Canadian Association Of Pediatric Surgeons Research Articles

A Canadian national survey: Perspectives on routine pathological examination of hernia sacs after inguinal hernia and hydrocele repair among pediatric urologists, surgeons, and pathologists

This study aims to understand perspectives on routine pathological examination of hernia sacs following pediatric inguinal hernia and hydrocele repair among Canadian pediatric urologists, surgeons, and pathologists. All active members of Pediatric Urologists of Canada (PUC), Canadian Association of Pediatric Surgeons (CAPS), and the divisional heads of anatomical pathology at the Canadian children's hospitals (AP) were invited to participate between June 2019 and January 2021 in an anonymous multiple-choice-based questionnaire. The response rates were 71% from PUC (24/34), 20% from CAPS (25/130), and 64% from AP (7/11). The majority of the surgeons (PUC:54%, CAPS:68%) did not routinely send hernia sacs for pathological examination after inguinal hernia repair. Most felt there was a little value in such examination (PUC:96%, CAPS:72%). Among those who submit hernia sacs, the majority did not receive reports that were clinically significant impacting patient management (PUC:82%, CAPS:50%). On the other hand, the pathologists had mixed opinion on the value of examining hernia sacs. Most of them only did gross examination (86%), unless requested by surgeons or concerning features were noted on gross examination. The majority have found clinically meaningful abnormal findings (71%), including vas deferens and portions of the spermatic cord. Currently, there are no evidence-based clinical guidelines on pathological assessment of hernia sacs after pediatric inguinal hernia and hydrocele repair. Instead of making it mandatory, future guidelines should highlight specimens that should be submitted for further investigations (e.g., challenging cases where inadvertent surgical injuries might have occurred). Future studies should also address whether patients who may be at higher risk of having clinically significant pathology can be identified pre- or perioperatively to more efficiently triage specimens that would benefit from pathological examination. Limitation of the study includes low response rate from the CAPS members during the COVID-19 pandemic. While most of the pediatric urologists and surgeons felt there is a little value of pathological examination of hernia sacs following inguinal hernia and hydrocele repair, half of the anatomical pathologists felt there is value. Future studies should aim to establish evidence-based clinical guidelines taking stakeholders perspectives into consideration.

Management of the normal-appearing appendix during laparoscopy for clinically suspected acute appendicitis in the pediatric population

PurposeThe widespread use of laparoscopy has brought forth the question of how to manage a macroscopically normal-appearing appendix in cases of clinically suspected appendicitis. This study aimed to determine the current practices of pediatric general surgeons in Canada regarding this matter. MethodsAn online survey was created following the American Pediatric Surgical Association (APSA) guidelines and distributed via email to the Canadian Association of Pediatric Surgeons (CAPS) staff surgeons. The questions assessed clinician characteristics, standard practice, and rationale. Results were analyzed using descriptive statistics. ResultsA total of 54/72 (75%) CAPS members practicing in Canada completed the survey. All (100%) agreed they would remove a normal-appearing appendix during laparoscopy for suspected acute appendicitis. The most common reasons were: possibility of microscopic appendicitis (39/54, 72.2%), avoiding future diagnostic confusion (28/54, 51.9%), and patient preference/consent discussion (21/54, 38.9%). Most (53/54, 98.1%) had performed a negative appendectomy and 49/54 (90.7%) agreed there were no sufficient guidelines. ConclusionsThe majority of pediatric surgeons agree sufficient guidelines do not exist to support decision making when a normal-appearing appendix is found during laparoscopy for suspected acute appendicitis. This survey shows that removal of the appendix in this case would be supported by the majority of Canadian pediatric surgeons. Type of studySurvey Level of evidenceVII (Expert Opinion)

P148: What do surgeons expect of the Emergency Department in the diagnosis and management of pediatric appendicitis?

Introduction: The optimal diagnostic strategy for children presenting to the Emergency Department (ED) with suspected appendicitis (SA), the most common non-traumatic surgical emergency in children, remains unclear. This study aims to identify which investigations and management priorities are preferred by Canadian surgeons prior to consultation from the ED. Methods: An internet survey was extended to practicing surgeons who are members of the Canadian Association of Pediatric Surgeons and Canadian Association of General Surgeons. Three case-based scenarios evaluated surgeons expected ED investigations and management for SA with varying severity of disease (simple - SA vs perforated - PA) and sex (male vs female). Differences across scenarios were determined by ANOVA and direct comparisons were reported using proportions and odds ratios with 95% confidence intervals. Results: Surveys were completed by 82 surgeons. Across the 3 cases, CBC (227/246, 92.3%) and urinalysis (188/246, 76.4%) were the sole investigations expected in >75% of responses. Expectations differed across cases for use of blood cultures (p<0.001), electrolytes (p<0.001), sexually transmitted infection testing (0.015) and ultrasound (US) (p<0.001). Blood cultures (26/82, 31.7% vs 4/82, 4.9%; OR 9.05 95%CI 2.88-37.33) and electrolytes (58/82, 70.7% vs 33/82, 40.2%; OR 3.59 95%CI 1.79-7.24) were expected more often in severe disease. US was expected more often in females (58/82,70.7% vs 25/82, 30.5%; OR 5.51, 95% CI 2.68-11.38). Expected management differed across cases for fluid boluses (p=0.01), intravenous (IV) analgesia (p<0.001) and antibiotics (p<0.001), with all differences attributed to severity of illness (fluids 73/82, 89.0% vs 59/82, 72.0% OR 3.16 95%CI 1.28-8.33; IV analgesia 66/82, 80.5% vs 42/82, 51.2% OR 3.93 95%CI 1.86-8.45; antibiotics 44/82, 53.7% vs 10/82, 12.2% OR 8.34 95%CI 3.59-20.44). Conclusion: Severity of illness and sex of the child impact the ED investigations and management expected by surgeons consulted for suspected appendicitis. Further research focusing on how these expectations influence patient outcomes should be conducted. Collaborative ED-surgery protocols for the diagnosis and management of acute appendicitis in children should be established.

The Shrinking Landscape of Pediatric Surgery: Is Less More?

The Fred MacLeod Lecture was given at the 49th Annual Canadian Association of Pediatric Surgeons meeting held October 5-7th, 2017, in Banff, Alberta, Canada.

The 49th annual meeting of the Canadian Association of Pediatric Surgeons.

The 49th annual meeting of the Canadian Association of Pediatric Surgeons.

The level of evidence keeps improving: An updated analysis of the scientific program at the Canadian Association of Paediatric Surgeons Annual Meeting

IntroductionThe purpose of this study is to examine the scientific program of the Canadian Association of Pediatric Surgeons (CAPS) to determine if the quality of research has improved. MethodsCAPS abstracts from 2010 to 2013 were reviewed by two independent researchers. Presentation type, study design, and level of evidence (LOE) were recorded. All differences were adjudicated by an epidemiologist. Fisher's exact test compared results to a previous study that assessed LOE in CAPS abstracts from 2005 to 2009. Results291 abstracts were reviewed with 53 excluded and 238 included in final analysis. Reviewers demonstrated high agreement for study design (ICC=0.767 95%CI 0.715–0.810) and LOE (ICC=0.914 95%CI 0.892–0.931). Out of 238 studies, 117 (49%) were podium and 122 (51%) posters. Number of high-quality studies increased in 2010–2013 versus 2005–2009 (n=253), specifically systematic reviews (n=15 (6%) vs. n=3 (1%) p<0.01), randomized controlled trials (n=4 (2%) vs. n=0 (0%), p=0.05), and prospective cohort studies (n=41 (17%) vs. n=26 (10%), p<0.001). Retrospective cohort is still the most common. However, the number of studies has significantly decreased (n=121 (51%) vs. n=171 (68%), p<0.001). The proportion of high-level studies (LOE 2 or better) also improved (48 (20%) vs. 24 (10%) p<0.001). ConclusionThe quality of research presented at CAPS has greatly improved, especially in the past five years.

Post-operative management of esophageal atresia–tracheoesophageal fistula and gastroesophageal reflux: A Canadian Association of Pediatric Surgeons annual meeting survey

BackgroundEsophageal atresia (EA), with or without tracheoesophageal fistula (TEF), is commonly associated with gastroesophageal reflux (GER) after surgical repair. One risk factor for anastomotic stricture is post-operative GER. This survey assessed practice patterns among attendees at the Canadian Association of Pediatric Surgeons (CAPS) annual meeting with respect to management of GER post EA-TEF repair. MethodsA pre-piloted survey was handed out and collected at the 2012 CAPS annual meeting. Data were entered and coded, and descriptive statistics were calculated. ResultsWe distributed 70 surveys, and 57 (81.4%) surveys were returned. On average, the incidence of EA-TEF is 8–10 cases per institution, per year. Anti-reflux medication is started immediately post-operatively in 74% of patients at institution of feeds (11%), or if symptoms of reflux develop (14%). Proton pump inhibitors and H2-receptor antagonists are used in approximately equal proportion. Patients are typically kept on anti-reflux medication for 3–6months (37%) or 6–12months (35%). ConclusionsMost CAPS attendees treat postoperative GER prophylactically. However, there is no consistency in management strategy regarding which anti-reflux agent to use or for how long. A multi-centered study is required to establish a standardized protocol for the post-operative management of EA-TEF to prevent reflux and its effect on anastomotic strictures.

The Pediatric Laparoscopic Surgery (PLS) simulator: Methodology and results of further validation

BackgroundThe Pediatric Laparoscopic Surgery (PLS) simulator is the only validated tool for pediatric Minimal Access Surgery. Construct validity (the ability to discriminate between novice, intermediate and expert) for the PLS simulator had previously been established on the basis of the total PLS score, as well as the individual performance on three of the five tasks. We describe the process and methods used to establish independent construct validity for a fourth task: pattern-cutting. MethodsAfter considering various options for the possible modifications of the task itself, we retrospectively altered the way the pattern-cutting task was scored by modifying the weighting of precision versus time without changing the task itself. This was subsequently tested prospectively at the 2011 Canadian Association of Pediatric Surgeons meeting. ResultsModification in the scoring metrics allowed differentiation within a previously tested cohort of 84 candidates (20 novices: score=48±16, 19 intermediates: score=59±18, 45 experts: score=69±12 p=0.01). This was validated prospectively in a cohort of 18 experts and 7 intermediates (65±8, 54±17 p=0.03). ConclusionsConstruct validity for the pattern-cutting task was established by modification of the scoring metrics. This was validated both retrospectively and prospectively.

Classification and appraisal of the level of clinical evidence of publications from the Canadian Association of Pediatric Surgeons for the past 10 years

Introduction Increasing evidence is placed on the evidence-based quality of publications. We classified the publication type and assessed the reporting quality of the highest evidence level publications from the Canadian Association of Pediatric Surgeons between 1998 and 2007. Methods All publications from Canadian Association of Pediatric Surgeons issues in the Journal of Pediatric Surgery from 1998 to 2007 were classified by study type and level of evidence (Oxford Center for Evidence-based Medicine Levels of Evidence). Cohort studies (level 2) were evaluated by 2 independent assessors using the Newcastle-Ottawa Quality Assessment Scale (NOQAS). Reliability and χ 2 analyses were performed. Results Three hundred two publications were classified by level of evidence as follows: level 2, 46; level 3, 13; level 4, 109; and level 5, 134. The median NOQAS score of the 46 level-2 cohort studies was 8 (range, 5-9), and the interrater reliability was 0.94 (95% confidence interval, 0.89-0.96). There was a significant increase in the number of level-2 evidence publications ( P = .001) over the study period. Conclusions Level-2 evidence cohort studies met a high scientific standard as assessed by the NOQAS and significantly increased in number over the study period. However, there were no level-1 evidence (randomized controlled trial) publications, and most were in the lower evidence classification levels (3-5).

The Canadian Association of Pediatric Surgeons' position paper on the pediatric surgeon and blood-borne pathogens

Blood-borne pathogens including, but not restricted to, hepatitis B and C and the human immunodeficiency virus (HIV) are transmittable during the course of surgical care. The available scientific data indicate that transmission of HIV and other infections such as hepatitis B or C from a physician, surgeon, or nurse is extremely rare. The Canadian Association of Pediatric Surgeons (CAPS) understands the concerns of caregivers about the potential risk of exposure to blood-borne pathogens for their patients from blood transfusions, other patients, and health care workers including pediatric surgeons and the devastating effect that a blood-borne pathogen transmission would have on both the patients, their family and the pediatric surgeons.

Canadian Association of Pediatric Surgeons' position statement on the use of all-terrain vehicles by children and youth

The goal of the Canadian Association of Pediatric Surgeons is to improve the surgical care of infants and children in Canada. Its areas of interest include all aspects of general and thoracic pediatric surgery with recognition of its unique responsibility to infants born with congenital anomalies and children with malignancies. Although its responsibility to pediatric trauma is not unique, that injury remains the number one cause of death of all children beyond infancy creates a pivotal role of this association in issues related to pediatric trauma. With modern methods of first aid, transportation, resuscitation, intensive care, and specialized surgical team effort, many of these seriously traumatized children can be saved. However, despite these advances in trauma care, it is recognized that the most important and ultimate approach to childhood injuries lies in the realm of prevention.

Lack of consensus among Canadian pediatric surgeons regarding the management of congenital cystic adenomatoid malformation of the lung

PurposeReview of the literature suggests that there is lack of consensus regarding the management of antenatally diagnosed congenital cystic adenomatoid malformation of the lung (CCAM) that is asymptomatic at birth. This study aims to describe the variability among Canadian pediatric surgeons in how this pathologic finding is managed. MethodsSurveys were sent to all practicing Canadian members of Canadian Association of Pediatric Surgeons. Responders were asked to state whether they recommend resection or nonoperative management and to describe the follow-up imaging type and frequency used. ResultsA 69% response rate was obtained. There was no consistency regarding the imaging modality used to detect asymptomatic CCAM. Sixty-seven percent of responders recommend resection of persistent but asymptomatic CCAM; there was neither consensus with regard to age at which resection is performed (2-18 months) nor technical considerations at resection (61% open, 83% lobectomy). Among the responders who do not recommend resection, the frequency of follow-up was variable (every 3 months to every year), as were the imaging modality used and the length of follow-up (3 years to indefinitely); 80% of neonates in whom nonoperative management was recommended initially ultimately underwent resection. ConclusionsLack of consensus among Canadian pediatric surgeons, and even within institutions, regarding the management of antenatally diagnosed CCAM in the asymptomatic neonate, is demonstrated. This clearly highlights the need for prospective studies.

The 38th Annual Meeting of the Canadian Association of Pediatric Surgeons

The beautiful city of Calgary was the backdrop for the meeting of the Canadian Association of Pediatric Surgeons (CAPS) held on September 7 to 10, 2006. Dr David Sigalet was our local host. The meeting was held for the first time in conjunction with the Canadian Association of General Surgeons (CAGS) to facilitate attendance to both meetings and encourage exchange of ideas and techniques. For the second time, the CAPS meeting included a poster sessions that was a joint poster presentation with CAGS during the welcoming reception.

Research publication in pediatric surgery: a cross-sectional study of papers presented at the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association

Introduction Several studies have examined predictors of publication of research presented in scientific meetings in different disciplines. A tendency toward publishing studies with positive results has been described as “publication bias.” Our objective was to determine the proportion of the studies that were published, time to publication, and factors that could predict publication in pediatric surgery. Methods The abstract books of the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association meetings for 2001 to 2002 were reviewed. Data were gathered regarding the methodology and characteristics of each study. Case reports and editorials were excluded. A Medline search was then conducted to determine the publication status. Analysis using univariate and multivariate techniques was undertaken, comparing the difference between published and unpublished studies. Results Two hundred seven abstracts were reviewed. Of the 183 abstracts included, 118 (64.5%) were published. Most studies were published 1 year after presentation (93.2%). Presentation in the American Pediatric Surgery Association meeting and research originating from North America and reporting statistically significant results were significantly associated with subsequent publication on univariate analysis. The presence of statistically significant results was the only factor associated with successful publication on multivariate analysis (odds ratio, 3.3; confidence interval, 1.5-7.7). Conclusion The strong association between successful publication and the presence of statistically significant results point to the strong possibility of publication bias affecting decisions made about publishing research in the pediatric surgery.

The 37th Annual Meeting of the Canadian Association of Pediatric Surgeons

The 37th Annual Meeting of the Canadian Association of Pediatric Surgeons

The two-week pediatric surgery rotation: is it time wasted?

Background With increasing medical school emphasis on generalist training and decreasing enrollment in surgical residency, the authors assessed the adequacy of a 2-week pediatric surgery rotation on meeting the learning and competency objectives outlined in The Canadian Association of Pediatric Surgeons’ Self-Directed Evaluation Tool. Methods A prospective survey was conducted of 39 clinical clerks. An anonymous self-assessment scale measuring competency objectives ( medical and psychosocial) was administered pre-and postrotation. Also, exposure to pediatric surgical conditions from a list of “essential” and “nonessential” learning objectives was measured. Statistical analysis was performed using paired t test with significance at .05 level. Results Response rate was 77% and 54% for the competency and learning objectives, respectively. Students reported improvement in medical ( P < .00001; 95% CI, 1.30, 1.90) and psychosocial ( P = .00036; 95% CI 0.64, 1.28) competency objectives after the rotation. Almost all “essential” learning objectives were met. Overall, students reported an increased awareness of the breadth of pediatric surgical practice ( P < .0001; 95% CI 2.06, 3.18). Conclusions A 2-week rotation in pediatric surgery appears adequate in fulfilling most competency and learning objectives, but discussion is needed about how to best assess student competency, which topics are considered essential, and the long-term effect on recruitment to the profession.