A Call to Evaluate Manual Dexterity of Prospective Surgical Trainees.

INTRODUCTION: This study assesses the correlation between academic grades and gross and fine motor skills in prospective surgical trainees. METHODS: Forty-seven General Surgery Residency applicants and 32 medical students with prospective surgical interests were recruited. Manual dexterity (MD) was assessed through six tasks: O'Connor Tweezer Dexterity Test and Minnesota Manual Dexterity Test; Peg Transfer Test Fundamentals of Laparoscopic Surgery (box); Ring and Rail, Thread the Ring and Suture Sponge (da Vinci Surgical Simulator). RESULTS: Medical students with higher academic scores had longer completion times for the peg transfer test (P = 0.013). Individuals who played musical instruments and perceived themselves to have "Excellent" MD and motor coordination (MC) were more likely to score higher on the Thread the Ring test (P = 0.007; P = 0.009 ,respectively). Those who perceived themselves to have "Mediocre" MD and MC performed the worst on the: O'Connor Tweezer Dexterity Test (P = 0.023). CONCLUSIONS: Preliminary data suggest that MD ability correlates with neither high United States Medical Licensing Examination scores nor high academic grades; however, previous experience playing a musical instrument and high self-ratings of MD/MC may be associated with better test performance.

Impact of positive preoperative urine cultures before pediatric lower urinary tract reconstructive surgery.

PURPOSE: Children who undergo lower urinary tract reconstruction (LUTR) often have asymptomatic bacteriuria or recurrent urinary tract infections (UTI). We aimed to determine the prevalence of positive preoperative urine cultures (PPUC) before LUTR and to analyze any impact on postoperative outcomes. METHODS: This retrospective review included all pediatric LUTR procedures utilizing bowel segments performed by one surgeon over 2 years. Preoperative cultures were obtained 1-2 days before surgery. Baseline characteristics and 90-day infection/readmission rates between patients with and without PPUC were compared using descriptive statistics, Fisher's exact, and Mann-Whitney tests with significance p < 0.05. RESULTS: 54 patients with mean age 10.1 ± 5.6 years underwent LUTR procedures using bowel including continent catheterizable channel (85%), enterocystoplasty (81%), and/or urinary diversion (9%). PPUC was present in 28 patients (52%). Postoperatively, 20% had inpatient infections, including eight UTI, four surgical site infections, and two bloodstream infections with no difference between those with or without PPUC. Within 90 days of discharge, 28% of patients were readmitted to the hospital, and there was no difference between groups. Postoperative urine cultures were positive in 83% of patients within 90 days. CONCLUSIONS: Half of the patients undergoing LUTR have PPUC, but it does not increase the risk of postoperative infections or hospital readmissions. We believe complex LUTR can be safely performed in patients with PPUC.

VACTERL associations in children undergoing surgery for esophageal atresia and anorectal malformations: Implications for pediatric surgeons.

PURPOSE: The aim of this study was to compare the frequency and nature of VACTERL associations between children who underwent surgery for esophageal atresia/tracheoesophageal fistula (EA/TEF) and anorectal malformation (ARM). METHODS: We identified all children who underwent surgery for EA/TEF and/or ARM at hospitals participating in the Pediatric Health Information System (PHIS) database between 2004 and 2012. PHIS is an administrative database of free-standing children's hospitals managed by the Child Health Corporation of America (Overland Park, KS) that contains patient-level care data from 43 hospitals. The complete records of patients in this cohort were cross-referenced for diagnoses of vertebral, cardiac, renal and limb anomalies. RESULTS: 2689 children underwent repair of esophageal atresia. Mean gestational age was 36.5±3.2weeks and mean birth weight was 2536.0±758.7g. Associated VACTERL diagnoses included vertebral anomaly in 686 (25.5%), ARM in 312 (11.6%), congenital heart disease in 1588 (59.1%), renal disease in 587 (21.8%) and limb defect in 192 (7.1%). 899 (33.4%) had 3 or more anomalies and met criteria for a VACTERL diagnosis. 4962 children underwent repair of ARM. Mean gestational age was 37.4±2.7weeks and mean birth weight was 2895.2±765.1g. Associated VACTERL diagnoses included vertebral anomaly in 1562 (31.5%), congenital heart disease in 2007 (40.4%), EA/TEF in 348 (7.0%), renal disease in 1723 (34.7%) and limb defect in 359 (7.2%). 1795 (36.2%) had 3 or more anomalies and met criteria for a VACTERL diagnosis. CONCLUSION: VACTERL associations are relatively common in children with EA/TEF and ARM and occur in specific clusters, with cardiac disease more common in EA/TEF and spinal and renal/urinary anomalies more common in ARM.

Accessory hemi diaphragm.

BACKGROUND/PURPOSE: Accessory hemi diaphragm (AHD) is an uncommon condition. Its clinical features, diagnosis and management have not been clearly defined. METHODS: We reviewed the world literature and added a case of our own. RESULTS: There are 40 proven cases in the literature. The lesion occurs almost exclusively in the right hemithorax. Twenty seven cases presented with cardiovascular and/or respiratory symptoms while 3 had symptoms pertaining to other systems. In the remaining 10 patients the diagnosis was either made accidentally or information pertaining to their presentation is missing. Abnormalities of pulmonary and systemic blood vessels often accompany the abnormality. The diagnosis is usually suspected because of an abnormal chest radiograph and confirmed by a variety of tests. CONCLUSIONS: If the AHD prevents proper aeration of the lung it should be excised. If vascular abnormalities coexist they should be treated along with the AHD. Asymptomatic patients may be observed after confirming the diagnosis.

Concurrent congenital peritoneopericardial diaphragmatic hernia and bochdalek hernia in a neonate.

We present the first report of a neonate with, concurrent left sided Bochdalek hernia and peritoneopericardial diaphragmatic hernia.

Fate of the uterus in 46XX cloacal exstrophy patients.

PURPOSE: Genetically female cloacal exstrophy (46XX CE) patients develop complications later in life due to their abnormal uterine anatomy, resulting in various invasive gynecologic procedures. Furthermore, they have difficulty becoming pregnant, and if they do conceive, they are unlikely to carry the pregnancy to term. We performed this review to determine the rate of gynecological complications, the fate of the uterus, and the rate of pregnancy in 46XX cloacal exstrophy patients. METHODS: All charts for 46XX CE patients treated by us were reviewed following IRB approval. Patient age at last follow-up, surgical management of the uterus, uterine complications, and pregnancies were recorded. RESULTS: The charts of all 16 of our 46XX CE patients who survived past the neonatal period were reviewed. Two patients underwent hemi-hysterectomy (HH): 1 for an atretic hemi-uterus at birth, another for abnormal uterine insertion at 3 years. A third patient initially had HH for hydrometrocolpos leading to ureteral and colonic obstruction at 14 years but she required a completion hysterectomy a year later. Four patients underwent total hysterectomy (TH) at the outset: 2 neonates for a diminutive uterus with extreme disparity in the halves, another for uterine prolapse at 1 month of age, and a fourth for hematometrocolpos at 16 years of age. Six patients reached adulthood without requiring gynecologic intervention; one of these six is now being managed at another institution. Two patients are prepubertal and one was lost to follow-up. The only patient in the series who became pregnant miscarried at 11 weeks gestation. CONCLUSION: Out of 13 post-pubertal patients 6 have retained the entire uterus and another 2 had a hemi-hysterectomy. One patient who became pregnant miscarried at 11 weeks gestation. We believe it is appropriate to avoid ablative genital surgery as far as possible and for these patients to become pregnant after detailed discussion with physicians experienced in the care of 46XX CE patients.

Current diagnosis and management of urachal remnants.

PURPOSE: The purposes of this study are to review our experience with patients who were found to have urachal remnants. We discuss their diagnosis and management and we also evaluate post-operative complications in our cohort of patients with this entity. METHODS: We performed a retrospective review of all patients diagnosed with a urachal remnant (UR) between January 2006 and December 2010. Patient variables included age, gender, presenting symptoms and signs, diagnostic modality, and type of urachal remnant. Operative management, post-operative complications, and non-operative follow-up were abstracted. RESULTS: We identified 103 pediatric patients with either a urachal cyst (n = 38), urachal diverticulum (n = 13), urachal sinus (n = 11), patent urachus (n = 21), or a non-specific atretic urachal remnant (n = 20). Seventy-eight patients had symptomatic URs. Thirty-four symptomatic patients underwent surgical excision of the UR and 44 symptomatic patients were observed. Eighteen URs were incidentally diagnosed in asymptomatic patients, none of whom underwent surgical excision. In 7 patients symptoms could not be determined from the records. No patients with non-specific atretic remnants were operated upon. Nineteen of the observed patients were reimaged subsequently. In fifteen (78.9%) of these patients, the URs had resolved spontaneously. None of the patients who were observed required subsequent excision of the UR. Post-operative complications occurred in 14.7% of patients in whom URs were excised. CONCLUSION: Review of our patients diagnosed with URs indicates there is a subset of patients in whom spontaneous resolution could be expected. Complications are not uncommon after surgical excision.

Utility of the computed tomography severity index (Balthazar score) in children with acute pancreatitis.

BACKGROUND: Previous studies in children with acute pancreatitis have demonstrated that clinical scoring systems such as the Ranson, modified Glasgow, and pediatric acute pancreatitis scores are of value in predicting severity of the disease. The aim of this study was to determine the predictive value of the computed tomography severity index (CTSI or Balthazar score) in pediatric patients. METHODS: All children (≤ 18 years) admitted to our institution with acute pancreatitis from 2000 through 2009 were reviewed. Contrast-enhanced computed tomographic (CT) images at presentation were retrospectively reviewed by 2 pediatric radiologists. Peripancreatic fluid and the extent of necrosis were assessed to determine the CTSI. The predictive value of the CTSI was calculated and compared with clinical scoring systems. RESULTS: Of 211 children with acute pancreatitis, 64 underwent contrast-enhanced CT at presentation. The median age was 12.3 years. Etiology of pancreatitis was idiopathic (35.9%), gallstone (17.2%), medication-induced (20.3%), posttransplant (9.4%), traumatic (6.3%), structural (1.6%), and other (9.4%). The sensitivity, specificity, positive predictive value, and negative predictive value of the CTSI (using a cutoff score of 4+) were 81%, 76%, 62%, and 90%, respectively, which compared favorably to the results of the pediatric acute pancreatitis (53%, 72%, 41%, 80%), Ranson (71%, 87%, 67%, 89%), and modified Glasgow (71%, 87%, 67%, 89%) scores. CONCLUSION: The CTSI is superior to clinical scoring systems for identifying children with acute pancreatitis at heightened risk for developing serious complications.

Acute pancreatitis in children: spectrum of disease and predictors of severity.

BACKGROUND: The aim of this study was to describe the spectrum of disease in children with acute pancreatitis and assess predictors of severity. METHODS: Children (≤ 18 years) admitted to a single institution with acute pancreatitis from 2000 to 2009 were included. The accuracy of the Ranson, modified Glasgow, and pediatric acute pancreatitis severity (PAPS) scoring systems for predicting major complications was assessed. RESULTS: The etiology of pancreatitis in these 211 children was idiopathic (31.3%), medication-induced (19.9%), gallstones (11.8%), trauma (7.6%), transplantation (7.6%), structural (5.2%), and hemolytic-uremic syndrome (3.3%). Fifty-six patients (26.5%) developed severe complications. Using the cutoff thresholds in the PAPS scoring system, only admission white blood cell count more than 18,500/µL (odds ratio [OR], 3.1; P = .010), trough calcium less than 8.3 mg/dL (OR, 3.0; P = .019), and blood urea nitrogen rise greater than 5 mg/dL (OR, 4.1; P = .004) were independent predictors of severe outcome in a logistic regression model. The sensitivity (51.8%, 51.8%, 48.2%) and negative predictive value (83.2%, 83.5%, 80.5%) of the Ranson, modified Glasgow, and PAPS scores were, respectively, insufficient to guide clinical decision making. CONCLUSION: Commonly used scoring systems have limited ability to predict disease severity in children and adolescents with acute pancreatitis. Careful and repeated evaluations are essential in managing these patients who may develop major complications without early signs.

The effect of indomethacin on systemic and renal hemodynamics in neonatal piglets during experimental endotoxemia.

Systemic and renal hemodynamics are affected by prostaglandin production during endotoxemia. To study indomethacin effects on endotoxinemia in a neonatal piglet model, sixteen 7-10 day old piglets were anesthetized, ventilated, and catheterized. Mean arterial pressure (MAP), heart rate (HR), and urine output were continuously monitored. Endotoxin (0.06 mcg/kg) was injected after baseline measurements. We studied two groups with either endotoxinemia alone (n = 7) or an additional indomethacin infusion (0.2 mg/kg per h, n = 9). HR, MAP, renal blood flow (RBF), systemic and renal vascular resistance (SVR, RVR), cardiac index (CI), and glomerular filtration rate (GFR), were obtained at baseline, at 1, 2 and 3 h. We observed a drop in CI and an increase in SVR and HR within 3 h of endotoxinemia, while MAP remained unchanged. These effects were prevented by indomethacin. RVR was not altered significantly. Endotoxinemia triggered a drop of RBF in both control (P < 0.01) and intervention group (P < 0.05). In the intervention group, drop of GFR, urine volume, and paraaminohippuric acid clearance were apparent signs of nephrotoxicity (P < 0.01, <0.05, and <0.01). In conclusion, indomethacin maintains hemodynamic parameters during endotoxinemia at the expense of nephrotoxicity. We speculate that indomethacin counteracts the renoprotective effect of prostaglandins.

Early effects of lipopolysaccharide on cytokine release, hemodynamic and renal function in newborn piglets.

BACKGROUND: Gram-negative sepsis in newborns is associated with high mortality and morbidity. Lipopolysaccharide (LPS) and cytokines released upon exposure to gram-negative sepsis are well known to be involved in the pathophysiology. OBJECTIVE: In this report we investigate cytokine release, hemodynamic, and renal function induced by LPS in a newborn animal model with the intention to further examine early changes in gram-negative sepsis. METHODS: Five 7- to 10-day-old domestic piglets were anesthetized and catheters placed in the jugular veins, left ventricle, and femoral artery. Urine output was monitored via suprapubic cystostomy. Mean arterial pressure, heart rate, and arterial blood gases were continuously monitored. Thirty minutes after line placement and obtaining baseline values, 0.06 mug/kg LPS were administered intravenously. One, 2, and 3 h later samples were taken to monitor tumor necrosis factor (TNF)-alpha, interleukin (IL)-1beta, endothelin, and nitric oxide (NO)/nitrate via ELISA. In addition, blood flow was assessed by the microsphere method. RESULTS: Our data show an initial surge of TNF-alpha and IL-1beta at 1 h after exposure to LPS. NO/nitrate, endothelin, and hemodynamic as well as metabolic changes became apparent mostly 3 h after exposure, by which time TNF-alpha and IL-1beta fell back to baseline. CONCLUSIONS: Our sepsis model suggests a brief initial TNF-alpha and IL-1beta surge following LPS challenge; however, their effects become apparent by the time the levels are already subsiding. The emergence of vasoactive substances, NO and endothelin, precedes the first substantial clinical symptoms.

Rhabdomyosarcoma.

Rhabdomyosarcoma, the most common soft tissue sarcoma of children, carried a 10-15% survival rate in the late 1960s. Since then, better understanding of biology and pathology of the tumor and the judicious use of chemotherapy and radiation has improved the prognosis drastically. In addition instead of extirpative surgery, organ salvage is now feasible in many of these children. In this article the authors review current information regarding pathology, diagnosis and treatment of rhabdomyosarcoma.

Laparoscopy for nonpalpable testes.

PURPOSE: Laparoscopy is now considered integral to the management of nonpalpable testes, although its benefits are not clearly documented. The authors prospectively determined the value of laparoscopy in patients with nonpalpable testes. METHODS: Between December 1997 and October 2001, 37 patients with 40 nonpalpable testes were scheduled for laparoscopy followed by definitive treatment. Laparoscopy was cancelled in 4 patients (5 testes) because their testes became palpable under anesthesia. In the remaining 33 patients (35 testes), it was determined at the time of surgery whether, as a consequence of laparoscopy: (1) retroperitoneal exploration was avoided (2) definitive treatment was facilitated. RESULTS: Laparoscopy did not alter the management of 27 testes (77%) that were treated through an inguinal incision with orchiopexy for 17 testes (6 intraabdominal and 9 at the deep ring) and removal of 10 atrophic nubbins. It was only useful in avoiding retroperitoneal dissection for 5 (14%) vanishing testes, and it may have been of benefit for 3 testes treated with a 2-stage Fowler-Stephens orchiopexy. CONCLUSIONS: The majority of our patients with nonpalpable testes could have been treated through an inguinal incision with laparoscopy being reserved for situations in which the testis was not identified on inguinal exploration.

Continent catheterizable urinary conduit constructed from defunctionalized colon.

The authors describe a technique for construction of a continent catheterizable stoma from distal defunctionalized colon in a patient with imperforate anus, urethral atresia, and sacral agenesis.

Testicular extrusion due to scrotoschisis.

We present the eighth case of testicular extrusion through a congenital defect in the scrotal wall, along with a review of the published reports and a discussion of its possible embryogenesis.

Endotoxemia and the effects of dopamine on renal functions of neonatal piglets.

In this study, we observed the effects of moderate and high doses of dopamine on the renal functions of neonatal piglets during endotoxic shock. We found that fluid therapy alone was better at maintaining cardiac index and preventing elevation of systemic vascular resistance, than dopamine at 10 and at 20 microg/kg/min. Furthermore, urine output and glomerular filtration rate were reduced by dopamine. Following endotoxin administration dopamine decreased SVR and maintained a CI better than fluid alone. However, in spite of a better CI, greater deterioration in renal functions occurred in the dopamine groups as compared to the fluid group.

Effects of tezosentan, a dual endothelin receptor antagonist, on the cardiovascular and renal systems of neonatal piglets during endotoxic shock.

BACKGROUND/PURPOSE: Endothelin is a potent mediator of the cardiovascular and renal systems. Studies have found that endothelin has an important role in regulating cardiac function and renal perfusion in neonates who are suffering from endotoxic shock. The authors believe that blockade of the endothelin response during endotoxemia will have a beneficial effect on neonatal cardiac and renal functions. In this study the authors have examined the effects of tezosentan, a dual endothelin-receptor antagonist, on the cardiovascular and renal systems of neonatal piglets during endotoxemia. METHODS: Thirteen piglets were subjected to endotoxic shock and divided into a fluid-therapy group that received 0.9% normal saline and a group that received tezosentan (1 mg/kg/h). Mean arterial pressure (MAP), heart rate (HR), and glomerular filtration rate (GFR) were plotted at baseline, 1, 2, and 3 hours. Cardiac index (CI), renal blood flow (RBF), systemic vascular resistance (SVR), and renal vascular resistance (RVR) were obtained at baseline, 1, and 3 hours after baseline. RESULTS: (P <.05 for 3 hours versus baseline and tezosentan versus fluid). Although fluid therapy in endotoxemia had no significant effect on MAP and RVR, it significantly increased HR (139 plus minus 17 to 246 plus minus 17 beats/min) and SVR (0.08 plus minus 0.05 to 0.33 plus minus 0.09 mm Hg/mL/min) and decreased CI (407 plus minus 208 to 98 plus minus 13 mL/min/kg), RBF (1.84 plus minus 0.38 to 0.97 plus minus 0.34 mL/min/kg kidney), and GFR (0.20 plus minus 0.05 to 0.11 plus minus 0.04 mL/min/kg) at 3 hours. The use of tezosentan also significantly increased HR (130 plus minus 14 to 220 plus minus 31 beats/min), but unlike in the fluid therapy group, there was a significant fall in MAP (77 plus minus 10 to 54 plus minus 9 mm Hg) and RVR (1.92 plus minus 0.44 to 1.77 plus minus 0.64 mm Hg/mL/min) and a less severe decrease in CI (482 plus minus 188 to 176 plus minus 67 mL/min/kg) at 3 hours. SVR, RBF, and GFR were maintained. CONCLUSIONS: Endotoxic shock affected cardiac and renal functions in both treatment groups. Fluid therapy alone could not prevent a statistically significant fall in CI, RBF, and GFR or prevent the increase in HR and SVR. Endothelin antagonism with tezosentan resulted in a statistically significant fall in MAP and RVR from baseline, not seen in the fluid-therapy group. CI and RBF were significantly higher, and MAP, SVR, and RVR were significantly lower when compared with the fluid-therapy group at 3 hours. GFR also was maintained at baseline with tezosentan. During endotoxemia, endothelin antagonism maintained renal and cardiac functions better than with fluid therapy alone.

Superselective mesenteric embolization with microcoils in a porcine model.

PURPOSE: There is a lack of data regarding the degree of ischemic change that may occur in small and large bowel after superselective arterial embolotherapy with platinum microcoils. The purpose of this study was to gain a clearer understanding of the ischemic complications of superselective embolization of peripheral mesenteric arteries with microcoils by gross and histologic examination of postembolectomy bowel specimens at several time intervals in an adult porcine model. METHODS: Two-millimeter platinum microcoils with fibrils were superselectively deployed into six isolated mesenteric branch vessels in each of nine adult pigs. The animals were observed for two days (n = 3), one month (n = 3), or three months (n = 3) and then killed. At necropsy, intestines were examined for gross abnormalities. Sections of bowel containing microcoils were identified under fluoroscopy, resected, and evaluated histologically. RESULTS: A total of 54 microcoils were deployed into the distal arterial mesentery supplying the jejunum (n = 14), ileum (n = 26), and colon (n = 14) of nine adult pigs. Each animal received six microcoils. There were no clinical complications, and all pigs gained weight during their observation periods. Gross examination of the intestines did not reveal any evidence of acute or chronic ischemia. The coils were found in the distal arterial vasculature of the intestine. Histologic examination revealed mild superficial necrosis of villous tips in several samples; however, this finding is likely related to a fixation artifact rather than ischemic injury. There was no other histologic evidence suggestive of ischemic injury. CONCLUSIONS: Gross and histologic findings after superselective arterial embolotherapy demonstrated minimal changes in the bowel, and there were no significant clinical consequences to the animals. We conclude that transcatheter arterial embolotherapy in pigs is safe and may be applicable in the control of massive lower gastrointestinal hemorrhage in humans.