A Minimally Interventional Approach to Oesophageal Atresia Repair With Early Enteral Feeding is Safe, Optimises Neonatal Outcomes, and Reduces Resource use.

PURPOSE: Recent series of newborn Oesophageal Atresia (OA) repair continue to report widespread use of chest drains, gastrostomy, routine contrast studies and parenteral nutrition (PN) despite evidence suggesting these are superfluous. We report outcomes using a minimally interventional approach to post-operative recovery. METHODS: Ethically approved (15/WA/0153), single-centre, retrospective case-note review of consecutive infants with OA 2000-2022. Infants with OA and distal trache-oesophageal fistula undergoing primary oesophageal anastomosis at initial surgery were included (including those with comorbidities such as duodenal atresia, anorectal malformation and cardiac lesions). Our practice includes routine use of a trans-anastomotic tube (TAT), no routine chest drain nor gastrostomy, early enteral and oral feeding, no routine PN and no routine contrast study. Data are median (IQR). RESULTS: Of total 186 cases of OA treated during the time period, 157 met the inclusion criteria of which 2 were excluded as casenotes unavailable. TAT was used in 150 infants. A chest drain was required in 13 (8%) and two infants had a neonatal gastrostomy. Enteral feeds were started on postoperative day 2 (2-3), full enteral feeds established by day 4 (4-6) and oral feeds started on day 5 (4-8). PN was required in 15%. Median postoperative length of stay was 10 days (8-17). Progress was quicker in term infants than preterm. One infant died of cardiac disease prior to neonatal discharge. Two planned post-operative contrast studies were performed (surgeon preference) and a further 7 due to clinical suspicion of anastomotic leak. Contrast study was therefore avoided in 94%. There were 2 anastomotic leaks; both presented clinically at day 4 and day 8 after oral feeds had been started. CONCLUSION: Our minimally interventional approach is safe. It facilitates prompt recovery with lower resource use, reduced demand on nursing staff, reduced radiation burden, and early discharge home compared to published series without adversely affecting outcomes. LEVEL OF EVIDENCE: Level 4.

'Cut and push' as an alternative to endoscopic retrieval of PEG type gastrostomy tubes.

PURPOSE: Percutaneous Endoscopically placed Gastrostomy (PEG) tubes are frequently used in children. The traditional endoscopic method to remove/change the PEG device requires general anaesthesia in children. A minimally invasive alternative is the 'Cut and Push' method (C&P): avoiding the risks/wait times of general anaesthesia and reducing resource burden. Data regarding the safety/effectiveness of C&P in children are lacking with concerns raised about the possibility of gastrointestinal obstruction. METHODS: We retrospectively reviewed all cases of PEG removal / change to button in children (< 18 years) between December 2020 and January 2022. Cases were identified from a prospectively maintained database and all cases of C&P included. Parents/carers were asked if the child had suffered any complications following C&P and if flange was visualised in stools. RESULTS: During the time period, 27 PEGs were either removed or changed to button via C&P. The average waiting time for C&P was 14.29 days, significantly shorter than the minimum 6-month waiting time for elective endoscopy. Our evaluation revealed no complications of C&P at median 70 days (range 25-301). In three cases the flange was visualised in the stool, at 2 days, 3 days and 5 weeks following C&P respectively. DISCUSSION: These data support the available literature suggesting C&P is an effective means to facilitate minimally invasive and prompt PEG removal/change to button in children. We recommend minimum weight and age parameters for this procedure and further evaluation of the safety and resource implications of this technique.

Cost-Effectiveness of Laparoscopic and Open Pediatric Inguinal Hernia Repair.

Aim: Laparoscopic inguinal hernia (IH) repair is an alternative to open surgery. A potential advantage of laparoscopic repair is prevention of contralateral metachronous hernia although some studies report higher recurrence rate. We aim to determine the cost-effectiveness of open versus laparoscopic IH repair taking into account metachronous and recurrence rates. Methods: Retrospective single-center study of children (<5 years) undergoing elective open or laparoscopic repair for a unilateral IH between February 2018 and October 2019. Ten cases in each of four groups were included (open day case, open overnight, laparoscopic day case, and laparoscopic overnight). Cases incurring a higher cost due to comorbidities or additional procedure were excluded. Patient-level information and costing system data were obtained from the hospital finance. Mean (standard deviation [SD]) procedural cost was compared for open and laparoscopic procedures. A financial model was created factoring metachronous and recurrent rates. Results: Cost of open day case repair was £1866.24 (SD: 311.15) compared with £2210.13 (SD: 391.36) for day case laparoscopic repair. For overnight repair, cost of open was £2442.82 (SD: 497.05) compared with £2585.35 (SD: 384.66) for laparoscopic. On calculating the cost-effectiveness point using the difference in metachronous and recurrence rate between the two procedures, laparoscopic is more cost-effective than open day case repair at 18.43%. For overnight repair, the difference rate is 5.84%. Conclusion: Our data suggest that based on metachronous and recurrence rates in the current literature, laparoscopic IH repair is more cost-effective than open repair for cases requiring overnight stay, whereas for day case procedures open IH repair is more cost-effective.

Implementing an early feeding pathway post gastrostomy insertion reduces inpatient stay.

BACKGROUND: There is no consensus regarding optimal postoperative feeding strategy following gastrostomy insertion in children. The aim of this study was to determine whether implementing an early postoperative feeding pathway reduces length of stay (LOS) without increasing complications. METHODS: A retrospective case note review of all children having a new gastrostomy inserted during a one-year period prior to (July 2016-July 2017) and following (July 2017-July 2018) pathway introduction was performed. Children unable to follow the pathway for coexisting medical or nutritional reasons were excluded. The pathway comprised feeding 50% of normal feed 2 hours postprocedure, followed by 100% of normal feed at 5 and 8 h. Previously, patients were fed postoperatively according to surgeon preference. RESULTS: 116 cases met inclusion criteria, 55 prior to and 61 after pathway implementation. Children following the early feeding pathway had a shorter postoperative LOS than the historical group (median 28 vs 33 h, p < 0.003), while immediate (<72 h) and early (<30 day) complication rates were similar (8.2 vs 7.3%, p = 1.00 and 12 vs 16%, p = 0.59, respectively). CONCLUSIONS: Early postoperative feeding after gastrostomy insertion is safe and reduces LOS. TYPE OF STUDY: Quality improvement. LEVEL OF EVIDENCE: III.

The Safer Delivery of Surgical Services Program (S3): Explaining Its Differential Effectiveness and Exploring Implications for Improving Quality in Complex Systems.

OBJECTIVE: To analyze the challenges encountered during surgical quality improvement interventions, and explain the relative success of different intervention strategies. SUMMARY BACKGROUND DATA: Understanding why and how interventions work is vital for developing improvement science. The S3 Program of studies tested whether combining interventions addressing culture and system was more likely to result in improvement than either approach alone. Quantitative results supported this theory. This qualitative study investigates why this happened, what aspects of the interventions and their implementation most affected improvement, and the implications for similar programs. METHODS: Semistructured interviews were conducted with hospital staff (23) and research team members (11) involved in S3 studies. Analysis was based on the constant comparative method, with coding conducted concurrently with data collection. Themes were identified and developed in relation to the program theory behind S3. RESULTS: The superior performance of combined intervention over single intervention arms appeared related to greater awareness and ability to act, supporting the S3 hypothesis. However, we also noted unforeseen differences in implementation that seemed to amplify this difference. The greater ambition and more sophisticated approach in combined intervention arms resulted in requests for more intensive expert support, which seemed crucial in their success. The contextual challenges encountered have potential implications for the replicability and sustainability of the approach. CONCLUSIONS: Our findings support the S3 hypothesis, triangulating with quantitative results and providing an explanatory account of the causal relationship between interventions and outcomes. They also highlight the importance of implementation strategies, and of factors outside the control of program designers.

Current Practice and Outcomes in the Management of Intra-abdominal Testes.

INTRODUCTION: Fowler-Stephens orchidopexy is the most widely used technique for the surgical management of intra-abdominal testes with laparoscopy being the preferred approach. The aim of this study was to review all two-stage laparoscopic Fowler-Stephens orchidopexies performed in one pediatric surgical unit over a 7-year period. METHODS: A retrospective case series of all patients undergoing two-stage laparoscopic Fowler-Stephens orchidopexy was performed. Primary outcome measure was testicular atrophy at follow-up. Secondary outcomes included testicular atrophy at second-stage operation and testicular ascent requiring redo surgery. RESULTS: A total of 83 two-stage laparoscopic Fowler-Stephens orchidopexy were performed, with outcome data available for 67. Median age at first stage was 1 year 11 months. No testes had undergone atrophy at the second-stage laparoscopy. Median follow-up was 1 year. The overall success rate was 86.4%. Seven patients were noted to have an atrophic testis at the initial clinic review. Five patients required redo orchidopexy for testicular ascent. Of these, two patients had a successful result, two patients subsequently had testicular atrophy and one awaits redo surgery. CONCLUSION: We conclude that Fowler-Stephens orchidopexy has a relatively good outcome. The rates of reoperation after the two-stage Fowler-Stephens orchidopexy were low in this study. Overall success rate compares very favorably to published literature.