Lived experiences of pain in children and young people with cerebral palsy.

AIM: To explore the lived experiences of pain in children and young people with cerebral palsy (CP). METHOD: Participants were recruited from the Sydney Children's Hospitals Network and the New South Wales/Australian Capital Territory CP Registers. Inclusion criteria were as follows: CP; aged 9 to 17 years; current/past experience of pain; fluent in English; no greater than mild intellectual disability. Purposive sampling ensured representation across age, motor subtypes, and Gross Motor Function Classification System (GMFCS) levels. Semi-structured face-to-face interviews were conducted. Data were analysed following an interpretative phenomenological approach. RESULTS: Ten participants (three male) were included (mean age 14y 5mo, SD 2y), GMFCS levels I (n=4), II (n=3), III (n=2), and IV (n=1). Analysis led to three superordinate themes: (1) Everybody's experience of pain is different; (2) When the pain is winning; (3) 'I know how to deal with it'. Pain contributors and locations varied between children. Pain intruded on school, physical activity, and psychosocial functioning. Children described personalized strategies used to deal with pain. INTERPRETATION: In this study, children self-reported highly individualized pain experiences which interfered with their daily life and psychosocial well-being. There is a need for improvement in pain assessment and a personalized approach to pain management.

Does the false-negative rate for 1 or 2 negative sentinel nodes after neo-adjuvant chemotherapy translate into a high local recurrence rate?

Prospective trials demonstrate that sentinel node (SN) biopsy after neo-adjuvant chemotherapy (NACT) has a significant false-negative rate (FNR) when only 1 or 2 SNs are removed. It is unknown whether this increased FNR correlates with an elevated risk of recurrence. Tumor Registry data at an NCI-Designated Comprehensive Cancer Center were reviewed from 2004 to 2018 for patients having a negative SN biopsy after NACT. Among 190 patients with histologically negative nodes after NACT having 1 (n = 42), 2 (n = 46), and ≥3 (n = 102) SNs, axillary recurrences occurred in 7.14%, 0%, and 1.96% (p = 0.09), breast recurrences occurred in 2.38%, 6.52%, and 0.98% (p = 0.12), and distance recurrences occurred in 16.67%, 8.70%, and 7.84% (p = 0.27), respectively. Time to first recurrence did not differ by SN count (p = 0.41). After adjustment for age, race, clinical stage, and receptor status, there were no differences in the rates of axillary (p = 0.26), breast (p = 0.44), or distance recurrence (p = 0.24) by numbers of SNs harvested. Median follow-up was 46.8 months. Despite higher post-NACT FNRs reported in randomized trials for patients having <3 sentinel nodes, recurrence rates were not significantly different for 1 versus 2 versus ≥3 SNs. This suggests that patients having 1 or 2 post-NACT SNs identified may not necessitate axillary dissection.

Laparoscopic pyloromyotomy: comparing the arthrotomy knife to the Bovie blade.

BACKGROUND: Laparoscopic pyloromyotomy was performed at our institution using an arthrotomy knife until it became unavailable in 2010. Thus, we adapted the use of the blunt Bovie tip, which can be used with or without electrocautery to perform the myotomy. This study compared the outcomes between using the arthrotomy knife versus the Bovie blade in laparoscopic pyloromyotomies. MATERIALS AND METHODS: Retrospective review was performed on all laparoscopic pyloromyotomy patients from October 2007 to September 2012. Arthrotomy knife pyloromyotomy patients were compared with those performed with the Bovie blade. Patient demographics, diagnostic measurements, electrolyte levels, length of stay, operative time, and complications were compared. RESULTS: A total of 381 patients were included, with 191 in the arthrotomy group and 190 in the Bovie blade group. No significant differences existed between groups in age, weight, gender, pyloric dimensions, electrolyte levels, or length of stay. Mean operative times were 15.8±5.6 min with knife and 16.4±5.3 min for Bovie blade (P=0.24). In the arthrotomy knife group, there was one incomplete pyloromyotomy and one omental herniation. There was one wound infection in each group. Readmission rate was greater in the arthrotomy knife group (5.7%) versus the Bovie blade group (3.1%). CONCLUSIONS: The Bovie blade appears to offer no objective disadvantages compared with the arthrotomy knife when performing laparoscopic pyloromyotomy.

Fever after redo Nissen fundoplication with hiatal hernia repair.

BACKGROUND: Fevers often arise after redo fundoplication with hiatal hernia repair. We reviewed our experience to evaluate the yield of a fever work-up in this population. METHODS: We performed a retrospective review of children undergoing redo Nissen fundoplication with hiatal hernia repair between December 2001 and September 2012. Temperatures and fever evaluations of those children receiving a mesh repair were compared with those without mesh. A fever defined as temperature ≥38.4°C. RESULTS: Fifty one children received 46 laparoscopic, 4 open, and 1 laparoscopic converted to open procedures. Biosynthetic mesh was used in 25 children whereas 26 underwent repair without mesh. A fever occurred in 56% of those repaired with mesh compared with 23.1% without mesh (P = 0.02). A fever evaluation was conducted in 32% of those with mesh compared with 11.5% without mesh (P = 0.52). A urinary tract infection was identified in one child after mesh use and an infection was identified in two children without mesh, one pneumonia and one wound infection (P = 1). In those repaired with mesh, there was no significant difference in maximum temperature. CONCLUSIONS: Fever is common after redo Nissen fundoplication with hiatal hernia repair and occurs more frequently, and with higher temperatures in those with mesh. Fever work-up in these patients is unlikely to yield an infectious source and is attributed to the extensive dissection during the redo procedure.

Radiation exposure from head computed tomography scans in pediatric trauma.

BACKGROUND: We have previously reported that children receive significantly less radiation exposure after abdominal and/or pelvis computed tomography (CT) scanning for acute appendicitis when performed at our children's hospital (CH) rather than at outside hospitals (OH). In this study, we compare the amount of radiation children receive from head CTs for trauma done at OH versus those at our CH. METHODS: A retrospective chart review was performed on all children transferred to our hospital after receiving a head CT for trauma at an OH between July 2012 and December 2012. These children were then blindly case matched based on date, age, and gender to children at our CH. RESULTS: There were 50 children who underwent head CT scans for trauma at 28 OH. There were 21 females and 29 males in each group. Average age was 7.01 ± 0.5 y at the OH and 7.14 ± 6.07 at our CH (P = 0.92). Average weight was 30.81 ± 4.69 kg at the OH and 32.69 ± 27.21 kg at our CH (P = 0.81). Radiation measures included dose length product (671.21 ± 22.6 mGycm at OH versus 786.28 ± 246.3 mGycm at CH, P = 0.11) and CT dose index (53.4 ± 2.26 mGy at OH versus 49.2 ± 12.94 mGy at CH, P = 0.56). CONCLUSIONS: There is no significant difference between radiation exposure secondary to head CTs for traumatic injuries performed at OH and those at a dedicated CH.

Comparison of outcomes for single-incision laparoscopic inguinal herniorrhaphy and traditional three-port laparoscopic herniorrhaphy at a single institution.

BACKGROUND: Evidence in the literature regarding the potential of single-incision laparoscopic (SILS) inguinal herniorrhaphy currently is limited. A retrospective comparison of SILS and traditional multiport laparoscopic (MP) inguinal hernia repair was conducted to assess the safety and feasibility of the minimally invasive laparoscopic technique. METHODS: All laparoscopic inguinal hernia repairs performed by three surgeons at a single institution during 4 years were reviewed. Statistical evaluation included descriptive analysis of demographics including age, gender, body mass index (BMI), and hernia location (uni- or bilateral), in addition to bivariate and multivariate analyses of surgical technique and outcomes including operative times, conversions, and complications. RESULTS: The study compared 129 patients who underwent SILS inguinal hernia repair and 76 patients who underwent MP inguinal hernia repair. The cases included 190 men (92.68 %) with a mean age of 55.36 ± 18.01 years (range, 8-86 years) and a mean BMI of 26.49 ± 4.33 kg/m(2) (range, 17.3-41.7 kg/m(2)). These variables did not differ significantly between the SILS and MP cohorts. The average operative times for the SILS and MP unilateral cases were respectively 57.51 and 66.96 min. For the bilateral cases, the average operative times were 81.07 min for SILS and 81.38 min for MP. A multivariate analysis using surgical approach, BMI, case complexity, and laterality as the covariates demonstrated noninferiority of the SILS technique in terms of operative time (p = 0.031). No conversions from SILS to MP occurred, and the rates of conversion to open procedure did not differ significantly between the cohorts (p = 1.00, Fisher's exact test), nor did the complication rates (p = 0.65, χ (2)). CONCLUSIONS: As shown by the findings, SILS inguinal herniorrhaphy is a safe and feasible alternative to traditional MP inguinal hernia repair and can be performed successfully with similar operative times, conversion rates, and complication rates. Prospective trials are essential to confirm equivalence in these areas and to detect differences in patient-centered outcomes.

Nursing preference of topical silver sulfadiazine versus collagenase ointment for treatment of partial thickness burns in children: survey follow-up of a prospective randomized trial.

We performed a nursing survey to inquire about nursing preferences toward the use of silver sulfadiazine (SSD) and collagenase (CO). We performed a survey between September 2012 and December 2012 asking nurses to rate the application/removal of both products and provide a description of their preferences. Ten study nurses (83%) preferred CO over SSD (P < .001). Two nurses (17%) had no preference. Negative comments on SSD were pseudoeschar (50%), difficult application burns (25%), messiness (67%), and increased number of dressing changes (25%). Negative comments on CO were the need for an additional antimicrobial agent (58%), although 1 nurse noted the higher expense with CO. Nurses preferred CO because of cleanliness of dressing (17%), lack of pseudoeschar (25%), and less pain with dressing changes (8%). Despite no difference in outcomes between SSD and CO, experienced burn nurses prefer CO because of perceptions of decreased trauma and frequency of dressing changes.

Implications of Foley catheterization in children with perforated appendicitis.

BACKGROUND: We treat patients after appendectomy for perforated appendicitis with patient controlled analgesia (PCA) using a background continuous dose. We usually place urinary catheters in these patients because of concerns of urinary retention. The objective of the present study was to determine the rate of urinary retention in this patient population when a catheter was not used or was removed before the continuous PCA infusion was discontinued. METHODS: We performed a retrospective review of all patients who had received PCA postoperatively for perforated appendicitis from December 2008 to May 2011. The demographics, need for replacement of a Foley catheter, number of recorded nursing calls to physicians, and the incidence of urinary tract infection was recorded. Patients who had received a urinary catheter intraoperatively were compared with those who had not. Subgroups were also created according to whether the patients with a Foley catheter had undergone removal of their catheter before or after cessation of the continuous PCA infusion. RESULTS: Of 242 patients, 20 (8.3%) did not have a catheter postoperatively, 1 of whom required a catheter because of retention. Of the 222 patients who started with a catheter, 2 required reinsertion for retention (P = 0.59). Age, gender, and body mass index were similar for patients with and without a catheter. In the subgroup analysis, of the patients with a catheter, 48 (21.6%) had their catheter removed before discontinuation of the continuous PCA infusion and none required Foley catheter replacement. Of the 174 patients whose catheters were removed after discontinuation of the continuous PCA dose, 2 required catheter replacement (P = 0.46). A significantly higher percentage of telephone calls was generated for patients with a catheter than for patients without a Foley catheter (41.4% versus 10%, P = 0.007). No patients with a catheter developed a urinary tract infection. CONCLUSIONS: Patients with a perforated appendicitis who receive a continuous PCA have a low rate of urinary retention whether or not a catheter has been placed intraoperatively.

Accuracy of American College of Surgeons National Surgical Quality Improvement Program Pediatric for laparoscopic appendectomy at a single institution.

BACKGROUND: In October 2008, the American College of Surgeons revealed the National Surgical Quality Improvement Program (NSQIP) Pediatric in an effort to improve quality of surgical care in children. A 5% disagreement rate of data reported between institutions is accepted. The two goals of this study were to (1) determine if the random sampling performed with NSQIP data collection was representative of the population, and (2) verify that data captured in NSQIP was accurate. METHODS: For children undergoing laparoscopic appendectomy from April 2010-April 2011, demographic data, length of stay (LOS), and rates of surgical site infection (SSI) and postoperative abscess recorded in NSQIP (group 1) were compared with data from chart review (group 2). Secondarily, all NSQIP data were examined for accuracy by comparing relevant data points to existing databases. All disagreements were further examined with review of the medical chart. Unpaired t-test and χ(2) with Fisher's exact test were used in the statistical analysis. RESULTS: NSQIP Pediatric captured data from 126 children (group 1); group 2 had 525 children. There were no significant differences in age, body mass index, gender, race or LOS between the two groups. Rate of SSI was 1.6% in group 1 and 1.7% in group 2 (P = 0.92). Abscess rate was 1.6% in group 1 and 3.4% in group 2 (P = 0.28). There were six errors in the NSQIP database. One child was listed as having two SSI. One child with postoperative abscess was missed and another was not counted as they were not categorized correctly. Recorded LOS was incorrect for two children and the other had incorrect age. CONCLUSIONS: NSQIP Pediatric captured a representative sample of patients undergoing laparoscopic appendectomy. Errors were found in the reporting of outcomes for SSI and postoperative abscess in children undergoing laparoscopic appendectomy. Given the low incidence of these outcomes, there is little effect on percentages of complications reported.

Clinical outcomes following bowel resection versus reduction of intussusception.

BACKGROUND: Intussusception is most commonly managed with air-contrast reduction. However, when this fails, emergent operation with resection or manual reduction is indicated. It is not known if there are advantages to resection compared with manual reduction. METHODS: A retrospective review of all patients receiving operative care for intussusception from February 2000 to December 2011. Patients undergoing intestinal resection were compared with those treated with manual reduction alone. RESULTS: Of 111 patients, 49 underwent resection and 62 underwent manual reduction. Mean (±SD) time to oral intake favored manual reduction (2.1 ± 1.2 versus 2.6 ± 1.2 d, respectively, P=0.05). Manual reduction was associated with a greater need for repeat imaging (47% versus 18%, P=0.002) and the only recurrences were with manual reduction (8% versus 0%, P=0.1). Mean duration of stay was no different (P=0.36), nor was the need for reoperation (P=0.9). CONCLUSIONS: Patients undergoing manual reduction have an increased number of radiographic imaging procedures. The surgeon should have a low threshold for resection for intussusceptions requiring operative management.

The prevalence of Hirschsprung disease in premature infants after suction rectal biopsy.

BACKGROUND: The prevalence of Hirschsprung disease (HD) in the premature infant population is not well documented. However, delayed passage of stool is common in premature infants, and suction rectal biopsy (SRB) is often used to evaluate for HD in this population. The use of SRB is unknown. Therefore, we evaluated the role of SRB in premature infants with abnormal stooling patterns. METHODS: After Institutional Review Board approval, a retrospective study was conducted on all infants having an SRB performed to exclude HD from January 2000 to December 2010. Infants were divided into two groups according to gestational age (premature < 37 wk; term ≥ 37 wk). Demographics, diagnosis, treatments, and outcomes were collected. A subset analysis was performed on patients diagnosed with HD. RESULTS: Two hundred sixty-nine infants were identified (113 premature and 156 term). Six premature infants (5.3%) and 79 term infants (50.6%) were found to have HD (P < 0.01). As expected, gestational age was significantly different between groups (31.7 versus 38.9 wk, P < 0.01) (Table 1). Premature infants were less likely to have prenatal care (35% versus 55%, P < 0.01) and had longer lengths of hospital stay (45.6 versus 17.6 d, P < 0.01). The most common location of aganglionosis was rectosigmoid in both groups (group 1, 50%; group 2, 33%, P = 0.7). CONCLUSIONS: HD occurs significantly less often in premature infants than in term infants. Alternative diagnoses should be investigated in this population when delayed stooling patterns are encountered. SRB should be used more selectively in this group.

The role of minimally invasive surgery in pediatric trauma: a collective review.

Although minimally invasive surgery (MIS) has been utilized in selective trauma patients, there a relative paucity of literature on its role in both blunt and penetrating trauma in the pediatric population. Our purpose is to review the current literature on the role of MIS in abdominal and thoracic pediatric trauma. A review of the literature, indications, risks, and benefits of MIS in trauma will be presented. Relevant literature was obtained from use of the PubMed database.

Reduced use of computed tomography in patients treated with interval appendectomy after implementing a protocol from a prospective, randomized trial.

BACKGROUND: In 2009, we instituted a protocol to standardize care for patients undergoing interval appendectomy based on results from a prospective trial that demonstrated a reduction in the mean number of computed tomography (CT) scans performed. The goal of this study was to determine if our current practice now resulted in fewer CT scans as a result of this trial. METHODS: A retrospective review of all patients undergoing interval appendectomy for perforated appendicitis from March 2009 to March 2011 was performed. Demographics and outcomes were compared to previously collected data from a retrospective study prior to institution of the protocol and to the prospective trial. RESULTS: During the study period, 45 patients underwent interval appendectomy. There were no differences in demographics among the three studies. Similar numbers of patients underwent aspiration or percutaneous drainage. There continues to be a significant reduction in the number of CT scans (3.5 ± 2.0 vs. 2.1 ± 1.3, P = 0.0001) and health care visits (7.6 ± 2.8 vs. 4.5 ± 1.4, P = 0.0001) when comparing management prior to the prospective trial to management since its completion. CONCLUSION: A protocol for management of patients undergoing interval appendectomy care results in fewer health care visits and CT scans.

Program evaluation of an adapted PEERS® social skills program in young adults with autism spectrum disorder and/or mild intellectual impairment and social skills difficulties.

RATIONALE, AIMS AND OBJECTIVES: Social challenges are common for young adults with autism spectrum disorder (ASD) and/or mild intellectual impairment, yet few evidence-based interventions exist to address these challenges. PEERS®, the Program for the Education and Enrichment of Relational Skills, has been shown to be effective in improving the social skills of young adults with ASD; however, it requires a significant time commitment for parents of young adults. As such, this mixed-methods study aimed to investigate the experiences of young adults, parents and PEERS® social coaches participating in an adapted PEERS® program, and to evaluate its acceptability and efficacy. METHOD: Young adults with ASD and/or mild intellectual impairment participated in a 16-week PEERS® program. Parents and PEERS® social coaches attended fewer, condensed sessions, where they learnt program content to support the young adults' social skill development at home and in the community. Focus groups were conducted post intervention. Quantitative pre-post assessment using the Social and Emotional Loneliness Scale for Adults, the Test of Young Adult Social Skills Knowledge, and Quality of Socialization Questionnaire-Young Adults was completed by young adults. The Social Responsiveness Scale Second Edition was completed by young adults and their parents. RESULT: Qualitative results revealed that, taken together, young adults, parents and PEERS® social coaches all felt that the adapted PEERS® program was 'challenging, but worth it'. The program was acceptable with a 93% attendance rate across all sessions. Whilst young adults' perceptions of their own social functioning did not change post-intervention, their knowledge of social skills content improved significantly (p < 0.05). Parent perceptions of young adults' social responsiveness also improved (p < 0.05). CONCLUSIONS: Social skill knowledge, social responsiveness, and social engagement improved significantly following the completion of the adapted PEERS® program. It was deemed acceptable and worthwhile by young adults, their parents and PEERS® social coaches.

Understanding the utility of "Talk-to-Me" an online suicide prevention program for Australian university students.

BACKGROUND: Australian university students are at risk of experiencing poor mental health, being vulnerable to self-harm and suicidal ideation. AIM: "Talk-to-Me" is a suicide ideation prevention Massive open online course (MOOC) previously showing it can support Western Australian university students' knowledge of identifying and responding to suicide ideation in themselves and others. METHODS: A multi-site one-group pre-test/post-test design with a 12-week follow-up explored the efficacy of "Talk-to-Me" for university students Australia-wide, evaluating the influence of COVID-19 and location. Overall, 217 students (55% female; mage = 24.93 years [18, 60]) enrolled in this study from 2020 to 2021. Participants' responses to suicidal statements, mental health literacy, generalized self-efficacy, help-seeking behavior, and overall utility of the program were collected at baseline, post-MOOC (10 weeks from baseline) and 12-week follow-up. The effect of time and location interaction was explored using a random-effects regression model. RESULTS: Findings indicated significant improvement in participants' knowledge of positive mental health support strategies (ES = 0.42, p < 0.001) and recognizing appropriate responses to suicidal statements (ES = 0.37, p < 0.001) at 10-weeks, with further improvement at 12 weeks follow-up (ES = 0.47 and 0.46, p < 0.001). Students reported higher generalized self-efficacy at the 12-week follow-up compared to baseline (ES = 0.19, p = 0.03) and an increased tendency to seek professional help for mental health issues (ES = 0.22, p = 0.02). CONCLUSION: These findings provide preliminary evidence of the efficacy of the "Talk-to-Me" program in supporting university students across Australia to increase their suicide-related knowledge and skills, general self-efficacy, and overall mental fitness.

BrightHearts: A pilot study of biofeedback assisted relaxation training for the management of chronic pain in children with cerebral palsy.

Background: Chronic pain is estimated to impact one-in-three children with cerebral palsy (CP). Psychological interventions including behavioral and cognitive strategies play a key role in chronic pain management, but there is a paucity of research exploring their use in children with CP. Aim: To investigate the acceptability and feasibility of biofeedback assisted relaxation training (BART) for chronic pain management in children with CP using a mixed-methods study design. Methods: Biofeedback assisted relaxation training was delivered via BrightHearts, an iOS application. Inclusion criteria were as follows: CP; self-reported chronic pain; age 9-18 years; and fluent English speaker. Children used BrightHearts for ten minutes daily, over four weeks. Qualitative post-intervention interviews were undertaken (child, parent) and quantitative pre-post measures (child) were gathered including pain intensity (numerical rating scale), and anxiety intensity (numerical rating scale). Content analysis was conducted for qualitative data. Descriptive statistics and exploratory analyses were performed for quantitative data. Results: Ten children participated (n = 3 male, mean age = 13.1 years SD = 2.5 years, GMFCS level I = 4, II = 2, III = 3, IV = 1). Predominant movement disorder was spasticity (n = 7) and dyskinesia, mainly dystonia (n = 3). Content analysis suggested an overarching theme "BrightHearts is a good thing to put in my toolbox" providing an overall representation of participants' experiences. For many, BrightHearts was a valuable supplement to children's pain management strategies: "The source of the pain is still there, but the actual effect of the pain isn't so relevant." Four sub-themes were identified: "Managing my pain;" "Managing my anxiety and stress," "Helping me do what I need to do;" and "Fitting it into my life." Some participants reported improvements in their anxiety management, and others described benefits in sleep and school following improved pain/anxiety management. A range of practical and personal factors within this heterogeneous group presented barriers to using BrightHearts including limited time, attention, and boredom. Seven-out-of-eight children would recommend BrightHearts to others with chronic pain and six-out-of-eight noticed a difference in their pain since using BrightHearts (n = 2 missing data). Non-significant reductions in pain or anxiety intensity scores were found following the intervention. Conclusion: This pilot suggests BrightHearts is an acceptable and feasible intervention for chronic pain management in children with CP and may be useful for some children as part of a multimodal approach.

Acute Kidney Injury After Large Ventral Hernia Repair Requiring Transversus Abdominis Release.

BACKGROUND: Acute kidney injury (AKI) is a known postoperative complication of open ventral hernia repair contributing to increased costs, hospital length of stay, and mortality. The aim of this study was to identify whether the muscle injury that occurs in a posterior separation of components via transversus abdominis release (TAR) contributes to a higher incidence of postoperative AKI. METHODS: A retrospective cohort study of patients who underwent open retrorectus ventral hernia repair with and without TAR at a single institution between 2012 and 2019 was performed. Patients who underwent a separation of components via either unilateral or bilateral transversus abdominis release were compared to those who did not undergo TAR as part of their hernia repair (non-TAR). The outcome of interest was the development of postoperative AKI. Acute kidney injury was defined as an increase in creatinine of greater than 50% of the preoperative baseline. Univariate and multivariate analyses were performed to determine the influence of TAR on the development of AKI. RESULTS: There were 523 patients who met inclusion criteria, of which 159 (30.4%) had a TAR as part of their retrorectus hernia repair. No differences were found in preoperative characteristics between the TAR and non-TAR group including age, gender, history of kidney disease, or history of diabetes. By contrast, the TAR group had significantly greater median estimated blood loss (100 mL vs 75 mL, P < .01), mean positive intraoperative fluid balance (2255 mL vs 1887 mL, P < .01), and operative duration (321 min vs 269 min, P < .001). The rate of AKI in the TAR group was 11% (n = 18) vs 6% (n = 23, P = .0503) in the non-TAR group. On multivariate analysis controlling for patient characteristics and intraoperative factors, TAR was the only factor with a significantly increased odds of AKI (OR 1.97, 95% CI 0.994-3.905, P = .0521). CONCLUSIONS: In patients with large ventral hernias requiring retrorectus repair, performing a TAR is associated with a nearly 2-fold increase in the development of postoperative AKI. These findings suggest that these patients should be optimized perioperatively with emphasis on fluid resuscitation, limiting nephrotoxic medications and monitoring urine output.

Robotic Inguinal Hernia Repair Outcomes: Operative Time and Cost Analysis.

BACKGROUND: Robotic inguinal hernia repair is the latest iteration of minimally invasive herniorrhaphy. Previous studies have shown expedited learning curves compared to traditional laparoscopy, which may be offset by higher cost and longer operative time. We sought to compare operative time and direct cost across the evolving surgical practice of 10 surgeons in our healthcare system. METHODS: This is a retrospective review of all transabdominal preperitoneal robotic inguinal hernia repairs performed by 10 general surgeons from July 2015 to September 2018. Patients requiring conversion to an open procedure or undergoing simultaneous procedures were excluded. The data was divided to compare each surgeon's initial 20 cases to their subsequent cases. Direct operative cost was calculated based on the sum of supplies used intra-operatively. Multivariate analysis, using a generalized estimating equation, was adjusted for laterality and resident involvement to evaluate outcomes. RESULTS: Robotic inguinal hernia repairs were divided into two groups: early experience (n = 167) and late experience (n = 262). The late experience had a shorter mean operative time by 17.6 min (confidence interval: 4.06 - 31.13, p = 0.011), a lower mean direct operative cost by $538.17 (confidence interval: 307.14 - 769.20, p < 0.0001), and fewer postoperative complications (p = 0.030) on multivariate analysis. Thirty-day readmission rates were similar between both groups. CONCLUSION: Increasing surgeon experience with robotic inguinal hernia repair is associated with a predictable reduction in operative time, complication rates, and direct operative cost per case. Thirty-day readmission rates are not affected by the learning curve.

Meaningful autonomy in general surgery training: Exploring for gender bias.

BACKGROUND: Resident autonomy is essential to the development of a surgical resident. This study aims to analyze gender differences in meaningful autonomy (MA) given to general surgery trainees intraoperatively. METHODS: This is a retrospective study of general surgery residents at an academic-affiliated tertiary care facility. Attending surgeons completed post-operative evaluations based on the Zwisch model (4-point scale, ≥3 indicating MA). RESULTS: Attending faculty members (37 males, 15 females) completed evaluations of 35 residents (18 males, 17 females). A total of 3574 evaluations were analyzed (1380 female, 2194 male residents) over 28 months. Multivariate analysis revealed case complexity, post graduate year level and rater gender were significantly associated with MA. Resident gender and faculty experience did not impact MA. CONCLUSIONS: In contrast to published literature, resident gender did not influence MA. This may be encouraging to surgical programs seeking strategies to address gender bias.

The role of 2-octyl cyanoacrylate in prevention of penile adhesions after circumcision: A prospective, randomized trial.

PURPOSE: Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision. METHODS: Patients <7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5. RESULTS: From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49). CONCLUSION: The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level II.