Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial.

Importance: Recurrence continues to be a significant challenge in the treatment and management of pilonidal disease. Objective: To compare the effectiveness of laser epilation (LE) as an adjunct to standard care vs standard care alone in preventing recurrence of pilonidal disease in adolescents and young adults. Design, Setting, and Participants: This was a single-institution, randomized clinical trial with 1-year follow-up conducted from September 2017 to September 2022. Patients aged 11 to 21 years with pilonidal disease were recruited from a single tertiary children's hospital. Intervention: LE and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone. Main Outcomes and Measures: The primary outcome was the rate of recurrence of pilonidal disease at 1 year. Secondary outcomes assessed during the 1-year follow-up included disability days, health-related quality of life (HRQOL), health care satisfaction, disease-related attitudes and perceived stigma, and rates of procedures, surgical excisions, and postoperative complications. Results: A total of 302 participants (median [IQR] age, 17 [15-18] years; 157 male [56.1%]) with pilonidal disease were enrolled; 151 participants were randomly assigned to each intervention group. One-year follow-up was available for 96 patients (63.6%) in the LE group and 134 (88.7%) in the standard care group. The proportion of patients who experienced a recurrence within 1 year was significantly lower in the LE treatment arm than in the standard care arm (-23.2%; 95% CI, -33.2 to -13.1; P < .001). Over 1 year, there were no differences between groups in either patient or caregiver disability days, or patient- or caregiver-reported HRQOL, health care satisfaction, or perceived stigma at any time point. The LE group had significantly higher Child Attitude Toward Illness Scores (CATIS) at 6 months (median [IQR], 3.8 [3.4-4.2] vs 3.6 [3.2-4.1]; P = .01). There were no differences between groups in disease-related health care utilization, disease-related procedures, or postoperative complications. Conclusions and Relevance: LE as an adjunct to standard care significantly reduced 1-year recurrence rates of pilonidal disease compared with standard care alone. These results provide further evidence that LE is safe and well tolerated in patients with pilonidal disease. LE should be considered a standard treatment modality for patients with pilonidal disease and should be available as an initial treatment option or adjunct treatment modality for all eligible patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03276065.

Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients.

Importance: Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health. Objective: To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies. Design, Setting, and Participants: Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up. Intervention: Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons. Main Outcomes and Measures: Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution. Results: A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; P = .03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%. Conclusions and Relevance: Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.

Sexual and reproductive health education for patients with myelomeningocele.

AIM: To evaluate the sexual and reproductive health education received by patients with myelomeningocele, the most severe form of spina bifida. METHOD: A survey designed to assess the sexual and reproductive health education given by a healthcare provider to patients with myelomeningocele was offered to all English-speaking patients aged 12 years or older with a myelomeningocele clinic visit. RESULTS: In total, 67 surveys were completed. Menstruation and menstrual management were discussed at a rate of 85% in females. Few patients had discussions with a provider about fertility (42%), sexuality (37%), risk of sexually transmitted infections (45%), or had a relationship with a reproductive healthcare provider (54%). Differences by sex were observed for contraceptive education. The rate of discussions increased with age. A total of 67% of female patients and 33% of male patients requested a referral to a reproductive healthcare provider. INTERPRETATION: Sexual and reproductive health education is part of comprehensive care for all patients and those with disabilities should not be excluded. The lack of consistent education received by patients supports the need for increased attention to this topic. We encourage multidisciplinary myelomeningocele clinics to establish a process for delivering complete and patient-specific sexual and reproductive health education.

Use and Accuracy of Intraoperative Frozen Section Analysis for Ovarian Masses in Children and Adolescents.

STUDY OBJECTIVE: Describe the current practice patterns and diagnostic accuracy of frozen section (FS) pathology for children and adolescents with ovarian masses DESIGN: Prospective cohort study from 2018 to 2021 SETTING: Eleven children's hospitals PARTICIPANTS: Females age 6-21 years undergoing surgical management of an ovarian mass INTERVENTIONS: Obtaining intraoperative FS pathology MAIN OUTCOME MEASURE: Diagnostic accuracy of FS pathology RESULTS: Of 691 patients who underwent surgical management of an ovarian mass, FS was performed in 27 (3.9%), of which 9 (33.3%) had a final malignant pathology. Among FS patients, 12 of 27 (44.4%) underwent ovary-sparing surgery, and 15 of 27 (55.5%) underwent oophorectomy with or without other procedures. FS results were disparate from final pathology in 7 of 27 (25.9%) cases. FS had a sensitivity of 44.4% and specificity of 94.4% for identifying malignancy, with a c-statistic of 0.69. Malignant diagnoses missed on FS included serous borderline tumor (n = 1), mucinous borderline tumor (n = 2), mucinous carcinoma (n = 1), and immature teratoma (n = 1). FS did not guide intervention in 10 of 27 (37.0%) patients: 9 with benign FS underwent oophorectomy, and 1 with malignant FS did not undergo oophorectomy. Of the 9 patients who underwent oophorectomy with benign FS, 5 (55.6%) had benign and 4 (44.4%) had malignant final pathology. CONCLUSIONS: FSs are infrequently utilized for pediatric and adolescent ovarian masses and could be inaccurate for predicting malignancy and guiding operative decision-making. We recommend continued assessment and refinement of guidance before any standardization of use of FS to assist with intraoperative decision-making for surgical resection and staging in children and adolescents with ovarian masses.

Examining the Utility of Preoperative Telemedicine Care Across Multiple Pediatric Surgery Disciplines.

INTRODUCTION: Telemedicine use within pediatric surgery fields has been growing, but research on the utility of remote evaluation in the perioperative period remains scarce. The objective of this study was to examine the utility of perioperative telemedicine care for the pediatric patient by evaluating the outcomes following completion of an outpatient appointment with a surgical provider. MATERIALS AND METHODS: We performed a retrospective chart review of all patients who completed a telemedicine appointment with a provider across nine pediatric surgery divisions, without a limitation based on patient-specific characteristics or telemedicine platform. We examined the result of the initial telemedicine appointment and the outcome of any surgical procedure that was performed as a result. RESULTS: A total of 803 patients were evaluated by telemedicine during the study period. Of the 164 encounters (20.2%) that were followed by a surgery, nearly 70% were performed using a video. There was no discordance in the preoperative and postoperative diagnoses for more than 98% of patients. Nearly 25% of operations were followed by at least a 1-night hospital stay and 6.7% of patients developed a postoperative complication. CONCLUSIONS: Telemedicine is a safe tool for evaluating pediatric patients in the preoperative and postoperative phases of care and offers potential value for families seeking an alternative to the traditional in-person appointment. Ongoing support will require permanent legislative changes aimed at ensuring comparable compensation and the development of strategies to adapt the outpatient healthcare model to better accommodate the evolving requirements of remotely evaluating and treating pediatric patients.

Variability in the management of adhesive small bowel obstruction in children.

BACKGROUND: This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO). METHODS: A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO. RESULTS: Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001). CONCLUSIONS: Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation. LEVEL OF EVIDENCE: III.

Room for Improvement: The Trephination Procedure for Pediatric Patients with Pilonidal Disease.

BACKGROUND: Pilonidal disease is common amongst adolescent males and females and often leads to recurrent symptoms and life-altering morbidity. The traditional surgical approach includes wide excision of the involved area and carries a high rate of postoperative morbidity. A minimally invasive surgical approach using trephines was described by Gips in 2008 and has since been widely adopted by many surgeons. The aim of this study was to explore outcomes of the trephination procedure for pediatric and adolescent patients by evaluating postoperative wound healing and disease recurrence. MATERIALS AND METHODS: A retrospective cohort study for patients that underwent the trephination procedure as part of standard of care for the treatment of pilonidal disease from November 1, 2019-November 1, 2020 was performed. Patient demographics, presenting characteristics, and previous treatment history were identified. Outcome measures included healing time, recurrent disease, and need for reoperation. RESULTS: A total of 19 patients underwent the trephination procedure at a mean age of 16.4 years of age. An average of 3.8 pits were excised and there were no reported intraoperative complications. Following trephination, 26.3% of patients were healed at 30-day's, with just over 40% showing complete healing by 6-months. The recurrence rate was 16.1% at 6-months and approximately 15% of patients required a second surgery. CONCLUSION: Early results for trephination at our institution show a high rate of healing complications and frequent reoperation. Future research is needed to establish the role of the trephination procedure in the context of defining the best practices for treating this challenging disease.

Recognizing the Benefit of Telemedicine Before and After COVID-19: A Survey of Pediatric Surgery Providers.

BACKGROUND: Prior to the COVID-19 pandemic, the use of telemedicine to evaluate pediatric surgery patients was uncommon. Due in part to restrictions imposed to mitigate the spread of the virus, the use of telemedicine within pediatric surgery has significantly expanded. METHODS: Prior to the use of telemedicine within surgery divisions at our institution, pediatric surgeons were surveyed to determine their perspectives on the use of telemedicine. Following the expanded use of telemedicine in response to the COVID-19 pandemic, a follow up survey was distributed to determine the impact of telemedicine and the perceived benefits and barriers of continuing its use going forward. RESULTS: The pre-COVID survey was completed by 37 surgeons and the post-COVID survey by 36 surgeons and advanced practice providers across 10 pediatric surgical divisions. General surgeons were the most represented division for both the pre- (25%) and post-COVID (33.3%) survey. Less than 25% of providers reported use of telemedicine at any point in their career prior to COVID-19; but following the expanded use of telemedicine 95% of respondents reported interest in continuing its use. After expansion, 25% of respondents were concerned with the possibility of inaccurate diagnoses when using telemedicine compared to nearly 50% prior to expanded use. CONCLUSION: Following the expanded use of telemedicine within pediatric surgery, there was a decrease in the concern for inaccurate diagnoses and a near uniform desire to continue its use. Going forward, it will be imperative for pediatric surgeons to take an active role in creating a process for implementing telemedicine that best fits their needs and the needs of their patients and patients' families.

Principles in treating pediatric patients with pilonidal disease - An expert perspective.

Pilonidal disease is common amongst adolescent males and females and often leads to recurrent symptoms and life-altering morbidity. Traditionally, surgery included wide excision of the involved area with primary closure. Post-operative complication rates were high and recurrence of disease common, leading to a search for alternative approaches for treating pilonidal disease. A minimally invasive (trephination) approach was described by Gips in 2008 and has since been adopted by many surgeons. Although the trephination procedure is less morbid than total excision, the risk of wound complications is not insignificant and post-operative recurrence has been reported in more than 10% of patients. The lack of a clear advantage for any single treatment strategy has led a wide variation in provider approach. To standardize the care for pediatric patients with pilonidal disease, a dedicated clinic was created at our institution in 2018. The aim of this paper is to describe an approach to treating pediatric patients with pilonidal disease that has been established through the experience of treating hundreds of adolescent males and females per year. Given the impact on quality of life for those that are affected by pilonidal disease, it is important that future research be directed toward discovery of the best practices for treating this challenging disease.

The value of telemedicine for the pediatric surgery patient in the time of COVID-19 and beyond.

BACKGROUND: Prior to COVID-19, the use of telemedicine within pediatric surgery was uncommon. To curb the spread of the virus many institutions restricted non-emergent clinic appointments, resulting in an increase in telemedicine use. We examined the value of telemedicine for patients presenting to a pediatric surgery clinic before and after COVID-19 METHODS: Perspectives and the potential value of telemedicine were assessed by surveying patients or caregivers of patients being evaluated by a general pediatric surgeon in-person prior to COVID-19 and by patients or caregivers of patients who completed a telemedicine appointment with a pediatric surgical provider during the COVID-19 period. RESULTS: The pre-COVID survey was completed by 57 respondents and the post-COVID survey by 123. Most respondents were white and were caregivers 31-40 years of age. Prior to COVID-19, only 26% were familiar with telemedicine, 25% reported traveling more than 100 miles and >50% traveled more than 40 miles for their appointment. More than 25% estimated additional travel costs of at least $30 and in 43% of households, at least one adult had to miss time from work. Following a telemedicine appointment during the COVID-19 period, 76% reported the care received as excellent, 86% were very satisfied with their care, 87% reported the appointment was less stressful for their child than an in-person appointment, and 57% would choose a telemedicine appointment in the future. CONCLUSION: For families seeking an alternative to the in-person encounter, telemedicine can provide added value over the traditional in-person encounter by reducing the burden of travel without compromising the quality of care. Telemedicine should be viewed as a viable option for pediatric surgery patients and future research directed toward optimizing the experience for patients and providers. LEVEL OF EVIDENCE: III.