The Novel Use of Rare Earth Magnets for the Extraction of Metallic Soft Tissue Foreign Bodies in Children.

INTRODUCTION: Metallic foreign bodies (mFB) are common following penetrating injuries in children. The mFB commonly occur in the head and neck region and extremity soft tissues. Removal may be indicated due to morbidity related to pain or migration. Extraction can be challenging to localize, often requiring wide exposure, and may be difficult to achieve in cosmetically sensitive areas. Different technological adjuncts have been used to facilitate foreign body removal including fluoroscopy, ultrasound, and more recently in adults, surgical magnets. The most powerful commercially available magnets are rare earth magnets comprised of neodymium iron and boron (Ndy). With the goal of reducing radiation exposure and the morbidity of mFB removal with associated soft tissue injury in children, a strategy was introduced utilizing Ndy to optimize extraction with minimal soft tissue surgical dissection. MATERIALS AND METHODS: Two children with extremity mFB treated with Ndy between January 2021 and July 2021 were analyzed. We utilized commercially available ring type neodymium-iron-boron magnets with dimensions of 1 3/8-inch outer diameter x 1/8-inch inner diameter and 1/16 inch thick with a power of 13 200 gauss that were processed for use according to our hospital protocols. Our main clinical indication was for the detection and retrieval of small ferromagnetic foreign bodies embedded in superficial extremity soft tissues. RESULTS: In the operating room under general anesthesia, the mFB were localized utilizing fluoroscopy. A 1.0 cm skin incision was made into the subdermal soft tissues overlying the area of the mFB. No surgical tissue dissection was performed. The mFB could not be visualized in the soft tissue. Using fluoroscopy to localize the mFB, the Ndy was then placed into the wound in close proximity to the mFB. The mFB were immediately magnetized to the Ndy and the mFB were extracted from the soft tissues without any further surgical dissection. Two simple interrupted nylon sutures were placed to close the incision. The total operative time was 2 and 2.5 minutes respectively. The children recovered uneventfully and are without complication. CONCLUSIONS: The use of Ndy to remove extremity soft tissue mFB in children appears to be feasible, safe, and efficient. Use of the Ndy allowed extraction via a small incision, optimizing the aesthetic result and avoiding the need for cross-sectional imaging, extensive surgical dissection, tissue reconstruction and prolonged operative time or x-ray exposure. The development of magnets of increasing energy density may be indicated to further optimize metallic soft tissue foreign body extraction in children in a minimally invasive manner.

Laparoscopic versus open inguinal hernia repair in children ≤3: a randomized controlled trial.

PURPOSE: Laparoscopy is being increasingly applied to pediatric inguinal hernia repair. In younger children, however, open repair remains preferred due to concerns related to anesthesia and technical challenges. We sought to assess outcomes after laparoscopic and open inguinal hernia repair in children less than or equal to 3 years. METHODS: A prospective, single-blind, parallel group randomized controlled trial was conducted at three clinical sites. Children ≤3 years of age with reducible unilateral or bilateral inguinal hernias were randomized to laparoscopic herniorrhaphy (LH) or open herniorrhaphy (OH). The primary outcome was the number of acetaminophen doses. Secondary outcomes included operative time, complications, and parent/caregiver satisfaction scores. RESULTS: Forty-one patients were randomized to unilateral OH (n = 10), unilateral LH (n = 17), bilateral OH (n = 5) and bilateral LH (n = 9). Acetaminophen doses, LOS, complications, and parent/caregiver scores did not differ among groups. Laparoscopic unilateral hernia repair demonstrated shorter operative time, a consistent finding for overall laparoscopic repair in univariate (p = 0.003) and multivariate (p = 0.010) analysis. No cases of testicular atrophy were documented at 2 (SD = 2.7) years. CONCLUSION: Children ≤3 years of age in our cohort safely underwent LH with similar pain scores, complications, and recurrence as OH. Parents and caregivers report high satisfaction with both techniques.

Pancreatic surgery for tumors in children and adolescents.

PURPOSE: Pancreatic neoplasms are uncommon in children. This study sought to analyze the clinical and pathological features of surgically resected pancreatic tumors in children and discuss management strategies. METHODS: We conducted a retrospective review of patients ≤21 years with pancreatic neoplasms who underwent surgery at a single institution between 1995 and 2015. RESULTS: Nineteen patients were identified with a median age at operation of 16.6 years (IQR 13.5-18.9). The most common histology was solid pseudopapillary neoplasm (SPN) (n = 13), followed by pancreatic neuroendocrine tumor (n = 3), serous cystadenoma (n = 2) and pancreatoblastoma (n = 1). Operative procedures included formal pancreatectomy (n = 17), enucleation (n = 1) and central pancreatectomy (n = 1). SPNs were noninvasive in all but one case with perineural, vascular and lymph node involvement. Seventeen patients (89.5 %) are currently alive and disease free at a median follow-up of 5.7 (IQR 3.7-10.9) years. Two patients died: one with metastatic insulinoma and another with SPN who developed peritoneal carcinomatosis secondary to a concurrent rectal adenocarcinoma. CONCLUSIONS: Pediatric pancreatic tumors are a heterogeneous group of neoplastic lesions for which surgery can be curative. SPN is the most common histology, is characterized by low malignant potential and in selected cases can be safely and effectively treated with a tissue-sparing resection and minimally invasive approach.

The Impact of Pediatric Laparoscopic Inguinal Hernia Repair in a Community Based Children's Ambulatory Surgery Center - It's Safe and Effective.

PURPOSE: Pediatric surgery in a free-standing children's ambulatory surgery center (C-ASC) is a common practice. The implementation of minimally invasive surgery in this setting may be associated with unique challenges. The purpose of this study was to compare a cohort of children who underwent laparoscopic (LHR) and open inguinal hernia repairs (OHR) at the C-ASC as part of a quality assurance initiative to assess safety and efficacy. METHODS: From January 2021 to December 2021, the records of all children who underwent LHR or OHR at our C-ASC were analyzed. The following data was retrieved and compared with the Student's t-test: age, weight, gender, procedure type, total room time (RT), total operative time (OT), and outcomes. RESULTS: Eighty-eight (n = 88) children underwent LHR or OHR during this period. There was no difference between the two groups regarding their age or weight. Both groups had equal outcomes, specifically, no wound infections or recurrent hernias. (2.5 year follow-up). There was a significant reduction in RT and OT in those children who underwent unilateral LHR compared to unilateral OHR (15% and 17% respectively, p < 0.05). In those children who underwent bilateral LHR and bilateral OHR, there was a reduction in RT and OT in the LHR group compared to OHR, but it was not significant (10% and 12% respectively, p > 0.05). CONCLUSIONS: Pediatric LHR is safe and effective in the C-ASC. The unilateral LHR technique is associated with a significant reduction in total room time and operative time compared to the unilateral OHR technique. Additional analyses would be important to examine the relationship of time and outcomes in this setting. TYPE OF STUDY: Original Research Retrospective Case-control study.

Simultaneous Bilateral Thoracoscopy During the Nuss Procedure is Safe, Effective and Allows for Optimal Visualization of the Bar Passer Throughout the Substernal Dissection.

PURPOSE: Cardiac injury during the Nuss procedure is a rare risk that can lead to a catastrophic outcome. The specific aim of this pilot study was to evaluate the safety and efficacy of simultaneous bilateral thoracoscopy (SBT) compared to standard unilateral right thoracoscopy (RT) in children undergoing the Nuss procedure in order to mitigate that risk. METHODS: IRB approval was obtained to analyze data on children who underwent SBT and RT during the Nuss procedure. Data retrieval included age, gender, Haller index (HI), operative time (OT), length of stay (LOS), complications and follow up. RESULTS: From August 2022 to August 2023, 10 children who underwent SBT were compared to 10 children who underwent RT. Both groups underwent intercostal nerve cryoablation. Following completion of cryoablation, SBT or RT was carried out during the Nuss procedure. SBT allowed for the tip of the bar passer to be visualized during the entire dissection in both thoraces. There was no significant difference in either group with respect to age, HI, OT, LOS. There were no anesthetic or surgical complications in either group. CONCLUSION: We found that SBT is safe, effective and allows for 100% visualization of the tip of the bar passer during the entire critical phase of the Nuss procedure. It does not impact OT or LOS compared to children who underwent only RT. SBT may benefit children who undergo the Nuss procedure by reducing the risk of cardiac injury. TYPE OF STUDY: Original Research Retrospective Case-control study.

A novel low cost minimally invasive surgical system allows for the translation of modern pediatric surgical technology to low- and middle-income nations.

BACKGROUND: There is a critical need for pediatric surgical humanitarian care. The role of minimally invasive surgery (MIS) in these environments with its reduction in pain and wound care, operative time, length of hospitalization, and morbidity is logical. However, the costs, logistics and feasibility of MIS in Low- and Middle-Income Countries (LMIC) can be challenging. Our goal was to develop a new low cost rapidly deployable minimally invasive surgical system (RDMIS) for use during remote pediatric general surgical (GPS) missions in LMIC. METHODS: RDMIS system components consist of a universal serial bus (USB) interfaced laparoscopic camera, portable computer and a battery powered wireless portable laparoscopic light source. The surgeon transports the RDMIS in a single standard carry-on luggage. Utilizing prepositioning logistics from prior World Pediatric GPS missions, a standard MIS tower system (sMIS) was maintained on site. RESULTS: The RDMIS was utilized to carry out procedural components of laparoscopic appendicostomy and laparoscopic cholecystectomy. Both sMIS and RDMIS were interchanged during the cases to allow for subjective comparison of surgical exposure and visualization. The RDMIS system allowed for safe and effective visualization and dissection of surgical structures. All children recovered uneventfully and were discharged the following day and have had no complications. The RDMIS system costs were significantly less than those of sMIS. CONCLUSIONS: RDMIS appears to be a safe, inexpensive option that will allow for the translation of modern MIS technology during GPS in remote locations. Further studies validating the RDMIS are indicated, however, the lower costs, ease of transport and potential benefit to children in the LMIC may be significant.

Mini thoracic CT adequately determines Haller index and decreases radiation exposure in children with pectus excavatum.

INTRODUCTION: The preoperative assessment of Pectus Excavatum (PE) is resource intensive. CT chest for the purpose of calculating a Haller index (HI) remains a central component and is necessary for third-party reimbursment for surgical correction. With the goal of minimizing radiation exposure, a strategy was introduced to perform a mini-Thoracic CT (mini-CT) for the calculation of HI. OPERATIVE TECHNIQUE: The mini-CT was performed as follows: a radio-opaque marker (ROM) was placed at the clinical deepest point of the deformity. The CT was then columnated to scan 3 cm above and 3 cm below the ROM. HI was calculated according to previously described technique. Seven children with PE who underwent mini-CT were age and weight matched to 7 children with PE who underwent standard low dose CT chest during the same time period. Radiation doses were evaluated using dose length product (DLP) and effective dose (mSv) between the two groups. Significance of differences was determined using the students t-test. The DLP of mini-CT compared to chest-CT was 17.9 vs 48.9,mGycm respectively. (p< 0.001) The mSv of the mini-CT compared to chest-CT was 0.32 vs 0.88, sMV respectively. (p<0.001) Both DLP and mSv were reduced by 63% in children who received a mini-CT. All children obtained insurance authorization and underwent uncomplicated Nuss repair. CONCLUSION: For children with pectus excavatum deformities the mini-Thoracic CT is an effective method to calculate the HI. Compard to the conventional low dose chest CT, the mini-CT strategy significantly reduces radiation exposure to the child by 63% with no impact on third-party authorizations or Nuss repair.

Laparoscopic assisted extracorporeal ovarian harvest: A novel technique to optimize ovarian tissue for cryopreservation in young females with cancer.

BACKGROUND: Advances in pediatric cancer therapy have improved the long-term survival for many children with cancer. The awareness of quality of life aspects, specifically fertility preservation, has become a reality for many of these families and children. Ovarian tissue cryopreservation has emerged as an available fertility option for young females with cancer. Safe and effective removal of ovarian tissue in these girls is paramount. We report a laparoscopic assisted extracorporeal ovarian harvest technique that achieves this goal. OPERATIVE TECHNIQUE: We place a 5 mm port at the umbilicus and in the right lower quadrant. Under laparoscopic guidance we place a 12 mm port in the left suprapubic area. Utilizing the 12 mm port site a monofilament traction suture is placed through the left ovary. The traction suture is used to translocate the ovary to an extracorporeal position via the 12 mm port site. Ovarian tissue is then excised utilizing standard surgical technique with the scalpel. Hemostasis is obtained and the capsule is closed with a running absorbable suture. The ovary is placed back in its native position laparoscopically. CONCLUSIONS: The use of this extracorporeal ovarian harvesting technique is a safe and effective method to optimize removal and minimize tissue injury. Utilization of this technique, may have potential benefit to the young female with cancer.

Ovarian tissue cryopreservation in young females with cancer and its impact on ovarian follicle density.

BACKGROUND: Cancer therapy in young females results in irreversible damage to their ovaries potentially leading to premature ovarian failure (POF) and infertility. Ovarian follicle density (FD) serves as a key predictor of reproductive potential for a woman. FD is significantly reduced after cryopreservation in adult women with cancer. FD in young females with cancer has not been investigated. The specific aim of this study was to assess the efficacy of ovarian tissue cyropreservation (OTC) in young females with cancer by evaluating its impact on FD. METHODS: An IRB approved prospective human and animal trial enrolled girls (ages 6-18 years) with cancer at high risk for POF from July 1, 2012 through June 30, 2018. All participants underwent pre-operative ultrasounds evaluating their ovaries.  Following a normal ultrasound, each patient underwent a left ovarian tissue harvest prior to cancer therapy. The ovarian tissue was sectioned for use in pathologic analysis, fertility preservation and xenotransplantation before and after cryopreservation. Comparative statistical analyses of the means of FD before and after cryopreservation were implemented using mixed regression modeling that accounted for the correlation among samples from the same patient and differences in age. RESULTS: Six girls were enrolled (mean, 12 years; median, 13 years, range, 6-17 years). Pathologic analysis was carried out in all viable grafts and ovarian follicle densities were determined. Mean ovarian follicle density (+/- SEM) before cryopreservation was 50.5 +/- 4.26 follicles/mm2 and after cryopreservation was 44.1 +/- 4.25 follicles/mm2, p < 0.001. Following cryopreservation, on average the ovarian tissue retained 89.0.% of the FD of paired fresh samples (95% CI 82.8%, 95.2%). CONCLUSIONS: FD in young females with cancer is significantly reduced following OTC. However, the degree of reduction may be less than that reported in adult women. This is the first study in adolescent girls to provide histologic evidence of preservation of ovarian follicle density and potential efficacy of the ovarian tissue cryopreservation strategy.  By providing this evidence base, the potential benefit to young females with cancer and their family may be prognostically and clinically significant.

Minimally Invasive Pediatric Surgery During Remote Humanitarian Missions Is Feasible, Safe, and Effective.

PURPOSE: There remains a critical need for the provision for pediatric humanitarian aid worldwide. Historically, the emphasis of global pediatric health needs has been focused on infectious diseases. Today, we are witnessing a shift in this paradigm, with growing attention being paid toward the surgical needs of children. The use and deployment of minimally invasive surgery (MIS) in these austere environments with its concomitant reduction in length of hospitalization, pain, and morbidity is logical. The goal of this study was to report our deployment strategy and review our experience with pediatric MIS during humanitarian missions to determine if it is safe, feasible, and efficacious. METHODS: As part of the World Pediatric Project (WPP), data were collected retrospectively from the general pediatric surgery (GPS) team missions from January 2007 to January 2017. All cases were performed at a single medical center in the Eastern Caribbean Island Nation of St. Vincent and the Grenadines (SVG). Data included patient demographics, diagnosis, procedure, conversion to open procedure, complications, and postoperative course. The teams utilized a dedicated WPP operating theater, prepositioned and deployed GPS supplies, and MIS resources. All anesthesia, surgical, and nursing personal were board certified and trained professionals functioning as part of the WPP team. RESULTS: One hundred thirty-four children underwent general and thoracic pediatric surgical procedures during the study period. Mean age 9.2 years (2-19 years). Thirty-seven children underwent MIS procedures (27%). There were no conversions to open procedures. There were only two postoperative complications, cellulitis following laparoscopic appendicostomies, which required intravenous antibiotics and were discharged on a course of oral antibiotics. The postoperative course for all children was uneventful and no child required readmission. There were no technical failures in the MIS systems or instrumentation. CONCLUSIONS: Our retrospective review supports the use of MIS techniques as part of GPS humanitarian missions. We have found it to be a safe, feasible, and effective modality that may reduce length of stay, pain, and morbidity compared with open procedures in these remote environments. Although our MIS systems and instrumentations functioned effectively, concerns regarding the storage and sustainability for future missions are significant. Onsite health care partners, redundant systems, and remote technical support access could potentially alleviate these concerns.

Microdeformational wound therapy: A novel option to salvage complex wounds associated with the Nuss procedure.

BACKGROUND: Complex wounds associated with the Nuss procedure are a resource intensive complication that may lead to significant morbidity with potential removal of the implanted device and abandonment of the repair. We report our management technique of this complication utilizing microdeformational wound therapy (MDWT) that is safe, is efficacious and allows for salvage of the repair. OPERATIVE TECHNIQUE: We defined a complex wound as a wound that became suppurative and drained in the postoperative period and failed to resolve with a trial of conventional wound management and antibiotics. Upon recognition of a complex wound, we recommend an initial operative wound debridement. This allows wound cultures, wound assessment and precise initiation of MDWT. It is not uncommon to have exposed hardware in the wound early in the course of therapy. Metal allergy must be excluded. The patient is transitioned to oral antibiotics following resolution of the acute process. MDWT is performed until the wounds are completely epithelialized with no clinical signs of drainage or infection. The average length of MDWT in our patients was 39 days. Following complete wound healing the patients are maintained on antibiotics until implant removal. CONCLUSIONS: The use of microdeformational wound therapy in complex wounds associated with the Nuss procedure is a safe and effective modality. The technique may reduce the likelihood of implant removal with potential recurrent pectus excavatum. TYPE OF STUDY: Operative technique. LEVEL OF EVIDENCE: Level IV, case series with no comparison group.

Laparoscopic appendectomy in children: use of the endoloop vs the endostapler.

HYPOTHESIS: Two techniques are used for laparoscopic appendectomy (LA): division of the mesoappendix with the harmonic scalpel and ligation of the appendix with an endoloop (EL), or division of the mesoappendix and appendix with an endostapler (ES). Using an ES is a cost-effective technique that provides an outcome benefit in children who require appendectomy. DESIGN: Case series. SETTING: Academic, tertiary care children's hospital. PATIENTS: Seventy-five children who underwent LA from January 1, 2002, to March 31, 2004. INTERVENTION: Laparoscopic appendectomy. MAIN OUTCOME MEASURES: Age, diagnosis, length of stay, surgical time, total operating room time, complications, and instrumentation costs were compared between the EL and ES groups. RESULTS: There was no significant difference in age, length of stay, perforated, gangrenous, or acute appendicitis diagnoses, or complications between the groups. The surgical time and total operating room time for LA in children in the ES group were significantly shorter than in children in the EL group by 15% and 17%, respectively (P<.05). The disposable equipment costs for LA were $201 per case in the ES group vs $400 per case in the EL group. The mean 14.9-minute increase in total operating room time in children in the EL group resulted in $373 of additional operating room and anesthesia costs. The decreased disposable equipment costs and shorter surgical time of LA in the ES group led to cost savings of $572 per case as compared with children who underwent LA with an EL. CONCLUSIONS: There is no significant difference in outcome between children who undergo LA with an EL or with an ES. However, this study supports the use of the ES for LA as a more cost-effective technique that is associated with reduced surgical time.

Minimally Invasive Patent Ductus Arteriosus Ligation.

A patent ductus arteriosus is a common condition, particularly in premature infants. Many spontaneously resolve but those that lead to clinical instability require closure. Conservative measures can be highly successful in selected groups. Surgical repair is effective and both open and minimally invasive approaches can be used. The minimally invasive approach may result in less long-term morbidity from a thoracotomy and may prove advantageous for these fragile infants, including less pain, shorter time on the ventilator, and shorter hospital stays.

Classical positioning decreases the cross-sectional area of the subclavian vein.

BACKGROUND: The classic position for subclavian venipuncture is the Trendelenberg position, with the head turned away and placement of a shoulder roll (SR). The purpose of this study was to determine whether this position results in the largest cross-sectional area (CSA) of the subclavian vein (SV). METHODS: Adult volunteers underwent ultrasound imaging of the right SV in supine and Trendelenberg positioning in the following four head and shoulder positions: head neutral with the chin midline (NL), head turned away (TA), head neutral with an SR, and head TA with an SR (TA/SR). The mean CSA of the SV in each position was calculated. Statistical significance was determined using Student's t, Wilcoxon signed rank, and Bonferroni test. RESULTS: Eighteen adults participated in the study. Trendelenberg positioning significantly increased the CSA of the SV in all positions except NL compared to supine positioning (P < .03). An SR significantly decreased SV CSA in all positions. The largest SV CSA was obtained in the TA/Trendelenberg position (1.41 +/- .06 cm(2)). The classic positioning for subclavian cannulation, TA/SR/Trendelenberg, resulted in a significantly smaller CSA than TA/Trendelenberg position (1.27 +/- .06 cm(2), 15% reduction, P < .01). CONCLUSIONS: The classic recommended maneuvers of turning the head and placing an SR significantly reduce the CSA of the SV. Positioning patients in Trendelenberg with the head turned away without an SR optimizes SV size. Positioning patients in this manner may serve to reduce the morbidity associated with percutaneous access of the SV.

Intraluminal Meckel's Duplication Cyst Causing Bowel Obstruction in an Infant: A Role for Laparotomy.

This report describes a two-month-old girl who presented with signs and symptoms of a distal small bowel obstruction. She underwent an abdominal ultrasound that revealed a right lower quadrant cystic mass. A Technetium-99 scan revealed increased activity in the right lower quadrant consistent with a Meckel's diverticulum. Following a nondiagnostic laparoscopic evaluation, a laparotomy was performed to allow direct palpation of the small bowel and colon. Direct palpation of the ileum revealed a soft intraluminal mass at the ileocecal valve. The child underwent an ileocecectomy and anastomosis incorporating the intraluminal mass. Pathologic analysis revealed an intraluminal enteric duplication cyst containing ectopic gastric mucosa. This case represents the first report of such an entity in an infant. A discussion of the diagnostic and therapeutic aspects of the case and enteric duplication cysts is provided.

Mucous fistula refeeding decreases parenteral nutrition exposure in postsurgical premature neonates.

BACKGROUND/PURPOSE: Premature neonates can develop intraabdominal conditions requiring emergent bowel resection and enterostomy. Parenteral nutrition (PN) is often required, but results in cholestasis. Mucous fistula refeeding allows for functional restoration of continuity. We sought to determine the effect of refeeding on nutrition intake, PN dependence, and PN associated hepatotoxicity while evaluating the safety of this practice. METHODS: A retrospective review of neonates who underwent bowel resection and small bowel enterostomy with or without mucous fistula over 2years was undertaken. Patients who underwent mucous fistula refeeding (RF) were compared to those who did not (OST). Primary outcomes included days from surgery to discontinuation of PN and goal enteral feeds, and total days on PN. Secondary outcomes were related to PN hepatotoxicity. RESULTS: Thirteen RF and eleven OST were identified. There were no significant differences among markers of critical illness (p>0.20). In the interoperative period, RF patients reached goal enteral feeds earlier than OST patients (median 28 versus 43days; p=0.03) and were able to have PN discontinued earlier (median 25 versus 41days; p=0.04). Following anastomosis, the magnitude of effect was more pronounced, with RF patients reaching goal enteral feeds earlier than OST patients (median 7.5 versus 20days; p≤0.001) and having PN discontinued sooner (30.5 versus 48days; p=0.001). CONCLUSIONS: RF neonates reached goal feeds and were able to be weaned from PN sooner than OST patients. A prospective multicenter trial of refeeding is needed to define the benefits and potential side effects of refeeding in a larger patient population in varied care environments.

Personal satisfaction and mentorship are critical factors for today's resident surgeons to seek surgical training.

The specific aim of this study was to summarize the viewpoints of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) membership regarding current training and quality of life-related issues prior to implementation of the new duty-hour guidelines. The goal was to gain insight of the members that may be useful to recruit and guide the future training of surgical residents. An Internet-based survey was developed to evaluate the viewpoints of RAS-ACS. The survey was administered by Esurveymaker.com via the ACS Web page from 2000 to 2003. RAS-ACS member participation was voluntary and anonymous. Analyses were performed to determine the frequency of response for each survey item. Two hundred thirty-five members completed the survey representing 5 per cent of RAS-ACS. Eighty-four per cent were general surgery residents. Personal satisfaction (64%) and mentorship (49%) were top factors for respondents to pursue surgical training; discussion with colleagues and future income was less important. Forty-five per cent reported that job performance was their most important concern during residency. A rewarding surgical career and family life were ranked as the most important expectations. Eighty-six per cent reported that they were satisfied with their residency, and 66 per cent reported that work hours should be limited. Personal satisfaction and mentorship were critical factors for members of the RAS-ACS to seek surgical training. Although most of the members report that work hours should be limited, an overwhelming majority reports satisfaction with surgical training prior to institution of the new duty-hour guidelines. Further emphasis on mentorship and work-hour reform may be beneficial in recruiting medical students into surgical residencies.

Ultrasound-Guided Percutaneous Central Venous Access in Low Birth Weight Infants: Feasibility in the Smallest of Patients.

PURPOSE: The insertion of tunneled central venous access catheters (CVCs) in infants can be challenging. The use of the ultrasound-guided (UG) approach to CVC placement has been reported in adults and children, but the technique is not well studied in infants. SUBJECTS AND METHODS: A retrospective review was performed of infants under 3.5 kg who underwent attempted UG CVC placement between August 2012 and November 2013. All infants underwent UG CVC placement using a standard 4.2-French or 3.0-French CVC system (Bard Access Systems, Inc., Salt Lake City, UT). The UG approach was performed on all infants with the M-Turbo(®) ultrasound system (SonoSite, Inc., Bothell, WA). The prepackaged 0.025-inch-diameter J wire within the set was used in all infants weighing greater than 2.5 kg. A 0.018-inch-diameter angled glidewire (Radiofocus(®) GLIDEWIRE(®); Boston Scientific Inc., Natick, MA) was used in infants less than 2.5 kg. Data collected included infant weight, vascular access site, diameter of cannulated vein (in mm), and complications. RESULTS: Twenty infants underwent 21 UG CVC placements (mean weight, 2.4 kg; range, 1.4-3.4 kg). Vascular CVC placement occurred at the following access sites: 16 infants underwent 17 placements via the right internal jugular vein, versus 3 infants via the left internal jugular vein. The average size of the target vessel was 4.0 mm (range, 3.5-5.0 mm). One infant had inadvertent removal of the UG CVC in the right internal jugular vein on postoperative Day 7. This infant returned to the operating room and underwent a successful UG CVC in the same right internal jugular vein. There were no other complications in the group. CONCLUSIONS: The UG CVC approach is a safe and efficient approach to central venous access in infants as small as 1.4 kg. Our experience supports the use of a UG percutaneous technique as the initial approach in underweight infants who require central venous access.

A novel continuous stitch fundoplication utilizing knotless barbed suture in children with gastroesophageal reflux disease: a pilot study.

INTRODUCTION: The intracorporeal placement and tying of suture (IT) can be challenging leading to prolonged CO2 insufflation, anesthesia, and potential morbidity. The unidirectional barbed knotless suture (V-LOC) has emerged as an innovative technology that has been shown to reduce the time associated with IT. Therefore, we conducted a retrospective analysis comparing our initial experience utilizing V-LOC to perform a novel continuous stitch laparoscopic fundoplication (CF) to standard laparoscopic Nissen fundoplication (NF). METHODS: Institutional review board approval was obtained to analyze data on patients who underwent V-LOC CF and NF. Data retrieval included age, gender, weight, diagnosis, procedure, operative time, major complications (reoperation for wrap failure/migration or recurrent symptoms), and follow up. RESULTS: Twenty patients underwent the V-LOC CF and gastrostomy placement (GT) from January to October 2013. Seventeen patients underwent NF and GT from March 2012 to February 2013. There were no significant differences in age, weight, or incidence of major complications. V-LOC CF led to a significant 30% reduction in operative time compared to NF (79.1±24.2 min vs. 113.8±25.9 min, respectively, P<0.05). CONCLUSIONS: This is the first report documenting the continuous stitch fundoplication utilizing the unidirectional barbed knotless suture in children. Although follow-up is short, the V-LOC CF appears to be a safe and effective technique that may reduce operative time in children with gastroesophageal reflux disease. This technology may be beneficial in other minimally invasive applications in pediatric surgery.

Secondary overtriage in pediatric trauma: can unnecessary patient transfers be avoided?

BACKGROUND: In an era of wide regionalization of pediatric trauma systems, interhospital patient transfer is common. Decisions regarding the location of definitive trauma care depend on prehospital destination criteria (primary triage) and interfacility transfers (secondary triage). Secondary overtriage can occur in any resource-limited setting but is not well characterized in pediatric trauma. METHODS: The National Trauma Data Bank from 2008 to 2011 was queried to identify patients 15 years or younger who were transferred to pediatric trauma centers. Secondary overtriage was defined as meeting all 4 of the following criteria: injury severity score (ISS) less than 9, no need for surgical procedure, no critical care admission, and length of stay of less than 24 hours. All other transfers were deemed appropriate triage. RESULTS: Our definition of secondary overtriage was met in 32,318 patients out of 144,420 transfers (22.4%). Within this group, 37.5% were discharged directly from the emergency department of the receiving hospital without hospital admission. Appropriately triaged patients required a therapeutic procedure in 43.5% of cases. Differences in age, sex, mechanism of injury, and payer status were modest. CONCLUSIONS: Secondary overtriage is prevalent in pediatric trauma systems nationwide and is not associated with any particular patient characteristics. Because clinical outcomes and healthcare spending are increasingly scrutinized, secondary overtriage may reflect unnecessary patient transfer and a source of potential cost savings. Development of better guidelines for secondary triage of pediatric trauma patients may enable timely assessment and treatment of children who require a higher level of care while also preventing inefficient use of available resources.