Optimizing Outcomes After Cleft Palate Repair: Design and Implementation of a Perioperative Clinical Care Pathway.

OBJECTIVE: To evaluate the development process and clinical impact of implementing a standardized perioperative clinical care pathway for cleft palate repair. DESIGN: Medical records of patients undergoing primary cleft palate repair prior to pathway implementation were retrospectively reviewed as a historical control group (N = 40). The historical cohort was compared to a prospectively collected group of patients who were treated according to the pathway (N = 40). PATIENTS: Healthy, nonsyndromic infants undergoing primary cleft palate repair at a tertiary care pediatric hospital. INTERVENTIONS: A novel, standardized pathway was created through an iterative process, combining literature review with expert opinion and discussions with institutional stakeholders. The pathway integrated multimodal analgesia throughout the perioperative course and included intraoperative bilateral maxillary nerve blocks. Perioperative protocols for preoperative fasting, case timing, antiemetics, intravenous fluid management, and postoperative diet advancement were standardized. MAIN OUTCOME MEASURES: Primary outcomes include: (1) length of hospital stay, (2) cumulative opioid consumption, (3) oral intake postoperatively. RESULTS: Patients treated according to the pathway had shorter mean length of stay (31 vs 57 hours, P < .001), decreased cumulative morphine consumption (77 vs 727 µg/kg, P < .001), shorter time to initiate oral intake (9.3 vs 22 hours, P = .01), and greater volume of oral intake in first 24 hours postoperatively (379 vs 171 mL, P < .001). There were no differences in total anesthesia time, total surgical time, or complication rates between the control and treatment groups. CONCLUSIONS: Implementation of a standardized perioperative clinical care pathway for primary cleft palate repair is safe, feasible, and associated with reduced length of stay, reduced opioid consumption, and improved oral intake postoperatively.

Suprazygomatic maxillary nerve block: an ultrasound and cadaveric study to identify correct sonoanatomical landmarks.

​PURPOSE: Suprazygomatic maxillary nerve blocks (SMB) are used in adult and pediatric patients to provide analgesia for midface surgery and chronic maxillofacial pain syndromes. The ultrasound-guided SMB technique ensures visualisation of the needle tip, avoidance of the maxillary artery and confirmation of local anesthetic spread. The goal of this study was to correctly identify SMB sonoanatomical landmarks to ensure the nerve block is performed safely and effectively. METHODS: Following an ultrasound-guided SMB with dye injection on 2 embalmed cadavers, pre-tragal face-lift style incision with a full thickness flap dissection was performed allowing accurate visualization of the bony landmarks being used for sonography and identification of the location of the injected dye. RESULTS: This study identifies the correct sonoanatomic landmarks as the maxilla and the coronoid process of the mandible which suggests that the block needle tip and local anesthetic injection are within the infratemporal fossa as opposed to the previously reported pterygopalatine fossa. CONCLUSION: An improved understanding of the sonoanatomy will aid clinicians who are learning, performing and teaching the ultrasound-guided suprazygomatic approach to the maxillary nerve block.

Iliac Crest Bone Graft Harvest for Alveolar Cleft Repair: A Systematic Review Comparing Minimally Invasive Trephine and Conventional Open Techniques.

Background: In the course of developing a standardized pathway for alveolar cleft repair, we conducted a systematic review comparing minimally invasive trephine with conventional open technique for iliac crest bone graft harvest in a pediatric population. Methods: A systematic review was conducted of studies comparing open with minimally invasive trephine techniques in pediatric populations undergoing alveolar cleft repair. Exclusion criteria included reviews, case series, editorials, abstracts, and those with adult-only populations. Data were compiled with outcome variables selected a priori. Results: Of 422 manuscripts screened, five met criteria. These comprised 257 patients (116 open, 141 trephine). Average age was 11 years. Patients undergoing trephine harvest had reduced length of stay (1.0-5.0 days trephine vs 1.25-5.4 days open), time to unassisted ambulation (16-46 hours vs 20-67 hours open), and less postoperative narcotic use (0.31 mg/kg vs 1.64 mg/kg IV morphine). Volume of cancellous bone was reported as 2.53 mL for open versus 1.22 mL for trephine in one study, and trephine graft was supplemented with demineralized bone in 54% of cases in another study. The use of anesthetic adjuncts was inconsistent but had a significant effect on postoperative pain and ambulation. Conclusions: Compared to open techniques, the minimally invasive trephine bone graft harvest is associated with a shorter time to discharge, slightly lower infection rates, and reduced opioid use. The possible benefits of trephine harvest must however be balanced against the risk of insufficient graft harvest. Finally, the choice of perioperative analgesic adjuncts significantly impacts patient outcomes regardless of the technique employed.

Contexte: Dans le cours de l'élaboration d'une méthode standardisée de réparation des fentes palatines, nous avons réalisé une revue systématique comparant la technique par tréphine peu invasive à la technique conventionnelle ouverte pour la collecte d'os de la crête iliaque dans une population pédiatrique. Méthodes: Une revue systématique a été réalisée sur les études comparant les techniques ouvertes avec les techniques utilisant une tréphine peu invasive dans des populations pédiatriques subissant une réparation de fente palatine. Les critères d'exclusion incluaient les revues, les séries de cas, les éditoriaux, les résumés et les études ne portant que sur une population adulte. Les données ont été compilées avec des variables de résultats sélectionnées a priori. Résultats: Parmi les 422 manuscrits sélectionnés, cinq répondaient aux critères. Ils incluaient 257 patients (116 techniques ouvertes, 141 tréphines). L'âge moyen des patients était de 11 ans. Les patients pour lesquels une collecte avait été obtenue par tréphine avaient une durée de séjour plus courte (tréphine : 1,0 à 5,0 jours; contre technique ouverte : 1,25 à 5,4 jours), un délai de déambulation non aidée plus court (16 à 46 heures contre 20 à 67 heures pour la technique ouverte) et un moindre recours aux antalgiques postopératoires (0,31 mg/kg contre 1,64 mg/kg de morphine IV). Le volume d'os spongieux collecté était de 2,53 ml avec les techniques ouvertes contre 1,22 ml avec la tréphine; le greffon par tréphine a été complété par de l'os déminéralisé dans 54% des cas dans une autre étude. L'utilisation de suppléments anesthésiques n'était pas homogène, mais a eu un effet significatif sur la douleur postopératoire et la déambulation. Conclusions: Comparativement aux techniques ouvertes, la collecte peu invasive de greffon osseux par tréphine est associée à une délai de congé plus court, des taux d'infections légèrement inférieurs et à une moindre utilisation d'opioïdes. Toutefois, les avantages éventuels de la collecte par tréphine doivent être soupesés par rapport au risque de collecte insuffisante de greffon. Enfin, le choix de suppléments analgésiques périopératoires a des répercussions significatives sur l'évolution des patients, indépendamment de la technique employée.

Improved Operative Efficiency and Surgical Times in Autologous Breast Reconstruction: A 15-year Single-center Retrospective Review.

Background: Autologous breast reconstruction using a free deep inferior epigastric perforator (DIEP) flap is a complex procedure that requires a dedicated approach to achieve operative efficiency. We analyzed data for DIEP flaps at a single center over 15 years to identify factors contributing to operative efficiency. Methods: A single-center, retrospective cohort analysis was performed of consecutive patients undergoing autologous breast reconstruction using DIEP free flaps between January 1, 2005, and December 31, 2019. Data were abstracted a priori from electronic medical records. Analysis was conducted by a medical statistician. Results: Analysis of 416 unilateral and 320 bilateral cases (1056 flaps) demonstrated reduction in operative times from 2005 to 2019 (11.7-8.2 hours for bilateral and 8.4-6.2 hours for unilateral, P < 0.000). On regression analysis, factors significantly correlating with reduced operative times include the use of venous couplers (P < 0.000), and the internal mammary versus the thoracodorsal recipient vessels (P < 0.000). Individual surgeon experience correlated with reduced OR times. Post-operative length of stay decreased significantly, without an increase in 30-day readmission or emergency presentations. Flap failure occurred in two cases. Flap take-back rate was 2% (n = 23) with no change between 2005 and 2019. Conclusions: Operative times for breast reconstruction have decreased significantly at this center over 15 years. The introduction of venous couplers, use of the internal mammary system, and year of surgery significantly correlated with decreased operative times. Surgeon experience and a shift in surgical workflow for DIEP flap reconstruction likely contributed to the latter finding.

Pregnancy and Parenthood Remain Challenging During Surgical Residency: A Systematic Review.

PURPOSE: To examine common themes and synthesize data surrounding pregnancy and parenthood during surgical residency training. METHOD: The authors conducted a systematic search of the literature in March 2019. They searched MEDLINE, EMBASE, and Scopus, seeking articles published from 2003 to 2018 that focused on pregnancy, parenthood, and the experience of surgical residents. They excluded articles that examined nonsurgical programs, as well as editorials, abstracts, and commentaries. Two investigators independently reviewed all citations, selected articles for full-text review, and extracted data from the selected articles. RESULTS: Of 523 titles and abstracts screened, 27 were included. Overall, female surgical residents had fewer children during residency training than their male counterparts (18%-28% vs 32%-54%). As compared with the general population, surgical residents had their first child later in life (30-34 vs 25 years old), and had fewer children overall (0.6-2.1 vs 2.7). Infertility rates were higher among female surgeons than in the general population (30%-32% vs 11%), as were assisted reproductive technology rates (8%-13% vs 1.7%). Pregnant surgical residents experienced a high rate of obstetrical complications; working more than 6 overnight calls shifts per month or 60 hours per week were predictors of increased complication rates. The authors noted no differences in attrition, caseload, or exam pass rates amongst female surgical residents who had become pregnant as compared with other residents. Despite these similar academic outcomes, negative attitudes and perceptions toward pregnancy during residency were consistently identified. CONCLUSIONS: Female surgical residents experience high rates of infertility and obstetrical complications, contend with negative attitudes and stigma during their pregnancies, and voluntarily delay childbearing. Formal maternity policies, a shift in surgical culture, and ongoing discussion with all stakeholders are needed to attract and retain female surgical residents.

Pediatric Hand Fracture Referring Practices: A Scoping Review.

BACKGROUND: Pediatric hand fractures are common, but few require surgery; therefore, these fractures are often perceived to be overreferred. Our objective is to systematically identify and describe pediatric hand fracture referring practices. METHOD: A scoping review was performed, searching electronic databases and grey literature up to January 2018 to identify referring practices for children (17 years and younger) with hand fractures (defined as radiographically confirmed fractures distal to the carpus) to hand surgeons. All study designs were included, and study selection and data extraction were independently performed in duplicate by 2 reviewers. Outcomes included referring rates, necessity of referral, referring criteria, and management of fractures. RESULTS: Twenty (10 cross-sectional, 7 prospective cohorts, and 3 narrative reviews) studies reporting on referring practices or management of 21,624 pediatric hand fractures were included. Proportion of pediatric hand fractures referred to hand surgeons ranged from 6.5% to 100%. Unnecessary referral, defined as those fractures within the scope of primary care management, ranged from 27% to 78.1%. Ten studies reported referring criteria, with 14 unique criteria identified. The most common referring criteria were displacement (36.4%), loss of joint congruity (36.4%), and instability (36.4%). The most common justification for these criteria was increased likelihood of requiring surgery. The most common initial management was immobilization (66%-100%). Final management was provided by orthopedic or plastic hand surgeons with 0% to 32.9% of fractures requiring surgery. CONCLUSION: Referring practices vary widely in the literature. Major gaps in the literature include objective measures and justification for referring criteria and primary care education on hand fracture referring practices.

HISTORIQUE: Les fractures de la main sont courantes en pédiatrie, mais rares sont celles qui exigent une opération. C'est pourquoi on a souvent l'impression qu'elles sont trop envoyées en consultation. Les chercheurs avaient comme objectif de déterminer et de décrire systématiquement les pratiques de consultation à cause d'une fracture de la main en pédiatrie. MÉTHODOLOGIE: En janvier 2018, dans le cadre d'une analyse exploratoire, les chercheurs ont fouillé les bases de données électroniques et la documentation parallèle pour déterminer les pratiques de consultation de chirurgiens de la main pour les enfants (de 17 ans et moins) victimes de fractures de la main (définies comme des fractures de la partie distale du carpe, confirmées par radiographie). Ils ont inclus toutes les méthodologies, et deux analystes ont chacun effectué toute l'extraction des données. Les résultats incluaient le taux, la nécessité et les critères de consultation ainsi que le traitement des fractures. RÉSULTATS: Les chercheurs ont inclus 20 études (dix transversales, sept cohortes prospectives, trois examens narratifs) sur les pratiques de consultation ou de prise en charge de 21,624 fractures de la main en pédiatrie. De 6,5 % à 100 % de ces fractures étaient envoyées en consultation à un chirurgien de la main. De 27 % à 78,1 % des consultations étaient inutiles, c'est-à-dire qu'elles pouvaient être traitées en soins primaires. Dix études faisaient état de critères de consultation, pour un total de 14 critères uniques. Ainsi, les principaux critères de consultation étaient un déplacement (36,4 %), la perte de la congruence articulaire (36,4 %) et l'instabilité (36,4 %). La principale justification de ces critères était une plus grande probabilité d'opération. L'immobilisation (66 % à 100 %) demeurait le traitement initial le plus courant. Un chirurgien orthopédique ou plastique de la main effectuait le traitement définitif, et de 0 % à 32,9 % des fractures devaient être opérées. CONCLUSION: Les publications font état de pratiques de consultation très variables. Elles comportent de grandes lacunes, soit l'objectivité des mesures, la justification des critères de consultation retenus et la formation en soins primaires sur les pratiques de consultation en cas de fracture de la main.