Short-term outcomes of thoracoscopic versus open lobectomy for congenital lung malformations.

PURPOSE: Thoracoscopic and open approaches for the management of congenital lung malformations (CLM) has been debated. The aim of this study is to compare 30-day outcomes for non-emergent lobectomies in children. METHODS: The National Surgical Quality Improvement Program-Pediatric database was queried for patients undergoing CLM resection from 2013 to 2020. Outcomes were compared by operative technique in an intention-to-treat model and then propensity matched. RESULTS: 2157 patients met inclusion criteria and underwent non-emergent pulmonary lobectomy for CLM. The intended operative approach was thoracoscopic in 57.7% of patients. Patients in the open group compared to the thoracoscopic were more likely to be born premature, have chronic lung disease, require preoperative oxygen support, and be ventilator dependent. After propensity matching, there was no statistically significant difference in 30-day mortality, unplanned readmission, and other complications between the thoracoscopic and open groups. Thoracoscopic approach was associated with a shorter length of stay. The proportion of cases approached via thoracoscopy increased over time from 48.8% in 2013 to 69.9% in 2020. CONCLUSIONS: This large multicenter retrospective matched analysis demonstrates thoracoscopic lobectomy in children has similar favorable 30-day outcomes and shorter length of stay for the non-emergent management of CLM, compared to open thoracotomy. LEVEL OF EVIDENCE: Level III.

Personality traits within a pediatric surgery fellowship applicant pool.

BACKGROUND: The Big Five framework examines five factors that represent a description of human personality. These factors correlate with success measures and job satisfaction. The Big Five Inventory is a 44-item instrument designed to measure the Big Five framework. Our aim was to document the distribution of Big Five personality traits among Pediatric Surgery fellowship applicants, compare with community norms, surgical residents, between genders, and correlate to the fellowship match results. MATERIALS AND METHODS: Forty Pediatric Surgery fellowship applicants at a university hospital completed the Big Five Inventory during the interview process. It was analyzed and compared with general surgery residents' results and community norms. The data were compared regarding gender and match results. Continuous variables were compared by unpaired t-tests and Mann-Whitney tests. A P value <0.05 was considered significant. RESULTS: The 40 applicants were equally divided between male and female. When compared with general surgery residents and community norms, applicants of both genders scored higher on agreeableness (P < 0.01), conscientiousness (P < 0.01), and emotional stability (P < 0.01). Applicants scored higher on openness when compared with surgical residents (P < 0.01). Male applicants scored higher on emotional stability than females (P = 0.026). Matched applicants scored higher for conscientiousness than unmatched applicants (P = 0.016). CONCLUSIONS: Pediatric Surgery fellowship applicants expressed higher levels of desirable professional traits compared with general surgery residents and community norms. Male applicants demonstrated higher emotional stability than females. Conscientiousness was higher in matching applicants. This first reported experience with personality testing in Pediatric Surgery fellow selection demonstrated potential utility in applicant matching.

Case report: Duplicated appendicitis with history of cloacal exstrophy causing bowel obstruction.

INTRODUCTION: Cloacal and bladder exstrophy are rare embryological defects that can cause developmental disruption of surrounding organ structures, the pelvis, spinal cord, and small intestines being the most commonly affected. Duplicated appendix is another rare embryological defect that has historically caused confusing clinical presentations. Our case highlights a rare instance of a patient with cloacal exstrophy who presented with a bowel obstruction and an associated inflamed duplicated appendix. CASE PRESENTATION: A newborn male is born with omphalocele-exstrophy-imperforate anus-spinal defects (OEIS) complex. As primary surgical reconstruction was pursued, the patient was found to have a non-inflamed duplicated appendix, which was left unremoved. In the following months, the patient experienced episodes of small bowel obstruction, eventually requiring surgical intervention. During this operation, the duplicated appendix was noted to be inflamed, prompting removal of both appendices. DISCUSSION: This case highlights the increased prevalence of duplicated appendix in a patient with cloacal exstrophy, as well as the utility of prophylactic appendectomy for patients incidentally found to have a duplicated appendix intraoperatively. The duplicated appendix may lead to increased rates of complications and atypical presentation of appendicitis, supporting the practice of prophylactic appendectomy in patients with an incidentally found duplicated appendix. CONCLUSION: We suggest clinicians be aware of the association and potentially atypical presentation of appendicitis in patients with a duplicated appendix, particularly in the setting of cloacal exstrophy. The decision to prophylactically remove an incidentally found, non-inflamed duplicated appendix may be beneficial in preventing confusing clinical presentations and future complications.

Establishment of a successful robotic pediatric general surgery practice.

Robotic-assisted surgery (RAS) has a variety of theoretical advantages, including tremor filtration, optimal visualization, and improvement of surgeon ergonomics. Though it has achieved wide application in pediatric urology, the majority of pediatric general surgeons do not employ RAS. This study reports our institution's experience with RAS on a pediatric general surgery team. Following IRB approval, a retrospective review of all pediatric patients at our academic children's hospital who underwent RAS between 2017 and 2022 for pediatric general surgical conditions was performed. Patient demographics, operation performed, operating time, complications, and recovery were evaluated. A total of 159 children underwent RAS, increasing from 10 patients in 2017 to 59 patients in 2022. The median age and weight were 15.3 years and 76.4 kg, and 121 (76.1%) were female. The application of RAS was successful in all cases. There were no intraoperative complications and no conversions to an open approach. Eleven patients (6.9%) had unplanned presentations to the emergency department within 30 days. Five of these patients (3.1%) required admission to the hospital. This study demonstrates that the application of RAS in an academic pediatric general surgery practice is feasible and safe. The application of RAS to pediatric general surgery should continue to increase as operative teams increase their experience and comfort.Level of evidence Level IV.

The Current Pediatric Surgery Job Market: A Perspective of Recent Fellowship Graduates.

PURPOSE: This study describes the job market from the perspective of recent pediatric surgery graduates. METHODS: An anonymous survey was circulated to the 137 pediatric surgeons who graduated from fellowships 2019-2021. RESULTS: The survey response rate was 49%. The majority of respondents were women (52%), Caucasian (72%), and had a median student debt burden of $225,000. Considering job opportunities, respondents strongly emphasized camaraderie (93%), mentorship (93%), case mix (85%), geography (67%), faculty reputation (62%), spousal employment (57%), compensation (51%), and call frequency (45%). 30% were satisfied with the employment opportunities available, and 21% felt strongly prepared to negotiate for their first job. All respondents were able to secure a job. Most jobs were university-based (70%) or hospital employed (18%) positions where surgeons covered median of two hospitals. 49% wanted protected research time, and 12% of respondents were able to secure substantial, protected research time. The median compensation for university-based jobs was $12,583 below the median AAMC benchmark for assistant professors for the corresponding year of graduation. CONCLUSION: These data highlight the ongoing need for assessment of the pediatric surgery workforce and for professional societies and training programs to further assist graduating fellows in preparing to negotiate their first job. TYPE OF STUDY: Survey LEVEL OF EVIDENCE: Level V.

Large mesenteric cyst mimicking an ovarian cyst in an 8-year-old: A case report.

INTRODUCTION AND IMPORTANCE: Pediatric mesenteric cysts, rare and usually benign intra-abdominal tumors, are a difficult preoperative diagnosis due to ambiguous clinical characteristics. The final diagnosis is typically established only during surgery or histological analysis. CASE PRESENTATION: An 8-year-old female presented with five days of worsening abdominal pain, associated with nausea, vomiting, and fever, as well as vague tenderness in the right quadrants on examination. Computed tomography imaging showed a 10.5 × 8.7 × 7 cm abdominal mass, most suspicious for a cystic mass of ovarian origin. Upon diagnostic laparoscopy, a mesenteric cyst extending to the root of the mesentery was visualized and entirely resected after conversion to an exploratory laparotomy. Histopathological examination of both the cystic fluid and specimen suggest a benign mesenteric cyst. CLINICAL DISCUSSION: Although mesenteric cysts are noticeably rare, it is important differential to consider in pediatric patients with non-specific symptoms like abdominal pain and distention, intestinal obstruction, or a palpable abdominal mass. Notably, these cysts can be managed successfully by complete surgical resection with an excellent outcome. CONCLUSION: This report recounts an interesting case of a large mesenteric cyst that mimicked an ovarian cyst in a pre-pubertal girl.

A Rare Combination of Left-Sided Gastroschisis and Omphalocele in a Full-Term Neonate: A Case Report.

BACKGROUND Left-sided gastroschisis is a rare congenital birth defect characterized by herniation of intra-abdominal organs through an abdominal wall defect to the left of the umbilicus. Approximately half of the 31 cases reported in the literature describe other associated anomalies. To the best of our knowledge, it has never been reported in association with an omphalocele. CASE REPORT Here, we present the case of a female newborn, 37 weeks gestational age, born with a 3×6 cm omphalocele and a left-sided gastroschisis with herniation of the small bowel. Both of these anomalies were managed separately, with initial placement of a silo bag on the gastroschisis defect and application of topical agents to the omphalocele until complete epithelialization was achieved. The herniated bowel at the gastroschisis site was reduced with the aid of the silo by 96 hours and the fascia then closed primarily. A gastrostomy tube (G-tube) was placed at 16 weeks of age because of poor oral intake. Definitive closure of the omphalocele and removal of the gastrostomy tube was achieved at 13 months. Her subsequent follow-up visits in the clinic have been uneventful. CONCLUSIONS Our case report highlights the importance of recognizing this combination of rare conditions and directing appropriate surgical care.

V.A.C. Therapy in the management of paediatric wounds: clinical review and experience.

Usage of negative pressure wound therapy (NPWT) in the management of acute and chronic wounds has grown exponentially in the past decade. Hundreds of studies have been published regarding outcomes and methods of therapy used for adult wounds. This treatment is increasingly being used to manage difficult-to-treat paediatric wounds arising from congenital defects, trauma, infection, tumour, burns, pressure ulceration and postsurgical complications in children, although relatively few studies have been aimed at this population. Given the anatomical and physiological differences between adults and children, a multidisciplinary expert advisory panel was convened to determine appropriate use of NPWT with reticulated open cell foam (NPWT/ROCF) as delivered by Vacuum Assisted Closure (V.A.C. Therapy, KCI Licensing, Inc., San Antonio, TX) for the treatment of paediatric wounds. The primary objectives of the expert advisory panel were to exchange state-of-practice information on paediatric wound care, review the published data regarding the use of NPWT/ROCF in paediatric wounds, evaluate the strength of the existing data and establish guidelines on best practices with NPWT/ROCF for the paediatric population. The proposed paediatrics-specific clinical practice guidelines are meant to provide practitioners an evidence base from which decisions could be made regarding the safe and efficacious selection of pressure settings, foam type, dressing change frequency and use of interposing contact layer selections. The guidelines reflect the state of knowledge on effective and appropriate wound care at the time of publication. They are the result of consensus reached by expert advisory panel members based on their individual clinical and published experiences related to the use of NPWT/ROCF in treating paediatric wounds. Best practices are described herein for novice and advanced users of NPWT/ROCF. Recommendations by the expert panel may not be appropriate for use in all circumstances. Decisions to adopt any particular recommendation must be made by the collaborating medical team, including the surgeon and wound care specialist based on available resources, individual patient circumstances and experience with the V.A.C. Therapy System.

Isolated Thoracoschisis with Rib Agenesis and Liver Herniation: A Case Report.

BACKGROUND Thoracoschisis is a very rare congenital birth defect defined by the herniation of intra-abdominal organs through a defect in the thoracic wall. Though often associated with other birth defects as a part of the "limb-body wall complex" deformities, thoracoschisis has very rarely been reported as an isolated finding. CASE REPORT Here we present the case of a 30-day-old term male infant with an isolated left thoracoschisis managed successfully by primary closure. The patient was monitored postnatally in the Neonatal Intensive Care Unit (NICU) of Maputo Central Hospital because of the presence of a herniated mass through a left chest wall defect below the left nipple. Computed tomography (CT) scans suggested the presence of a left diaphragmatic hernia, left rib agenesis, and herniation of an unidentifiable intra-abdominal organ through the anterior left chest wall. On day of life (DOL) 30, when global health outreach pediatric surgeons arrived at the hospital, the decision was made to operate on the child. The mass was found to be of liver origin, the exposed tissue was excised, and primary closure of the chest wall was accomplished. The patient's postoperative course involved a wound infection that resolved favorably with treatment, allowing for discharged home on postoperative day (POD) 17 in stable condition. CONCLUSIONS Our case report highlights the importance of recognizing this rare condition and directing appropriate surgical care.

Intestinal Function after Early versus Late Appendectomy in Children with Perforated Appendicitis.

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3-9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

Young children with perforated appendicitis benefit from prompt appendectomy.

BACKGROUND/PURPOSE: To identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy. METHODS: After IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1-18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval. The median time from pain onset to treatment initiation was 3 days (range: 1-14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence. RESULTS: Of 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57-0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81-0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity. CONCLUSION: Younger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy. LEVEL OF EVIDENCE: Treatment Study Level II.

Writing Signed Languages: What For? What Form? A Response.

In his article in an American Annals of the Deaf special issue that also includes the present article, Grushkin divides his discussion of a written sign system into three basic parts. The first presents arguments against the development of a written form of American Sign Language; the second provides a rationale for a written form of ASL; the third advances opinions of the form such a system might take. The arguments in the first part are weak and reflect the same bias that historically has been shown against ASL itself. The third section advances some ideas that should provide the basis for interesting discussions. Among these are the relationship, if any, of a written sign language to English print, the extent to which it should be alphabetic and horizontal, and its role in the current American educational system.

Laparoscopic skills assessment: an additional modality for pediatric surgery fellowship selection.

AIM: The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity. MATERIALS AND METHODS: Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data. RESULTS: Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01). CONCLUSIONS: Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability. TYPE OF STUDY: Prospective study. LEVEL OF EVIDENCE: Level II.

Atropine: A Cure for Persistent Post Laparoscopic Pyloromyotomy Emesis?

BACKGROUND: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy. MATERIALS AND METHODS: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis. RESULTS: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths. CONCLUSION: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy.

A Dialogue on the Multiple Facets of Sustainability.

This chapter contains excerpts from a conversation among the contributors to Sign Language, Equal Opportunities, and Sustainable Development (De Clerck & Paul, 2016) during a workshop that preceded the International Conference on Sign Language, Sustainable Development, and Equal Opportunities (Ghent University, Belgium, April 2014). The objective of the conversation was to illustrate an open-ended, dialogical approach that added an interactive component to the book and inspired further thoughts and exchanges. Videos of the conversation were posted online by the European Union of the Deaf at http://www.eud.eu/news/university-gent/.

Oral antibiotics in the management of perforated appendicitis in children.

After appendectomy for perforated appendicitis children have traditionally been managed with intravenous broad-spectrum antibiotics for 5 to 10 days and then until fever and leukocytosis have resolved. We prospectively evaluated a protocol of hospital discharge on oral antibiotics when oral intake is tolerated-regardless of fever or leukocytosis-in a consecutive series of 80 children between one and 15 years of age who underwent appendectomy (38 open and 42 laparoscopic) for perforated appendicitis. At discharge subjects began a 7-day course of oral trimethoprim/sulfamethoxazole and metronidazole. Patients were discharged between 2 and 18 days postoperatively (mean 5.3 days). Sixty-six were discharged on oral antibiotics, and 28 of these had persistent fever or leukocytosis. Two patients (2.5%) developed postoperative intra-abdominal abscesses while inpatients. Wound infections developed in seven patients (8.8%) four of whom were on intravenous antibiotics. Among the 66 children who were discharged on oral antibiotics without having had an inpatient infectious complication there were three wound infections (4.4%). None of these patients had a fever or leukocytosis at discharge. We conclude that after appendectomy for perforated appendicitis children may be safely discharged home on oral antibiotics when enteral intake is tolerated regardless of fever or leukocytosis.

One size does not fit all: individualized instruction in a standardized educational system.

This essay is based on a keynote address, "A Tour of the Horizons," presented to the 2012 annual conference of the Association of College Educators/Deaf and Hard of Hearing (ACE/DHH), held in Atlantic Beach, Florida.

Abdominal compartment syndrome: focus on the children.

This article is a concise summary of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) with an emphasis on factors relevant to their occurrence in children. It discusses the limitations in the direct application of the current World Society of Abdominal Compartment Syndrome consensus definitions and extrapolation of management practices derived from studying adult patients to the pediatric age group. Techniques that may be used for measuring intra-abdominal pressure (IAP) in children, normal IAP ranges, risk factors for developing ACS as well as current medical and surgical management options in children are discussed.