Evaluation of the learning curve for laparoscopic pyloromyotomy.

BACKGROUND: Laparoscopic pyloromyotomy is the preferred surgical management of hypertrophic pyloric stenosis at most centers. We aimed to analyze the learning curve for laparoscopic pyloromyotomy using the experience of five fellowship-trained pediatric surgeons. METHODS: A retrospective review of consecutive patients undergoing laparoscopic pyloromyotomy was performed. All cases were performed with general surgery residents. Cumulative sum (CUSUM) analysis for operating time was performed for up to the first 150 consecutive cases for individual surgeons. Outcomes were compared to identify different phases of the learning curve for operative competency. RESULTS: A total of 414 patients were included in the analysis as not all surgeons had reached 150 cases at time of analysis. The mean operating time was 29.2 min for all cases across the 5 surgeons. CUSUM analysis for mean operating time revealed three phases of learning: Learning Phase (cases 1-16), Plateau Phase (cases 17-87), and a Proficiency Phase (cases 88-150). The mean operating time during the three phases was 34.1, 29.0, and 28.3 min, respectively (P = 0.005). There were no differences in complications, reoperations, length of stay, or readmissions across the three phases. CONCLUSION: Three distinct phases of learning for laparoscopic pyloromyotomy were identified with no differences in outcomes across the phases. The operating time differed only for the Learning Phase, suggesting that some degree of proficiency occurs after 16 cases.

Suprascapular nerve entrapment in young kayaker: a case report.

Kayaking has become one of the most popular paddle sports throughout the world. The shoulder is the most commonly injured area of the body among kayaking participants as a result of acute traumatic events and chronic overuse injuries. Therefore, kayaking participants may often seek advice for shoulder problems and there is a scarcity of studies regarding shoulder injuries in this population. In this case report, we present a young male recreational whitewater kayaker with a severe suprascapular nerve (SSN) entrapment who presented with shoulder pain and inability to perform his sport. He was initially evaluated elsewhere and was treated with nonsteroidal anti-inflammatory medications and physical therapy for presumptive diagnosis of subacromial impingement. After 5 months of failed non-operative treatment, the patient sought a second opinion with our group. SSN entrapment diagnosis was confirmed by a thorough careful physical examination, magnetic resonance imaging and electrodiagnostic study. Given the failure of non-operative treatment, the patient was treated with arthroscopic SSN decompression and successfully returned to kayaking without symptoms. While SSN entrapment has been reported in a variety of sports, especially those involving overhead movements, this is the first case report of SSN entrapment reported which impaired participation in kayaking. This case report supports the consideration of SSN entrapment in the differential diagnosis of painful shoulder among kayaking participants and highlights the importance of undressing the patient and examining the posterior shoulder for atrophy, winging or deformity.