Surgical Emergencies in the Pediatric Office.

Infants and children often present with common signs and symptoms that may or may not be manifestations of a surgical emergency. This review expands the differential diagnosis of several common presentations to include surgical causes suggesting surgical emergencies and the need for immediate referral to a pediatric surgeon. The presenting signs and symptoms reviewed include bilious emesis, abdominal distention, acholic stools, bloody stools, and scrotal mass.

Pediatric primary splenic angiosarcoma: an aggressive multidisciplinary approach to the oncologic management of a rare malignancy.

Primary splenic angiosarcoma is an extremely rare and aggressive neoplasm of the vasculature. Uniformly, primary splenic angiosarcoma is a fatal disease despite early diagnosis and treatment. Only patients with localized disease amenable to surgical resection achieve long-term, disease-free survival. We present a review of the literature and report a case of a 3-year-old girl with metastatic primary splenic angiosarcoma who was offered aggressive surgical and medical treatment with curative intent despite her advanced presentation.

"Sip & Share": Building Resilience in Surgery Residency Through Moral Distress Rounds.

OBJECTIVE: Resident moral distress rounds were instituted during the COVID-19 pandemic to provide a safe zone for discussion, reflection, and the identification of the ethical challenges contributing to moral distress. The sessions, entitled "Sip & Share," also served to foster connectedness and build resilience. DESIGN: A baseline needs assessment was performed and only 36% of general surgery residents in the program were satisfied with the current non-technical skills curriculum. Only 62% were comfortable with navigating ethical issues in surgery. About 72% were comfortable with leading a goals-of-care discussion, and 63% of residents were comfortable with offering surgical palliative care options. Case-based discussions over video conferencing were organized monthly. Each session was structured based on the eight-step methodology described by Morley and Shashidhara. Participation was voluntary. The sessions explored moral distress, and the ethical tensions between patient autonomy and beneficence, and beneficence and non-maleficence. SETTING: Large general surgery residency in an urban tertiary medical center. PARTICIPANTS: General surgery residents. RESULTS: A post-intervention survey was performed with improvement in the satisfaction with the non-technical skills curriculum (70% from 36%). The proportion of residents feeling comfortable with navigating ethical issues in surgery increased from 62% to 72%. A survey was performed to assess the efficacy of the moral distress rounds after eight Sip & Share sessions over ten months. All thirteen respondents agreed that the discussions provided them with the vocabulary to discuss ethical dilemmas and define the ethical principles contributing to their moral distress. 93% were able to apply the templates learned to their practice, 77% felt that the discussions helped mitigate stress. All respondents recommended attending the sessions to other residents. CONCLUSIONS: Moral distress rounds provide a structured safe zone for residents to share and process morally distressing experiences. These gatherings mitigate isolation, promote a sense of community, and provide a support network within the residency. In addition, residents are equipped with the vocabulary to identify the ethical principles being challenged and are provided practical take-aways to avoid similar conflicts in the future.

Targeting pediatric pedestrian injury prevention efforts: teasing the information through spatial analysis.

BACKGROUND: Pediatric pedestrian injuries remain a major cause of childhood death, hospitalization, and disability. To target injury prevention efforts, it is imperative to identify those children at risk. Racial disparities have been noted in the rates of pediatric pedestrian injury and death. Children from low-income families living in dense, urban residential neighborhoods have a higher risk of sustaining pedestrian injury. Geographic information systems (GIS) analysis of associated community factors such as child population density and median income may offer insights into prevention. METHODS: Using trauma registry E-codes for pedestrian motor vehicle crashes, children younger than 16 years were identified, who received acute care and were hospitalized at the University of Chicago Medical Center, a Level I pediatric trauma center, after being struck by a motor vehicle from 2002 to 2009. By retrospective chart review and review of the Emergency Medical Services run sheets, demographic data and details of the crash site were collected. Crash sites were aggregated on a block by block basis. A "hot spot" analysis was performed to localize clusters of injury events. Using Gi* statistical method, spatial clusters were identified at different confidence intervals using a fixed distance band of 400 m (≈ » mile). Maps were generated using GIS with 2000 census data to evaluate race, employment, income, density of public and private schools, and density of children living in the neighborhoods surrounding our medical center where crash sites were identified. Spatial correlation is used to identify statistically significant locations. RESULTS: There were 3,521 children admitted to the University of Chicago Medical Center for traumatic injuries from 2002 to 2009; 27.7% (974) of these children sustained injuries in pedestrian motor vehicle injuries. From 2002 to 2009, there were a total of 106 traumatic deaths, of which 29 (27.4%) were due to pedestrian motor vehicle crashes. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, predominantly African-American neighborhoods. A lower prevalence of crash sites was observed in the predominantly higher income, non-African-American neighborhoods. CONCLUSIONS: Spatial analysis using GIS identified associations between pediatric pedestrian motor vehicle crash sites and the neighborhoods served by our pediatric trauma center. Pediatric pedestrian motor vehicle crash sites occurred predominantly within low-income, African-American neighborhoods. The disparity in prevalence of crash sites is somewhat attributable to the lower density of children living in the predominantly higher income, non-African-American neighborhoods, including the community immediately around our hospital. Traffic volume patterns, as a denominator of these injury events, remain to be studied.

Is necrotizing enterocolitis the same disease in term and preterm infants?

INTRODUCTION: Necrotizing enterocolitis predominantly affects preterm (PT) infants. The paucity of data regarding the clinical course in term infants makes it difficult to predict outcomes and counsel families. To identify predisposing factors and gain a better understanding of the clinical course of NEC in term infants, we reviewed our experience with term infants and compared it to outcomes in PT infants. METHODS: We performed a 10 year retrospective review of all infants admitted to our NICU with Bell stage 2 NEC or greater. Infants < 37 weeks gestation were considered PT. Term and PT infant comorbidities, outcomes and intraoperative findings were compared. RESULTS: Fifteen (12%) of 125 infants were term. Compared to PT infants, term infants were more likely to have congenital heart disease (33% term vs. 10% PT, p = 0.02) and develop NEC sooner (4 days in term vs. 17 days in PT, p < 0.001) but were less likely to require operative intervention (20% term vs. 38% PT; p = 0.17). There was no significant difference in Bell stage, survival and development of intestinal failure. NEC totalis occurred exclusively in PT infants. CONCLUSIONS: NEC in term infants has unique clinical features that distinguishes it from NEC in PT infants.

Children With Intellectual and Developmental Disabilities as Organ Transplantation Recipients.

The demand for transplantable solid organs far exceeds the supply of deceased donor organs. Patient selection criteria are determined by individual transplant programs; given the scarcity of solid organs for transplant, allocation to those most likely to benefit takes into consideration both medical and psychosocial factors. Children with intellectual and developmental disabilities have historically been excluded as potential recipients of organ transplants. When a transplant is likely to provide significant health benefits, denying a transplant to otherwise eligible children with disabilities may constitute illegal and unjustified discrimination. Children with intellectual and developmental disabilities should not be excluded from the potential pool of recipients and should be referred for evaluation as recipients of solid organ transplants.

Feasibility and efficacy of gamification in general surgery residency: Preliminary outcomes of residency teams.

BACKGROUND: Comprehensive studies evaluating the efficacy of team-based competition ("Gamification") in surgery have not been performed. Board pass rates and resident satisfaction may improve if surgical residents are involved in competition. METHODS: Residents at Montefiore Medical Center (Bronx, New York) were surveyed and separated into teams during a draft. Each resident's performance was converted into a point system. Resident scores were combined into a team score and presented as a leaderboard. Awards were given. ABSITE, ACGME residency satisfaction, and ABS qualifying exam pass rates were compared. RESULTS: Sixty percent of residents are inspired to improve their performance during gamification. ABSITE average percentile score improved from 28 to 43. ABS qualifying exam pass rates improved from 73% to 100%. Resident satisfaction improved from 65% to 88%. The point system allowed for establishing "growth curves" for each resident enabling enhanced assessment of residents. CONCLUSIONS: A comprehensive team-based competition inspires performance, is feasible, and seems to improve ABSITE scores, ABS pass rates, and satisfaction while being a tool for assessment of performance.

The Ethics of Creating a Resource Allocation Strategy During the COVID-19 Pandemic.

The coronavirus disease 2019 pandemic has affected nearly every aspect of medicine and raises numerous moral dilemmas for clinicians. Foremost of these quandaries is how to delineate and implement crisis standards of care and, specifically, how to consider how health care resources should be distributed in times of shortage. We review basic principles of disaster planning and resource stewardship with ethical relevance for this and future public health crises, explore the role of illness severity scoring systems and their limitations and potential contribution to health disparities, and consider the role for exceptionally resource-intensive interventions. We also review the philosophical and practical underpinnings of crisis standards of care and describe historical approaches to scarce resource allocation to offer analysis and guidance for pediatric clinicians. Particular attention is given to the impact on children of this endeavor. Although few children have required hospitalization for symptomatic infection, children nonetheless have the potential to be profoundly affected by the strain on the health care system imposed by the pandemic and should be considered prospectively in resource allocation frameworks.

Handlebar injuries in children: should we raise the bar of suspicion?

Injury prevention strategies for child bicyclists have focused on helmet use to prevent head trauma. Handlebars are another source of injury. A retrospective review from 2005 identified 385 admissions to a Level 1 pediatric trauma center of which 23 (5.9%) were pedal cyclists. Four cases (<1.0%) of handlebar injuries were identified. Three children (two bicyclists, one riding a scooter) sustained handlebar impact to the neck. All children with neck injuries had subcutaneous emphysema. Two of the children had pneumomediastinum, which after work-up was managed nonoperatively. One child had a tracheal injury requiring operative intervention. Another child was struck in the upper abdomen resulting in a traumatic abdominal wall hernia requiring emergent exploration and hernia repair. Discordance exists between the apparently minor circumstances of handlebar trauma and the severity of injury sustained by bicyclists. Recognizing the mechanism of handlebar-related injuries and maintaining a high index of suspicion for visceral injuries aids in the diagnosis. The incidence of these injuries is underestimated due to insufficient documentation of the circumstances of injury events and a lack of applicable E-codes specific for handlebar injury.

Pediatric pelvic fractures: a marker for injury severity.

Pelvic fractures comprise a small number of annual Level I pediatric trauma center admissions. This is a review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures. This is a retrospective review of the University of Chicago Level I Pediatric Trauma Center experience with pediatric pelvic fractures during the 12-year period from 1992 to 2004. From 1992 to 2004, there were 2850 pediatric trauma admissions. Thirteen patients were identified with pelvic fractures; seven were boys and six were girls. The average age was 8 years old. The mechanism of injury in all cases was motor vehicle related; 11 patients (87%) sustained pedestrian-motor vehicle crashes. According to the Torode and Zeig classification system, type III fractures occurred in eight patients (62%) and type IV fractures occurred in six patients (31%). Associated injuries occurred in eight patients (62%). Seven of these patients (88%) had associated injuries involving two or more organ systems. Of the associated injuries, additional orthopedic injuries were the most common, occurring in 62 per cent of our patients. Neurological injuries occurred in 54 per cent of patients, vascular injuries in 39 per cent, pulmonary injuries in 31 per cent, and genitourinary injuries in 15 per cent. Five patients (38%) were treated operatively; only two patients underwent operative management directly related to their pelvic fracture. The remaining three patients underwent operative management of associated injuries. The mortality rate was 0 per cent. Although pelvic fractures are an uncommon injury in pediatric trauma patients, the morbidity associated with these injuries can be profound. The majority of pelvic fractures in children are treated nonoperatively, however, more than one-half of these patients have concomitant injuries requiring operative management. When evaluating and treating pediatric pelvic fractures, a systematic multidisciplinary approach must be taken to evaluate and prioritize the pelvic fracture and the associated injuries.

Sequential linear stapling technique for perineal resection of intractable pediatric rectal prolapse.

Rectal prolapse (RP), although most frequently encountered in the frail elderly, may also occur in children. This condition is most troublesome in the premature infant with significant associated comorbidities. Pediatric RP most often can be managed conservatively with expectant and/or judicious use of laxative-based bowel regimens. In rare instances of intractable RP, surgical intervention ranging from simple (sclerotherapy, Thiersch wire) to complex (perineal or transabdominal bowel resection) becomes necessary. We describe a modification of the Altemeier technique using a novel sequential linear stapling technique to treat intractable RP in a 5.0-kg infant with severe coexisting life-threatening comorbidities. The child had resumption of bowel movements on postoperative Day 1 and has had no recurrences. Sequential linear stapling technique for perineal resection of intractable pediatric RP appears to be a safe and potentially attractive alternative.

Ready for the frontline: is early thoracoscopic decortication the new standard of care for advanced pneumonia with empyema?

Video-assisted thoracoscopic decortication (VATD) has been established as an effective and potentially less morbid alternative to open thoracotomy for the management of empyema. However, the timing and role of VATD for advanced pneumonia with empyema is still controversial. In assessing surgical outcome, the authors reviewed their VATD experience in children with empyema or empyema with necrotizing pneumonia. The charts of 42 children who underwent VATD at our institution between July 2001 and July 2005 were retrospectively reviewed for surgical outcome. For purposes of analysis, patients were cohorted into four classes with increasing severity of pneumonia: 1 (-) intraoperative pleural fluid cultures, (-) necrotizing pneumonia, 18 (43%); 2 (+) pleural fluid cultures, (-) necrotizing pneumonia, 10 (24%); 3 (-) pleural fluid cultures, (+) necrotizing pneumonia, 6 (14%); 4 (+) pleural fluid cultures, (+) necrotizing pneumonia, 8 (19%). A P value of < 0.05 via Student's t test or Fischer's exact analysis was considered an indicator of significant difference in the comparison of group outcomes. VATD was successfully completed in all 42 patients with no mortality and without significant morbidity (82% had less than 20 cc blood loss). There was found to be no significant difference (p = NS) in time to surgical discharge (removal of chest tube) among all groups. Hospital length of stay postsurgery was found to be significantly increased between 1 and 4 (6 days vs 9 days; P = 0.038). 14/14 (100%) of children with necrotizing pneumonia were found to have evidence of lung parenchymal preservation with improved aeration on follow-up CT scan and/or chest x-rays. The authors conclude that early VATD in children with advanced pneumonia with empyema is indicated to avoid unnecessarily lengthy hospitalization and prolonged intravenous antibiotic therapy. Furthermore, early VATD can be safely performed in various stages of advanced pneumonia with empyema, promoting lung salvage, and accelerating clinical recovery.

Sequential Participation in a Multi-Institutional Mock Oral Examination Is Associated With Improved American Board of Surgery Certifying Examination First-Time Pass Rate.

OBJECTIVE: We sought to determine whether sequential participation in a multi-institutional mock oral examination affected the likelihood of passing the American Board of Surgery Certifying Examination (ABSCE) in first attempt. DESIGN: Residents from 3 academic medical centers were able to participate in a regional mock oral examination in the fall and spring of their fourth and fifth postgraduate year from 2011 to 2014. Candidate׳s highest composite score of all mock orals attempts was classified as risk for failure, intermediate, or likely to pass. Factors including United States Medical Licensing Examination steps 1, 2, and 3, number of cases logged, American Board of Surgery In-Training Examination performance, American Board of Surgery Qualifying Examination (ABSQE) performance, number of attempts, and performance in the mock orals were assessed to determine factors predictive of passing the ABSCE. RESULTS: A total of 128 mock oral examinations were administered to 88 (71%) of 124 eligible residents. The overall first-time pass rate for the ABSCE was 82%. There was no difference in pass rates between participants and nonparticipants. Of them, 16 (18%) residents were classified as at risk, 47 (53%) as intermediate, and 25 (29%) as likely to pass. ABSCE pass rate for each group was as follows: 36% for at risk, 84% for intermediate, and 96% for likely pass. The following 4 factors were associated with first-time passing of ABSCE on bivariate analysis: mock orals participation in postgraduate year 4 (p = 0.05), sequential participation in mock orals (p = 0.03), ABSQE performance (p = 0.01), and best performance on mock orals (p = 0.001). In multivariable logistic regression, the following 3 factors remained associated with ABSCE passing: ABSQE performance, odds ratio (OR) = 2.9 (95% CI: 1.3-6.1); mock orals best performance, OR = 1.7 (1.2-2.4); and participation in multiple mock oral examinations, OR = 1.4 (1.1-2.7). CONCLUSIONS: Performance on a multi-institutional mock oral examination can identify residents at risk for failure of the ABSCE. Sequential participation in mock oral examinations is associated with improved ABSCE first-time pass rate.

Primary insertion of a silastic spring-loaded silo for gastroschisis.

Gastroschisis is traditionally managed by emergency primary closure, with a temporary silo reserved for large defects unable to be closed primarily. We recently have begun primary Silastic (Dow Coming, Midland, MI) spring-loaded silo (SLS) closure followed by elective closure and report our preliminary experience. A total of 15 infants (weight range, 2.1-13.5 kg) at 2 different institutions were treated by SC by 3 different surgeons between 1998 and 2002. A 3-, 4-, or 5-cm (ring diameter) silo was used depending on size of abdominal wall defect. Elective closure was performed in the operating room or at the bedside. Surgical parameters assessed included success of SLS, peak inspiratory pressures (PIPs) pre- and post-SLS closure, total time of staged closure with SLS, time to full feedings, and intra- and postoperative complications. Fifteen of 15 infants were successfully treated by SLS closure followed by elective closure. Two of 15 (13.3%) experienced temporary dislodgement of the silo prior to permanent closure. In both cases, the silo was safely reinserted at the bedside. Comparison of PIP values measured at various stages of SLS closure revealed no significant difference (P > 0.05). Mean times to final fascial closure (3.7 days) and full enteral feedings (22 days) were similar to historical controls obtained from the surgical literature. In 1 case where there was associated intestinal atresia, SLS closure was effective in permitting concomitant elective closure and re-establishment of bowel continuity. All children are alive and well at the time of this report. SLS closure permits safe, gentle, and gradual reduction of the exposed viscera leading to successful permanent abdominal wall closure. Respiratory embarrassment and hemodynamic instability associated with emergent (primary) closure of large abdominal wall defects can thus be avoided.

The ethics consultation and the pediatric surgeon.

The cultural, ethnic, religious, socioeconomic, and educational diversity of the patient population and the expanded surgical options provided by innovation and technology can pose significant ethical challenges. The questions confronting pediatric surgeons and their patients' families have greater complexity, and both the pediatric surgeon and the family perceive increasing vulnerability and uncertainty. The analysis and management of ethical issues in pediatric surgery cannot simply be extrapolated from the approach applied to adult cases. By reviewing the history of the events that contributed to the creation and utilization of hospital ethics committees and examining the role of the ethics consultant in the context of pediatric surgical care, practitioners and trainees will be better able to address these multifaceted situations.

Can we talk about sex?

A three-year-old female undergoes elective inguinal hernia repair and unexpectedly is found to have testes in the hernia sacs. A recommendation is made not to disclose the patient's genotype to her mother. This case study addresses the ethical conflict of whether to disclose the patient's male genotype to the parent that has been raising the child as female.