Survival effect of complete surgical resection of the primary tumor in patients with metastatic, high-risk neuroblastoma in a large Canadian cohort.

PURPOSE: To determine whether extent of surgical resection of the primary tumor correlates with survival in patients with International Neuroblastoma Staging System (INSS) stage 4, high-risk neuroblastoma. METHODS: Data were extracted for patients with newly diagnosed INSS stage 4, high-risk neuroblastoma between 2001 and 2019 from the national Cancer in Young People in Canada (CYPC) database. Complete resection was defined as gross total resection of primary tumor based on operative reports. Primary endpoints were 3 and 5-year event-free (EFS) and overall survival (OS). Survival analyses were completed using log-rank test and Cox proportional hazards regression including covariates of age, sex, decade of treatment (2001-2009 vs. 2010-2019), immunotherapy, and tandem stem cell transplant (SCT). RESULTS: One-hundred and forty patients with complete surgical data were included. On univariate analysis, 3-year EFS and OS for patients that had complete versus incomplete resection was 71% (95% CI 57-80%) vs. 48% (36-60%) and 86% (75-93%) vs. 64% (51-74%), p = .008 and p = .002, respectively. 5-year EFS and OS for patients with complete resection also demonstrated significantly improved survival. On Cox Proportional Hazards models adjusted for age, immunotherapy, tandem SCT, and surgical resection, only complete resection was associated with statistically significant improved 3 year EFS and OS, HR = 0.48 (0.29-0.81; p = .006) and HR = 0.42 (0.24-0.73; p = .002). CONCLUSIONS: In a large Canadian INSS stage 4 high-risk neuroblastoma cohort, complete surgical resection was associated with increased EFS and OS. Within the constraints of a retrospective study, these results suggest that the ability to achieve primary tumor complete resection in patients with metastatic high-risk disease is associated with improved survival.

Unusual case of coronal complete bladder duplication associated with rectoprostatic fistula to duplicated prostatic urethra.

Anorectal malformations are a common congenital anomaly, while bladder duplication is rare. Bladder duplications are classified as complete or incomplete and sagittal or coronal. We present a rare case of coronal complete bladder duplication with rectoprostatic fistula to the blind ending prostatic urethra of the duplicated bladder.

The First Two Years of the Association of Pediatric Surgery Training Program Directors (APSTPD) Transition to Fellowship Course: Lessons Learned and Future Directions.

OBJECTIVE: The first transition to fellowship course for incoming pediatric surgery fellows was held in the US in 2018 and the second in 2019. The course aimed to facilitate a successful transition in to fellowship by introduction of the professional, patient care, and technical aspects unique to pediatric surgery training. The purpose of this study was to evaluate the feasibility and effectiveness of the first two years of this course in the US and discuss subsequent evolution of this endeavor. DESIGN: This is a descriptive and qualitative analysis of two years' experience with the Association of Pediatric Surgery Training Program Directors' (APSTPD) Transition to Fellowship course. Course development and curriculum, including clinical knowledge, soft skills, and hands-on skills labs, are presented. Participating incoming fellows completed multiple choice, boards-style pre- and post-tests. Scores were compared to determine if knowledge was effectively transferred. Participants also completed post-course evaluations and subsequent 3- or 12-month surveys inquiring on the lasting impact of the course on their transition into fellowship. Standard univariate statistics were used to present results. SETTING: The first APSTPD Transition to Fellowship course was held at the Johns Hopkins Hospital in Baltimore, Maryland in 2018, and the second course was held at the Oregon Health and Science University in Portland, Oregon in 2019. PARTICIPANTS: All fellows entering ACGME-certified Pediatric Surgery fellowships in the United States were invited to participate. Twenty fellows accepted and attended in 2018, and fourteen fellows participated in 2019. RESULTS: There were 34 incoming pediatric surgery fellow participants over 2 years. Faculty represented more than 10 institutions each year. Pre- and post-test scores were similar between years, with a significant improvement of scores after completion of the course (67±10% vs 79±8%, p < 0.001). Feedback from participants was overwhelmingly positive, with skills labs being attendees' favorite component. When asked about usefulness of individual course sessions, more attendees found clinical sessions more useful than soft skills (93% vs 73%, p = 0.011). Almost all (90%) of participants reported the course met its stated purpose and would recommend the course to future fellows. This was further reflected on 3 and 12 month follow up surveys wherein 85% stated they found the course helpful during the first few months of fellowship and 90% would still recommend it. CONCLUSIONS: A transition to fellowship course in the US for incoming pediatric surgery fellows is logistically feasible, effective in transfer of knowledge, and highly regarded among attendees. Feedback from each course has been used to improve the subsequent courses, ensuring that it remains a valuable addition to pediatric surgical training in the US.

The future is here! Pediatric surgery and the move to the royal college of physicians and surgeons of Canada's competence by design.

This interactive session was held at the 51st Annual Meeting of the Canadian Association of Pediatric Surgeons (CAPS) in preparation for the transition of Pediatric Surgery training in Canada to Competency by Design (a CBME-based model of residency training developed by the Royal College of Physicians and Surgeons of Canada).

A transition to discipline curriculum for pediatric surgery trainees: Evaluation of a pediatric surgery boot camp from 2017 to 2018.

INTRODUCTION: Boot camps seek to impart knowledge and skills for individuals entering new roles. We sought to evaluate knowledge, skills, and confidence of in-coming pediatric surgery trainees with a 2.5-day pediatric surgery boot camp. METHODS: A curriculum included key aspects of pediatric surgery delivered during interactive lectures, small group discussions, and simulation. With REB approval, participant demographics were collected. Pre- and posttests assessed knowledge and trainee confidence. Comparative statistics and multivariate analysis of variance (MANOVA) were performed. RESULTS: Between 2017 and 2018, 16 individuals from North American pediatric surgery training programs participated in two boot camps. Ten had North American general surgery training, and eleven had no pediatric surgery exposure ≥1 year prior. All participants expressed increased confidence with course material after boot camp [F(18,11) = 3.137;p < 0.05]. Performance improved significantly (pre- vs. posttests, 47.0% vs. 62.4%; p < 0.05). MANOVA between faculty and trainees demonstrated agreement on the value of individual sessions [F(15,3) = 0.642;p = 0.76]. Neonatal bowel obstruction, gastrostomy tube complications, esophageal atresia, pain management, and informed consent were rated most useful. CONCLUSION: Trainees and teaching faculty considered the boot camp valuable. Trainees demonstrated significant improvements in core knowledge and confidence. The initial pediatric surgery boot camp experience shows promise in facilitating the transition to discipline for new trainees. STUDY TYPE: Prospective treatment study. LEVEL OF EVIDENCE: IV.

Pectus deformities: a review of open surgery in the modern era.

Pectus deformities represent a spectrum of relatively common congenital chest malformations. The adoption of less invasive techniques has renewed interest in surgical repair by both patients and clinicians. The aim of this review is to identify current management, outcomes, and controversy in the treatment of pectus excavatum and pectus carinatum.

Optimal management of high-risk T1G3 bladder cancer: a decision analysis.

BACKGROUND: Controversy exists about the most appropriate treatment for high-risk superficial (stage T1; grade G3) bladder cancer. Immediate cystectomy offers the best chance for survival but may be associated with an impaired quality of life compared with conservative therapy. We estimated life expectancy (LE) and quality-adjusted life expectancy (QALE) for both of these treatments for men and women of different ages and comorbidity levels. METHODS AND FINDINGS: We evaluated two treatment strategies for high-risk, T1G3 bladder cancer using a decision-analytic Markov model: (1) Immediate cystectomy with neobladder creation versus (2) conservative management with intravesical bacillus Calmette-Guérin (BCG) and delayed cystectomy in individuals with resistant or progressive disease. Probabilities and utilities were derived from published literature where available, and otherwise from expert opinion. Extensive sensitivity analyses were conducted to identify variables most likely to influence the decision. Structural sensitivity analyses modifying the base case definition and the triggers for cystectomy in the conservative therapy arm were also explored. Probabilistic sensitivity analysis was used to assess the joint uncertainty of all variables simultaneously and the uncertainty in the base case results. External validation of model outputs was performed by comparing model-predicted survival rates with independent published literature. The mean LE of a 60-y-old male was 14.3 y for immediate cystectomy and 13.6 y with conservative management. With the addition of utilities, the immediate cystectomy strategy yielded a mean QALE of 12.32 y and remained preferred over conservative therapy by 0.35 y. Worsening patient comorbidity diminished the benefit of early cystectomy but altered the LE-based preferred treatment only for patients over age 70 y and the QALE-based preferred treatment for patients over age 65 y. Sensitivity analyses revealed that patients over the age of 70 y or those strongly averse to loss of sexual function, gastrointestinal dysfunction, or life without a bladder have a higher QALE with conservative therapy. The results of structural or probabilistic sensitivity analyses did not change the preferred treatment option. Model-predicted overall and disease-specific survival rates were similar to those reported in published studies, suggesting external validity. CONCLUSIONS: Our model is, to our knowledge, the first of its kind in bladder cancer, and demonstrated that younger patients with high-risk T1G3 bladder had a higher LE and QALE with immediate cystectomy. The decision to pursue immediate cystectomy versus conservative therapy should be based on discussions that consider patient age, comorbid status, and an individual's preference for particular postcystectomy health states. Patients over the age of 70 y or those who place high value on sexual function, gastrointestinal function, or bladder preservation may benefit from a more conservative initial therapeutic approach.

Outcomes of an accelerated care pathway for pediatric blunt solid organ injuries in a public healthcare system.

PURPOSE: An accelerated clinical care pathway for solid organ abdominal injuries was implemented at a level one pediatric trauma center. The impact on resource utilization and demonstration of protocol safety was assessed. METHODS: Data were collected retrospectively on patients admitted with blunt abdominal solid organ injuries from 2012 to 2015. Patients were subdivided into pre- and post-protocol groups. Length of hospital stay (LOS) and failure of non-operative treatment were the primary outcomes of interest. RESULTS: 138 patients with solid organ injury were studied: 73 pre- (2012-2014) and 65 post-protocol (2014-2015). There were no significant differences in age, gender, injury severity score (ISS), injury grade, or mechanism (p>0.05). LOS was shorter post-protocol (mean 5.6 vs. 3.4days; median 5 .0 vs. 3.0days; p=0.0002), resulting in average savings of $5966 per patient. Patients in the protocol group mobilized faster (p<0.0001) and experienced fewer blood draws (p=0.02). On multivariate analysis, protocol group (p<0.001) and ISS (p<0.001) were independently associated with LOS. There were no differences between groups in the need for operation, embolization, or transfusion. CONCLUSION: An accelerated care pathway is safe and effective in the management of pediatric solid organ injuries with early mobilization, less blood draws, and decreased LOS without significant morbidity and mortality. LEVEL OF EVIDENCE: Therapeutic, cost effectiveness, level III.

Effectiveness and meaningful use of paediatric surgical safety checklists and their implementation strategies: a systematic review with narrative synthesis.

OBJECTIVE: To examine the effectiveness and meaningful use of paediatric surgical safety checklists (SSCs) and their implementation strategies through a systematic review with narrative synthesis. SUMMARY BACKGROUND DATA: Since the launch of the WHO SSC, checklists have been integrated into surgical systems worldwide. Information is sparse on how SSCs have been integrated into the paediatric surgical environment. METHODS: A broad search strategy was created using Pubmed, Embase, CINAHL, Cochrane Central, Web of Science, Science Citation Index and Conference Proceedings Citation Index. Abstracts and full texts were screened independently, in duplicate for inclusion. Extracted study characteristic and outcomes generated themes explored through subgroup analyses and idea webbing. RESULTS: 1826 of 1921 studies were excluded after title and abstract review (kappa 0.77) and 47 after full-text review (kappa 0.86). 20 studies were of sufficient quality for narrative synthesis. Clinical outcomes were not affected by SSC introduction in studies without implementation strategies. A comprehensive SSC implementation strategy in developing countries demonstrated improved outcomes in high-risk surgeries. Narrative synthesis suggests that meaningful compliance is inconsistently measured and rarely achieved. Strategies involving feedback improved compliance. Stakeholder-developed implementation strategies, including team-based education, achieved greater acceptance. Three studies suggest that parental involvement in the SSC is valued by parents, nurses and physicians and may improve patient safety. CONCLUSIONS: A SSC implementation strategy focused on paediatric patients and their families can achieve high acceptability and good compliance. SSCs' role in improving measures of paediatric surgical outcome is not well established, but they may be effective when used within a comprehensive implementation strategy especially for high-risk patients in low-resource settings.

Pneumatic dilatation and surgical myotomy for achalasia.

CONTEXT: Pneumatic dilatation and surgical (Heller) myotomy are the 2 principal methods for treatment of achalasia. There are no population-based studies comparing outcomes of these 2 treatments in typical practice settings. OBJECTIVE: To compare the outcomes of pneumatic dilatation and surgical myotomy for achalasia. DESIGN, SETTING, AND PARTICIPANTS: Retrospective longitudinal study using linked administrative health data in Ontario. A total of 1461 persons aged 18 years or older received treatment for achalasia between July 1991 and December 2002, 1181 (80.8%) of whom had pneumatic dilatation and 280 (19.2%) of whom had surgical myotomy as the first procedure. MAIN OUTCOME MEASURES: Use of subsequent interventions for achalasia (pneumatic dilatation, surgical myotomy, or esophagectomy) following the first treatment during the study period, subsequent physician visits, and use of gastrointestinal medications among persons aged 65 years or older. We adjusted for confounding variables using regression models. RESULTS: The cumulative risk of any subsequent intervention for achalasia after 1, 5, and 10 years, respectively, was 36.8%, 56.2%, and 63.5% for persons treated initially with pneumatic dilatation and was 16.4%, 30.3%, and 37.5% for persons treated initially with surgical myotomy (adjusted hazard ratio [HR], 2.37; 95% confidence interval [CI], 1.86-3.02; P<.001). Differences in risk were observed only when subsequent pneumatic dilatation was included as an adverse outcome; there was no statistical difference between the 2 groups with respect to the risk of subsequent surgical myotomy or esophagectomy. Compared with persons treated initially with surgical myotomy, those treated with pneumatic dilatation were not statistically different with respect to subsequent physician visits (adjusted rate ratio, 1.01; 95% CI, 1.00-1.03), or time to use of histamine-2 receptor blockers (adjusted HR, 1.19; 95% CI, 0.79-1.80), proton pump inhibitors (HR, 1.02; 95% CI, 0.70-1.49), and prokinetic medications (HR, 0.92; 95% CI, 0.60-1.41). CONCLUSIONS: Subsequent intervention after the initial treatment of achalasia is common. Although the risk of subsequent interventions among persons treated with surgical myotomy in typical practice settings is higher than previously thought, the risk of subsequent intervention is greater among persons treated with pneumatic dilatation than with surgical myotomy. This difference is attributable to the use of subsequent pneumatic dilatation rather than surgical procedures.

Treatment Options for Pediatric Patent Ductus Arteriosus: Systematic Review and Meta-analysis.

BACKGROUND: Patent ductus arteriosus (PDA) in the nonpremature pediatric patient is currently treated by surgical ligation or catheter occlusion. There is no clear superiority of one technique over the other. This meta-analysis compares the clinical outcomes of the two treatment options for PDA. METHODS: We performed a literature search of MEDLINE, Embase, PubMed, and the Cochrane database of randomized controlled trials (RCTs) that took place between 1950 and February 2014 and hand-searched references from included studies. We excluded studies of adult or premature patients and those without a direct comparison between surgical and catheter-based treatments of PDAs. Outcomes of interest were reintervention, total complications, length of stay, and cost. RESULTS: One thousand three hundred thirty-three manuscripts were screened. Eight studies fulfilled the inclusion criteria (one RCT and seven observational studies [N = 1,107]). In pooled observational studies, there were significantly decreased odds (OR, 0.12; 95% CI, 0.03-0.42) for reintervention in the surgical ligation group but insignificantly higher odds for overall complications (OR, 2.01; 95% CI, 0.68-5.91). There were no complications reported in the RCT, but surgical ligation was associated with decreased odds for reintervention and a longer length of stay. Funnel plots revealed a possible publication bias and a quality review identified comparability bias. CONCLUSIONS: Both therapies have comparable outcomes. Reintervention is more common with catheter-based treatment, but overall complication rates are not higher and hospital stay is shorter. Our data span > 2 decades and may not reflect current surgical and catheterization outcomes. Large, randomized, prospective studies may help determine the optimal treatment strategy.

Evaluating the introduction of extracorporeal life support technology to a tertiary-care pediatric institution: Smoothing the learning curve through interprofessional simulation training.

BACKGROUND: Extracorporeal life support (ECLS) is a life-saving technology for the critically ill child. Our objective was to evaluate the outcomes of an educational curriculum designed to introduce an ECLS program to a noncardiac pediatric surgical center. METHODS: An interdisciplinary curriculum was developed consisting of didactic courses, animal labs, simulations, and debrief sessions. We reviewed all patients requiring ECLS between October 2011 and December 2013. All health care practitioners involved in the ECLS training curriculum were surveyed to evaluate their perception of the educational program. Primary outcomes include successful cannulation and 30-day survival. RESULTS: The knowledge and confidence improved with statistical significance (p<0.0001-0.0003) for all of the components of the training curriculum. The highest score was given to the simulations. Twenty-one patients underwent cannulation. All patients were successfully cannulated to bypass, including six (28.6%) ECPR. Median time from activation to cutting was 52min (IQR 40-72), and from cutting to bypass 40min (IQR 30-45). Sixteen patients (76.2%) were decannulated to a sustainable cardiac rhythm and survived 30-days. CONCLUSION: An ECLS curriculum incorporating simulation and dedicated practice seems to have eliminated the potential learning curve associated with the introduction of a complex technology to a novice environment.

Effects of Postgraduate Medical Education "Boot Camps" on Clinical Skills, Knowledge, and Confidence: A Meta-Analysis.

BACKGROUND: Throughout their medical education, learners face multiple transition periods associated with increased demands, producing stress and concern about the adequacy of their skills for their new role. OBJECTIVE: We evaluated the effectiveness of boot camps in improving clinical skills, knowledge, and confidence during transitions into postgraduate or discipline-specific residency programs. METHODS: Boot camps are in-training courses combining simulation-based practice with other educational methods to enhance learning and preparation for individuals entering new clinical roles. We performed a search of MEDLINE, CINAHL, PsycINFO, EMBASE, and ERIC using boot camp and comparable search terms. Inclusion criteria included studies that reported on medical education boot camps, involved learners entering new clinical roles in North American programs, and reported empirical data on the effectiveness of boot camps to improve clinical skills, knowledge, and/or confidence. A random effects model meta-analysis was performed to combined mean effect size differences (Cohen's d) across studies based on pretest/posttest or comparison group analyses. RESULTS: The search returned 1096 articles, 15 of which met all inclusion criteria. Combined effect size estimates showed learners who completed boot camp courses had significantly "large" improvements in clinical skills (d  =  1.78; 95% CI 1.33-2.22; P < .001), knowledge (d  =  2.08; 95% CI 1.20-2.96; P < .001), and confidence (d  =  1.89; 95% CI 1.63-2.15; P < .001). CONCLUSIONS: Boot camps were shown as an effective educational strategy to improve learners' clinical skills, knowledge, and confidence. Focus on pretest/posttest research designs limits the strength of these findings.

Cost-effectiveness analysis of immediate radical cystectomy versus intravesical Bacillus Calmette-Guerin therapy for high-risk, high-grade (T1G3) bladder cancer.

BACKGROUND: Although both radical cystectomy and intravesical immunotherapy are initial treatment options for high-risk, T1, grade 3 (T1G3) bladder cancer, controversy regarding the optimal strategy persists. Because bladder cancer is the most expensive malignancy to treat per patient, decisions regarding the optimal treatment strategy should consider costs. METHODS: A Markov Monte-Carlo cost-effectiveness model was created to simulate the outcomes of a cohort of patients with incident, high-risk, T1G3 bladder cancer. Treatment options included immediate cystectomy and conservative therapy with intravesical Bacillus Calmette-Guerin (BCG). The base case was a man aged 60 years. Parameter uncertainty was assessed with probabilistic sensitivity analyses. Scenario analyses were used to explore the 2 strategies among patients stratified by age and comorbidity. RESULTS: The quality-adjusted survival with immediate cystectomy and BCG therapy was 9.46 quality-adjusted life years (QALYs) and 9.39 QALYs, respectively. The corresponding mean per-patient discounted lifetime costs (in 2005 Canadian dollars) were $37,600 and $42,400, respectively. At a willingness-to-pay threshold of $50,000 per QALY, the probability that immediate cystectomy was cost-effective was 67%. Immediate cystectomy was the dominant (more effective and less expensive) therapy for patients aged <60 years, whereas BCG therapy was dominant for patients aged >75 years. With increasing comorbidity, BCG therapy was dominant at lower age thresholds. CONCLUSIONS: Compared with BCG therapy, immediate radical cystectomy for average patients with high-risk, T1G3 bladder cancer yielded better health outcomes and lower costs. Tailoring therapy based on patient age and comorbidity may increase survival while yielding significant cost-savings for the healthcare system.

Regional variation in surgery for gastroesophageal reflux disease in Ontario.

The optimal treatment for gastroesophageal reflux disease (GERD) is unclear, and the degree of variation in the rate of antireflux surgery in different regions is unknown. Large variation has significant implications for health care spending and may represent uncertainty among health care providers. The objective of this study was to identify population-based utilization and measure area rate variations in the use of GERD surgery; 11,685 primary antireflux procedures in the provincial administrative health databases were studied. Small-area variation was quantified using 4 measures. The crude rate of antireflux procedures was 11.6/100 000 adults. Patients between the ages of 45 and 64 had the highest rates of surgery. More women than men underwent antireflux surgery (13.6 vs. 9.4 per 100,000). Between counties, adjusted surgical rates ranged from 5.0 to 28.7 per 100,000 persons. Significant regional variation exists for antireflux surgery across Ontario, suggesting that its appropriate role in the management of GERD remains ill-defined.

The optimal timing of intestinal transplantation for children with intestinal failure: a Markov analysis.

OBJECTIVE: Identify an optimal approach to the timing of intestinal transplantation for children dependent on total parenteral nutrition (PN). SUMMARY BACKGROUND DATA: Children with short bowel syndrome are frequently dependent on PN for growth and development. Intestinal transplantation is often considered after PN-related complications occur, but optimal timing of transplantation is controversial. METHODS: A Markov analytic model was used to determine life expectancy (LY) and quality-adjusted life years on a theoretical cohort of 4-year-old subjects for two treatment strategies: (1) standard care consisting of PN and referral to transplantation according to accepted guidelines and (2) early listing for isolated small intestine transplantation. RESULTS: Early listing for intestinal transplantation was associated with 0.27 additional life years (13.16 vs. 12.89) and 0.76 additional quality-adjusted life years (10.51 vs. 9.75) as compared with current standard care. The unadjusted analysis was sensitive to the development of PN-associated liver disease, at a threshold of approximately 11% per year, and its related probability of dying at a threshold of 80% 2-year mortality. Early listing for transplantation was the dominant strategy until the probability of late bowel rejection reached 35% per year. CONCLUSIONS: Children with short bowel syndrome dependent on PN should be considered for intestinal transplantation earlier than what is current practice.

Coronary artery bypass surgery with heparin-coated perfusion circuits and low-dose heparinization.

OBJECTIVE: To evaluate the safety and efficacy of heparin-coated perfusion circuits with low-dose heparinization and centrifugal pumping compared with the standard method during coronary artery bypass grafting. DESIGN: Prospective, randomized, single-blind clinical trial. SETTING: A primary care institution. PATIENTS: Ninety patients who underwent first-time elective coronary artery bypass grafting were eligible for the study. After giving informed consent, they were randomly assigned to 1 of 3 groups (30/group). INTERVENTIONS: Perfusion on regular uncoated bypass equipment with a roller pump and full-dose heparinization (300 IU/kg bolus, activated clotting time [ACT] > 400 s) (group 1), on a heparin-coated oxygenator with a centrifugal pump and full-dose heparinization (group 2) and on fully heparin-coated bypass equipment with a centrifugal pump and low-dose heparinization (100 IU/kg bolus, ACT of 180-400 s) (group 3). Standard coronary artery bypass grafting was performed. OUTCOME MEASURES: Postoperative bleeding, transfusion requirements and clinical outcomes. RESULTS: There were no complications related to the study protocol. Study groups were similar in terms of postoperative bleeding, transfusion requirements and clinical outcomes. CONCLUSIONS: Heparin-coated cardiopulmonary bypass with low-dose heparinization and centrifugal pumping is a safe practice but showed no advantages over the use of regular uncoated bypass circuits for coronary bypass surgery.