococcus aureus at 1 x 10(4), 1 x 10(5), or 1 x 10(6) by direct application; controls (n=12) were not exposed. At 5 and 28 d, abdominal walls were explanted and tissue ingrowth assessed via tensiometry measuring energy (E) and max stress (MS) at the AHD-tissue interface. Vascularity, fibroblast migration, and inflammatory cell migration were compared using light microscopy. RESULTS: Shear strength reported as energy and max stress were significantly greater at 28 versus 5 d in all experimental groups, remaining unchanged in controls. Plasma cells and histiocytes significantly increased in all groups; macrophages increased in experimental groups only. Vascular ingrowth increased significantly in all groups; fibroblast migration was greater in controls and 1 x 10(6) exposed group only. CONCLUSIONS: Contamination of AHD results in inflammatory cell influx and a surprising increase in shear strength. Interestingly, shear strength does not increase without contamination. Inflammation stimulates vascular ingrowth, but not equally significant fibroblast migration. Longer survivals are required to determine if energy and max stress of controls increase, and fibroblast migration follows vascular ingrowth.

Laparoscopic versus open live donor nephrectomy: outcomes analysis of 266 consecutive patients.

BACKGROUND: Minimally invasive surgical techniques have become the preferred method for live donor nephrectomy (DN) in many centers. We compared our experience with laparoscopic and open DN in a single institution. METHODS: Data for 266 consecutive live DNs were collected. Demographic, intraoperative, and postoperative data were compared. RESULTS: A total of 199 hand-assisted laparoscopic (HAL) DNs, 18 totally laparoscopic (TL), and 49 open DNs were performed. Laparoscopic DN was associated with a shorter operative time (p < 0.013), less blood loss (p < 0.0001), and shorter hospital stay (p < 0.0001) than open DN. Warm ischemia time was less for HAL versus TL DN (59.9 vs. 90.0 seconds; p < 0.0001). Compared with open DN, laparoscopic patients had fewer complications (p < 0.03), fewer wound infections (p < 0.004), less wound paresthesias (p < 0.0009), and fewer complaints of chronic incisional pain (p < 0.0001). Delayed graft function during the first 24 h postoperatively was significantly less for the laparoscopic DN versus the open cases (12.9% vs. 30.4%; p = 0.003), but the need for hemodialysis for the recipient was similar between groups (6.9% vs. 5%; p = not significant). CONCLUSIONS: Laparoscopic DN resulted in less blood loss, reduced operative time, and shorter hospital stay than open DN. Hand-assisted laparoscopic DN has the potential to decrease warm ischemia time for renal allografts. Donors managed laparoscopically had fewer complications, significantly less wound-related morbidity, and less delayed graft function than patients who underwent open DN.

What is the ideal interval between training sessions during proficiency-based laparoscopic simulator training?

BACKGROUND: The aim of this study was to identify the ideal interval between training sessions in a proficiency-based laparoscopic suturing simulator curriculum. METHODS: We analyzed performance data from 3 randomized controlled trials of novices (n = 66) who followed a similar proficiency-based simulator curriculum in laparoscopic suturing on the Fundamentals of Laparoscopic Surgery model. The change in performance and intertraining interval were correlated. RESULTS: Overall participant performance improved from 530 +/- 58 seconds at baseline to 81 +/- 14 seconds at training completion (P < .001). Intertraining intervals ranged from 1 to 43 days and performance change between training sessions varied widely. There was no correlation of performance change with intertraining interval (r = .05, P = .30). Performance deterioration was similar at different intertraining intervals. Shorter intervals were associated, however, with shorter training duration (r = .35, P = .005). CONCLUSIONS: No association was found between intertraining interval and change in performance during proficiency-based laparoscopic simulator training but shorter intervals were associated with improved skill acquisition. Further study is needed to confirm these findings.

Treatment of appendiceal adenocarcinoma in the United States: penetration and outcomes of current guidelines.

Current treatment guidelines for appendiceal adenocarcinoma specify that right hemicolectomy should be performed. This study evaluates appendiceal cancer outcomes in the United States and treatment guideline compliance. Data for patients diagnosed with appendiceal adenocarcinoma in the Surveillance, Epidemiology, and End Results database (1988 to 2003) were analyzed. The 2511 patients with appendiceal adenocarcinoma had an average age of 59.3 years, average tumor size of 4.05 cm, and 5-year survival rate of 57 per cent. The 5-year survival rate by stage was statistically different (P < 0.001): Stage 0, 95.7 per cent; Stage I, 88 per cent; Stage II, 75.2 per cent; Stage III, 37.1 per cent; and Stage IV, 25.6 per cent. Appendectomy was performed in 33.4 per cent, which does not follow the current guidelines. In this group, 5-year survival was significantly less for patients with Stage III and IV disease (48% vs. 38.2%, P = 0.03; 46% vs. 26.4%, P = 0.04, respectively). Patients with Stage I and II disease had similar 5-year survival for appendectomy and colectomy (90.2% vs. 90.1%, P = 0.7; 78.3% vs. 76%, P = 0.6, respectively). One-third of patients with adenocarcinoma did not undergo current surgical guideline therapy. However, it appears hemicolectomy only improved survival for patients with later-stage disease. The current data raise the question of whether Stage I and II appendiceal cancer can be adequately treated with simple appendectomy.

Improved outcomes for laparoscopic appendectomy compared with open appendectomy in the pediatric population.

INTRODUCTION: The appendectomy is a common emergent surgical procedure in the pediatric population. The aim of this study was to examine our institution's experience and outcomes in the appendectomy in the pediatric population early in our transition from open surgery to a predominantly laparoscopic approach. METHODS: We retrospectively studied all pediatric patients (age 20 years) that underwent an appendectomy at a tertiary care center over 2 years. The data collected included patient demographics, comorbidities, operative details, outcomes, and complications. RESULTS: Two hundred twenty-three consecutive patients, with a mean age of 9.5 (3.9) years, were included in the study. Forty-four laparoscopic and 179 open appendectomies were performed. Two of the laparoscopic cases were converted to open appendectomies. Significant differences were seen between the two groups, with longer operative times (P < 0.0001) and lower estimated blood loss (P = 0.007) in the laparoscopic group. Operative times improved significantly for the laparoscopic group as the surgeons became more experienced (P = 0.03). The laparoscopic group used intravenous pain medication for a shorter time (0.8 vs. 1.9 days; P = 0.0003) and had a shorter postoperative hospital length of stay (2.2 vs. 3.4 days; P = 0.004). The laparoscopic group had fewer wound infections (2.3% vs. 6.2%; P = 0.3), intra-abdominal abscesses (4.5% vs. 5.6%; P = 0.8), and postoperative ileus (0% vs. 2.2%; P = 0.3), although these differences did not reach statistical significance. CONCLUSION: The laparoscopic appendectomy procedure is a safe alternative to open appendectomy in pediatric patients and results in shorter hospital stays with less postoperative pain.

Oral cancer knowledge and experience: a survey of South Carolina medical students in 2002.

BACKGROUND: Compared to the U.S. states and District of Columbia, the adult population in South Carolina ranks in the high five in oral cavity and pharynx cancer mortality rate and top ten for incidence rate. Previous studies revealed a lack of knowledge related to the diagnosis of oral cancer among health professionals in the USA. This study assessed the oral cancer knowledge and experience of medical students in an academic setting. METHODS: This IRB approved cross-sectional survey used a self-administered pilot-tested questionnaire and the census of the Medical University of South Carolina medical students. Data were summarized by frequencies and chi-square comparisons of pre-clinical (first and second year) and clinical (third and fourth year) students. RESULTS: The overall response rate was 79% (450/571 students), range 61-91% by year. Significant (p < 0.001) differences were found between pre-clinical and clinical students for knowledge of risk factors, signs and symptoms of oral cancer, and tobacco cessation techniques; with clinical students more knowledgeable but at less than 78% accuracy. All students were in high agreement of the role and responsibility of physicians in tobacco cessation, and in medical history taking. Four students had seen or been instructed on how to perform an oral biopsy. Most (75%) of fourth year students felt adequately trained to palpate neck lymph nodes. However, less than 7% of all students perceived they were adequately trained to examine patients for oral cancers. CONCLUSIONS: Results suggest that these students may not receive adequate exposure to oral cancer prevention and detection knowledge and practices. Additional training to increase knowledge of risk factors and cessation counseling, and knowledge of signs and symptoms and examination skills may improve oral cancer prevention and detection. The implication is that additional education for the medical students in prevention and detection may lead to improvements in South Carolina oral cavity and pharyngeal cancer incidence and mortality rates.

Research subject privacy protection in otolaryngology.

BACKGROUND: Health Insurance Portability and Accountability Act regulations, which took effect on April 14, 2003, placed new constraints on the use of protected health information for research purposes. OBJECTIVE: To review practices of research subject privacy protection in otolaryngology in order to determine steps necessary to achieve compliance with Health Insurance Portability and Accountability Act regulations. STUDY DESIGN: Literature review. METHODS: Articles appearing in 2001 in 3 widely circulated otolaryngology journals were classified according to study design. The "Methods" section of each article was reviewed to determine whether the informed consent and institutional review board processes were clearly documented. RESULTS: Descriptive studies involving case reports and case series were more common than observational studies that include a control group (66% vs 11%). Few case series documented the consent process (18%) and institutional review board process (19%). Observational designs demonstrated better documentation of the consent process (P<.001) and the institutional review board exemption and approval process (P<.001). CONCLUSIONS: Methods used to protect subject privacy are not commonly documented in case series in otolaryngology. More attention needs to be given to research subject privacy concerns in the otolaryngology literature in order to comply with Health Insurance Portability and Accountability Act regulations.