Reoperative surgery after magnetic sphincter augmentation.

Reoperative surgery following magnetic sphincter augmentation (MSA) is rare. The clinical indications include the removal of MSA for dysphagia, the recurrence of reflux, or the issues of erosion. Diagnostic evaluation follows that of patients with recurrent reflux and dysphagia following surgical fundoplication. Procedures following the complications of MSA can be performed in a minimally invasive fashion, either endoscopically or robotic/laparoscopically, with good clinical outcomes.

Ambulatory colectomy: a pathway for advancing the enhanced recovery protocol.

Enhanced recovery after surgery (ERAS) protocols employ multiple factors to decrease surgical stress and improve recovery (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). These protocols use multimodal approaches to improve outcomes, including length of stay and morbidities (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012; Carmichael et al., Dis Colon Rectum 60:761-784, 2017). The ERAS guidelines have evolved since development; however, the question is posed of how to improve next (Lyon et al., World J Gastroenterol 18(40):5661-5663, 2012). With the success of ERAS, in combination with milestones made by minimally invasive surgery (MIS), it is our aim to describe the next step of same day discharge colectomy. Retrospective review was performed on all colectomies from February 2019 to January 2022. Same day discharge (SDD) was defined as admission less than 23 h and no overnight stay. Procedures were nonemergent and MIS. Patients were candidates SDD based on comorbidities, communication means, and social support. SDD candidacy continued if surgery was uncomplicated. Next, patients were required to achieve strict Post Anesthesia Care Unit (PACU) criteria for discharge. SDD patients were monitored via calls or messages until their first appointment. After analysis, 326 total colectomies were identified; based on inclusion and exclusion criteria, 115 patients underwent SDD, 35.3%. Of the 115 SDD, 5 patients returned to the emergency department, only 1 required readmission (0.9%). The most performed procedures were low anterior resection, 61 (53.0%), and right hemicolectomy, 25 (21.7%). Using ERAS protocols as a groundwork to improve upon, we identified several ways to advance select patients into SDD. Using strict patient selection, intraoperative regulations, and rigorous postoperative criteria, we found that SDD as an advancement of ERAS is a relatively safe procedure with minimal complications.

Ambulatory colectomy: A pilot protocol for same day discharge in minimally invasive colorectal surgery.

BACKGROUND: Since its inception colectomy has routinely been performed in the inpatient setting. The advent of Enhanced Recovery After Surgery (ERAS) protocols has led improved outcomes, including decreased length of stay (LOS). These improvements have introduced the possibility of ambulatory colectomy. However, indications, protocols, and limitations of ambulatory colectomy have not been extensively explored. METHODS: We conducted a retrospective review on ambulatory colectomies performed between February 2019 and August 2021. Patients were candidates for same day discharge (SDD) if they met rigorous preoperative criteria. Following an uncomplicated operation, strict postoperative parameters were required for safe discharge. If the patient underwent SDD following their operation, they were monitored closely via telehealth visits and/or patient communication messages until their one-week postoperative visit. RESULTS: From our review, we identified sixty-nine (n = 69) patients who underwent SDD after colectomy. Of the 69, only one patient was readmitted after discharge (1.4%). All procedures were performed via a robotic-assisted approach (Da Vinci Xi). None of the patients underwent conversion to an open procedure. The most frequently performed procedures included: low anterior resection (LAR) (n = 32, 46.4%) and right hemicolectomy (n = 11, 15.9%). CONCLUSION: Through proper patient education and strictly defined communication between the patient care teams, safe and effective care in the setting of SDD after colectomy can be provided. With recent technological advancements, enhanced mechanisms for patient education throughout all phases, and emerging means of patient-physician communication, via the data included herein the opportunity for same day discharge (SDD) after colectomy is a feasible and safe management plan in the proper patient.

The relationship of eosinophilia with outcomes of Hirschsprung disease in children.

PURPOSE: It has been postulated that children with Hirschsprung disease (HD) and mucosal eosinophilia have been thought to have poorer outcome, but supporting evidence is lacking. The objective of our study was to review the outcomes of children with HD and mucosal eosinophilia. METHODS: A single center, retrospective review was conducted on all patients diagnosed with HD between 1999 and 2016. Pathology specimens were evaluated for mucosal eosinophilia. Demographics, complications, and outcomes were analyzed. RESULTS: A total of 100 patients were diagnosed with HD and 27 had mucosal eosinophilia. Median age at the time of surgery was 12 days (8, 30) and 82 were males. Comparing patients with HD with and without mucosal eosinophilia, there was no statistically significant difference in time to bowel function (2 days vs. 2 days; p = 0.85), time to start feeds (3 days vs. 3 days; p = 0.78) and time to goal feeds (5 days vs. 5 days; p = 0.47). There was no statistically significant difference in feeding issues (13% vs. 9%; p = 1.0) and stooling issues (60% vs. 50%; p = 0.38). There was no statistically significant difference in postoperative complications and readmissions rates (63% vs. 56%; p = 0.53). CONCLUSION: Hirschsprung-associated mucosal eosinophilia may not increase postoperative complications, and may not change feeding and bowel management. Further prospective studies are in process to evaluate long term follow-up outcomes for this patient population.

Does Intravenous Acetaminophen Improve Postoperative Pain Control after Laparoscopic Appendectomy for Perforated Appendicitis? A Prospective Randomized Trial.

INTRODUCTION: The recent increased awareness of the dangers of opioids in the United States has highlighted the need to minimize narcotics and identify nonopioid options for pain control after surgery. With evidence suggesting that intravenous acetaminophen (IVA) can be an opioid sparing option, we conducted a prospective, randomized trial that evaluated the effect of IVA on the postoperative pain course of children with perforated appendicitis. MATERIALS AND METHODS: After IRB approval, children with perforated appendicitis were randomized to receive postoperative IVA with the standard patient/nurse-controlled analgesia (PCA) or to receive the PCA alone. All patients were treated according to an evidence-based treatment protocol. The primary outcome was duration of time on PCA. RESULTS: Eighty-two patients were analyzed from 7/14 to 11/15. There was no statistically significant difference in the time to transition from the PCA to oral pain medications for children given IVA compared with children not receiving IVA (76.4 ± 32.5 versus 86.7 ± 49.3 hours; p = 0.73). Children in the IVA group had no statistically significant difference in intravenous narcotics delivered and pain scores compared with the non-IVA group. There was no significant difference in the amount of oral narcotics between both groups (2.8 ± 2.4 versus 2.9 ± 2.5; p = 0.88). Patients who received IVA had higher medication charges ($3752.7 ± 1618.3 vs. $1198.19 ± 521.51; p < 0.01), but not total hospital charges ($53842.0 ± 19409.2 vs. $50501.03 ± 16223.32; p = 0.76). CONCLUSION: Children given IVA showed no difference in the transition time off the PCA and to oral pain medications after laparoscopic appendectomy for perforated appendicitis.

Primary Closure versus Bedside Silo and Delayed Closure for Gastroschisis: A Truncated Prospective Randomized Trial.

BACKGROUND: We report a prospective randomized trial comparing primary closure (PC) to bedside silo and delayed closure (DC) for babies with gastroschisis. MATERIALS AND METHODS: Patients were randomized to PC versus DC. We excluded those with atresia/necrosis, <34 weeks' gestation, or congenital anomalies. The primary outcome was length of stay (LOS). RESULTS: A total of 38 patients were included from August 2011 to August 2016; 18 patients underwent DC and 20 PC. There were no differences in gestational age or birth weight. Fifty percent of PC patients were successfully closed with the rest closed at a median of 4 days (interquartile range [IQR]: 2-4 days). DC patients were closed at a median of 4 days after silo placement (IQR: 2-5.8 days). None of the patients in this series developed abdominal compartment syndrome after closure. Median LOS, median time to enteral tolerance, and median time on ventilation were not statistically different. Two patients (one DC and one PC) had bowel ischemia and necrosis following silo placement requiring reoperation. Four patients (two DC and two PC) were noted to have small umbilical defects; none have yet required operative correction. CONCLUSION: There were no differences seen between PC and DC in LOS, time to enteral feeds, or ventilator times.

Success of Bolus Gastric Feeding After Fundoplication Among Children Who Require Preoperative Jejunal Feeding.

PURPOSE: Management of complicated reflux in infants and children is controversial. Jejunal feedings are used when reflux complications occur with gastric feeds. We sought to determine how successful fundoplication is to allow for return of physiologic gastric feeds in patients requiring jejunal feeds preoperatively. METHODS: A retrospective review of patients requiring jejunal feeds before fundoplication between 2010 and 2015 was conducted. RESULTS: Two hundred thirteen children underwent fundoplication during the study period. One hundred fourteen (49%) children required preoperative jejunal feeds. Median preoperative jejunal feeding trial was 15 days (interquartile range [IQR] 8-36). After fundoplication, gastric feeds were attempted in all patients. Ninety-one (80%) patients tolerated feeds postoperatively without return of preoperative symptoms. Twenty-one (18%) children developed gastric feeding intolerance and were treated with jejunal feeds at a mean of 8 months postoperatively (range 3-17). Ten (9%) children eventually tolerated intragastric bolus feeds, requiring jejunal feeds for a median duration of 2.3 months (IQR 1-5). There were no differences seen in those who were able to tolerate gastric early after the operation and those who did not. Of the patients who were unable to tolerate bolus gastric feeds during the study, a higher proportion had neurologic impairment and were on jejunal feeds for a longer period of time before fundoplication. CONCLUSION: In the majority of patients requiring continuous jejunal feeds to manage complications of reflux, fundoplication allows for transition to gastric bolus feeding.

Feeding Advancement and Simultaneous Transition to Discharge (FASTDischarge) after laparoscopic gastrostomy.

BACKGROUND: Laparoscopic gastrostomy (LG) is a common surgical procedure. However, there is little consensus on a postoperative feeding regimen. With prior nasogastric feed tolerance, there should be no delay in resumption of feeds and subsequent discharge to home. This is a report on a Feeding Advancement and Simultaneous Transition-Discharge (FAST-Discharge) pathway, which to date has not been reported in the literature. METHODS: A retrospective review of patients who underwent LG was performed from May 2010 to May 2015. All were outpatients who were on prior nasogastric feeds. The postoperative order set initiates feeds in 4 h to advance to goal as tolerated. Time to initial feed and goal nutrition, and overall length of stay (LOS) were evaluated. RESULTS: 122 patients were identified with 55% percent being male and with a median operative age of 15 months (IQR 8-27). 53% were started on bolus feeds. Initial feeds were started at a median of 2.8 h (IQR: 1.8-4.7). The median duration to goal nutrition was 6 h (IQR: 0-14). 97% reached full feeds within 24 h with no complications related to feed advancement. Median LOS was 26 h (IQR: 24-30). CONCLUSION: An expedited pathway with early feeding and discharge is possible after laparoscopic gastrostomy tube placement with a low risk for adverse events. LEVEL OF EVIDENCE: Level III.

Transabdominal Versus Subcuticular Sutures to Secure a Laparoscopic Gastrostomy.

PURPOSE: Traditional methods for securing a laparoscopic gastrostomy (LG) involve the placement of two monofilament transabdominal (TA) sutures to be removed after a short interval of 5 days. A modified technique employing an absorbable suture tunneled subcutaneously has been adopted by many surgeons. The aim of this study was to compare wound complications between these techniques. METHODS: A retrospective review of patients who underwent LG placement between 2010 and 2016 was conducted, dividing patients into two cohorts by securing stitch type, TA and subcutaneous (SC), and evaluating for complications. RESULTS: A total of 740 children underwent laparoscopic gastrostomy tube (GT) placement, of whom 554 (75%) patients had a TA stitch and the remaining 186 (25%) had a SC stitch. Demographic data were comparable in both groups. The most common wound complication was granulation tissue (22%), dislodgement (19%), external drainage (16%), cellulitis (10%), erosion (3%), and abscess formation (2%). Seven patients required operative revision for dislodgement; TA patients comprised the majority of these patients. Operative times were significantly longer in the SC group (22 minutes versus 28 minutes, P < .05). Rates of granulation, erosion, external and internal leakage, and dislodgement were equivalent between cohorts. There were higher rates of cellulitis (7.3% versus 19%, P < .05) and abscess (0.8% versus 7.6%, P < .05) noted in the SC group. Time to external leakage was significantly earlier in the SC group (P < .05); however, all other complications occurred at comparable times following initial operation. Persistent gastrocutaneous fistula requiring surgical closure occurred at equal rates with no difference in times to closure from GT discontinuation in both groups. CONCLUSION: While both techniques are feasible, there was a significant increase in infectious complications and operative times observed in the SC stitch patients, suggesting this may not be the optimal securing method.

Utility of pediatric female fertility preservation discussions following pelvic radiation.

INTRODUCTION: While many childhood cancers are curable with therapy, adverse consequences in fertility exist. We sought to assess the number of female patients with pelvic tumors receiving radiation therapy, and the proportion that undergo measures for fertility preservation (FP). METHODS: A total of 53 female patients treated with pelvic tumors from 2000 to 2016 were retrospectively identified. RESULTS: 19 (34%) of these patients underwent pelvic radiation therapy (pXRT). Three of the patients received pXRT for palliative treatment. Of the 19 female patients receiving pXRT, six (31%) were prepubertal and 13 (68%) were postpubertal. Three patients (16%) had documentation of a discussion of FP measures prior to pXRT. One was prepubertal and the others were post-pubertal. Six patients (32%) were evaluated by endocrinology after radiation therapy, diagnosed with ovarian failure, and placed on hormone therapy. Current guidelines recommend discussion of FP in pre-and postpubertal patients with cancer. This 16-year retrospective review of female patients that underwent pXRT for pelvic tumors demonstrated < 17% of patients have documentation of a discussion of FP measures. CONCLUSION: Female pediatric patients who underwent chemotherapy and pXRT suffer a high rate of premature ovarian failure, high morbidity and mortality as well as low rates of documented FP discussions. Based on these findings we have established a multi-disciplinary fertility preservation team available for consultation and a protocol for discussing and documenting the impact of pXRT, along with other treatments, on fertility. LEVEL OF EVIDENCE: III.

Maturation of effect size during enrollment of prospective randomized trials.

BACKGROUND: Randomized clinical trials are powered by calculating the minimum sample size required to achieve statistical significance, given an estimated effect size (ES). The ES is the raw difference between two treatment arms. ES quantifies the actual magnitude of clinical differences between cohorts and is usually reflective of the true meaning of the trial, regardless of statistical significance. Under a fixed protocol, we hypothesize that the ES may be attained at a smaller sample than predesigned. To investigate patterns of ES during enrollment, we analyzed completed trials that were completed at our institution. METHODS: Outcomes of 11 prospective randomized clinical trials from our institution were reviewed. ES was calculated at intervals throughout each trial to determine at which point a steady clinical difference was achieved between treatment cohorts. RESULTS: ES stabilized at a median of 64% enrollment. All patients were needed to meet the precise ES in our smallest study, indicating the need for full enrollment in smaller studies. Otherwise, 50% of our trials required between 48% and 76% of patient enrollment to meet ES. In comparing clinical outcomes, 9 of 12 found a final difference that was nearly identical to the difference that could have been determined much earlier. Categorical outcomes met stabilized ES at 51% enrollment and continuous outcomes at 68%. CONCLUSIONS: ES and final clinical outcomes were achieved before the completion of enrollment for most of our studies. This suggests that clinical differences detected by randomization may not necessarily require the robust sample size often needed to establish statistical significance. This is particularly relevant in fixed-protocol interventional trials of homogenous populations.

Re-Tubularization of Highly-Ischemic Anti-Mesenteric Border (ReHAB): A Novel Bowel Preservation Technique in Complex Gastroschisis.

Complex gastroschisis with bowel necrosis poses an operative challenge. Surgeons must weigh the decision between resection versus preservation of ischemic bowel. As one of the leading causes of short bowel syndrome, aggressive resection in complicated gastroschisis subjects children to prolonged dependence on parenteral nutrition and its attendant complications. Herein, we describe a novel technique aimed towards bowel preservation in complex gastroschisis patients with severe bowel ischemia with the ultimate goal for enteral autonomy.

The role of 2-octyl cyanoacrylate in prevention of penile adhesions after circumcision: A prospective, randomized trial.

PURPOSE: Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision. METHODS: Patients <7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5. RESULTS: From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49). CONCLUSION: The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level II.

The risk of developing a symptomatic inguinal hernia in children with an asymptomatic patent processus vaginalis.

BACKGROUND: Children with a symptomatic indirect inguinal hernia have a patent processus vaginalis (PPV). However, the reverse is unknown, as the natural history of PPV is unclear. Currently, there are little data regarding the incidence and time frame for developing a symptomatic hernia with a known asymptomatic PPV. METHODS: A retrospective chart review was conducted in children who were evaluated for a PPV during nonhernia laparoscopic surgery by a single pediatric surgeon (GWH) from 2000 to 2014. Those patients with intraoperative findings of PPV were followed up by chart review and phone inquiry. RESULTS: 1548 children underwent a laparoscopic operation, with 308 having an asymptomatic PPV. Phone contact was successful in 125 (43%) of these patients at a median of 8.1years (range 4.8-12.7) after the initial laparoscopic operation. Nineteen (13%) patients returned with a symptomatic hernia at a median age of 17months (range: 5-74) and a median presentation of 9months (range: 1-66) after the initial laparoscopy. Ten hernia repairs were unilateral and 9 bilateral. None of those who were contacted via phone inquiry reported hernia symptoms or hernia repair. CONCLUSIONS: These data suggest that the risk of developing a symptomatic hernia during childhood in the presence of a known PPV is relatively low. LEVEL OF EVIDENCE: Level 3; type of study: retrospective study.

The effectiveness of costal cartilage excision in children for slipping rib syndrome.

PURPOSE: Slipping rib syndrome (SRS) is an elusive diagnosis. Previous reports have been single cases or small series. We previously reported a small multicenter review with encouraging early results. We now describe our matured experience. METHODS: This is a follow-up study of patients with SRS from 2006 to 2015. Included are 5 previously analyzed patients and 25 new patients. Patients were called to review current symptoms, course, and satisfaction. RESULTS: From 2006 to 2015, 30 patients underwent 38 operations. Eight underwent re-operation. All had reproducible pain localized to the costal margin, 60% had a popping sensation, and 23% were bilateral. 86% were female. Median age of symptom onset was 14 (IQR 13.75-15) years, while median age at diagnosis was 16 (IQR 15-17). Contact was possible with 18/30 patients, and mean follow up time was 1.3years. 72% of those felt they were cured, and 44% rated satisfaction a 10/10 (mean 7.84). Of those not cured, all reported significant improvement. CONCLUSIONS: Costal cartilage excision is an effective treatment for SRS and should be considered early in the workup of costal margin pain in a normally active population. Case Series with no Comparison Group - Level IV.

Same day discharge protocol implementation trends in laparoscopic cholecystectomy in pediatric patients.

PURPOSE: After investigating barriers for same day discharge (SDD) after laparoscopic cholecystectomy (LC), we employed a protocol which we have followed with a prospective, observational study. METHODS: A single institution, prospective observational study was performed from July 2014 to 2015 (2nd period). These data were compared to our initial experience with an SDD protocol from January 2013 to July 2014 (1st period). RESULTS: A total of 191 LCs were analyzed, 116 in the 1st period and 75 in the second period. In the 1st period, 47% were discharged the same day compared to 78% in the 2nd period (P<0.001). There was no difference in postoperative complications or readmissions between those discharged and those who spent the night. Additionally, there was no difference between admitted and SDD patients in age, BMI, or gender. Reasons for admission included pain (12%) and emesis (12%), and 1 patient had a syncopal event. However, the majority stayed with no identifiable patient factor. CONCLUSION: SDD after LC is safe and effective and implementing and revising a standardized clinical protocol can substantially improve the success of SDD. LEVEL OF EVIDENCE: Retrospective comparative study, level III.

The impact of developing a pectus center for chest wall deformities.

PURPOSE: In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS: A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS: 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION: Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.