Resuming elective paediatric surgical procedures in the era of COVID-19.

BACKGROUND: The novel coronavirus and the disease it causes COVID-19, like other viral outbreaks, have an unpredictable timeline. Therefore, a triumph in the battle against COVID-19 could only be achieved if a health care system's capacity to support a potentially overwhelming increase in critical patient care needs is maintained, and the viral curve is flattened. Accordingly, health care bodies around the globe called upon prioritising appropriate resource allocation as it relates to elective invasive procedures and minimising the use of essential items required to care for patients. The unpredictability COVID-19 timeline in the absence of effective drug treatments and vaccination along with the restrictive health care policies implemented suggest that patients may be deprived of access to needed surgical care, likely for many months. However, the potential undue delay in delivering essential elective surgical care may have a more detrimental impact on patients' health compared to that of COVID-19 itself. This particularly applies to the paediatric population in which infection rates have been demonstrated to be considerably lower and mortalities have not been reported yet. Therefore, the need emerges for actions to be taken that allow for the resumption of essential elective surgical procedures in this population of patients. MATERIALS AND METHODS: A comprehensive search through surgical guidance and recommendations to develop a set of evidence based recommendations that allow for the safe and timely delivery of essential paediatric surgical care during the time of COVID-19. CONCLUSION: No compelling evidence that the paediatric population is at an increased risk of morbidity or mortality exists. Therefore, delaying essential paediatric surgical care cannot be justified as it may have a potentially negative health impact, and continuous refinements of surgical recommendations are encouraged in view of evolving circumstances.

Introducing a new scrotal orchiopexy technique: The fat anchor orchiopexy.

Cryptorchidism is the most common congenital anomaly of the male genital tract. Cryptorchidism is associated with potentially serious consequences including reduced fertility, increases risk of cancer, susceptibility to torsion and traumatic injury, as well as future psychological problems related to an abnormal scrotal appearance. The mainstay of orchiopexy is to achieve an adequate tension-free and permanent scrotal fixation of the testis; one that prevents recurrent ascent. A number of suggestions have been made regarding keeping the testis in the scrotal position once it was brought down in the scrotum without tension. Several techniques for testicular fixation have been described to date; however, the optimal method remains controversial. We herein introduce a novel scrotal orchidopexy technique. This innovative fixation technique utilizes the sub-scrotal fat as a permanent anchor for fixing the low-lying cryptorchid testicle in the scrotum through a trans-scrotal incision. Therefore, the procedure was named "the fat anchor orchiopexy". We believe our method will give better options for scrotal fixation especially in cases of low-lying cryptorchid testes. This article provides a detailed description of this new fixation technique.

Developing a tool that could reliably refute total thyroidectomy for solitary Bethesda IV thyroid nodules.

PURPOSE: To assess the reliability of a simple, accessible, cost-effective rule-out tool, for use in triaging patients with Bethesda IV nodules to appropriate surgery. METHODS: The diagnostic tool was assembled by combining the negativity for suspicious ultrasound features (irregular margins, microcalcification, and a taller-than-wide orientation), and mutational marker negativity (BRAF and NRAS). The tool, (US-/mutation-), was tested on 167 patients with solitary Bethesda IV nodules. The primary outcome was its negative predictive value (NPV) for lesions requiring total thyroidectomy (TT). The impact of mutational marker negativity, as part of the tool, was evaluated by comparing the NPV of (US-/mutation-) to that of (US-/mutation+). RESULTS: 10 out of 167 lesions were positive for a mutational marker. These underwent TT, and only 2/10 (20%) were benign, on final histology. In 6/8 malignant lesions, TT was concordant with current clinical guidelines. 157 patients comprised the negative study cohort, for both mutational markers and suspicious US features. These underwent thyroid lobectomy, and 17 cases resulted in malignancy, only 8 of which required completion thyroidectomy. Accordingly, the NPV of (US-/mutation-) for malignancy was 89% (140/157), and 95% (149/157) for malignancy requiring TT. However, the NPV of (US-/mutation+) was 20% for malignancy, and 40% for malignancy requiring TT. These differences were statistically significant (89% vs. 20%; p < 0.0001, and 95% vs. 40%; p < 0.0001). CONCLUSION: US-/mutation- is a reliable rule-out tool, with sufficient diagnostic accuracy to spare patients, with Bethesda IV nodules, an overly radical TT.

Postoperatively determined high-risk histopathologic features in papillary thyroid carcinoma initially eligible for thyroid lobectomy: a game changer.

PURPOSE: Recent clinical practice guidelines consider thyroid lobectomy a viable alternative for low-risk papillary thyroid carcinoma PTC measuring 1-4 cm in size. We aimed to assess the likelihood of finding postoperatively determined high-risk histopathologic features that would lead to the recommendation of completion thyroidectomy. METHODS: A retrospective review of patients who underwent total thyroidectomy for PTC measuring 1-4 cm in size between Jan 2012 and Jan 2018 was conducted. Patients with pre-operative high-risk characteristics were excluded: history of radiation exposure, positive family history, clinically suspicious cervical lymphadenopathy, and gross extrathyroidal extension (ETE). A hypothetical group of 245 patients remained eligible for lobectomy. The pathology specimens from the cancer-containing lobes were evaluated for high-risk features: aggressive histology, capsular and/or vascular invasion, microscopic ETE, and multifocality. A subgroup analysis was performed with 2 cm being the cut-off size. RESULTS: The average age was 39 years with 73% being females. Mean cancer size was 16 mm. Evaluation of the cancer-containing lobe for high-risk features revealed: aggressive histology (33%), ETE (12%), capsular invasion (33%), vascular invasion (17%), and ipsilateral multifocality (30%). The cumulative risk of having ≥1 high-risk feature mandating completion thyroidectomy was 59%. The risk was considerably higher for lesions ≤2 cm compared to larger lesions (64% vs.48%; p = 0.049; RR = 1.3). CONCLUSIONS: A considerable proportion of patients initially eligible for lobectomy have high-risk features that only become evident at pathology. Therefore, a comprehensive approach is advocated to determine the extent of surgery for PTC incorporating patient preferences regarding risks and benefits.

Congenital Hairy Polyp Causing Severe Upper Airway Obstruction in a Newborn: A Case Report.

BACKGROUND Hairy polyps are rare tumors mainly comprising fatty tissues covered by skin and hair follicles, with varied localizations and sizes. Early excision of the polyps by surgery is an effective treatment resulting in a permanent cure. We present a case of successful management of severe obstruction of the oropharynx in a newborn who presented with a large mass of congenital hairy polyp. CASE REPORT A vaginally delivered infant, weighing 3 kg, presented immediately after birth with cyanosis symptoms, failure of the first cry, and respiratory distress signs. The newborn was born to a mother with an uneventful pregnancy. Screening tests during the pregnancy reported no congenital anomalies. The newborn's hematological and biochemical test results were normal. After presenting these symptoms, the newborn was immediately intubated and put on a nasogastric feeding tube, which revealed a small portion of a polyp-like mass. A computed tomography (CT) scan further confirmed a large pedunculated mass, measuring 3×2 cm, arising from the soft palate, and obstructing the oropharynx. Histopathological examination confirmed the presence of a hairy polyp. The polyp was wholly removed transorally using the Covidien LigaSure device without the need for endoscopy. This procedure allowed safe extubation, and the baby was discharged home without symptoms 4 days after birth. CONCLUSIONS This case sheds light on the importance of considering hairy polyp in the differential diagnosis of pharyngeal mass with respiratory distress in pediatric patients. This report also describes our experience using the LigaSure surgical device without needing endoscopic visualization to successfully resect the hairy polyp without complications.

Resuming elective surgery in the time of COVID-19: a safe and comprehensive strategy.

The 2019 novel corona virus and the disease it causes (COVID-19) is a public health crisis that has profoundly modified the way medical and surgical care is delivered. Countries around the globe had a variable initial response to the COVID-19 pandemic from imposing massive lock downs and quarantine to surrendering to herd immunity. However, healthcare bodies worldwide recognized early on that a triumph against COVID-19 could only be achieved by maintaining the infrastructure of healthcare systems and their capacity to accommodate a potentially overwhelming increase in critical patient care needs. Therefore, they reacted by restricting medical care to emergency cases and postponing elective surgical procedures in all disciplines. The priority was made for treatment of COVID-19 patients and emergency cases. Nevertheless, the battle against the COVID-19 pandemic is still ongoing. In the absence of vaccines or effective drug treatments, its timeline remains uncertain and it cannot be forecast how long healthcare systems will need to cope with it in managing inpatient and outpatient services. Accordingly, extreme measures and restriction may become a recipe for a disaster in the context of the potential adverse health implications imposed by delaying timely medical and surgical care. Therefore, restrictive measures should be substituted with a comprehensive surgical and medical care strategy. One that provides a safe balance between the prevention of COVID-19 and the delivery of essential surgical care. This article provides an overview on how to safely deliver essential surgical care in the time of COIVD-19.

Impact of COVID-19 on thyroid cancer surgery and adjunct therapy.

COVID-19 has profoundly modified the way healthcare is delivered. Jordan imposed lockdown and restrictive policies between March 17 and May 20, 2020. We aimed to assess the impact of such measures on thyroid cancer treatment plans. In the specified period, 12 patients were scheduled for surgery. Since papillary carcinoma was the preoperative diagnosis in all cases, radioactive iodine ablation (RIA) therapy was also planned 3-4 weeks following surgery after withdrawing thyroxine and achieving a thyroid stimulating hormone (TSH) level > 30 mU/L. Thyroxine withdrawal is the routine method applied for RIA in Jordan as it is less costly compared to the rapid method of exogenous stimulation using recombinant TSH. All surgical procedures were performed without delay since all patients were asymptomatic per flu-like illness and came from a region of low COVID-19 prevalence. These included total thyroidectomy (n = 11), bilateral therapeutic central compartment neck dissection (n = 7), lateral compartment neck dissection (n = 5). However, the RIA treatment plan was altered considerably according to the period in which they were operated. 6 out of the 7 patients operated in March changed to the stimulated method of RIA at a considerable additional extra cost. The seventh patient and the April patient opt to delay RIA until after lockdown. The remaining cases (operated in May) followed the usual withdrawal method as restrictions were due to an end. The restrictive measures applied during COVID-19 did not affect the safe and timely delivery of surgical care. However, it added a financial and psychological burden to the entire cancer management plan.

The "weekend effect" in pediatric surgery - increased mortality for children undergoing urgent surgery during the weekend.

BACKGROUND: For a number of pediatric and adult conditions, morbidity and mortality are increased when patients present to the hospital on a weekend compared to weekdays. The objective of this study was to compare pediatric surgical outcomes following weekend versus weekday procedures. METHODS: Using the Nationwide Inpatient Sample and the Kids' Inpatient Database, we identified 439,457 pediatric (<18 years old) admissions from 1988 to 2010 that required a selected index surgical procedure (abscess drainage, appendectomy, inguinal hernia repair, open fracture reduction with internal fixation, or placement/revision of ventricular shunt) on the same day of admission. Outcome metrics were compared using logistic regression models that adjusted for patient and hospital characteristics as well as procedure performed. RESULTS: Patient characteristics of those admitted on the weekend (n=112,064) and weekday (n=327,393) were similar, though patients admitted on the weekend were more likely to be coded as emergent (61% versus 53%). After multivariate adjustment and regression, patients undergoing a weekend procedure were more likely to die (OR 1.63, 95% CI 1.21-2.20), receive a blood transfusion despite similar rates of intraoperative hemorrhage (OR 1.15, 95% CI 1.01-1.26), and suffer from procedural complications (OR 1.40, 95% CI 1.14-1.74). CONCLUSION: Pediatric patients undergoing common urgent surgical procedures during a weekend admission have a higher adjusted risk of death, blood transfusion, and procedural complications. While the exact etiology of these findings is not clear, the timing of surgical procedures should be considered in the context of systems-based deficiencies that may be detrimental to pediatric surgical care.

Age at presentation of common pediatric surgical conditions: Reexamining dogma.

PURPOSE: The commonly cited ages at presentation of many pediatric conditions have been based largely on single center or outdated epidemiologic evidence. Thus, we sought to examine the ages at presentation of common pediatric surgical conditions using cases from large national databases. METHODS: A retrospective analysis was performed on Healthcare Cost and Utilization Project databases from 1988 to 2009. Pediatric discharges were selected using matched ICD9 diagnosis and procedure codes for malrotation, intussusception, hypertrophic pyloric stenosis (HPS), incarcerated inguinal hernia (IH), and Hirschsprung disease (HD). Descriptive statistics were computed. RESULTS: A total of 63,750 discharges were identified, comprising 2744 cases of malrotation, 5831 of intussusception, 36,499 of HPS, 8564 of IH, and 10,112 of HD. About 58.2% of malrotation cases presented before age 1. Moreover, 92.8% of HPS presented between 3 and 10weeks. For intussusception, 50.3% and 91.4% presented prior to ages 1 and 4years, respectively. Also, 55.8% of IHD cases presented before their first birthday. For HD, 6.5% of cases presented within the neonatal period and 45.9% prior to age 1year. CONCLUSION: Our findings support generally cited presenting ages for HPS and intussusception. However, the ages at presentation for HD, malrotation, and IH differ from commonly cited texts.

Regionalization of the surgical care of children: a risk-adjusted comparison of hospital surgical outcomes by geographic areas.

BACKGROUND: There is an ongoing debate among pediatric surgeons regarding the need or lack thereof to centralize the surgical care of children to high-volume children's centers. Risk-adjusted comparisons of hospitals performing pediatric surgery are needed. METHODS: Admissions from 2006 to 2010 from two national administrative databases were analyzed. Only nontrauma pediatric patients undergoing a noncardiac surgical procedure were included. Risk-adjustment was performed with a validated International Classification of Diseases, 9th Revision code-based tool. Hospitals were grouped into metropolitan regions using the first three digits of their zip code. Poorly performing outlier hospitals were defined by an odds ratio >1 and P value <.05 for mortality compared with the center with the greatest pediatric operative volume in that same region. RESULTS: Information was obtained from 415,546 pediatric surgical admissions, and 173 hospitals in 55 regions were compared. A total of 18 poor performing hospitals (adjusted odds ratio, range 1.91-35.95) in 15 regions were identified. Mortality in poor performers ranged from 1.11% to 10.19% whereas that in the high-volume reference centers was 0.37-2.41%. A subset analysis in patients <1 year of age showed 37 poor performers in 46 regions. Median number of surgical admissions was 345 (interquartile range 152-907) for nonoutlier and 240 (interquartile range 135-566) for outlier centers (P = .30). CONCLUSION: The present analysis is a novel risk-adjusted assessment of the performance of hospitals delivering pediatric surgical care. By identifying the existence of multiple poor performing outlier hospitals, this study provides valuable data for discussion as health care delivery systems continue to debate optimal resource distribution and regionalization of the surgical care of children.