Long-term outcomes following H-type tracheoesophageal fistula repair in infants.

PURPOSE: To evaluate outcomes following repair of H-type tracheoesophageal fistula (TEF). METHODS: Retrospective chart review of infants with H-type TEF treated at our institution between 2000 and 2014. Patient demographics, surgical management, and postoperative function were evaluated. RESULTS: Of the 268 patients with esophageal atresia/TEF treated at our center, 16 (6%) had an H-type TEF (10 males). Thirteen (81%) had associated anomalies. All patients were symptomatic: choking and sputtering were the most common presentation (n = 10, 63%). Diagnosis Age at diagnosis was 8 days (1 day-34 months). All patients were diagnosed based on a single esophagogram. Prior to surgery, 12 (75%) patients underwent bronchoscopy and 11 underwent cannulation of the TEF tract. Surgery All patients underwent open repair. One was started thoracoscopically but converted to open due to esophageal sero-muscular injury. Repair was achieved in all patients via a transcervical approach (right-sided incision in 15). One patient had an unsuccessful prior attempt at repair using tissue glue. Following TEF division, 11 patients had tissue interposition grafts placed (9 muscle, 2 fat). Postoperative course Eight (50%) patients had postoperative vocal cord paresis (6 right-sided, 2 bilateral). A patient developed recurrent TEF 78 days postoperatively that was subsequently repaired. Follow-up At 41 months (8-143), there were no mortalities, all patients with vocal cord paresis were asymptomatic despite the fact that only 3 of 8 (38%) regained function, and nine (56%) patients had gastro-esophageal reflux requiring treatment. CONCLUSIONS: This large, single-center series demonstrates that H-type TEF can be diagnosed with esophagogram at an early age. Postoperative recurrent laryngeal nerve paresis and gastro-esophageal reflux disease are common following repair. Although most patients with vocal cord paresis eventually become asymptomatic, two-thirds do not regain vocal cord function. This reinforces the importance of routine examination of vocal cord movement following H-type TEF repair.

Cutaneous melanoma in 1-year-old child: an insight on infantile melanoma.

In the past, malignant melanoma (MM) is a diagnosis of unheard in children, but nowadays MM is a very rare malignancy in children. Its diagnosis requires careful interpretation of the pathological diagnostic criteria with clinical correlation of the findings. In this study, the authors are presenting a pigmented lesion in a 12-month-old girl, which was present since her birth with increase in size and shape. The authors discussed the difficulty that confronted them in making a diagnosis of MM and the differential diagnosis.

Refining How We Define Laparoscopic Expertise.

BACKGROUND: Traditional stratification of expertise in laparoscopic simulation assigns participants to novice, intermediate, or expert groups based on case numbers. We hypothesized that expert video assessment might refine this discrimination of psychomotor expertise, especially in light of new measurable parameters. MATERIALS AND METHODS: One hundred five participants performed a defined intracorporeal suturing task in the pediatric laparoscopic surgery simulator armed with force-sensing capabilities. Participants were stratified into novice, intermediate, and expert groups via three classification schemes: (1) number of complex laparoscopic cases, (2) self-declared level of expertise, and (3) average expert rating of participants' videos. Precision, time to task completion, and force analysis parameters (FAP = total, maximum and mean forces in three axes) were compared using one-way analysis of variance tests. P < .05 was considered significant. RESULTS: Participants stratified on the basis of case numbers and on the basis of self-declared level of expertise had statistically significant differences in time to task completion, but no significant difference in FAP. When participants were restratified according to expert assessment of their video performance, time to task completion as well as total and mean forces in X, Y, and Z axes allowed discrimination between novices, intermediates, and experts, thus establishing construct validity for the latter. Precision did not allow discrimination in any stratification scheme. CONCLUSION: Compared with traditional stratification, video assessment allows refined discrimination of psychomotor expertise within a simulator. Assessment of FAP may become a relevant tool for teaching and assessing laparoscopic skills.

The Impact of Simulator Size on Forces Generated in the Performance of a Defined Intracorporeal Suturing Task: A Pilot Study.

Background: In pediatric minimal access surgery, the operative domain may vary from that of an adult to that of a neonate. This study aimed to quantify the impact of decreased operative domain on forces generated in the performance of a defined intracorporeal suturing task. Methods: One hundred five participants performed a defined intracorporeal suturing task in small and large simulators. Time to task completion and force analysis parameters (FAPs = total, maximum, and mean forces in X, Y, and Z axes) were measured. Expertise level was assigned based on the number of laparoscopic cases. Outcomes were analyzed using paired sample t-tests, P value of <.05. Results: Time to task completion varied significantly for experts between adult and pediatric simulators but not for intermediates or novices. Total, maximum, and mean forces in the X ("side to side") axis were significantly greater in the larger laparoscopic simulator for all levels of expertise. In the Y axis ("in and out" movement) and Z axis ("up and down" movement), total and mean forces were higher in the adult simulator regardless of the level of expertise. Differences in maximum force between the adult and pediatric simulators in the Z axis ("up and down" movement) varied significantly for novices and intermediates but not for experts. Conclusion: Forces were greater, particularly in the side-to-side plane, in the larger simulator for participants of all levels in the performance of this defined intracorporeal suturing task. Further analysis will determine the reasons for and implications of the increased force parameters in the simulator of larger domain.