Are Pediatric Trauma Transfers Justified?: A Unique Viewpoint From a Transferring Institution.

INTRODUCTION: Definitions of pediatric overtriage and unnecessary transfers for injured children have been instituted from a viewpoint of referral centers and have doubtful value for effecting interventions at referring centers. This study provides a unique insight into the factors prompting transfers at a peripheral institution. METHODS: The trauma registry of a level 2 pediatric trauma center was accessed, and pediatric transfers out to 2 level 1 pediatric trauma centers were identified over a period of 4 years. The outcomes of these patients at the accepting institutions were charted for descriptive analysis. RESULTS: The study identified 46 patients transferred out with a transfer rate of 6.6% when compared with total admissions. The mean Injury Severity Score (ISS) was 6.5, and the mean length of stay (LOS) at the receiving institution was 2.8 days. The reason for transfer from a specialty standpoint revealed 21 neurosurgical, 12 burn, 6 orthopedic, 4 faciomaxillary, and 2 ophthalmology patients. Overall transfer rate was 6.6%. Pediatric overtriage when defined as LOS < 24 hours at the receiving institution was 46.7%. Fifty percent of pediatric overtriage was prompted by need for a pediatric neurosurgery consult with medicolegal concern being cited as reason for transfer. Secondary overtriage when defined as LOS < 24 hours, no pediatric intensive care admission, no surgical intervention, and ISS < 9 was found in 13 patients (30.9%). The proportion of patients with Medicaid insurance was not different for the admissions (43.5%) when compared with the transfers (42.7%). CONCLUSIONS: Existing definitions of overtriage have limited value in effecting interventions to reduce unnecessary transfers. Identifying specific factors at referring institutions including providing local availability of pediatric surgical specialists will potentially help mitigate injury-related pediatric overtriage.

Inductive teaching method-an alternate method for small group learning.

BACKGROUND: Different forms of small group interactive teaching have found an increasing role in medical education in the recent past. OBJECTIVES: This study aimed to evaluate the efficacy of topic-based small group tutorials and compare between two such tutorials, the directed tutorial where the tutor takes the initiative and the inductive tutorial which places the initiative on the student. METHODS: Final-year medical students were exposed to alternate sessions of directed and inductive teaching during their rotation in paediatric surgery. For inductive teaching, the topic was announced and the students took turns in asking questions and answering them, the tutor stepping in only when required. The tutor both initiated and guided the discussion in the directed method. Students assessed the tutorials and compared the two learning methods evaluating eight different parameters using a Likert scale. Statistical significance was tested using the Wilcoxon signed ranks test. RESULTS: Feedback was available from 49 out of 52 students. The tutorials were ranked highly for all parameters studied. The inductive method was better for comfort, interest, memory, inspiration to read more, comprehension and for correlation with previous knowledge (P < 0.05). The directed method was superior for the content covered in a given time (P < 0.001). CONCLUSIONS: The topic-based tutorials were effective. The inductive method by adding a reflective component, appeared to facilitate deep learning. Further research will determine its suitability for formal introduction into the curriculum.

Impact of minimally invasive surgery on the pediatric surgical profession.

We conducted a survey among pediatric surgeons to examine the impact of the advent of minimally invasive surgery (MIS) on the pediatric surgical profession with respect to job satisfaction and training challenges. An invitation to participate in a web-based questionnaire was sent out to 306 pediatric surgeons. Apart from demographic details and training recommendations, parameters relevant to job satisfaction, including patient interaction, peer pressure, ethical considerations, academic progress, ability to train residents, and financial remuneration, were studied. The response rate was 38.2%. Working in a unit performing MIS was identified by 71% of respondents as the most effective and feasible modality of training in MIS. Inability to get away from a busy practice was the most common reason cited for inability to acquire MIS training. The overall responses to the job satisfaction parameters showed a positive trend in the current MIS era for patient interaction, ethical considerations, academic progress, and training residents, with a negative trend for peer pressure and financial remuneration. The enthusiastic minimally invasive surgeons (EMIS) were defined as those having more than 5 years of MIS experience and also performing more than 10% of their work using MIS. Of the 113 responses analyzed, 67 belonged to the EMIS category. Those belonging to the EMIS group were less likely to feel inadequate in training their residents, in meeting the felt needs of the patients, or to complain about peer pressure. They were more likely to consider MIS to be as relevant and beneficial in children as in adults. Embracing MIS, as represented by the EMIS group, correlated with an overall greater job satisfaction.

An optimum animal model for neonatal thoracoscopy.

PURPOSE: This study attempted to define an optimum animal model for neonatal thoracoscopy. MATERIALS AND METHODS: Seven rabbits and three 5-7-kg piglets were subjected to thoracoscopy by three pediatric surgeons. The outcome for the successful completion of esophageal anastomosis and additional procedures, including diaphragmatic plication and lung biopsy, were noted. RESULTS: Whereas esophageal anastomosis could be accomplished in all piglets, it could be achieved in only 1 rabbit. Additional procedures were possible in 2 piglets and no rabbits. Anesthetic complications were seen in 4 rabbits and 1 piglet. CONCLUSION: Our findings suggest that the piglet may be the optimum animal model for replicating neonatal thoracoscopy. The fragility of the rabbit, coupled with a limited intrathoracic working space, limits its use for thoracoscopy.

What causes intrathoracic gastric dilatation in a late-presenting diaphragmatic hernia?

A 13-year-old previously asymptomatic patient presented with abdominal pain and vomiting. Chest radiogram revealed a left intrathoracic stomach. Laparotomy confirmed a dilated, hypertrophic stomach herniating through a left Bochdalek hernia. The patient recovered after a period of prolonged gastric paresis. While highlighting the importance of considering this condition in the differential diagnosis of a cystic lesion in the chest, this article also postulates a mechanism for the hypertrophic gastric dilatation in a late presentation of a congenital diaphragmatic hernia.

Robotic-assisted single-site cholecystectomy in children.

BACKGROUND: Though single incision laparoscopic cholecystectomy (SILC) is cosmetically appealing, it is technically a difficult operation. The recent introduction of robotic single-site cholecystectomy (RSSC) has made single incision cholecystectomy easier to perform. While a few papers have reported its application in adults, it has not been documented in children. METHODS: Data on seventeen consecutive children who underwent RSSC by a single surgeon over a ten-month period were retrospectively reviewed. Patient demographics, total operative time, console time, hospital stay, complications and reasons for procedural delay were recorded. RESULTS: Sixteen operations were completed robotically using the single incision robotic platform. No major postoperative complications were noted. Median total operative time was 94 minutes with interquartile range (IQR) being 81.5-119.5 minutes. The median console time was 39 minutes (IQR: 30-72 minutes). The median total operative time for the first eight cases was 118 minutes (IQR: 103-127 minutes) and for the next nine cases 90 minutes (IQR: 76-93 minutes). Common causes for procedural delay were slipped clips, bile spillage, bleeding and leaking Single-Site® port. CONCLUSIONS: This unique series of RSSC documents its feasibility and safety in children. A short learning curve and operative times comparable to RSSC in adults and SILC in children were observed. Being technically easier, RSSC becomes an attractive alternative to SILC to sustain its cosmetic benefit.

Operative considerations in pediatric retroperitoneal teratomas--a review.

BACKGROUND: Retroperitoneal teratomas account for 5% of teratomas and occur predominantly in infants. The resection of these tumors has been variously reported as easy or difficult. This report presents a series of retroperitoneal teratomas and reviews the literature focusing on the relevant operative considerations in this tumor. METHODS: A retrospective chart review from 1996 to 2011 identified five children with retroperitoneal teratomas. Clinical features, radiologic findings, operative details, and outcome were recorded. The literature was reviewed to identify operative complications for these tumors. RESULTS: Out of the five patients, four were infants. The tumor was characterized by dense adhesions in all patients, and resection was complicated by gastric and common bile duct injury. Hiatal hernia repair was required in one and spillage was seen in two patients. One patient had a staged resection after birth with colostomy, vesicostomy, and eventual death on day 12 of life. Inferior vena cava (IVC) ligation was required in one. A total of four patients were well on long-term follow-up. Review of the literature revealed that computed tomography scan while being sufficient for diagnosing a retroperitoneal teratoma is often inadequate in delineating the vascular anatomy, which is usually distorted. The IVC and the mesenteric vessels may be inseparable and require ligation. Renal vessel injury is possible, leading onto ischemia and hypertension. The tumor may be intimately adherent to the viscera in the abdomen, making resection complicated. Adequate resection is possible and necessary for cure, but not always possible with clear resection margins. Late complications include recurrence, adhesions, and hypertension. The perioperative mortality is 0 to 8% and the complication rate is 50 to 100%. CONCLUSION: Surgical resection of retroperitoneal teratomas, while being the mainstay of treatment is challenging in view of its size, adhesions, and vascular distortion.

Navigating the thoracic inlet in children.

Though various approaches to the thoracic inlet have been described in adults, currently no guidelines exist in children. Reports in the literature of resection of thoracic inlet tumours in children are only anecdotal. Literature was reviewed to assess the various described approaches with reference to suitability in children. Experience with a 3.5-year-old boy having a thoracic inlet ganglioneuroma, using the anterior cervico-thoracic trap door incision demonstrated excellent access and minimal morbidity. We recommend the trap door incision as the preferable route for exploring thoracic inlet tumours in children.

Two decades of minimally invasive pediatric surgery-taking stock.

BACKGROUND: The past 2 decades have seen a rapid integration of minimally invasive surgery (MIS) to pediatric surgical practice. This study endeavored to delineate the current status of MIS in pediatric surgery. METHODS: Three hundred six pediatric surgeons were invited to participate in an anonymous Web-based survey. Apart from demographic details and opinion regarding robotic surgery, surgeons were asked to choose between "perform MIS," "do not perform MIS but recommend it," and "MIS not indicated" for common pediatric surgical conditions. RESULTS: Responses were received from 117 pediatric surgeons (38.2%). Sixty-one percent of respondents did more than 10% of their work using MIS, and 85% had more than 5 years experience in MIS. Cholecystectomy, nonpalpable testis, and exploration for abdominal pain scored highest among the positive recommendations for MIS, whereas liver tumors, biliary atresia, Wilms' tumor, and inguinal hernia scored highest among the negative recommendations for MIS. Fifty-one percent of the respondents had more than 20 years experience as a pediatric surgeon and were categorized as "senior" surgeons. Compared with the young surgeons, the senior surgeons were more likely to recommend MIS as a contraindication for simple and complicated appendicitis, reduction of intussusception, gastrostomy, fundoplication, pyloromyotomy, adhesiolysis, splenectomy, adrenalectomy, nephrectomy for dysplastic kidneys, heminephrectomy, pyeloplasty, anorectal malformations, pyeloplasty, achalasia cardia, hiatal hernia repair, lung resection, and diaphragmatic hernia repair. More than half the respondents believed that robotic surgery has a role for children in the future. CONCLUSIONS: A widespread integration of MIS into the pediatric surgical practice is evident from this study. Current practice and recommendations of the surveyed surgeons have been outlined. Significant differences between the young and senior surgeons reflect the evolving nature of the recommendations.

The ping-pong ball as a surgical aid in liver transplantation.

BACKGROUND: Liver transplantation using split adult segmental grafts in infants can be a technical challenge because the small abdominal cavity cannot comfortably accommodate the graft, leading to compression. This size mismatch can be a particularly difficult problem when the anteroposterior diameter of the graft is greater than the infant's available anteroposterior peritoneal space. We describe a simple and novel technique that may prevent this complication. METHODS AND RESULTS: Two infants with biliary atresia weighing 5 kg each and aged 6 and 5 months, received split adult liver left lateral segment transplants from deceased donors weighing 55 and 65 kg, respectively. Congestion of the graft and inadequate perfusion were prevented by placing a sterilized ping-pong ball in the retrohepatic space to elevate the graft off the native hepatic fossa. The bilateral subcostal incision was required to be extended vertically in the midline up to the xiphisternum in both patients to enlarge the abdominal cavity. Delayed closure of the wound was performed after 5 days using Surgisis (porcine small intestine submucosa, Cook Surgical Inc, Bloomington, IN) when it was possible to remove the ping-pong ball in one of the patients. Both patients have recovered well from the transplant. A follow-up of 1 year in the patient with the in situ ping-pong ball shows it to be well anchored and causing no symptoms. CONCLUSIONS: In children undergoing large-for-size split liver grafts, delaying the closure of the abdominal wound along with elevation of the graft using a ping-pong ball can be a useful and simple adjunct to prevent the complications of graft compression.

Post-liver transplant mycotic aneurysm of the hepatic artery.

BACKGROUND: Mycotic aneurysm of the hepatic artery is a rare complication of liver transplantation, occurring in 0% to 3% of patients and having a mortality of around 30%. We present a unique report of mycotic aneurysms of the hepatic artery following liver transplantation in children. METHODS AND RESULTS: A chart review of the 194 patients who underwent a liver transplantation over a 21-year period revealed 2 patients who developed a mycotic aneurysm of the hepatic artery. The first patient died due to rupture prior to diagnosis. The second patient was treated successfully using radiological coil embolization, followed by surgical excision with hepatic artery ligation and antibiotic therapy. CONCLUSIONS: Early diagnosis and prompt multidisciplinary treatment is crucial to optimize treatment in this condition.

Is the inferior vena cava dispensable?

Inferior vena caval (IVC) ligation during surgery is considered prohibitively risky. Most of the IVC ligations reported in the literature have been in the context of trauma damage control. There are only anecdotal reports in the literature of a successful elective ligation of the IVC in children. Records from a paediatric tertiary care centre were reviewed over a 20-year period to identify and evaluate patients who underwent an intentional ligation of the IVC during elective surgery. The reports from the literature of IVC ligations were reviewed. The physiologic and anatomic basis for the sequelae of IVC ligation was examined. Intentional ligation of the IVC was done in four patients. Apart from pedal oedema and ascites lasting for 1 and 9 months, respectively, in two of them, none of these patients had any long-term sequelae related to the ligation of their IVC. Adequate collaterals providing satisfactory drainage were demonstrated by Doppler studies postoperatively. We suggest that during surgery, when other options are absent, the IVC can be safely ligated in children, providing a therapeutic benefit to the patient.

An eighteen year follow-up after surgery for congenital microgastria--case report and review of literature.

Congenital microgastria is a rare disorder with only 59 previously reported cases in the literature. The best results are achieved by definitive surgery in the form of a Hunt-Lawrence (HL) jejunal pouch for gastric augmentation. Only 12 patients have previously undergone a HL pouch for microgastria. Long-term results after a HL pouch are not well known. We report a patient who underwent a HL pouch 18 years ago, now having a good quality of life and eating normal meals, though having a suboptimal somatic growth. It is likely that long-term results can be optimized by early gastric augmentation with a HL pouch.

Atypical congenital mesoblastic nephroma presenting in the perinatal period.

Congenital mesoblastic nephroma (CMN) is a rare tumour of infancy having an overall good prognosis. The less common, atypical CMNs have cellular elements in them and tend to have an unpredictable course. Occurrence in the perinatal period may further change the outcome. By reporting three patients presenting in the perinatal period with atypical CMN, an attempt is made in this paper to characterize the clinical behaviour of these variant tumours. Though one of our patients had an uneventful course, the other two had several complications including polyhydramnios, prematurity, hypertension, haemodynamic instability and tumour spillage. The course was complicated by recurrence in the latter two and refractoriness to chemotherapy and death in one. That the atypical subset of CMNs occurring in the perinatal period can have a stormy course is well illustrated by this report. Possible prognostic factors are evaluated and the sparse reports of similar cases in the literature are reviewed and compared.

Infantile visceral myofibromatosis--a rare cause of neonatal intestinal obstruction.

Infantile myofibromatosis (IM) is a rare cause of intestinal obstruction in the newborn. A neonate with generalized IM having multifocal intestinal lesions presenting with intestinal obstruction is reported here. Unique intraoperative pictures are provided. The presentation, management, and the prognosis of IM are discussed.

Late-onset inferior vena cava obstruction in a shunted patient--a unique cause of rebleeding in children with portal hypertension.

BACKGROUND: Rebleeding in the presence of an adequate patent portosystemic shunt in a patient with portal hypertension (PHT) is uncommon. Inferior vena cava (IVC) obstruction as the cause of rebleeding in this situation has not been reported in the literature. METHODS: Records from a pediatric tertiary care center were reviewed over a 15-year period. Portosystemic shunt procedures for bleeding esophageal varices were done in 39 children. Patients who, after a shunt surgery for PHT, developed a rebleed because of IVC obstruction in the presence of a patent shunt were identified. RESULTS AND CONCLUSIONS: Late IVC obstruction in the presence of a patent shunt was identified in 2 patients. The etiology included adhesions, caudate lobe hypertrophy, and macronodular cirrhosis. Diagnosis was by angiography, and treatment included angioplasty and liver transplantation. Awareness of this condition helps direct treatment appropriately in the clinical scenario of a rebleed in a shunted patient with PHT.

Posttraumatic small bowel obstruction in children.

BACKGROUND: The diagnosis of intestinal injuries in children after blunt abdominal trauma can be difficult and delayed. Most children who suffer blunt abdominal trauma are managed nonoperatively, making the diagnosis of intestinal injuries more difficult. We sought to gain information about children who develop intestinal obstruction after blunt abdominal trauma by reviewing our experience. METHODS: Review of records from a pediatric tertiary care center over an 11.5-year period revealed 5 patients who developed small bowel obstruction after blunt trauma to the abdomen. The details of these patients were studied. RESULTS: All patients were previously managed nonoperatively for blunt abdominal trauma. Intestinal obstruction developed 2 weeks to 1 year (median, 21 days) after the trauma. Abdominal x-ray, computerized tomography scan, or barium meal studies were used to establish the diagnosis. The pathology was either a stricture, an old perforation, or adhesions causing the intestinal obstruction. Laparotomy with resection and anastomosis was curative. CONCLUSIONS: Posttraumatic small bowel obstruction is a clinical entity that needs to be watched for in all patients managed nonoperatively for blunt abdominal trauma.