Pediatric Surgery from the Roads Less Traveled: Challenges, Communication, and Collaboration from a Community Nonteaching Hospital.

Unique challenges face pediatric surgeons at community-based nonteaching hospitals. Communication and collaboration among and between healthcare providers, hospital administrators, and quaternary referral programs is crucial for the success of these smaller hospitals as they care for children.

Subcutaneous Endoscopic-Assisted Ligation of the Internal Ring for Inguinal Hernia Repair in Neonates Under Spinal Anesthesia.

Introduction: While laparoscopy is now widely accepted for inguinal hernia repair in infants, it traditionally has required general anesthesia. We sought to evaluate the safety of laparoscopic inguinal hernia repair in infants under spinal anesthesia. Materials and Methods: We performed a retrospective cohort study of all inguinal hernia repairs at a single institution between December 2011 and June 2019 in patients younger than 6 months of age. Four groups were compared: laparoscopic under general anesthesia, laparoscopic with spinal anesthesia, open with spinal anesthesia, and open under general anesthesia. Main outcome measures include operative time, cost, and postoperative outcomes. These were assessed using Kruskal-Wallis median comparison. Results: Of the 226 patients meeting inclusion criteria, 54% (122/226) of patients underwent general anesthesia, while 46% (104/226) had spinal. When compared to general anesthesia, spinal anesthesia was associated with significantly shorter procedure times (P < .01) and lower cost (P < .01) for both open and laparoscopic approaches. Complications were few and underpowered to calculate significance across each group. Conclusions: Laparoscopic inguinal hernia repair can be safely performed in infants under spinal anesthesia without significant compromise of early perioperative outcomes. Advantages may include shorter procedure time and lower cost.

Surgeon perceptions of volume threshold and essential practices for pediatric thyroidectomy✰.

INTRODUCTION: The topics of sub-specialization and regionalization of care have garnered increased attention among pediatric surgeons. Thyroid surgeries are one such sub-specialty and are commonly concentrated within practices. A national survey was conducted examining current surgeon practices and beliefs surrounding pediatric thyroid surgery. METHODS: Non-resident members of the American Pediatric Surgical Association (APSA) were surveyed in October 2020. Respondents were stratified based on self-reported thyroid surgical experience. Those who performed thyroid surgery were asked about surgical technique and operative practices; those who did not were asked about referral patterns. All respondents were asked about perceptions surrounding the volume-outcome relationship for pediatric thyroid surgery. RESULTS: Among 1015 APSA members, 405 (40%) responded, with 79% (317/400) practicing at academic hospitals, 58% (232/401) practicing in major metropolitan area, and 41% (161/392) with over 10 years of attending pediatric surgery experience. Most respondents (88%, n = 356) agreed that thyroid surgery volume affects outcome, though wide variation was reported in the annual case threshold for "high volume" surgery. Eighty-four respondents (21%) reported performing ≥ 1 pediatric thyroid surgery in the past year. Of these, 82% routinely use recurrent laryngeal nerve monitoring, 32% routinely send hemithyroidectomy patients home the same day, and there was little consensus surrounding postoperative hypocalcemia management. The majority of respondents endorse performing thyroid procedures with a colleague. CONCLUSIONS: Pediatric thyroid surgery appears to be performed by a subset of active pediatric surgeons, most of whom endorse the use of a dual operating team. More evidence is needed to build consensus around additional perioperative practices.

Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics.

INTRODUCTION: North America is in the midst of an opioid epidemic. The role of pediatric surgeons and other procedural specialists in this public health crisis remains unclear. There is likely considerable variation in the use of opioid and non-opioid analgesics, but the spectrum of practice is still uncertain. METHODS: We performed an online survey in July 2018 of the 2086 pediatric surgeons and proceduralists who were active members in the American Academy of Pediatrics. The survey inquired about practice environment, use of opioid and non-opioid pain medications, and attitudes towards the opioid epidemic. RESULTS: 178 specialists completed the survey for a response rate of 8.5%. Most respondents utilize oral acetaminophen (86%) and ibuprofen (80%) after procedures >75% of the time. Self-reported opioid prescribing increases with age after both outpatient and inpatient procedures (P < 0.001). Pediatric general surgeons prescribe opioids less frequently than other specialists, particularly after inpatient procedures. The majority of respondents (81%) believe that the opioid epidemic is a major problem but only 31% indicated that they have a major role to play. CONCLUSIONS: There is significant variation in opioid prescribing patterns as reported by pediatric surgeons and proceduralists. Guidelines are needed to standardize the use of non-opioid analgesics and decrease reliance on opioids for outpatient and inpatient procedures.

Return of the Banana Knife: An Alternative Instrument for Laparoscopic Pyloromyotomy.

Background: When the disposable arthroscopic banana knife (Linvatec, Largo, FL) became unavailable, many pediatric surgeons adapted the use of spatula tip cautery for laparoscopic pyloromyotomy; however, reusable arthroscopic knives remain readily available and are well suited to the procedure. Methods: We compared laparoscopic pyloromyotomy with a reusable arthroscopic banana knife (Sklar, West Chester, PA; catalog no. 45-6050) to those using spatula tip cautery at a single institution between September 1, 2012, and December 31, 2019. Mann-Whitney U test was used to compare operative time, room time, and time to discharge between groups. Results: Overall, 109 patients underwent pyloromyotomy for hypertrophic pyloric stenosis during the study time period. Of these, 12 were open and one was undertaken with the Storz pyloromyotomy knife, so these were excluded. A total of 74 (77.1%) laparoscopic cases with spatula tip cautery and 22 (22.9%) with the banana knife were included. Mean age at the time of surgery was ∼37 days. The majority of patients in each group were white, male, and full term. The most common comorbid conditions were reactive airway disease and neonatal abstinence syndrome. There were no significant differences in operative time (P = .61), room time (P = .41), or time from surgery to discharge (P = .26) between procedures using the banana knife and those using the cautery spatula tip. There were no perforations or recurrences. Conclusion: Our findings suggest that the reusable banana knife is a safe and effective alternative to spatula tip cautery for laparoscopic pyloromyotomy, with no difference in operative time, time from surgery to discharge, or complications.

Defining the role of advanced care practitioners in pediatric surgery practice.

INTRODUCTION: The role of advanced care practitioners (ACPs) in pediatric surgery is increasingly important and not well described. METHODS: Electronic surveys were sent to pediatric surgery division chiefs within the Children's Hospital Association. RESULTS: We received 77/163 survey responses (47%). The median number of ACPs per service was 3.0 (range 0-35). ACP number correlated with inpatient census, surgeon number, case volume, trauma centers, intensive care unit status, and fellowship programs but not with presence of residents/hospitalists, hospital setting, or practice type. Nearly all programs incorporated nurse practitioners while almost half utilized physician assistants. Approximately one-third of ACPs were designated for subspecialties (35%) such as trauma and colorectal. Only 9% of centers had surgeon-specific ACPs. ACP responsibilities included both inpatient and outpatient tasks. Nearly all ACPs participated in procedures (89%), mostly bedside (80%). All ACPs worked daytime shifts, with less nights and weekends. Most ACPs billed for services (80%). Satisfaction with ACP coverage was widespread and did not correlate with ACP number. Most respondents felt that ACPs enhance, and not hinder, resident/fellow training (85%). CONCLUSION: ACPs are useful adjuncts in pediatric surgery. A better understanding of practice patterns may help optimize utilization to enhance patient care and can be used to advocate for appropriate resources.

Subspecialization in pediatric surgery: Results of a survey to the American Pediatric Surgical Association.

BACKGROUND: Current practice patterns and opinions regarding subspecialization within pediatric surgery are not well known. We aimed to characterize the prevalence of and attitudes surrounding subspecialization within pediatric surgery. METHODS: An anonymous survey regarding subspecialization was distributed to all nonresident members of the American Pediatric Surgical Association. RESULTS: Of 1118 surveys, we received 458 responses (41%). A majority of respondents labeled themselves 'general pediatric surgeons' (63%), while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases (52%). Common niches included oncology (10%) and anorectal malformations (9%). Subspecialists felt to be necessary included transplant (79%) and fetal (78%) surgeons. Opinions about subspecialization were variable: 41% felt subspecialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with subspecialization, while length of time in practice did not. CONCLUSION: While pediatric surgeons report that subspecialization may benefit patient care, concerns exist regarding the unfavorable effect it may have on the individual surgeon. A better understanding of how subspecialization affects quality and outcomes would help clarify its utility. TYPE OF STUDY: Review article. LEVEL OF EVIDENCE: Level V.

Clinical outcomes following identification of tip appendicitis on ultrasonography and CT scan.

BACKGROUND/PURPOSE: With recent improvements in imaging technology, subtler variations in the anatomy of the appendix can be appreciated. We hypothesized that radiographic findings of tip appendicitis may not correlate strongly with a pathologic diagnosis of appendicitis. METHODS: Our radiology database was searched for reports of a diagnosis of tip appendicitis between January 2013 and June 2017 for patients between the ages of 2 and 17. Retrospective chart review was performed for demographic and clinical data, including outcomes. For patients managed operatively, the pathology results were reviewed for evidence of acute appendicitis. Patients managed nonoperatively and those with negative pathology were considered to not have appendicitis. RESULTS: Fifty-five patients met inclusion criteria (31 boys and 24 girls); 46/55 patients with tip appendicitis on imaging ultimately did not have appendicitis. Twenty-one patients underwent appendectomy, and 9/21 had pathologic evidence of appendicitis. One patient had a ruptured appendix. No other pathology was identified in the negative appendectomies. Two patients managed nonoperatively required readmission, but not secondary to missed diagnosis of appendicitis. CONCLUSIONS: Ultrasound and CT findings of tip appendicitis may not accurately associate with a final diagnosis of acute appendicitis. Clinical judgment should ultimately dictate appropriate initial management, follow-up tests, and imaging. TYPE OF STUDY: Diagnostic Study. LEVEL OF EVIDENCE: Level III.

Evaluation of Rhodiola crenulata on growth and metabolism of NB-1691, an MYCN-amplified neuroblastoma cell line.

Outcomes of children with high grade neuroblastoma remain poor despite multi-agent chemotherapy regimens. Rhodiola crenulata extracts display anti-neoplastic properties against several cancers including breast cancer, melanoma, and glioblastoma. In this study, we evaluated the anti-neoplastic potential of Rhodiola crenulata extracts on human neuroblastoma cells. Through this work, cell viability and proliferation were evaluated following treatments with ethanol (vehicle control) or Rhodiola crenulata extract in neuroblastoma, NB-1691 or SK-N-AS cells, in vitro. HIF-1 transcriptional activity was evaluated using a dual luciferase assay. Quantitative real-time polymerase chain reaction was utilized to assess the expression of HIF-1 targets. Selected metabolic intermediates were evaluated for their ability to rescue cells from Rhodiola crenulata extract-induced death. Lactate dehydrogenase, pyruvate kinase, and pyruvate dehydrogenase activities and NAD+/NADH levels were assayed in vehicle and Rhodiola crenulata extract-treated cells. The effects of Rhodiola crenulata extracts on metabolism were assessed by respirometry and metabolic phenotyping/fingerprinting. Our results revealed striking cytotoxic effects upon Rhodiola crenulata extract treatment, especially prominent in NB-1691 cells. As a greater response was observed in NB-1691 cells therefore it was used for remaining experiments. Upon Rhodiola crenulata extract treatment, HIF-1 transcriptional activity was increased. This increase in activity correlated with changes in HIF-1 targets involved in cellular metabolism. Serendipitously, we observed that addition of pyruvate protected against the cytotoxic effects of Rhodiola crenulata extracts. Therefore, we focused on the metabolic effects of Rhodiola crenulata extracts on NB-1691 cells. We observed that while the activities of pyruvate kinase and pyruvate dehydrogenase activities were increased, the activity of lactate dehydrogenase activity was decreased upon Rhodiola crenulata extract treatment. We also noted a decline in the total NAD pool following Rhodiola crenulata extract treatment. This correlated with decreased cellular respiration and suppressed utilization of carbon substrates. Through this work, we observed significant cytotoxic effects of Rhodiola crenulata extract treatment upon treatment on NB-1691 cells, a human neuroblastoma cell line with MYCN amplification. Our studies suggest that these cytotoxic effects could be secondary to metabolic effect induced by treatment with Rhodiola crenulata extract.

Laparoscopic Pediatric Inguinal Hernia Repair: A Pilot Study in a Novel Guinea Pig Animal Model.

BACKGROUND: The purpose of this study was to compare different techniques for pediatric laparoscopic inguinal hernia repair. We hypothesize that the amount of dissection performed at the internal ring, with or without division of the peritoneum, will impact healing and thus long-term success of the repair. METHODS: Following the Institution's Animal Care and Use Committee approval (708024-4), 20 Hartley guinea pigs underwent laparoscopic repair of their natural open internal rings. The guinea pigs were divided equally into four surgical groups: intracorporeal suture repair (IS), hernia dissection and division with intracorporeal suture (DDIS) repair, subcutaneous endoscopically assisted ligation (SEAL), and Yueng (HOOK) repair. After a 6-week survival period, a necropsy was performed. Repairs were evaluated and tested under pressures up to 30 mmHg. The suture was then removed to assess primary healing. Experimental data were analyzed using chi-square test. RESULTS: There were no perioperative or postoperative complications. On initial evaluation, before suture removal, repair integrity was as follows: 5/10 IS, 10/10 DDIS, 7/10 SEAL, and 7/10 HOOK (P = .09). After suture removal, repair integrity was as follows: 3/10 IS, 10/10 DDIS, 5/10 SEAL, and 6/10 HOOK (P = .01). CONCLUSION: Overall, dissecting and dividing the sac with intracorporeal suture (DDIS) closure had the best outcome. This method appears to best replicate standard open high ligation.

Operative vs Nonoperative Management of Pediatric Blunt Pancreatic Trauma: Evaluation of the National Trauma Data Bank.

BACKGROUND: Traumatic pancreatic injury is associated with significant morbidity and mortality. We evaluated the differences in outcomes among children with blunt pancreatic injuries managed operatively and nonoperatively. STUDY DESIGN: The National Trauma Data Bank was evaluated from 2002 to 2011. Patients less than18 years of age with blunt pancreatic injuries and Abbreviated Injury Scale (AIS) scores ≥ 3 were identified. Patients were divided into nonoperative (NO), operative (O), and delayed operative (DO; operation performed 48 hours or more after admission) groups. Outcomes evaluated were total length of stay (LOS), ICU use/LOS, complications, and death. Univariate comparisons were performed using Fisher's exact and Kruskal-Wallis rank tests. Multivariable analyses were performed using robust regression and logistic regression. RESULTS: There were 424 cases analyzed. Mean (± SD) age was 10.6 ± 5.3 years, and mean Injury Severity Score (ISS) was 23.4 ± 13.4. Operative groups differed by age (p = 0.002), AIS severity (p = 0.04), and concomitant head injury (p = 0.01), but were similar with regard to sex, race, and ISS. Length of stay was significantly higher in the DO group compared with the NO or O groups; the NO group had the lowest LOS (covariate-adjusted: 18.7 days vs 11.8 days, p < 0.001 and 12.6 days, p < 0.001, respectively) and infection rates (10.2% vs 1.6% and 6.2%, respectively, p = 0.04). The ICU LOS was greatest in the DO group (vs NO, p = 0.03; O, p = 0.29), as was the likelihood of ICU use (vs NO, p = 0.02; O, p = 0.75). Groups did not differ with respect to outcomes including death (p = 0.94) and overall complication rate (p = 0.63). CONCLUSIONS: Overall, children managed nonoperatively have equivalent or better outcomes when compared with operative and delayed operative management in regard to death, overall complications, LOS, ICU LOS, and ICU use.

Evaluation of the treatment of pectus carinatum with compressive orthotic bracing using three dimensional body scans.

PURPOSE: The purpose of this study is to measure the effectiveness of compressive orthotic brace therapy for the treatment of pectus carinatum using an adjusted Haller Index (HI) measurement calculated from 3D body scan (BS) images. METHODS: Pediatric patients with pectus carinatum were treated with either compressive orthotic bracing or observation. An adjusted BS Haller index (HI) was calculated from serial 3D BS images obtained on all patients. Medical records were evaluated to determine treatment with bracing and brace compliance more than 12hours daily. Compliant patient measurements were compared to non-compliant and non-brace groups. RESULTS: Forty patients underwent compressive orthotic bracing, while ten were observed. Twenty-three patients were compliant with bracing, and seventeen patients were non-compliant. Compliant patients exhibited an 8.2% increase, non-compliant patients had a 1.5% increase, and non-brace patients exhibited a 2.5% increase in BS HI. The change in BS HI of compliant patients was significantly different compared to non-brace patients (p=0.004) and non-compliant patients (p<0.001). CONCLUSIONS: Three dimensional BS is an effective, radiation free, and objective means to evaluate patients treated with compressive orthotic bracing.

Guns and states: pediatric firearm injury.

BACKGROUND: A recent report indicates that firearm-related injuries are responsible for 30% of pediatric trauma fatality. The literature is however limited in examining pediatric firearm injuries and variations in state gun control laws. Therefore, we sought to examine the association between pediatric firearm injuries and the Stand-Your-Ground (SYG) and Child Access Protection (CAP) laws. METHODS: All pediatric (age, 0-20 years) hospitalizations with firearm injuries were identified from the Kids' Inpatient Database from 2006 and 2009. States were compared for SYG and CAP laws. RESULTS: A total of 19,233 firearm injury hospitalizations were identified, with 64.7% assault, 27.2% accidental, and 3.1% suicide injury. Demographics for assault injury were as follows: mean age of 17.6 years, 88.4% male, 44.4% black, 18.2% Hispanic, 70.5% from metropolitan areas, and 50.1% from the poorest median income neighborhoods. Suicide injury cases were more likely to be white (57.8% vs. 16.6%, p < 0.001) and female (15.1% vs. 9.8%, p < 0.001). States with the SYG law were associated with increased accidental injury (odds ratio [OR], 1.282; p < 0.001). There was no statistical association between CAP law and the incidence of accidental injury or suicide. Multivariate logistic regression analysis found other predictive demographic factors for firearm injury: black (OR, 6.164), urban areas (OR, 1.557), poorest median income neighborhoods (OR, 2.785), male (OR, 28.602), and 16 years or older (OR, 37.308). Total economic burden was estimated at more than $1 billion dollars, with a median length of stay of 3 days, 8.4% discharge to rehabilitation, and 6.2% in-hospital mortality. CONCLUSION: Pediatric firearm injuries continue to be a significant source of morbidity, mortality, and economic burden. A significant increase in accidental firearm injuries in states with the SYG law may highlight inadvertent effects of the law. Race, sex, and median income are additional contributing factors. Advocacy and focused educational efforts for specific socioeconomic and racial groups may potentially reduce firearm injuries. LEVEL OF EVIDENCE: Prognostic study, level II.

Less is more: management of pediatric splenic injury.

OBJECTIVE: To analyze national trends in the nonoperative management of pediatric splenic injury. DESIGN: Retrospective cohort analysis. PATIENTS: All children and adolescents 18 years or younger from 2 national databases who were hospitalized with pediatric splenic injury. SETTING: Data from 9 years of the National Inpatient Sample database (2000-2008) and 3 years of Kids' Inpatient Database (2000, 2003, and 2006). MAIN OUTCOME MEASURES: We calculated and chronicled rates of splenectomy, angiography, and transfusion from 2000 to 2008. RESULTS: During the study period, the rate of splenectomy decreased from 18.25% to 10.86%. Changes in nonoperative management included more than a 2-fold increase in angiography, from 2.43% to 6.94%, and a significant increase in transfusion, from 7.71% to 11.49%. Operative management was associated with increased length of stay (9.15 vs 6.52 days) and higher mean total hospital charges ($74 981.26 vs $36 156.30). Cases occurring in rural locations were more likely to undergo operative management (odds ratio, 1.24 [95% CI, 1.18-1.31]; P < .001), but less likely to undergo angiography (0.82 [0.76-0.89]; P < .001). CONCLUSIONS: Children with pediatric splenic injury are undergoing fewer splenectomies but more angiography. Rural location may be an independent risk factor for operative management. Further studies are needed to assess for disparity in access to and availability of aggressive nonoperative management.

Surgical management of pediatric adhesive bowel obstruction.

INTRODUCTION: The objective of this study was to analyze a population-based database for recent trends in surgical management of pediatric adhesive bowel obstruction and compare open versus laparoscopic lysis of adhesions (LOA). SUBJECTS AND METHODS: Pediatric adhesive bowel obstruction cases were identified in the Kids' Inpatients Database from 1997, 2000, 2003, 2006, and 2009. Data analysis included patients' demographics, hospital variables, length of stay (LOS), and total hospital charges (THC). Complications analysis included postoperative shock, hemorrhage, hematoma, seroma, wound complications, infection, fistula, and pulmonary complications. RESULTS: In total, 20,679 pediatric adhesive bowel obstruction cases were identified during the study period. These were characterized by a median age of 11 years old, with 59.0% of the population female. Overall treatment included 88.6% open and 11.4% laparoscopic LOA. A more than twofold increase in utilization of laparoscopy was observed from 7.2% in 1997 to 17.2% in 2009 (P<.001). Complication rates were lower for laparoscopic LOA versus open (5.6% versus 10.4%; odds ratio 0.512; 95% confidence interval 0.394-0.667; P<.001), especially accidental puncture or laceration rate (2.2% versus 3.9%; odds ratio 0.566; 95% confidence interval 0.375-0.854; P=.006). Conversion to open LOA occurred in 1.9%. Laparoscopy was associated with a shorter median LOS (6 versus 8 days; P<.001) and a lower mean THC ($38,241.11 versus $48,552.51; P<.001) compared with open LOA. Multivariate regression analysis did not find hospital bed size, location, teaching status, and regions to be statistically significant predictors for utilization of laparoscopy. CONCLUSIONS: Laparoscopic LOA is a safe option for pediatric adhesive bowel obstruction with lower complication rates and a reduced economic burden. Despite the increase in utilization of laparoscopy in recent years, only a minority of patients underwent laparoscopic LOA. Further studies are needed to identify and characterize the subgroup of patients who benefit from laparoscopic LOA.

Missed opportunities in the treatment of pediatric appendicitis.

INTRODUCTION: This study sought to evaluate the outcomes of in-hospital delay and determine associated co-morbidities in the treatment of pediatric acute appendicitis. METHODS: This was a retrospective analysis of the national inpatient sample from 2000 to 2008. Immediate treatment was defined as treatment in hospital day 0 or 1. Delay in treatment was defined as treatment in hospital day 2 and beyond. RESULTS: During the study period, 683,016 pediatric appendicitis were identified. 17,737 (2.6%) experienced a delay in treatment. Multivariate analysis identified associated co-morbidities for delay in treatment: ALL (OR 12.84, CI 11.04-14.94), AML (OR 9.41, CI 7.58-11.68), neutropenia (OR 5.53, CI 4.60-6.65), and ovarian cyst without torsion (OR 3.17, CI 2.94-3.42). Surgical management included more than 13-fold increase in drainage procedures (5.5 vs. 0.4%), sixfold increase in cecectomy (1.2 vs. 0.2%), 14-fold increase in hemicolectomy (1.4 vs. 0.1%), 11-fold increase in small bowel laceration suture repair (1.1 vs. 0.1%), and 15-fold increase in small bowel resection (1.5 vs. 0.1%). CONCLUSIONS: In-hospital delay beyond 2 days is associated with significant negative outcomes with regard to complications, economic burden, and subsequent surgical management. Using the co-morbidity index, high-risk co-morbidities with associated delay in treatment were identified.