Cold Therapy for Pain Control in Pediatric Appendectomy Patients: A Randomized Controlled Trial.

PURPOSE: Topical ice has been shown to reduce pain scores and opioid use in adults with midline abdominal incisions. This study was designed to evaluate the efficacy of a cold therapy system in children following laparoscopic appendectomy. METHODS: Patients 7 years and older who underwent laparoscopic appendectomy at our institution from December 2021-September 2022 were eligible. Patients were randomized to standard pain therapy (control) or standard plus cold therapy (treatment) utilizing a modified ice machine system with cool abdominal pad postoperatively. Pain scores on the first 3 postoperative days (PODs), postoperative narcotic consumption, and patient satisfaction were analyzed. RESULTS: Fifty-eight patients were randomized, 29 to each group. Average survey response rate was 74% in control and 89% in treatment patients. There was no significant difference in median pain scores or narcotic use between groups. Cold therapy contributed to subjective pain improvement in 71%, 74%, and 50% of respondents on PODs 1, 2, and 3 respectively. CONCLUSION: A majority of patients reported cold therapy to be a helpful adjunct in pain control after appendectomy, though it did not reduce postoperative pain scores or narcotic use in our cohort - likely due to this population's naturally expedient recovery and low baseline narcotic requirement. TYPE OF STUDY: Randomized Controlled Trial. LEVEL OF EVIDENCE: Level I.

Metastatic pulmonary calcifications after pediatric liver transplantation.

BACKGROUND: Pulmonary calcification (PC) is a rare clinical entity observed following liver transplantation (LT). Most often identified in adults or in patients with concomitant renal failure, PC is rarely reported in children. While the clinical course of PC is largely benign, cases of progressive respiratory failure and death have been reported. Additionally, PC may mimic several other disease processes making diagnosis and management challenging. Currently, little is reported regarding the diagnosis, management, and long-term outcomes of children with PC following LT. METHODS: We performed a retrospective chart review of patients undergoing LT at our institution between 2006 and 2023. We identified two patients who developed PC following LT. Their diagnosis, clinical course, and long-term outcomes are reported. A literature review of the presentation, diagnosis, management, and outcomes of adult and pediatric patients with PC post-LT was also performed. CONCLUSIONS: Pulmonary calcifications are a rare but notable complication after pediatric liver transplantation. Our case series adds to the limited literature on this clinical entity in children but also highlights the fact that effective diagnosis and treatment may be safely accomplished without the use of lung biopsy.

Autologous and synthetic pediatric iliofemoral reconstruction: a novel technique for pediatric iliofemoral artery reconstruction.

Pediatric lower extremity arterial catheterization-related injuries can result in significant long-term morbidity. Revascularization is challenging due to concerns for long-term patency and growth accommodation with synthetic grafts. We describe a novel technique for iliofemoral revascularization using common iliac artery transposition and bridging polytetrafluoroethylene grafts. We treated two children who underwent femoral catheterization resulting in lifestyle-limiting claudication. Both patients experienced immediate resolution of symptoms. Postoperative imaging demonstrated widely patent vasculature. ASPIRE (autologous and synthetic pediatric iliofemoral reconstruction) is a method of pediatric iliofemoral artery revascularization that allows for an autologous artery to span the hip joint, reducing graft thrombosis risk and accommodating patient growth.

Immediate extubation after pediatric liver transplantation: Update on a single-center experience.

PURPOSE: Immediate extubation (IE) following liver transplantation (LT) is increasingly common in adult patients. This study reviews our center's experience with IE in children following LT to determine characteristics predictive of successful IE and its effects on post-operative outcomes. METHODS: We performed a retrospective chart review of all patients who underwent LT at our institution between January 2005 and November 2022. Patients with concomitant lung transplants and chronic ventilator requirements were excluded. RESULTS: Overall, 235 patients met study criteria. IE was achieved in 164 (69.8%) patients across all diagnoses and graft types. Of IE patients, only two required re-intubation within 3 days post-transplant. IE patients exhibited significantly shorter ICU (2 [1, 3 IQR] vs. 4 [2, 4 IQR] days, p < .001) and hospital lengths of stay (17 [12, 24 IQR] vs. 22 [14, 42 IQR] days, p = .001). Pre-transplant ICU requirement, high PELD/MELD score, intraoperative transfusion, cold ischemia time, and pressor requirements were risk factors against IE. There was no association between IE and recipient age or weight. The proportion of patients undergoing IE post-transplant increased significantly over time from 2005 to 2022 (p < .001), underscoring the role of clinical experience and transplant team learning curve. CONCLUSION: Spanning 18 years and 235 patients, we report the largest cohort of children undergoing IE following LT. Our findings support that IE is safe across ages and clinical scenarios. As our center gained experience, the rate of IE increased from 40% to 83%. These trends were associated with lower ICU and LOS, the benefits of which include earlier patient mobility and improved resource utilization.

Bronchoscopic Localization of Tracheoesophageal Fistula in Newborns with Esophageal Atresia: Intubate Above or Below the Fistula?

PURPOSE: In neonates with suspected type C esophageal atresia and tracheoesophageal fistula (EA/TEF) who require preoperative intubation, some texts advocate for attempted "deep" or distal-to-fistula intubation. However, this can lead to gastric distension and ventilatory compromise if a distal fistula is accidently intubated. This study examines the distribution of tracheoesophageal fistula locations in neonates with type C EA/TEF as determined by intraoperative bronchoscopy. METHODS: This was a single-center retrospective review of neonates with suspected type C EA/TEF who underwent primary repair with intraoperative bronchoscopy between 2010 and 2020. Data were collected on demographics and fistula location during bronchoscopic evaluation. Fistula location was categorized as amenable to blind deep intubation (>1.5 cm above carina) or not amenable to blind deep intubation intubation (≤1.5 cm above carina or carinal). RESULTS: Sixty-nine neonates underwent primary repair of Type C EA/TEF with intraoperative bronchoscopy during the study period. Three patients did not have documented fistula locations and were excluded (n = 66). In total, 49 (74 %) of patients were found to have fistulas located ≤1.5 cm from the carina that were not amenable to blind deep intubation. Only 17 patients (26 %) had fistulas >1.5 cm above carina potentially amenable to blind deep intubation. CONCLUSIONS: Most neonates with suspected type C esophageal atresia and tracheoesophageal fistula have distal tracheal and carinal fistulas that are not amenable to blind deep intubation. LEVEL OF EVIDENCE: Level III.

Outcomes of laparoscopic gastrostomy in children with and without the use of a modified T-fastener technique.

BACKGROUND: Laparoscopic gastrostomy is commonly performed for durable enteral access in children. T-fasteners have been used intraoperatively to achieve a secure gastropexy, traditionally using external bolsters. We compare the safety profile of a modified paired T-fastener technique to standard laparoscopic-assisted suture gastropexy. METHODS: A retrospective matched case-control study was performed of pediatric patients who underwent laparoscopic gastrostomy at a single center from 2015 to 2021. In the paired T-fastener group, pairs of T-fasteners were passed into the stomach in a square configuration, allowing the suture pairs to be tied subcutaneously. This cohort was matched in a 1:2 fashion with age, sex, and body mass index or weight-matched controls who underwent laparoscopic gastrostomy with buried transabdominal gastropexy. RESULTS: Thirty patients underwent laparoscopic gastrostomy using the paired T-fastener technique and were matched to 60 controls. There was no significant difference in median operative time or 30-day complication rates between the groups, but the paired T-fastener technique significantly reduced the number of trocars required, and it was used for patients with thicker abdominal walls. CONCLUSION: We demonstrate the modified paired T-fastener technique as a safe, efficient means of gastropexy in pediatric laparoscopic gastrostomy. The paired T-fastener approach eliminates external bolsters, reduces additional trocars, and may be advantageous for thicker abdominal walls while maintaining a similar complication profile to standard laparoscopic gastrostomy.

Learning to SuRRF: Sustained Engagement and Increased Academic Productivity Over Two Years of a Resident-Led Virtual Laboratory.

OBJECTIVE: To determine if implementation of a resident-led virtual laboratory can sustain increased engagement and academic productivity in residents and faculty. DESIGN: We developed and introduced a multimodal virtual Surgery Resident Research Forum (SuRRF) in July 2019. SuRRF utilizes monthly virtual lab meetings, weekly newsletters, a centralized database of projects, project tracking tools, and a shared calendar of deadlines to facilitate research among surgical residents. Data on number of participating residents, faculty, and projects across SuRRF meetings at 1-year (7/2020) and 2-years post-implementation (9/2021) were collected to evaluate engagement. Institutional ACGME Resident Scholarly Activity and Faculty Scholarly Activity reports were evaluated for the pre-SuRRF implementation (2018-2019) and post-implementation (2020-2021) academic years to assess productivity pre- and post-implementation. SETTING: Three tertiary academic hospitals of a single health system in New York. PARTICIPANTS: All residents in our general surgery program during the study period, including research residents, were eligible to participate in our study. RESULTS: At 1-year, there were 2 attendings, 13 residents, and 23 projects, compared to 12 attendings, 25 residents, and 42 projects at 2-years post-implementation. Post-SuRRF implementation, residents had significantly more publications (0.56 ± 0.15 vs. 1.10 ± 0.15, p = 0.005), textbook chapters (0.00 vs. 0.010 ± 0.044, p = 0.014), research participation (p < 0.01), and scholarly activity (p = 0.02). Post-SuRRF, faculty had significantly more publications (0.74 ± 0.15 vs. 2.20 ± 0.33, p < 0.001) and scholarly activity (p = 0.006). CONCLUSIONS: SuRRF promotes exposure to projects and resources and increases collaboration and peer-to-peer mentorship. Our experience with SuRRF suggests that resident-led virtual laboratories may increase peer-reviewed publications and improve resident and faculty engagement in scholarly activity, thus supporting academic growth.

Diving Under the SuRRFace: Achieving More Than Just Compliance with ACGME Scholarly Activity Mandate.

OBJECTIVE: To determine if building a digital technology supported infrastructure improves general surgery residents' confidence to conduct clinical research. DESIGN: We developed and introduced a multimodal virtual Surgery Resident Research Forum (SuRRF) in July 2019. An anonymized survey asked residents to rate their confidence using a five-point Likert scale in various fields pre- and post-intervention. Fields included: finding a research mentor, developing a project, conducting research, performing an effective literature search, navigating internal and external resources, and ability to complete a research project. SETTING: Northwell Health - North Shore University Hospital / Long Island Jewish Medical Center: academic tertiary care centers. PARTICIPANTS: All 58 residents in our general surgery program, including research residents, were eligible to participate in our study. RESULTS: Survey response rate was 55% (28 clinical residents, 4 research fellows). Post-implementation of SuRRF, all respondents (PGY1-5) reported an increase in awareness of abstract/conferences submission deadlines (2.34 ± 1.1 pre- vs. 3.75 ± 1.1 post-implementation, p = 0.004) and ability to navigate institutional electronic medical information library resources (2.2 ± 1.0 pre- vs. 3.62 ± 1.2 post-implementation, p = 0.000). Junior residents (PGY1-3) had improvement in all areas except for finding a mentor and improving their confidence with literature review. CONCLUSIONS: Creation of a resident-led virtual laboratory infrastructure increases participation, improves perception of research abilities, and improves attitudes towards performing clinical research among general surgery residents. Future research will follow the impact of this virtual laboratory on publications and grants.

Spinal Epidural Abscess Patients Have Higher Modified Frailty Indexes Than Back Pain Patients on Emergency Room Presentation: A Single-Center Retrospective Case-Control Study.

OBJECTIVE: Spinal epidural abscess (SEA) patients have increased medical comorbidities and risk factors for infection compared with those without SEA. However, the association between frailty and SEA patients has not been documented. METHODS: A total of 46 SEA patients were randomly paired and matched by age and sex with a control group of patients with back pain who had presented to our emergency department from 2012 to 2017. Statistical analysis identified the risk factors associated with SEA and frailty using the modified frailty index (mFI), and the patients were stratified into robust, prefrail, and frail groups. We examined the value of the mFI as a prognostic predictor and evaluated the classic risk factors (CRFs). RESULTS: The SEA patients had higher mFIs and CRFs (P = 0.023 and P < 0.001, respectively) and a longer length of stay (22.89 days vs. 1.72 days; P < 0.001). Of the mFI variables, only diabetes had a significant association with SEA (odds ratio [OR], 3.60; P = 0.012). Among the stratified mFI subgroups, a frail ranking (mFI >2) was the strongest risk factor for SEA (OR, 5.18; P = 0.003). A robust ranking (mFI, 0-1) was a weak negative predictor for SEA (OR, 0.41; P = 0.058). The robust patients were also more likely to be discharged to home (OR, 7.58; P = 0.002). Of the CRF variables, only intravenous drug use had a statistically significant association with SEA (OR, 10.72; P = 0.015). CONCLUSIONS: Patients with SEA were more frail compared with the control back pain patients. Frailty was determined to be an independent risk factor for SEA, outside of the CRFs. The use of the mFI could be potentially useful in predicting the diagnosis, prognosticating, and guiding SEA treatment.

Management of air leaks post-surgical lung resection.

Airleaks are one of the most common complications associated with elective lung resection. There have been many techniques and modern advancements in thoracic surgery, however airleaks persist. This review article will discuss several interventions ranging from conservative noninvasive to surgical management of the persistent airleak. These techniques include stopping of suction on the plueravac, fibrin patches, pleurodesis, use of endobronchial valves (EBVs), return to OR for operative intervention, and lastly to send patients home with mini pleuravacs.