International Core Outcome Set for Acute Simple Appendicitis in Children: Results of a Systematic Review, Delphi Study, and Focus Croups With Young People.

OBJECTIVE: To develop an international core outcome set (COS), a minimal collection of outcomes that should be measured and reported in all future clinical trials evaluating treatments of acute simple appendicitis in children. SUMMARY OF BACKGROUND DATA: A previous systematic review identified 115 outcomes in 60 trials and systematic reviews evaluating treatments for children with appendicitis, suggesting the need for a COS. METHODS: The development process consisted of 4 phases: (1) an updated systematic review identifying all previously reported outcomes, (2) a 2-stage international Delphi study in which parents with their children and surgeons rated these outcomes for inclusion in the COS, (3) focus groups with young people to identify missing outcomes, and (4) international expert meetings to ratify the final COS. RESULTS: The systematic review identified 129 outcomes which were mapped to 43 unique outcome terms for the Delphi survey. The first-round included 137 parents (8 countries) and 245 surgeons (10 countries), the second-round response rates were 61% and 85% respectively, with 10 outcomes emerging with consensus. After 2 young peoples' focus groups, 2 additional outcomes were added to the final COS (12): mortality, bowel obstruction, intraabdominal abscess, recurrent appendicitis, complicated appendicitis, return to baseline health, readmission, reoperation, unplanned appendectomy, adverse events related to treatment, major and minor complications. CONCLUSION: An evidence-informed COS based on international consensus, including patients and parents has been developed. This COS is recommended for all future studies evaluating treatment ofsimple appendicitis in children, to reduce heterogeneity between studies and facilitate data synthesis and evidence-based decision-making.

Abdominal Tuberculosis in an Infant Presenting With a Small Bowel Obstruction.

ABSTRACT: Abdominal tuberculosis (TB) is rare in children and usually spread in the peritoneum or gastrointestinal tract. Symptoms tend to be vague and nonspecific, with no extra-abdominal involvement, presenting a challenge for clinicians and delayed diagnosis. Postnatally acquired abdominal TB is most commonly transmitted through inhalation or ingestion of respiratory droplets with Mycobacterium tuberculosis from the mother.Abdominal TB in infants is rare. We present a case of a 2-month-old infant presenting with an acute bowel obstruction secondary to abdominal TB acquired through contact with maternal TB mastitis. This unique case emphasizes the importance of considering abdominal TB in the differential for at-risk infants presenting with small bowel obstruction.

Consensus Guidelines for Perioperative Care in Neonatal Intestinal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations.

BACKGROUND: Enhanced Recovery After Surgery (ERAS®) Society guidelines integrate evidence-based practices into multimodal care pathways that have improved outcomes in multiple adult surgical specialties. There are currently no pediatric ERAS® Society guidelines. We created an ERAS® guideline designed to enhance quality of care in neonatal intestinal resection surgery. METHODS: A multidisciplinary guideline generation group defined the scope, population, and guideline topics. Systematic reviews were supplemented by targeted searching and expert identification to identify 3514 publications that were screened to develop and support recommendations. Final recommendations were determined through consensus and were assessed for evidence quality and recommendation strength. Parental input was attained throughout the process. RESULTS: Final recommendations ranged from communication strategies to antibiotic use. Topics with poor-quality and conflicting evidence were eliminated. Several recommendations were combined. The quality of supporting evidence was variable. Seventeen final recommendations are included in the proposed guideline. DISCUSSION: We have developed a comprehensive, evidence-based ERAS guideline for neonates undergoing intestinal resection surgery. This guideline, and its creation process, provides a foundation for future ERAS guideline development and can ultimately lead to improved perioperative care across a variety of pediatric surgical specialties.

Improving value and access to specialty medical care for families: a pediatric surgery telehealth program

Background: In Canada, access to subspecialty surgical services for children imposes inconvenience and financial hardship on geographically remote families. The purpose of this study was to evaluate a recently implemented pediatric surgical telehealth pilot program from the family and provider perspectives. Methods: Enabled by an existing telehealth infrastructure for pediatric subspecialty medicine and mental health, a pilot telehealth program for surgical consultation was established by a single surgeon in British Columbia. Following establishment of eligibility criteria, patients from remote communities requiring new consultation or clinical follow-up were offered a telehealth alternative. At the end of the encounter, both the parent and patient (if appropriate) provided feedback via a questionnaire. Provider satisfaction was also assessed via a questionnaire. We estimated costs avoided and analyzed data on pediatric surgery consultation wait time. Results: Between September 2014 and November 2017, 80 patients were seen in 19 remote telehealth centres, 23 as new referrals and 57 in follow-up consultation. Among new referrals, the commonest diagnosis was chest wall deformity. The average travel distance avoided was 705 km, with an estimated direct cost avoidance of $585. Sixty-four families (80%) completed the questionnaire. Almost all (63 [98%]) indicated high overall satisfaction with the telehealth experience. Provider satisfaction was similarly high, in terms of both the technology user interface and clinical effectiveness. Overall pediatric surgical consultation wait times were unaffected. Conclusion: Implementation of telehealth technology in a pediatric surgical practice offered high value to patients/families and, from the provider's perspective, yielded an acceptable alternative to in-person assessment.

Contexte: Au Canada, l'accès aux services chirurgicaux surspécialisés pour enfants est source d'inconvénients et de difficultés financières pour les familles vivant en région éloignée. L'objectif de cette étude était d'évaluer le point de vue des familles et des fournisseurs de services sur un programme pilote de télésanté pédiatrique récemment mis en oeuvre. Méthodes: Ce programme pilote de consultation chirurgicale à distance a été mis sur pied par un chirurgien de Colombie-Britannique, qui s'est servi d'une infrastructure de télésanté préexistante permettant la prestation de services surspécialisés de médecine et de santé mentale pour enfants. Une fois leur admissibilité établie, les patients vivant en région éloignée et ayant besoin d'une consultation ou d'un suivi clinique se sont vu offrir des services de télésanté. Après la consultation, les parents et le patient (lorsque c'était approprié) ont rempli un formulaire de rétroaction. La satisfaction des fournisseurs de soins a été également évaluée au moyen d'un questionnaire. Nous avons estimé les coûts évités et analysé les données sur le temps d'attente pour une consultation en chirurgie pédiatrique. Résultats: Entre septembre 2014 et novembre 2017, 80 patients ont consulté 19 centres de télésanté : 23 pour une nouvelle consultation et 57 pour un suivi. Parmi les nouveaux cas, le diagnostic le plus fréquent était une malformation de la paroi thoracique. En moyenne, 705 km de déplacements ont été évités, ce qui représente un coût estimé de 585 $. Soixante-quatre familles (80 %) ont rempli le questionnaire, et presque toutes (63 [98 %]) se sont dites globalement satisfaites de leur expérience de télésanté. La satisfaction des fournisseurs de soins était également élevée, tant en ce qui a trait à l'interface utilisateur des outils technologiques qu'à l'efficacité clinique. Le programme n'a eu aucun effet sur le temps d'attente général pour une consultation en chirurgie pédiatrique. Conclusion: L'utilisation de services de télésanté en chirurgie pédiatrique a été d'une grande valeur pour les patients et leur famille. Du point de vue des fournisseurs de soins, elle a constitué une solution de rechange acceptable aux consultations en personne.

Aggressive Surgical Management of Congenital Diaphragmatic Hernia: Worth the Effort?: A Multicenter, Prospective, Cohort Study.

OBJECTIVE: The objectives of this study were (i) to evaluate infants with congenital diaphragmatic hernia (CDH) that do not undergo repair, (ii) to identify nonrepair rate by institution, and (iii) to compare institutional outcomes based on nonrepair rate. BACKGROUND: Approximately 20% of infants with CDH go unrepaired and the threshold to offer surgical repair is variable. METHODS: Data were abstracted from a multicenter, prospectively collected database. Standard clinical variables, including repair (or nonrepair), and outcome were analyzed. Institutions were grouped based on volume and rate of nonrepair. Preoperative mortality predictors were identified using logistic regression, expected mortality for each center was calculated, and observed /expected (O/E) ratios were computed for center groups and compared by Kruskal-Wallis ANOVA. RESULTS: A total of 3965 infants with CDH were identified and 691 infants (17.5%) were not repaired. Nonrepaired patients had lower Apgar scores (P < 0.05) and increased incidence of anomalies (P < 0.0001). Low-volume centers ("Lo", n=44 total, < 10 CDH pts/yr) and high-volume centers ("Hi", n = 21) had median nonrepair rates of 19.8% (range 0%-66.7%) and 16.7% (5.1%-38.5%), respectively. High-volume centers were further dichotomized by rate of nonrepair (HiLo = 5.1-16.7% and HiHi = 17.6-38.5%), leaving 3 groups: HiLo, HiHi, and Lo. Predictors of mortality were lower birth weight, lower Apgar scores, prenatal diagnosis, and presence of congenital anomalies. O/E ratios for mortality in the HiLo, HiHi, and Lo groups were 0.81, 0.94, and 1.21, respectively (P < 0.0001). For every 100 CDH patients, HiLo centers have 2.73 (2.4-3.1, 95% confidence interval) survivors beyond expectation. CONCLUSIONS: There are significant differences between repaired and nonrepaired CDH infants and significant center variation in rate of nonrepair exists. Aggressive surgical management, leading to a low rate of nonrepair, is associated with improved risk-adjusted mortality.

Conservative therapy for appendicitis in children.

Question A 10-year-old girl who was seen in my office last week with acute-onset abdominal pain and fever was referred to an emergency department, was diagnosed with appendicitis, and was treated conservatively with antibiotics, without surgery. Has the paradigm for treating appendicitis changed, and which is the preferred treatment of appendicitis in children: antibiotics or appendectomy?Answer For more than 100 years, surgical management was the principal treatment of acute appendicitis. Potential adverse events associated with appendectomy include bleeding, surgical site infection, and ileus, as well as stress for children and their parents. The option of treating appendicitis with antibiotics has been known for decades, which has led to consideration of antibiotics alone as a therapeutic alternative to surgery for uncomplicated appendicitis. While there is a reasonable body of evidence in support of this practice in adults, the accumulation of evidence of the safety and effectiveness of non-operative management in children is ongoing. Large studies are still needed, and those are being conducted at this time, with results expected in the next few years.

Management of gastroschisis.

PURPOSE OF REVIEW: The diagnosis and treatment of gastroschisis spans the perinatal disciplines of maternal fetal medicine, neonatology, and pediatric surgery. Since gastroschisis is one of the commonest and costliest structural birth defects treated in neonatal ICUs, a comprehensive review of its epidemiology, prenatal diagnosis, postnatal treatment, and short and long-term outcomes is both timely and relevant. RECENT FINDINGS: The incidence of gastroschisis has increased dramatically over the past 20 years, leading to a renewed interest in causation. The widespread availability of maternal screening and ultrasound results in very high rates of prenatal diagnosis, which enables evaluation of the optimal timing and mode of delivery. The preferred method of surgical closure continues to be an issue of debate among pediatric surgeons, whereas postsurgical treatment seeks to expedite the initiation and progression of enteral feeding and minimize complications. A small subset of babies with complex gastroschisis leading to intestinal failure benefit from the knowledge and expertise of dedicated interdisciplinary teams, which seek to bring novel therapies and improved clinical outcomes. SUMMARY: The opportunities to increase the knowledge of causation, and identify best practices leading to improved outcomes, drive the ongoing need for collaborative clinical research in gastroschisis.

Recommendations for surgical safety checklist use in Canadian children's hospitals.

BACKGROUND: There is ample evidence that avoidable harm occurs in patients, including children, who undergo surgical procedures. Among a number of harm mitigation strategies, the use of surgical safety checklists (SSC) is now a required organizational practice for accreditation in all North American hospitals. Although much has been written about the effects of SSC on outcomes of adult surgical patients, there is a paucity of literature on the use and role of the SSC as an enabler of safe surgery for children. METHODS: The Pediatric Surgical Chiefs of Canada (PSCC) advocates on behalf of all Canadian children undergoing surgical procedures. We undertook a survey of the use of SSC in Canadian children's hospitals to understand the variability of implementation of the SSC and understand its role as both a measure and driver of patient safety and to make specific recommendations (based on survey results and evidence) for standardized use of the SSC in Canadian children's hospitals. RESULTS: Survey responses were received from all 15 children's hospitals and demonstrated significant variability in how the checklist is executed, how compliance is measured and reported, and whether or not use of the checklist resulted in specific instances of error prevention over a 12-month observation period. There was near unanimous agreement that use of the SSC contributed positively to the safety culture of the operating room. CONCLUSION: Based on the survey results, the PSCC have made 5 recommendations regarding the use of the SSC in Canadian children's hospitals.

CONTEXTE: Il a été prouvé maintes fois que les patients, y compris les enfants, sur qui des interventions chirurgicales sont pratiquées peuvent subir des méfaits évitables. Les normes d'agrément exigent dorénavant de tous les hôpitaux d'Amérique du Nord qu'ils utilisent une liste de contrôle de la sécurité chirurgicale, l'une des stratégies susceptibles de réduire ces méfaits. Si de nombreux articles portent sur l'efficacité d'une telle liste lors d'interventions chirurgicales sur des patients adultes, peu d'études ont été publiées sur l'utilisation et le rôle de ces listes dans le contexte de la sécurité des interventions chirurgicales effectuées sur des enfants. MÉTHODES: L'organisme Pediatric Surgical Chiefs of Canada (PSCC) représente tous les enfants canadiens qui subissent des interventions chirurgicales. Nous avons mené un sondage auprès des hôpitaux canadiens pour enfants pour déterminer le degré de mise en oeuvre de la liste de contrôle d'un endroit à l'autre, pour comprendre son rôle dans l'évaluation et l'amélioration de la sécurité des patients et pour formuler des recommandations précises (d'après les données probantes et les résultats obtenus) afin d'en normaliser l'utilisation dans les hôpitaux pour enfants du Canada. RÉSULTANTS: Les 15 hôpitaux pour enfants ont tous répondu à notre sondage. Leurs réponses étaient très variées en ce qui concerne la mise en oeuvre de la liste de contrôle, la façon dont ils évaluent et documentent le respect de la liste et l'efficacité de celle-ci à prévenir des erreurs concrètes pendant la période de 12 mois à l'étude. Les répondants ont indiqué presque à l'unanimité que la liste de contrôle favorisait grandement une culture de sécurité en salle d'opération. CONCLUSION: À partir de ces résultats, le PSCC a formulé 5 recommandations concernant l'utilisation de la liste de contrôle dans les hôpitaux pour enfants du Canada.

The Canadian Pediatric Surgery Network Congenital Diaphragmatic Hernia Evidence Review Project: Developing national guidelines for care.

The Canadian Pediatric Surgery Network (CAPSNet) has been collecting population-based data regarding congenital diaphragmatic hernia (CDH) across its 17 perinatal sites since 2005. With >500 infants registered to date, CAPSNet has addressed many critical knowledge gaps pertaining to CDH care. Most importantly, it has identified variability in both CDH practice and outcome across Canada. Using the successful Evidence-based Practice for Improving Quality (EPIQ) method, CAPSNet is undertaking a national, multidisciplinary effort to standardize best practices for CDH, from prenatal diagnosis to hospital discharge, based on the best available evidence. The present article outlines the value of clinical research networks and the process CAPSNet will undertake to produce national consensus guidelines for CDH care.

Le Réseau canadien de chirurgie pédiatrique recueille des données en population sur la hernie diaphragmatique congénitale (HDC) dans 17 sites périnatals depuis 2005. Puisque plus de 500 nourrissons y sont inscrits jusqu'à présent, le Réseau a corrigé de nombreuses lacunes liées aux soins de la HDC. Qui plus est, il a décelé la variabilité dans la pratique et les résultats de la HDC au Canada. Selon la méthode EPIC (un acronyme anglais qui signifie pratique fondée sur des données probantes pour améliorer la qualité), le Réseau déploie des efforts nationaux et multidisciplinaires pour normaliser les pratiques exemplaires en matière de soins de la HDC, du diagnostic prénatal au congé de l'hôpital, d'après les meilleures données probantes. Le présent article souligne la valeur des réseaux de recherche clinique et le processus que le Réseau entreprendra pour produire des lignes directrices consensuelles nationales sur les soins de la HDC.

Delivery planning for pregnancies with gastroschisis: findings from a prospective national registry.

OBJECTIVE: The purpose of this study was to determine the influence of planned mode and planned timing of delivery on neonatal outcomes in infants with gastroschisis. STUDY DESIGN: Data from the Canadian Pediatric Surgery Network cohort were used to identify 519 fetuses with isolated gastroschisis who were delivered at all tertiary-level perinatal centers in Canada from 2005-2013 (n = 16). Neonatal outcomes (including length of stay, duration of total parenteral nutrition, and a composite of perinatal death or prolonged exclusive total parenteral nutrition) were compared according to the 32-week gestation planned mode and timing of delivery with the use of the multivariable quantile and logistic regression. RESULTS: Planned induction of labor was not associated with decreased length of stay (adjusted median difference, -2.6 days; 95% confidence interval [CI], -9.9 to 4.8), total parenteral nutrition duration (adjusted median difference, -0.2 days; 95% CI, -6.4 to 6.0), or risk of the composite adverse outcome (relative risk, 1.7; 95% CI, 0.1-3.2) compared with planned vaginal delivery after spontaneous onset of labor. Planned delivery at 36-37 weeks' gestation was not associated with decreased length of stay (adjusted median difference, 5.9 days; 95% CI, -5.7 to 17.5), total parenteral nutrition duration (adjusted median difference, 3.2 days; 95% CI, -7.9 to 14.3), or risk of composite outcome (relative risk, 2.3; 95% CI, 0.8-5.4) compared with planned delivery at ≥38 weeks' gestation. CONCLUSION: Infants with gastroschisis who were delivered after planned induction or planned delivery at 36-37 weeks' gestation did not have significantly better neonatal outcomes than planned vaginal delivery after spontaneous onset of labor and planned delivery at ≥38 weeks' gestation.

Maternal risk factors for gastroschisis in Canada.

BACKGROUND: Gastroschisis is a congenital abdominal wall defect that occurs in one per 2200 pregnancies. Birth defect surveillance in Canada has shown that the prevalence of gastroschisis has increased threefold over the past 10 years. The purpose of this study was to compare maternal exposures data from a national gastroschisis registry with pregnancy exposures from vital statistics to understand maternal risk factor associations with the occurrence of gastroschisis. METHODS: Using common definitions, pregnancy cohorts were developed from two databases. The Canadian Pediatric Surgery Network database, a population-based dataset was used to record maternal exposures for women who experienced a gastroschisis pregnancy, while a contemporaneous, geographically cross-sectional "control" cohort of pregnant women and their exposures was developed from Canadian Community Health Survey data. Groups comparison of maternal risk factors was performed using univariate and multivariate logistic generalized estimating equation techniques. RESULTS: A total of 692 gastroschisis pregnancies (from Canadian Pediatric Surgery Network) and 4708 pregnancies from Canadian Community Health Survey were compared. Younger maternal age (odds ratio, 0.85; 95% confidence interval, 0.83-0.87; p < 0.0001), smoking (odds ratio, 2.86; 95% confidence interval, 2.22-3.66; p < 0.0001), a history of pregestational or gestational diabetes (odds ratio, 2.81; 95% confidence interval, 1.42-5.5; p = 0.0031), and use of medication to treat depression (odds ratio, 4.4; 95% confidence interval, 1.38-11.8; p = 0.011) emerged as significant associations with gastroschisis pregnancies. CONCLUSION: Gastroschisis in Canada is associated with maternal risk factors, some of which are modifiable. Further studies into sociodemographic birth defect risk are necessary to allow targeted improvements in perinatal health service delivery and health policy.

Advances in the Surgical Treatment of Gastroschisis.

Gastroschisis (GS) is a structural defect of the anterior abdominal wall, usually diagnosed antenatally, that occurs with a frequency of approximately 4 per 10,000 pregnancies. Babies born with GS require neonatal intensive care and surgical management of the abdominal wall defect soon after birth. Although contemporary survival rates for GS are over 90%, these babies are at risk for significant morbidity, and require 4 to 6 weeks of costly, resource-intensive care in specialized neonatal units. Much consideration has been given to how best to treat the abdominal wall defect of GS. The traditional approach, necessitated by a need to establish enteral feeding as quickly as possible, consists of early postnatal visceral reduction and sutured abdominal closure. Advances in neonatal nutritional support have enabled the development of surgical approaches, which permit gradual visceral reduction and delayed abdominal closure. In cases where early visceral reduction cannot be achieved, delayed closure enabled by the initial placement of a prosthetic silo has been a live-saving alternative. The development of preformed silos has simplified their use and led to an interest in treating all cases with a delayed closure philosophy. Most recently, a sutureless technique of abdominal closure has been reported, which has the benefit of avoiding general anesthesia and offers other outcome improvements over sutured closure of the defect. The debate over primary closure versus silo placement and delayed closure continues to receive much attention. The goal of this article is to review historical aspects of gastroschisis closure, and then focus on current surgical techniques, including the innovative sutureless closure, with an analysis of the comparative clinical effectiveness of these approaches to treatment of the abdominal wall defect in GS.

The promise and pitfalls of care standardization in congenital diaphragmatic hernia.

The aim of standardizing care is to enhance patient outcomes and optimize healthcare delivery by minimizing variations in care and ensuring the efficient allocation of healthcare resources. Despite these potential benefits to patients, healthcare providers and the healthcare system, standardization may also disadvantage these groups. With a specific focus on congenital diaphragmatic hernia, this article will review the promise and pitfalls of standardization, as well as a potential path forward that uses standardization to improve outcomes in this rare and complex disease process.

Decreased ß-catenin Protein in Lungs From Human Congenital Diaphragmatic Hernia Archival Pathology Specimens: A Case-control Study.

BACKGROUND: Lung hypoplasia contributes to congenital diaphragmatic hernia (CDH) associated morbidity and mortality. Changes in lung wingless-type MMTV integration site family member (Wnt)-signalling and its downstream effector beta-catenin (CTNNB1), which acts as a transcription coactivator, exist in animal CDH models but are not well characterized in humans. We aim to identify changes to Wnt-signalling gene expression in human CDH lungs and hypothesize that pathway expression will be lower than controls. METHODS: We identified 51 CDH cases and 10 non-CDH controls with archival formalin-fixed paraffin-embedded (FFPE) autopsy lung tissue from 2012 to 2022. 11 liveborn CDH cases and an additional two anterior diaphragmatic hernias were excluded from the study, leaving 38 CDH cases. Messenger ribonucleic acid (mRNA) expression of Wnt-signalling effectors WNT2B and CTNNB1 was determined for 19 CDH cases and 9 controls. A subset of CDH cases and controls lung sections were immunostained for ß-catenin. Clinical variables were obtained from autopsy reports. RESULTS: Median gestational age was 21 weeks. 81% (n = 31) of hernias were left-sided. 47% (n = 18) were posterolateral. Liver position was up in 81% (n = 31) of cases. Defect size was Type C or D in 58% (n = 22) of cases based on autopsy photos, and indeterminable in 42% (n = 16) of cases. WNT2B and CTNNB1 mRNA expression did not differ between CDH and non-CDH lungs. CDH lungs had fewer interstitial cells expressing ß-catenin protein than non-CDH lungs (13.2% vs 42.4%; p = 0.006). CONCLUSION: There appear to be differences in the abundance and/or localization of ß-catenin proteins between CDH and non-CDH lungs. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Case-Control Study.

Use of safety scalpels and other safety practices to reduce sharps injury in the operating room: what is the evidence?

BACKGROUND: The occupational hazard associated with percutaneous injury in the operating room (OR) has encouraged harm reduction through behaviour change and the use of safety-engineered surgical sharps. Some Canadian regulatory agencies have mandated the use of "safety scalpels." Our primary objective was to determine whether safety scalpels reduce the risk of percutaneous injury in the OR, while a secondary objective was to evaluate risk reduction associated with other safety practices. METHODS: We used evidence review methods described by the International Liaison Committee on Resuscitation and conducted a systematic, English-language search of Ovid, MEDLINE and EMBASE using the following search terms: "safety-engineered scalpel," "mistake proofing device," "retractable/removable blade/scalpel," "pass tray," "hands free passing," "neutral zone," "sharpless surgery," "double/cutproof gloving" and "blunt suture needles." Included articles were scored according to level of evidence; quality; and whether they were supportive, opposed or neutral to the study question(s). RESULTS: Of 72 included citations, none was supportive of the use of safety scalpels. There was high-level/quality evidence (Cochrane reviews) in support of risk reduction through double-gloving and use of blunt suture needles, with additional evidence supporting a pass tray/neutral zone for sharps handling (4 of 5 articles supportive) and use of suturing adjuncts (1 article supportive). CONCLUSION: There is insufficient evidence to support regulated use of safety scalpels. Injury-reduction strategies should emphasize proven methods, including double-gloving, blunt suture needles and use of hands-free sharps transfer.

CONTEXTE: Les risques professionnels associés aux lésions percutanées subies à la salle d'opération ont favorisé la réduction des préjudices grâce à des changements de comportement et à l'utilisation d'aiguilles et de lames chirurgicales conçues en fonction de la sécurité. Certaines agences de réglementation du Canada ont imposé l'utilisation de « scalpels de sécurité ¼. Nous voulions déterminer principalement si les scalpels de sécurité réduisent le risque de lésions percutanées à la salle d'opération et, dans un deuxième temps, évaluer la réduction du risque associée à d'autres mesures de sécurité. MÉTHODES: Nous avons utilisé des méthodes d'examen des données probantes décrites par le Comité international de liaison sur la réanimation et procédé à une recherche systématique en anglais dans les bases de données Ovid, MEDLINE et EMBASE en utilisant les termes de recherche suivants : « safety-engineered scalpel ¼, « mistake proofing device ¼, « retractable/removable blade/scalpel ¼, « pass tray ¼, « hands free passing ¼, « neutral zone ¼, « sharpless surgery ¼, « double/cutproof gloving ¼ et « blunt suture needles ¼. Nous avons évalué les articles inclus en fonction du niveau de preuve, de la qualité et de la prise de position en faveur des questions à l'étude, contre celles ci ou neutre. RÉSULTANTS: Sur 72 citations incluses, aucune n'appuyait l'utilisation des scalpels de sécurité. Des éléments probants de haut niveau ou de grande qualité (examens Cochrane) appuyaient la réduction des risques par le port de doubles gants et l'utilisation d'aiguilles émoussées, et d'autres éléments de preuve appuyaient l'utilisation d'un plateau de transition ou d'une zone neutre pour la manipulation des aiguilles ou des lames (4 articles sur 5 en faveur) et l'utilisation de moyens auxiliaires de suture (1 article en faveur). CONCLUSIONS: Il n'y a pas suffisamment de preuves pour appuyer l'utilisation réglementée de scalpels de sécurité. Les stratégies de réduction des traumatismes devraient mettre l'accent sur les méthodes éprouvées, y compris le port de doubles gants, l'usage d'aiguilles émoussées et l'utilisation de moyens mains libres de transfert des aiguilles et des lames.

Management of the base of the appendix in pediatric laparoscopic appendectomy: clip, ligate, or staple?

Options for intracorporeal appendiceal stump closure span a variety of techniques including ligation using intra-corporeal knots, extra-corporeal knots, or an endo-loop (EL), closure with endoscopic clips (EC), or endoscopic stapled (ES) closure. The guiding principles are the need for secure, inert closure of the appendiceal base without injury to the appendiceal stump or cecum, with minimal risks of complication attributable to the closure technique. Safety and complication rates, as well as cost data, should guide the techniques used for pediatric laparoscopic appendectomy. Based on the literature available there is not a clear answer as to the best method for closing the appendiceal stump in pediatric patients, with each of the methods described providing safe closure. Many institutions and surgeons may favor a selective approach, with choice of closure determined by the condition of the appendix at laparoscopy.

High frequency jet ventilation for congenital diaphragmatic hernia.

BACKGROUND: The optimal role of high frequency jet ventilation (HFJV) in lung protective stabilization of congenital diaphragmatic hernia (CDH) remains uncertain. We aimed to describe our center's experience with HFJV as both a rescue (following failed stabilization with CMV) and primary ventilation mode in the management of CDH. METHODS: Liveborn CDH patients treated from 2013 to 2021 in a single institution were reviewed. We compared 3 groups based on their primary and last ventilation mode prior to surgery: CMV (Group 1); HFJV (Group 2); and CMV/HFJV (Group 3). Outcomes included a composite primary outcome (≥1 of mortality, need for ECMO or need for supplemental O2 at discharge), total invasive ventilation days and development of pneumothorax. A descriptive analysis including univariate group comparisons was performed. Multivariate logistic regression models investigating the relationship between mode of ventilation and the primary outcome adjusted by potentially confounding covariates were constructed. RESULTS: 56 patients (32 Group 1, 18 Group 2, 6 Group 3) were analyzed. Group 2 and 3 patients had more severe disease based on liver position, SNAP-II score, pulmonary hypertension severity, need for inotropic support, CDHSG defect size and need for patch repair. There were no group differences in survival, need for ECMO, or pneumothorax occurrence, although infants receiving HFJV required longer invasive ventilation and had a greater need for O2 at discharge. Multivariate logistic regression revealed no associations between mode of ventilation and outcome. CONCLUSIONS: HFJV appears effective, both for CMV rescue and as a primary ventilation strategy in high risk CDH. LEVEL OF EVIDENCE: Level IV.

Disparities in surgical health service delivery and outcomes for indigenous children.

BACKGROUND: Evidence of health disparities for Indigenous children requiring surgical care is lacking. We present a systematic review of the literature examining possible disparities in surgical care and outcomes for pediatric patients of Indigenous ethnicity. DATA SOURCES: PubMed, Cochrane, MEDLINE, gray literature. METHODS: Literature review, using PubMed, Cochrane, MEDLINE, and gray literature was conducted to identify articles published more than 2010-2020 examining children's surgical health service delivery (epidemiology, access, operations provided) and outcomes for pediatric patients of Indigenous ethnicity compared with others. Extracted data included study design, setting, participant race/ethnicity, operations examined, and surgical outcomes. Article quality was assessed using the Newcastle-Ottawa Scales. RESULTS: From 411 abstracts, 125 articles were reviewed and 33 included for data abstraction. These were cohort and cross-sectional studies investigating a wide range of patient populations and procedures across the United States, Canada, Australia, and New Zealand. Articles were organized naturally by theme into birth malformations (15 articles), trauma (6 articles), pediatric general surgery/appendicitis (5 articles), pediatric otolaryngology (6 articles), and renal transplant (1 article) surgery. Four articles also described access and resource utilization related to inpatient care. Notable disparities observed included apparent increased prevalence of gastroschisis, rates of traumatic fatality, non accidental injury, and self harm among North American Indigenous children. CONCLUSIONS: Indigenous children appear to be vulnerable to a number of health and treatment outcome disparities related to conditions treated by surgeons. Surgeons are thus uniquely poised to act in identifying and eliminating Indigenous ethnicity-based pediatric health disparities.