Percutaneous Coronary Intervention with Stenting versus Coronary Artery Bypass Grafting in Stable Coronary Artery Disease.

The debate over coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with stent placement for the treatment of stable multivessel coronary artery disease (CAD) continues in spite of numerous studies investigating the issue. This paper reviews the most recent randomized control trials (RCT) and meta-analyses of pooled RCT data to help address this issue. General trends demonstrated that CABG was superior in all-cause mortality and fulfilling the need for repeat revascularization. These advantages tended to be more pronounced in multivessel CAD and diabetes, and less so in left main CAD. PCI showed a consistently lower rate of cerebrovascular events. CABG continues to offer significant advantages over PCI, even as drug-eluting stent technology continues to evolve. The ideal endpoint for comparing PCI and CABG remains to be determined. Furthermore, additional research is required to further refine patient selection criteria for each intervention.

Recurrence after laparoscopic high ligation in adolescents: A multicenter international retrospective study of ten hospitals.

PURPOSE: Inguinal hernia repairs are among the most common operations performed by pediatric surgeons. Laparoscopic high ligation is a popular technique, but its recurrence rate in adolescents is unknown. We hypothesized that recurrence after laparoscopic high ligation in adolescents would be similar to open repair (1.8%-6.3%). METHODS: We evaluated adolescent patients (12-18 years old at the time of surgery) who underwent laparoscopic high ligation across eleven hospitals. At least six months postoperatively, they were contacted by telephone for follow-up. Variables analyzed included demographics, operative details, recurrence, and other complications. RESULTS: A total of 144 patients were enrolled. One hospital (n=9) had a recurrence rate of 44.4%, compared to 3.0% (4/135) for the other hospitals. By accounting for 50.0% of recurrences, it represented a statistical outlier and was excluded, leaving 135 patients for analysis. The median age was 14 years, and 63.7% were male. Recurrence with the excluded center was 5.6% (8/144). Use of absorbable suture (OR 42.67, CI 4.41-412.90, p<0.01) and braided suture (OR 12.10, CI 1.54-95.25, p=0.02) was weakly associated with recurrence. Recurrence was not significantly different from published results. CONCLUSION: Laparoscopic high ligation of adolescent inguinal hernias has a recurrence rate similar to open repair when performed by experienced surgeons. TYPE OF STUDY: Prognosis study (retrospective study) LEVEL OF EVIDENCE: Level II.

Esophageal Atresia: State of the Art in Translating Experimental Research to the Bedside.

Long-gap esophageal atresia is one of the most challenging diseases in the field of pediatric surgery. There is no optimal therapy, and thus many potential therapies and techniques are being actively explored, both in animal models and in neonates. This article will review the available experimental treatment options with a focus on novel techniques.

Early CDH repair on ECMO: Improved survival but no decrease in ECMO duration (A CDH Study Group Investigation).

PURPOSE: "Early on-ECMO" repair of CDH entails repair within 48-72 h of cannulation in an effort to optimize pulmonary physiology, shorten ECMO duration, and, ultimately, improve survival. This study evaluated the effect of early on-ECMO repair as compared to leaving patients unrepaired during ECMO. METHODS: The CDH Study Group database was queried for CDH patients requiring ECMO who either underwent repair within the first 72 h after cannulation or remained unrepaired on ECMO. Primary outcomes were survival to decannulation and ECMO duration. RESULTS: A total of 248 patients underwent early repair and 922 remained unrepaired on ECMO. The early repair group had increased risk factors for poor outcomes, including higher odds of cardiac defects and thoracic liver location, and lower odds of hernia sac presence. Nonetheless, ECMO survival for the early repair group was 87.1% compared to 78.4% in the unrepaired group (p = 0.002). However, the early repair group had a longer median ECMO duration than the unrepaired group (240.6 vs 196.8 h, p = 0.001). CONCLUSION: While early ECMO repair does not shorten ECMO duration, it results in increased survival to decannulation as compared to those unrepaired on ECMO. This suggests that there may be a physiologic benefit leading to increased ECMO survival in a subset of patients undergoing on-ECMO repair over those designated to undergo post-ECMO repair. LEVEL OF EVIDENCE: Level III.

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia.

BACKGROUND: Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept. METHODS: Five pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3-4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10-14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed. RESULTS: The first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg. CONCLUSION: Magnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

Evaluating the utility of the "late ECMO repair": a congenital diaphragmatic hernia study group investigation.

PURPOSE: Optimal timing of congenital diaphragmatic hernia (CDH) repair in patients requiring extracorporeal membrane oxygenation (ECMO) remains controversial. The "late ECMO repair" is an approach where the patient, once deemed stable for decannulation, is repaired while still on ECMO to enable expeditious return to ECMO if surgery induces instability. The goal of this study was to investigate the potential benefit of this approach by evaluating the rate of return to ECMO after repair. METHODS: The CDH Study Group database was used to analyze CDH patients requiring ECMO support. The primary outcome was return to ECMO within 72 h of CDH repair among those repaired following ECMO decannulation ("post-ECMO" patients). Secondary outcomes were death within 72 h of repair and cumulative death and return to ECMO rate. RESULTS: A total of 668 patients were repaired post-ECMO decannulation. Six patients (0.9%) in the post-ECMO group required return to ECMO within 72 h of surgery and a total of 19 (2.8%) died or returned to ECMO within 72 h of surgery. CONCLUSION: The rate of return to ECMO and death following CDH repair is extremely low and does not justify the risks inherent to "on-ECMO" repair. Patients stable to come off ECMO should undergo repair after decannulation.

Simple diverticulectomy is adequate for management of bleeding Meckel diverticulum.

PURPOSE: It is unclear whether simple diverticulectomy, rather than segmental bowel resection (SBR), is adequate treatment for gastrointestinal bleeding (GIB) secondary to Meckel diverticulum (MD). There is concern that ulcers in the adjacent bowel may continue to bleed if only the diverticulum is removed. This study seeks to determine if diverticulectomy is satisfactory treatment for bleeding MD. METHODS: A multi-institution, retrospective review was performed for patients with a diagnosis of MD and GIB who underwent simple diverticulectomy or small bowel resection. Exclusion criteria were comorbid surgical conditions and other causes of GIB. The primary outcome was post-operative bleeding during the initial hospitalization. Secondary outcomes were bleeding after discharge, transfusion or additional procedure requirement, re-admission, and overall complications. RESULTS: There were 59 patients who met study criteria (42 diverticulectomy, 17 SBR). One patient in the SBR group had early post-operative bleeding (p = 0.288). There was one re-admission (p = 0.288) and three total complications in the SBR group (p = 0.021). There were no cases of bleeding or other complications in the diverticulectomy group. CONCLUSION: This study suggests that simple diverticulectomy is adequate for treatment of GIB caused by MD. Furthermore, diverticulectomy appears to have a lower overall complication rate.

New multimedia advances in surgical information.

When discussing new trends in pediatric surgery, the tendency is to focus on novel surgical technology and techniques. However, it is equally important to examine how the practicing surgeon stays abreast in an ever-changing field. This article serves as a brief guide to the future of surgical education for the attending surgeon. Broadly, advances in surgical education consist of new methods of filtration and delivery of knowledge.

Prospective observational study to assess the need for postoperative antibiotics following surgical incision and drainage of skin and soft tissue abscess in pediatric patients.

BACKGROUND: Post-operative antibiotics are often utilized for skin and soft tissue infection (SSTI) requiring surgical incision and drainage (I&D). We propose that antibiotics are unnecessary following I&D. METHODS: Patients aged 3months to 6years with SSTI of the buttocks, groin, thigh, and/or labia requiring I&D were prospectively enrolled. The primary outcome was the proportion of patients requiring re-drainage and/or antibiotics for SSTI recurrence, within 30days. Follow-up consisted of a 30-day phone call, with optional 2-week office visit, combined with chart review for patients lost to follow-up. A one-sample binomial proportion with 95% confidence interval (CI) was used to examine non-inferiority for rate of treatment success, using previously published success rates for patients receiving antibiotics post-operatively (95.9%, with a 7% margin of equivalence). RESULTS: A total of 92 patients were enrolled. All patients received pre-operative antibiotics. There was one treatment failure (success rate 0.989, CI 0.941-0.999). The recurrence rate was noninferior to previously-published data for patients receiving postoperative antibiotics (p<0.001). Subgroup analysis of patients who completed 30-day follow-up yielded a success rate of 0.973, CI 0.858-0.999 and evidence of non-inferiority (p=0.04). CONCLUSIONS: Post-operative management excluding antibiotics should be considered for patients who undergo I&D for SSTI. LEVEL OF EVIDENCE: Level II (prospective cohort study with <80% follow-up).

Public Perception of Telemedicine and Surgical Telementoring in the Pediatric Population: Results of a Parental Survey.

INTRODUCTION: Telemedicine and surgical telementoring strive to provide equal access to specialized healthcare, regardless of patient location. It also aims to provide providers in remote locations real-time, second opinions from more experienced physicians who are otherwise not readily available. The goal of this study is to gauge the public perception of this technology in the pediatric population. METHODS: Patient families in our pediatric surgery and gastroenterology clinics were asked to complete a seven-question survey after being shown a 1-minute video describing telemedicine and surgical telementoring. RESULTS: A total of 129 people were surveyed. Among respondents, 89% were amenable to telemedicine for routine physician visit, 70% said "yes" for a postoperative visit, and 67% agreed to telemedicine and telementoring as a way to be evaluated by a specialist. Regarding surgical telementoring, 49% would consider it for their child, 58% would consider it for themselves, and 10% said "yes" for themselves, but "no" for their child. In addition, 24% and 19% were unsure about surgical telementoring for their child and themselves, respectively. Those with history of surgery without complications were more likely to say "yes" than "no" to telemedicine for a postoperative visit and surgical telementoring. Although a higher proportion of those with an annual income of >$100K said "no" to surgical telementoring for their child and themselves, this was not statistically significant (P = .23 and .25, respectively). Desire to see a physician in person was cited by 63% as a reason against telemedicine, although 35% reported concern about a physician's competence as a reason against surgical telementoring. CONCLUSION: Overall, surgical telementoring was only supported by about half of the respondents. We predict that with increased education about surgical telementoring, this technology will have increased public support in the pediatric population.

Current Practices in the Management of Congenital Diaphragmatic Hernia Patients Requiring Extracorporeal Membrane Oxygenation: Results of an International Survey of Pediatric Surgeons.

INTRODUCTION: There is little consensus on optimal management for congenital diaphragmatic hernia extracorporeal membrane oxygenation (CDH ECMO) patients. Meaningful comparisons of the various approaches have been limited due to the low number of cases in institutions. In addition, the multidisciplinary reliance and rigid institutional framework of ECMO serve to further limit exposure to alternative practices. The goal of this study is to survey the international pediatric surgery community to describe the current practice trends. METHODS: A survey was electronically distributed to the international pediatric surgical community. The results were evaluated using statistical analysis. RESULTS: A total of 123 pediatric surgeons completed the survey, of whom 89% work at institutions offering both venoatrial (VA) and venovenous (VV) ECMO. Although 69% perform VA ECMO for CDH, only 46% felt VA was the "optimal method." Among VV proponents, 21% believe the rate of VV to VA conversion to be <5% and 16% believe it to be >30% compared with 0% and 40% in VA proponents. Distribution of timing of repair: 46% post-ECMO repair, 22% early ECMO repair, 15% whenever stabilized on ECMO, and 14% late ECMO repair. Sixty-four percent (71/111) would perform an ECMO CDH repair in the unweanable patient and 27% (30/111) report successful decannulation after repair of a patient who was unweanable on ECMO for 2 weeks. Ninety-two percent do not perform exit-to-ECMO. CONCLUSION: There are significant practice variations in the management of CDH ECMO. Majority of pediatric surgeons perform VA ECMO in CDH patients; however, a significant percentage of those believe VV to be more optimal. This discrepancy is not accounted for by the VA-only institutions. Although post-ECMO CDH repair is the most common approach, the majority would perform a repair "on ECMO" if the patient was unweanable. In addition, although many pediatric surgeons believe the "last ditch repair" for the unweanable patient to be futile, 27% have reported success. Exit-to-ECMO for CDH remains a minority practice.

Inguinal Hernia.

Laparoscopy is a safe and effective technique in the repair of inguinal hernias. This article describes the different laparoscopic herniorrhaphy technique, as well as controversial topics, such as premature infants, contralateral repair, and incarcerated hernias.

Creation of an Esophageal Atresia Animal Model Using a Bifurcated Esophagus to Maintain Digestive Tract Continuity.

INTRODUCTION: We previously developed a porcine model of long gap pure esophageal atresia (EA) to aid in the creation of novel devices and techniques for treatment of EA. Shortcomings of the model included difficulty decompressing the proximal esophageal pouch (leading to recurrent aspiration) and a requirement for gastrostomy tube (G-tube) feeds. Therefore, we sought to create a porcine model with a bifurcated esophagus wherein one portion of the esophageal lumen retained patency and the other part mimicked EA. METHODS: After G-tube placement, thoracotomy was performed with subsequent partial stapled transection of the esophagus in a transverse manner, followed by longitudinal, partial stapled transection of the esophagus proximally and distally. Magnets were placed in the esophageal pouches. RESULTS: Proximal and distal esophageal pouches were created while preserving a parallel, narrower segment of continuous esophagus. G-tube feeds were used initially, but the animal ultimately tolerated full nutrition by mouth. The magnets successfully restored esophageal continuity. The animal regained much of the initial weight lost and survived to planned euthanasia. Necropsy revealed anastomosis formation without evidence of leak. CONCLUSIONS: A bifurcated porcine esophagus model was successfully devised, simulating EA while allowing the animal to receive oral feeds and clear oral secretions. This model is anticipated to promote animal well-being and ease of care during future investigations, as well as a platform for the safe development of new therapies for EA.

Assessing the Adequacy of Absorbable Braided Suture for Laparoscopic High Ligation in Rabbits.

PURPOSE: Our previous work demonstrated that intentional peritoneal injury reduces the incidence of recurrence of a patent processus vaginalis even after removal of the suture. Therefore, the necessity of permanent suture has been brought into question because of the risk of suture granuloma formation. The purpose of this study was to evaluate the efficacy of absorbable, braided versus permanent, braided suture in a rabbit survival model of laparoscopic percutaneous ligation of the processus vaginalis with intentional peritoneal injury. MATERIALS AND METHODS: Eighteen New Zealand White rabbits underwent bilateral subcutaneous endoscopically assisted ligation (SEAL) of the internal ring. Before SEAL, peritoneal injury was caused with endoscopic shears. Each animal was randomized to receive absorbable braided suture on one side and permanent braided suture on the contralateral side. The rabbits were survived for 8 weeks to allow for complete hydrolysis of the absorbable suture. Necropsy was performed during which the integrity of the repair was assessed with insufflation of carbon dioxide up to 30 mm Hg. McNemar's test for paired data was performed for statistical analysis. RESULTS: Seventeen rabbits survived 8 weeks. One rabbit died in the early postoperative period because of urinary tract obstruction. After insufflation, four (24%) recurrences were present in the absorbable group and two (12%) recurrences were present in the permanent group. This difference was not statistically significant (P = .50). Both rabbits with a recurrence on the side with permanent suture also had a recurrence with absorbable suture on the contralateral side. In all rabbits, the permanent suture was identified, whereas there was no visual evidence of absorbable suture. CONCLUSIONS: A trend toward a higher recurrence rate with the use of absorbable braided suture was present, although, in this study, the finding was not statistically significant. Caution should be used when considering implementation of absorbable suture for laparoscopic inguinal hernia repair.

Same-day discharge after incision and drainage of soft-tissue abscess in diaper-age children is safe and effective.

PURPOSE: Many pediatric centers admit patients following incision and drainage (I&D) of soft-tissue abscesses. The purpose of this study is to assess the safety and efficacy of the same-day discharge following I&D. METHODS: Retrospective review was performed of children aged 3 months-4 years who underwent operative I&D of an abscess followed by same-day discharge. Patients receiving antibiotics within 2 weeks of presentation were excluded. Treatment failure was defined as readmission or repeat procedure related to the initial abscess. Statistical analysis was performed using Wilcoxon Rank-Sum and Fisher's Exact tests. RESULTS: There were 442 procedures performed in 408 patients. Mean age was 1.8 years. Fever was noted in 25.8%. Of those who had a white blood cell (WBC) count drawn, 59.7% had leukocytosis. Mean time from procedure to discharge was 2.3 h, and 85.0% were discharged with oral antibiotics. Treatment failure occurred in four (0.9%) and ten (2.3%) patients at 14 and 30 days, respectively. Mean WBC count was higher in the 14-day treatment failure group (24.1 versus 16.3; p = 0.10). In patients with leukocytosis, there were 2 (1.4%) treatment failures compared to none in those without leukocytosis. CONCLUSION: Same-day discharge after I&D of abscess in diaper-age children is safe and effective.

Treatment of routine adolescent inguinal hernia vastly differs between pediatric surgeons and general surgeons.

BACKGROUND: Surgical treatment of inguinal hernias in adolescents is controversial as these patients do not fit into the traditional pediatric and adult populations. We aimed to compare the preferences of adult general surgeons and pediatric surgeons in managing adolescents by conducting a survey through social media. METHODS: A poll was posted on the International Hernia Collaboration Group Facebook page as well as the Facebook page for the authoring pediatric surgeon. The poll gave scenarios of a 16-year-old male with an inguinal hernia and asked surgeons to select one of five listed procedures to repair the hernia: high ligation (open or laparoscopic), mesh repair (open or laparoscopic) or open muscle repair. The four scenarios differed in the diameter of the internal ring (1 vs. 4 cm) and the BMI of the patient (20 vs. 35). Fisher's exact test was implemented for statistical analysis. RESULTS: In total, 43 (67 %) adult surgeons and 21 (33 %) pediatric surgeons responded. In the routine adolescent (normal BMI, small defect), 65 % of adult surgeons chose adult-type repairs (mesh or muscle repairs) whereas 86 % of pediatric surgeons chose pediatric-type repairs (high ligation). When the size of the defect increased, 100 % of adult surgeons and 81 % of pediatric surgeons selected an adult-type repair, suggesting agreement. When the patient was obese, there was a tendency to prefer laparoscopy. In all patient scenarios, the answers were significantly different between pediatric and adult surgeons (p < 0.05). CONCLUSION: For the same routine adolescent inguinal hernia, pediatric surgeons and adult general surgeons choose a different procedure. This finding suggests that further study is needed to determine the optimal treatment for inguinal hernias in adolescents, as the type of practitioner to whom the patient is referred, rather than the disease process itself, currently dictates treatment.

Rural surgeons would embrace surgical telementoring for help with difficult cases and acquisition of new skills.

BACKGROUND: Surgical telementoring, consisting of an expert surgeon guiding a less experienced surgeon through advanced or novel cases from a remote location, is an evolving technology which has potential to become an integral part of surgical practice. This study sought to apprise the attitudes of rural general surgeons toward the possible benefits and applications of surgical telementoring in their practices. METHODS: A survey assessing demographics and attitudes toward telementoring was e-mailed to members of the American College of Surgeons (ACS) Advisory Council for Rural Surgery and posted to the ACS website in areas targeting rural surgeons. A link to a webpage with a description of surgical telementoring and brief demonstrative video were included with the survey. RESULTS: There were 159 respondents, with 82.3 % of them practicing in communities smaller than 50,000 people. Overall, 78.6 % felt that telementoring would be useful to their practice, and 69.8 % thought it would benefit their hospitals. There was no correlation between years of practice and perceived usefulness of surgical telementoring. When asked the single most useful, or primary, application of surgical telementoring there was a split between learning new techniques (46.5 %) and intraoperative assistance with unexpected findings (39.0 %). When asked to select all applications in which they would be interested in using telementoring from a list of possible uses, surgeons most frequently selected: intraoperative consultation for unexpected findings (67.7 %), trauma consultation (32.9 %), and laparoscopic colectomy (32.9 %). CONCLUSIONS: Surgical telementoring is on the verge of widespread use but industry and surgical societies remain ambivalent about supporting its implementation due to concerns over lack of interest. This study demonstrates interest among rural surgeons. While there are differing opinions regarding compensation of the telementoring, the most common, single interest in the use of surgical telementoring was for learning new techniques or skill sets.

Creation of an animal model for long gap pure esophageal atresia.

INTRODUCTION: Long gap pure esophageal atresia (LGPEA) is a congenital disorder in which the esophagus is in discontinuity, and the proximal and distal ends cannot be anastomosed in a primary fashion. No animal model for pure esophageal atresia exists. Here we describe a survival animal model for LGPEA, which will ultimately serve to test novel devices and techniques to restore continuity. METHODS: A non-survival study was first conducted in six rabbits to refine a protocol for the survival model. An open gastrostomy tube was placed, followed by a partial esophagectomy. Next, a survival study was performed with seven rabbits in which the same procedures were performed. Finally, the procedure was optimized in domestic swine. RESULTS: Despite developing the techniques and gaining valuable information in the non-survival study, none of the rabbits in the survival portion of the study lived beyond post-operative day four. Due to this complication with the rabbit, the LGPEA model was attempted in a porcine model. The pig survived to post-operative day ten, and was healthy enough to be used for further study. CONCLUSION: A porcine model of long gap pure esophageal atresia was developed which is effective and feasible to be used for testing new methods of treatment of LGPEA.