Minimizing Individual Learning Curves in a Mature Endoscopic Fetal Surgery Program.

INTRODUCTION: Twin-to-twin transfusion syndrome affects monochorionic twin pregnancies and can result in fetal death. Endoscopic laser treatment remains a relatively infrequent procedure for this condition. This presents difficulties for maintaining proficiency and for training new personnel. OBJECTIVE: The dual mentoring program at our institution allows for continuous mentoring of new providers. We hypothesize that this approach stabilizes program proficiency despite the addition of new practitioners. METHODS: Query of the fetal treatment program database returned 146 cases of laser ablation between 2000 and 2019. Patient and pregnancy characteristics as well as operative time and outcomes were recorded. The learning curve-cumulative summation method and rolling averages were used to analyze outcomes. RESULTS: Overall survival was 69%, and survival of at least 1 twin was 89%. Mean operative time was 53.6 ± 20.9 min. Overall twin survival stabilized after the first 40 cases. Rolling averages for operative time decreased from 71 to 49 min for the most recent cases. These results were not affected by the introduction of new surgeons. CONCLUSIONS: Creative mentoring can maintain stable overall program outcomes despite changes in team composition. This training approach may be applicable to other rare procedures in fetal surgery.

Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee.

PURPOSE: Variation in management characterizes treatment of infants with a congenital pulmonary airway malformation (CPAM). This review addresses six clinically applicable questions using available evidence to provide recommendations for the treatment of these patients. METHODS: Questions regarding the management of a pediatric patient with a CPAM were generated. English language articles published between 1960 and 2014 were compiled after searching Medline and OvidSP. The articles were divided by subject area and by the question asked, then reviewed and included if they specifically addressed the proposed question. RESULTS: 1040 articles were identified on initial search. After screening abstracts per eligibility criteria, 130 articles were used to answer the proposed questions. Based on the available literature, resection of an asymptomatic CPAM is controversial, and when performed is usually completed within the first six months of life. Lobectomy remains the standard resection method for CPAM, and can be performed thoracoscopically or via thoracotomy. There is no consensus regarding a monitoring protocol for observing asymptomatic lesions, although at least one chest computerized tomogram (CT) should be performed postnatally for lesion characterization. An antenatally identified CPAM can be evaluated with MRI if fetal intervention is being considered, but is not required for the fetus with a lesion not at risk for hydrops. Prenatal consultation should be offered for infants with CPAM and encouraged for those infants in whom characteristics indicate risk of hydrops. CONCLUSIONS: Very few articles provided definitive recommendations for care of the patient with a CPAM and none reported Level I or II evidence. Based on available information, CPAMs are usually resected early in life if at all. A prenatally diagnosed congenital lung lesion should be evaluated postnatally with CT, and prenatal counseling should be undertaken in patients at risk for hydrops.

How many tests does it take? Minimizing preoperative testing prior to surgical placement of gastrostomy tubes in children.

BACKGROUND: Gastrostomy tubes (GTs) provide life-saving enteral access for children. Although upper gastrointestinal (UGI) series and impedance studies (ISs) detect gastroesophageal reflux disease (GERD) or malrotation, their benefit for preoperative evaluation of asymptomatic patients requiring GT placement is controversial. This study investigated the value of routine preoperative testing and whether specific patient characteristics could guide the selective use of these studies. METHODS: The charts of children who underwent GT placement from 2003 to 2019 were reviewed retrospectively. Demographics, preoperative evaluation, and postoperative course were evaluated. RESULTS: Three hundred forty-three patients underwent GT placement, 61% with preoperative testing. Seven of 190 UGI (4%) series demonstrated malrotation, and 39 of 141 (28%) ISs revealed severe GERD. Although all malrotations were surgically addressed, only 59% (23/39) of IS-proven GERD cases prompted simultaneous fundoplication. Age <1 year was associated with a positive UGI series (6.7% positive vs 1.0%; P < 0.05), but no other patient characteristics were associated with either positive UGI series or IS. Elimination of the 96% of UGI series that did not alter care represented a cost savings of $89,487-$229,665 and avoided the radiation exposure from testing; elimination of the 84% of ISs that did not alter eventual treatment would have saved $127,776-$266,563. CONCLUSION: Routine preoperative evaluation with UGI series and IS can increase healthcare costs without substantially altering care. The only patients potentially benefiting from routine UGI series were <1 year old. Instead, a targeted, symptom-based preoperative evaluation may streamline the process by decreasing preoperative testing and minimizing cost and radiation exposure.

Management of the undescended testis in children: An American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee Systematic Review.

PURPOSE: Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. METHODS: A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. RESULTS: A total of 825 articles were identified in the initial search, and 260 were included in the final review. CONCLUSIONS: Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

Commentary on a cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S.

This is a commentary on the manuscript by Sarosi A, Coakley B, Berman L, et al., titled "A Cross-Sectional Analysis of Compassion, Fatigue, Burnout, and Compassion Satisfaction in Pediatric Surgeons in the U.S."

The effects of early anesthesia on neurodevelopment: A systematic review.

BACKGROUND: There is growing concern regarding the impact of general anesthesia on neurodevelopment in children. Pre-clinical animal studies have linked anesthetic exposure to abnormal central nervous system development, but it is unclear whether these results translate into humans. The purpose of this systematic review from the American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice (OEBP) Committee was to review, summarize, and evaluate the evidence regarding the neurodevelopmental impact of general anesthesia on children and identify factors that may affect the risk of neurotoxicity. METHODS: Medline, Cochrane, Embase, Web of Science, and Scopus databases were queried for articles published up to and including December 2017 using the search terms "general anesthesia and neurodevelopment" as well as specific anesthetic agents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to screen manuscripts for inclusion in the review. A consensus statement of recommendations in response to each study question was synthesized based upon the best available evidence. RESULTS: In total, 493 titles were initially identified, with 56 articles selected for full analysis and 44 included for review. Based on currently available developmental assessment tools, a single exposure to general anesthesia does not appear to have a significant effect on general neurodevelopment, although prolonged or multiple anesthetic exposures may have some adverse effects. Exposure to general anesthesia may affect different domains of development at different ages. Regional anesthetic techniques with the addition of dexmedetomidine and/or some intravenous agents may mitigate the risks of neurotoxicity. This approach may be performed safely in some patients and can be considered as an option in selected short procedures. CONCLUSION: There is no conclusive evidence that a single short anesthetic in infancy has a detectable neurodevelopmental effect. Data do not support waiting until later in childhood to perform general anesthesia for single short procedures. With the complexities and nuances of different anesthetic methods, patients and procedures, the planning and execution of anesthesia for the pediatric patient is generally best accomplished by an anesthesiologist, ideally a pediatric anesthesiologist. TYPE OF STUDY: Systematic review of level 1-4 studies. LEVEL OF EVIDENCE: Level 1-4 (mainly level 3-4).

Management of intussusception in children: A systematic review.

OBJECTIVE: The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS: The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS: A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS: Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE: Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.

Ovarian masses in the child and adolescent: An American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee systematic review.

BACKGROUND: The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy. METHODS: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review. RESULTS: Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence. CONCLUSIONS: Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature. TYPE OF STUDY: Systematic review of level 1-4 studies. LEVEL OF EVIDENCE: Level 1-4 (mainly 3-4).

Real-time ultrasonography for placement of central venous catheters in children: A multi-institutional study.

BACKGROUND: Recommendations for the use of real-time ultrasonography for placement of central venous catheters in children are based on studies involving adults treated by nonsurgeons. Our purpose was to determine the frequency of use of real-time ultrasonography use by pediatric surgeons during central venous catheter placement, patient and procedure factors associated with real-time ultrasonography use, and adverse event rates. METHODS: Using data gathered from 14 institutions, we performed a retrospective cohort study of patients <18 years old who underwent central venous catheter placement. Patient demographics and operative details were collected. We used a logistic regression model to evaluate factors associated with real-time ultrasonography use. RESULTS: Real-time ultrasonography was used in 33% of attempts (N = 1,146). The subclavian vein (64%) was accessed preferentially for first site insertion. Real-time ultrasonography was less likely to be used for subclavian vein (odds ratio = 0.002; P < .0001) and more likely to be used when coagulopathy (international normalized ratio >1.5) was present (odds ratio = 11.1; P = .03). The rate of mechanical complications was 3.5%. Real-time ultrasonography use was associated with greater procedural success rates on first-site attempt, but also with a greater risk of hemothorax. CONCLUSION: Pediatric surgeons access preferentially the subclavian vein for central venous access, yet are less likely to use real-time ultrasonography at this site. Real-time ultrasonography was superior to the landmark techniques for the first-site procedure success, yet was associated with greater rates of hemothorax. Prospective trials involving children treated by pediatric surgeons are needed to generate more definitive data.

Use of real-time ultrasound during central venous catheter placement: Results of an APSA survey.

PURPOSE: The purpose of this study was to document the attitudes and practice patterns of pediatric surgeons regarding use of RTUS with CVC placement. METHODS: An analytic survey composed of 20 questions was sent via APSA headquarters to all practicing members. Answers were summarized as frequency and percentage. Distributions of answers were compared using the chi-square tests. P-values ≤0.05 were considered statistically significant. RESULTS: 361 of 1072 members chose to participate for a response rate of 34%. Most placed CVCs into the subclavian veins (SCV) of patients without coagulopathy, with the left SCV chosen approximately four times more often than the right. Conversely, RTUS use at the internal jugular vein (IJV) was significantly greater than that for the SCV (p<0.001). Coagulopathy, multiple previous catheters, and morbid obesity were identified as patient characteristics that would encourage RTUS use. The most commonly cited potential barriers to RTUS use were lack of formal ultrasound training and the belief that ultrasound is not necessary. CONCLUSIONS: Variability exists among pediatric surgeons regarding use of RTUS during CVC placement. Additional studies are needed to document actual frequency of use, how RTUS is implemented, and its efficacy of preventing adverse events in children.

Guidelines for alcohol screening in adolescent trauma patients: a report from the Pediatric Trauma Society Guidelines Committee.

BACKGROUND: Alcohol misuse is an important source of preventable injuries in the adolescent population. While alcohol screening and brief interventions are required at American College of Surgeons-accredited trauma centers, there is no standard screening method. To develop guidelines for testing, we reviewed available evidence regarding adolescent alcohol screening after injury, focusing on the questions of which populations require screening, which screening tools are most effective, and at which time point screening should be performed. METHODS: A comprehensive PubMed search for articles related to alcoholism, trauma, and screening resulted in 1,013 article abstracts for review. Eighty-five full-length articles were considered for inclusion. Articles were excluded based on study type, location (non-US), year of publication, and nonapplicability to the study questions. RESULTS: Twenty-six articles met full inclusion criteria. Results support universal screening for alcohol misuse in the adolescent trauma population. Although adolescents 14 years and older are more likely to test positive for alcohol misuse, studies suggest screening may need to start at 12 years or younger. Both survey and biochemical screens can identify at-risk adolescents, with the Alcohol Use Disorders Identification Test and the two-question survey based on the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition criteria for alcohol-use disorders being the most sensitive surveys available. CONCLUSION: Injured adolescent trauma patients should be universally screened for alcohol misuse during their hospital visit. To maximize the number of at-risk adolescents targeted for interventions, screening should begin at minimum at 12 years. As no screen identifies all at-risk adolescents, a serial screening method using both biochemical tests and standardized questionnaires may increase screening efficacy.

Glowing in the dark: time of day as a determinant of radiographic imaging in the evaluation of abdominal pain in children.

BACKGROUND/PURPOSE: Although ultrasound is often the preferred pediatric imaging study, many institutions lack ultrasound access at night; and computerized tomography (CT) becomes the only radiological method available for evaluation of appendicitis in children. The purpose of this study was to characterize patterns of daytime and nighttime use of ultrasound or CT for evaluation of pediatric appendicitis and to measure consequent differences in radiation exposure and cost. METHODS: A retrospective chart review of patients evaluated for appendicitis from October 2004 to October 2009 (N = 535) was performed to evaluate daytime and nighttime use of ultrasound and CT for pediatric patients. RESULTS: Average age was 10.2 years (range, 3-17 years). During the day, 6 times as many ultrasounds were performed as CTs (230 vs 35). At night, half as many ultrasounds were performed (50 vs 110). Average radiation dose per child during the day was significantly lower than at night (day, 0.52 mSv per patient; night, 2.75 mSv per patient). Average radiology costs were lower for daytime patients ($2491.06 day vs $4045.00 night; P < .05). CONCLUSIONS: Dependence on CT at night results in higher average radiation exposure and cost. Twenty-four-hour ultrasound availability would decrease radiation exposure and cost of evaluation of children presenting with appendicitis.

Diagnosing ruptured appendicitis preoperatively in pediatric patients.

BACKGROUND: Over the past decade, pediatric patients with ruptured appendicitis (RA) have been successfully treated with IV antibiotics and an interval appendectomy. Because the treatment of acute appendicitis (AA) and RA in children is now diverging, distinguishing between these two conditions preoperatively is critical. STUDY DESIGN: A prospective cohort study was conducted. Clinical data were collected, and the attending surgeon's preoperative diagnosis was recorded. Accuracy of the pediatric surgeon's diagnosis was determined. Univariable and multivariable logistic regression were then used to determine independent clinical predictors of RA. Using the relative beta coefficients of these predictors, a scoring system was constructed to aid in the diagnosis of RA. RESULTS: Two hundred forty-seven patients were evaluated: 98 AA (40%), 53 RA (21%), and 97 not appendicitis (39%). Median age was 10 years old. The overall accuracy of the pediatric surgeon's preoperative diagnosis was 92%. Sensitivity and specificity for the diagnosis of RA were 96% and 83%, respectively. Multivariable regression analysis identified generalized tenderness on examination, duration of symptoms longer than 48 hours, WBC>19,400 cells/microL, abscess, and fecalith on CT scan as independent predictors for RA. A novel scoring system was developed with these variables, and, when applied to the study population, the specificity for the diagnosis of RA improved to 98%. CONCLUSIONS: Pediatric surgeons differentiate AA from RA and not appendicitis preoperatively with high accuracy and sensitivity, but the specificity for diagnosing ruptured appendicitis is lower. The scoring system improved the specificity of the preoperative diagnosis. The validity and utility of this scoring system should be examined in future studies in larger patient populations.

Endometrial cancer is a receptor-mediated target for Mullerian Inhibiting Substance.

Mullerian Inhibiting Substance (MIS), a 140-kDa homodimer glycoprotein member of the TGF-beta superfamily of biological-response modifiers, causes regression of the Mullerian ducts in developing male embryos. MIS also can induce growth arrest and apoptosis in ovarian and cervical cancer cell lines. The embryonic progenitor of the ovarian and cervical epithelium is the coelomic epithelium, the same tissue that regresses under the direction of MIS in the male. The endometrium and uterus also arise from the coelomic epithelium and the Mullerian ducts. Here, we show that both normal human endometrium and endometrial cancers express the receptor for MIS and that MIS can inhibit the proliferation of a number of human endometrial cancer cell lines that express the MIS type II receptor. In the representative endometrial cancer cell line AN3CA, MIS affects the expression of key cell-cycle regulatory proteins. This work broadens the scope of tumors that MIS can potentially control and, by elucidating the MIS signaling pathway, identifies other potential avenues for intervention.