Common Pediatric Surgical Procedures Research Articles

Incidence of Surgically Managed Post-Tonsillectomy Hemorrhage Associated With NSAID Prescribing for Postoperative Pain Management.

Tonsillectomy ranks high among the most common pediatric surgical procedures in the United States. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as ibuprofen, are routinely prescribed to manage post-tonsillectomy pain, but may carry the risk of hemorrhage. This retrospective, longitudinal, secondary-data analysis study compared the incidence of surgically managed post-tonsillectomy hemorrhage (sPTH) in pediatric patients prescribed ibuprofen at Brooke Army Medical Center (BAMC) after tonsillectomy compared to a similar cohort of pediatric patients at the Children's Hospital of Philadelphia (CHOP) not prescribed ibuprofen. Additional regression analysis examined predictors of sPTH at BAMC. The odds of sPTH was lower in patients who were prescribed ibuprofen at BAMC, relative to patients who were not at CHOP (OR 0.57, 95% CI, 0.37, 0.87; P < 0.01). In a generalized linear model evaluating BAMC patient data, there was a lack of a relationship between reason for tonsillectomy (tonsillitis versus tonsillar obstruction), primary procedure (tonsillectomy-only versus tonsillectomy with adenoidectomy), and presence of a co-occurring procedure. Post-tonsillectomy ibuprofen prescribing practices were not associated with an elevated risk of sPTH, relative to patients at CHOP not exposed to ibuprofen.

STANDARD OPIATE PRESCRIBING IN PEDIATRIC AND ADOLESCENT GYNECOLOGIC SURGERY TO REDUCE OPIATE USE: BRIEF REPORT

Study objective: The aim of this quality improvement (QI) project was to assess postoperative narcotic use after pediatric gynecologic surgeries and establish standard postoperative opioid dosing. Through standard dosing we hoped to decrease variability in postoperative opioid prescriptions and decrease excess opioid doses in the community. Methods: This QI project was approved by the Children's Minnesota IRB. Counseling on postoperative pain management was provided pre- and post-operatively. At the two-week postoperative visit, patients were asked the number of opioid doses used and pain control satisfaction. Baseline data was collected for 6 months with surgeons prescribing the number of opioid doses based on their personal preference. After reviewing the prescribing practices and number of doses used, standard opioid doses were established, and data collection repeated. Results: Complete data was recorded for 30 cases prior to implementation of standard doses and for 29 cases following implementation. Standardized opioid dosing resulted in 30% decrease in total opioid doses in circulation (252→176 doses; P=0.014) and 15% reduction in excess doses in circulation (162→137 doses). Forty-three percent of patients did not use any opioid doses. There was no significant difference P=0.8818) in patient pain control satisfaction rating. Conclusions: Standard opioid dose prescribing is feasible for common pediatric gynecologic surgeries without affecting patient pain control satisfaction. Opioid dose standardization may decrease opioid circulation within the community. Approximately 2 out of every 5 patients used zero opioid doses which suggests further reduction in the standard dose prescriptions is possible.

A Standardized Post-gastrostomy Feeding Protocol for Pediatric Patients Reduces Time to Postoperative Goal Feeding Volume.

Gastrostomy creation is a common pediatric surgical procedure, but the time to initiation of feeds and to goal feeding volumes postoperatively varies greatly. Delays in reaching goal feeding volumes promote malnutrition and may prolong hospital length of stay. We hypothesized that implementing an accelerated, standardized post-gastrostomy feeding protocol would allow patients to reach goal feeding volumes sooner, without increasing postoperative complications. We conducted a retrospective cohort study of children who underwent gastrostomy tube placement between 1/1/2022 and 11/30/2023. The feeding protocol was implemented on 11/16/2022, with patients separated into pre- and post-protocol cohorts. Abstracted data included comorbidities, time to initiation of enteral feeds, time to goal feeding volume, and postoperative complications. 322 patients were included: 166 pre-protocol and 156 post-protocol. The post-protocol cohort had a greater proportion of patients with gastrointestinal and/or cardiac comorbidities (P < .001). Through the protocol, postoperative enteral feeds were initiated significantly faster (5.4hrs [IQR 43-7.7] vs 7.0hrs [IQR 5.6-14.3]; P < .001). The post-protocol cohort also achieved goal feeding volumes sooner (12.8hrs [IQR 9.1-25.3] vs 26.3hrs [IQR 21.6-38.9]; P < .001). Postoperative complication rates did not differ between cohorts. Sub-analysis of children with complex cardiac conditions also demonstrated faster time to goal nutrition without an associated increase in postoperative events. These findings demonstrate that our accelerated post-gastrostomy feeding protocol was effective in achieving goal enteral nutrition earlier without increasing postoperative adverse outcomes. This protocol may be used by other centers to safely expedite time to goal enteral feeds in children postoperatively.

Does celecoxib prescription for pain management impact post-tonsillectomy hemorrhage requiring surgery? A retrospective observational cohort study.

Adenotonsillectomy and tonsillectomy (now referred to as tonsillectomy thereafter) are common pediatric surgeries. Postoperative complications include hemorrhage requiring surgery (2-3% of cases) and pain. While non-steroidal anti-inflammatory drugs are commonly administered for post-surgical pain, controversy exists regarding bleeding risk with cyclo-oxygenase-1 inhibition and associated platelet dysfunction. Preliminary evidence suggests selective cyclo-oxygenase-2 inhibitors, for example celecoxib, effectively manage pain without adverse events including bleeding. Given the paucity of data for routine celecoxib use after tonsillectomy, we investigated the association between post-operative celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery using chart-review data from the Children's Hospital of Eastern Ontario, Canada. After ethics approval we performed a retrospective single-center observational cohort study in children <18 yrs undergoing tonsillectomy from January 2007 to December 2017. Cases of adenoidectomy alone were excluded due to low bleed rates. The primary outcome was the proportion of patients with post-tonsillectomy hemorrhage requiring surgery. The association between a celecoxib prescription and post-tonsillectomy hemorrhage requiring surgery was estimated using inverse probability of treatment weighting based on propensity scores and using generalized estimating equations to accommodate clustering by surgeon. An initial patient cohort of 6468 was identified and 5846 children with complete data were included in analyses. Median (interquartile range) age was 6.10 (4.40, 9.00) years and 46% were female. In our cohort, 28.1% (n=1644) were prescribed celecoxib. Among the 4996 tonsillectomy patients, 1.7% (n=86) experienced post-tonsillectomy hemorrhage requiring surgery. The proportion with post-tonsillectomy hemorrhage requiring surgery among patients who had a tonsillectomy and were or were not prescribed celecoxib was 1.94% (30/1548; 95% CI: 1.36-2.75) and 1.62% (56/3448; 95% CI: 1.25-2.10), respectively. Modelling did not identify an association between celecoxib prescription and increased odds of post-tonsillectomy hemorrhage requiring surgery (OR=1.4, 95% CI: 0.85-2.31, p=0.20). Celecoxib does not significantly increase the odds of post-tonsillectomy hemorrhage requiring surgery, after adjusting for covariates. This large pediatric cohort study of celecoxib administered after tonsillectomy provides compelling evidence for safety but requires confirmation with a multi-site randomized controlled trial.

Income-Based Disparities in Outcomes Following Pediatric Appendectomy: A National Analysis.

Appendectomy remains a common pediatric surgical procedure with an estimated 80,000 operations performed each year. While prior work has reported the existence of racial disparities in postoperative outcomes, we sought to characterize potential income-based inequalities using a national cohort. All non-elective pediatric (<18years) hospitalizations for appendectomy were tabulated in the 2016-2020 National Inpatient Sample. Only those in the highest (HI) and lowest income (LI) quartiles were considered for analysis. Multivariable regression models were developed to assess the independent association of income and postoperative major adverse events (MAE). Of an estimated 87,830 patients, 36,845 (42.0%) were HI and 50,985 (58.0%) were LI. On average, LI patients were younger (11 [7-14] vs 12 [8-15] years, P < .001), more frequently insured by Medicaid (70.7 vs 27.3%, P < .05), and more commonly of Hispanic ethnicity (50.8 vs 23.4%, P < .001). Following risk adjustment, the LI cohort was associated with greater odds of MAE (adjusted odds ratio [AOR] 1.30 95% confidence interval [CI] 1.06-1.64). Specifically, low-income status was linked with increased odds of infectious (AOR 1.65, 95% CI 1.12-2.42) and respiratory (AOR 1.67, 95% CI 1.06-2.62) complications. Further, LI was associated with a $1670 decrement in costs ([2220-$1120]) and a +.32-day increase in duration of stay (95% CI [.21-.44]). Pediatric patients of the lowest income quartile faced increased risk of major adverse events following appendectomy compared to those of highest income. Novel risk stratification methods and standardized care pathways are needed to ameliorate socioeconomic disparities in postoperative outcomes.

Care of the Pediatric Patient for Ambulatory Tonsillectomy With or Without Adenoidectomy: The Society for Ambulatory Anesthesia Position Statement.

The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Evaluating the Clinical Utility of Brachial Plexus Block for Reducing Opioid Exposure in Pediatric Elbow Fracture Surgery: A Retrospective Cohort Study.

Background and Objectives: Reducing opioid exposure in common pediatric surgeries is of paramount importance. This study aimed to assess the efficacy of regional nerve blocks in reducing opioid exposure while preserving high success rates. Materials and Methods: We conducted a retrospective matched cohort study (1:1) including patients with elbow fractures < 12 years old who underwent treatment with percutaneous pinning. Patients were divided into general-anesthesia (GA) and GA-followed-by-supraclavicular-brachial-plexus-block (GA-SCB) groups. The primary outcome was the number of patients administered postoperative rescue opioids. The secondary outcomes included intraoperative and postoperative opioid administration, the time to first request for rescue analgesia, pain scores, block success rate, block performing time, and block-related complications. Results: In a total of 478 patients, 363 underwent percutaneous pinning, and 86 were cohort-matched (GA: n = 43, GA-SCB: n = 43). On the first postoperative day, 34 (79.0%) patients in the GA group were administered postoperative rescue opioids, compared with 12 (27.9%) in the GA-SCB group (p < 0.001). All the patients in the GA-SCB group were opioid-free during the intraoperative period. No SCB-associated complications were observed. Total opioid consumption was significantly lower in the GA-SCB group than in the GA group until the first postoperative day (GA vs. GA-SCB, 3.2 ± 3.0 mg vs. 0.9 ± 1.8 mg, p < 0.001). Conclusions: SCB application in pediatric patients who underwent elbow fracture surgery significantly reduced opioid exposure and had a high success rate when performed using ultrasound guidance by an expert. Furthermore, the complication risk and surgical delay were minimal.

An Intelligent Customer-Driven Digital Solution to Improve Perioperative Health Outcomes Among Children Undergoing Circumcision and Their Parents: Development and Evaluation.

Circumcision as a common elective pediatric surgery worldwide is a stressful and anxiety-inducing experience for parents and children. Although current perioperative interventions proved effective, such as reducing preoperative anxiety, there are limited holistic solutions using mobile apps. This paper aims to describe the development and primary evaluation of an intelligent customer-driven smartphone-based app program (ICory-Circumcision) to enhance health outcomes among children undergoing circumcision and their family caregivers. Based on the review of the literature and previous studies, Bandura's self-efficacy theory was adopted as the conceptual framework. A multidisciplinary team was built to identify the content and develop the apps. Semistructured interviews were conducted to evaluate the ICory-Circumcision. The ICory-Circumcision study was carried out from March 2019 to January 2020 and comprised 2 mobile apps, BuddyCare app and Triumf Health mobile game app. The former provides a day-by-day perioperative guide for parents whose children are undergoing circumcision, while the latter provides emotional support and distraction to children. In total, 6 participants were recruited to use the apps and interviewed to evaluate the program. In total, 4 main categories and 10 subcategories were generated from content analysis. ICory-Circumcision seemed to lean toward being useful. Revisions to ICory-Circumcision are necessary to enhance its contents and features before advancing to the randomized controlled trial. ClinicalTrials.gov NCT04174404; https://clinicaltrials.gov/ct2/show/NCT04174404.

Implementation of Guidelines Limiting Postoperative Opioid Prescribing at a Children's Hospital.

Variability in opioid-prescribing practices after common pediatric surgical procedures at our institution prompted the development of opioid-prescribing guidelines that provided suggested dose limitations for narcotics. The aims of this study were to improve opioid prescription practices through implementation of the developed guidelines and to assess compliance and identify barriers preventing guideline utilization. We conducted a single-center cohort study of all children who underwent the most common outpatient general surgery procedures at our institution from August 1, 2018, to February 1, 2020. We created guidelines designed to limit opioid prescription doses based on data obtained from standardized postoperative telephone interviews. Three 6-month periods were evaluated: before guideline implementation, after guideline initiation, and after addressing barriers to guideline compliance. Targeted interventions to increase compliance included modification of electronic medical record defaults and provider educations. Differences in opioid weight-based doses prescribed, filled, and taken, as well as protocol adherence between the 3 timeframes were evaluated. A total of 1033 children underwent an outpatient procedure during the 1.5-year time frame. Phone call response rate was 72.22%. There was a significant sustained decrease in opioid doses prescribed (P < 0.0001), prescriptions filled (P = 0.009), and opioid doses taken (P = 0.001) after implementation, without subsequent increase in reported pain on postoperative phone call (P = 0.96). Protocol compliance significantly improved (62.39% versus 83.98%, P < 0.0001) after obstacles were addressed. Implementation of a protocol limiting opioid prescribing after frequently performed pediatric general surgery procedures reduced opioids prescribed and taken postoperatively. Interventions that addressed barriers to application led to increased protocol compliance and sustained decreases in opioids prescribed and taken without a deleterious effect on pain control.

Long-term impact of commonly performed operations in pediatric urology on reproductive and sexual health.

Sexual dysfunction is highly prevalent among men of reproductive age. Clinical practice guidelines have been established to assist providers in identification and education of patients who are at increased risk for infertility and sexual dysfunction with certain congenital and acquired urogenital disorders. The authors sought to review the reproductive and sexual health implications of treating common childhood urological conditions with commonly performed surgical procedures. To ensure the inclusion of influential and highly regarded research, we prioritized citations from the most-frequently cited articles on our respective review topics. Our inclusion criteria considered studies with substantial sample sizes and rigorously designed methodologies. Several topics were reviewed, including penile chordee, hypospadias, posterior urethral valves, varicoceles, undescended testicles, and testicular torsion. For chordee, surgical plication or corporal grafting may be employed. Erectile function remains unaltered post-surgery, while penile length may decrease after repair, which may be avoided using dermal grafts. Hypospadias repair hinges on severity and availability of the urethral plate. Those who underwent hypospadias repair report decreased penile length, but sexual satisfaction, libido, and semen quality are comparable to controls. Posterior urethral valves are usually treated with valve ablation. While valve ablation and bladder neck incision have not been found to affect ejaculatory function, high degree of concurrent renal dysfunction related to nephrogenic and bladder dysfunction may impact semen parameters and erectile function. Regarding varicocele, earlier management has been associated with better long-term fertility outcomes, and surgical intervention is advisable if there is observable testicular atrophy. Earlier repair of undescended testicle with orchiopexy has been found to improve fertility rates as well as decrease malignancy rates. Unilateral orchiectomy for testicular torsion without the ability for salvage has been shown to have decreased semen parameters but unaffected fertility rates. Infertility and sexual dysfunction are multivariable entities, with etiologies both congenital and acquired. At the same time, many common pediatric urology surgeries are performed to correct anatomic pathology that may lead to reproductive dysfunction in adulthood. This review highlights the need for diagnosis and management of pediatric urologic conditions as these conditions may impact long-term sexual function post-operatively.

Standardization of Antibiotic Management and Reduction of Opioid Prescribing in Pediatric Complicated Appendicitis: A Quality Improvement Initiative

BackgroundAppendicitis is one of the most common pediatric surgical procedures in the United States. However, wide variation remains in antibiotic prescribing and pain management across and within institutions. We aimed to minimize variation in antibiotic usage and decrease opioid prescribing at discharge for children with complicated appendicitis by implementation of a quality improvement (QI) initiative. MethodsOn December 1st, 2021, a QI initiative standardizing postoperative care for complicated appendicitis was implemented across a tertiary pediatric healthcare system with two main surgical centers. QI initiative focused on antibiotic and pain management. An extensive literature search was performed and a total of 20 articles matching our patient population were critically appraised to determine the best evidence-based interventions to implement. Antibiotic regimen included: IV or PO ceftriaxone/metronidazole immediately post-operatively and transition to PO amoxicillin-clavulanic acid for completion of 7-day total course at discharge. Discharge pain control regimen included acetaminophen, ibuprofen, as needed gabapentin, and no opioid prescription. Guideline compliance were closely monitored for the first six months following implementation. ResultsIn the first 6-months post-implementation, compliance with use of ceftriaxone/metronidazole as initial post-operative antibiotics was 75.6 %. Transition to PO amoxicillin-clavulanic acid prior to discharge increased from 13.7 % pre-implementation to 73.7 % 6-months post-implementation (p < 0.001). Compliance with a 7-day course of antibiotics within the first 6-months post-implementation was 60 % across both sites. After QI intervention, overall opioid prescribing remained at 0 % at one surgical site and decreased from 17.6 % to 0 % at the second surgical site over the study timeframe (p < 0.001). ConclusionAntibiotic use can be standardized and opioid prescribing minimized in children with complicated appendicitis using QI principles. Continued monitoring of the complicated appendicitis guideline is needed to assess for further progress in the standardization of post-operative care. Study TypeQuality improvement. Level of EvidenceLevel III.

Maximum Surgical Blood Ordering Schedule in Common Pediatric Cardiac Surgeries in a Tertiary Center.

Unnecessary pre-operative ordering of red blood cells (RBCs) in elective surgeries increases costs and waste of blood inventory. Maximum surgical blood order schedule (MSBOS) is a helpful strategy in the estimation of blood units needed for surgery and the prevention of overconsumption. In this study, an MSBOS for pediatric cardiac surgeries is designed. In this cross-sectional study, we included all pediatric patients who underwent elective cardiac surgery in Children's Medical Center in Tehran, Iran, from March 21, 2019, to September 22, 2019. Data consisted of the type of surgery and the number of blood units transfused and units cross-matched, based on which cross-match to transfusion ratio (CTR), the transfusion index (TI), and transfusion probability (T%) were calculated. Overall 205 pediatric patients were included in the study. Four hundred and ten RBCs units were cross-matched, and 262 were transfused. The overall results of the CTR, T%, and TI for all the eight types of cardiac surgery were 1.56 (410/262), 76% (157/205), and 1.28 (262/205), respectively. The raw MSBOS for cardiac surgeries included ventricular septal defect, tetralogy of fallot, dextro-transposition of the great arteries, atrial septal defect, aortic coarctation, patent ductus arteriosus, pulmonary stenosis, and pacemaker insertion, which were 1.58, 1.03, 1.54, 1.66, 0.77, 0, 1.25, and 0 unit, respectively, and the figures were rounded up. Accurate MSBOS protocols reduce cross-match workload in laboratories, lead to the appropriate use of blood stocks with less wastage, save human and economic resources, and eventually, promote patient safety.

A Prospective Observational Study Analyzing the Analgesic Efficacy of Caudal Block and Nerve Stimulator-Guided Pudendal Nerve Block in Children Undergoing Hypospadias Repair.

Hypospadias repair is a common pediatric surgery. While caudal block (CB) is the most widely used procedure for analgesia, pudendal nerve block (PNB) can be utilized as an alternative. We evaluated the postoperative analgesic efficacy of CB and PNB in children undergoing hypospadias repair. In this prospective observational study, we evaluated 101 patients who received standard general anesthesia along with CB or PNB. Postoperative pain score (Face, Legs, Activity, Cry, and Consolability {FLACC} score) along with the total number of analgesicdoses and the total amount of analgesic drugs consumed within 24 hours were noted. Time to first rescue analgesia, post-block penile length and midshaft circumference, surgeon satisfaction score, and postoperative complications were also evaluated. Out of 101 patients observed, 50 received CB, and 51 received PNB. At 24-hour interval, the median FLACC score in CB was 6, while in the PNB, it was 4 (p<0.001). None of the patients who were given PNB received more than three doses (p<0.001), and the average consumption of analgesic drugs within 24 hours was significantly higher in CB (38.4±4.28) compared to PNB (21.7±6.33) (p<0.0001). The median time to first rescue analgesia in CB was four hours, while in patients receiving PNB, it was eight hours(p<0.001). The increase in penile volume was significantly higher with CB as compared to PNB (p<0.001). Surgeon satisfaction score was found to be better with PNB (p<0.002). Patients who received PNB had significantly reduced pain scores and analgesic consumption in the first 24 hours post surgery.

Endoscopic coblation adenoidectomy and conventional adenoidectomy: a comparative study

Background: Adenoidectomy is most common paediatric surgical procedures. Commonly used methods for adenoidectomy are conventional curettage adenoidectomy and endoscopic coblator assisted adenoidectomy. The technique of coblation adenoidectomy has considerable influence on the duration of surgery, the blood lost intra operatively, pain on the first postoperative period. Methods: Sample selected for study were children of age group 3 to 11 years attending ENT OPD with clinical signs of adenoid hypertrophy, who underwent adenoidectomy during the time period from October 2019 to June 2021. We compared the efficacy of ECA with CCA based on the intra-operative (operative time and bleeding) and post-operative parameters (pain on the first post operative day). Results: Our study revealed that intra operative bleeding was more in CCA compared to ECA (p&lt;0.001). ECA took more operative time than CCA group (p&lt;0.001). Pain on the first post-operative day was more in CCA than ECA. Conclusions: Primary objective was comparison of intra operative bleeding among both groups and the outcome was blood loss in ECA was less than CCA. Secondary objective was comparison of operative duration and pain on the first post-operative day and the outcome was, operative duration was less in CCA and pain in the first post-operative day was more in CCA. Our conclusion is that ECA was efficient on the basis of intra operative blood loss and post- operative pain in the first day. CCA was effective in operative duration.

Comparison between Tonsillectomy by Coblation, Bipolar and Surgical Dissection

Abstract Background Tonsillectomy is one of the most common paediatric surgical procedures performed worldwide. Although it is one of the most widely performed procedures in otorhinolaryngology, none of the commonly used techniques for tonsillectomy is considered optimal till now. Objective To compare coblation, bipolar diathermy, and surgical dissection approaches for tonsillectomy in terms of operative time, surgical blood loss, postoperative pain and the incidence of postoperative complications. Methods A systematic review and meta-analysis in accordance to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Meta-analysis Of Observational Studies in Epidemiology (MOOSE) statement. Guidelines and an electronic search of information was conducted to identify studies that compare between coblation, cold dissection and bipolar diathermy techniques. Results This study showed that bipolar diathermy tonsillectomy was the lowest risk of primary bleeding followed by coblation then cold dissection tonsillectomy but with insignificant difference. Coblation technique was the highest secondary bleeding risk followed by cold dissection and the lowest risk was figured in bipolar diathermy procedure also the difference did not reach statistical significance. Coblation tonsillectomy was the best technique regarding blood loss and operative time with significant difference in the comparison with cold dissection and insignificant in the comparison with bipolar diathermy. Because of using a different postoperative pain measures in the studies we could not pool its data, but the majority of studies showed that coblation technique was better as regard postoperative pain than cold dissection and bipolar diathermy. While there was no significant difference between cold dissection and bipolar diathermy in the most studies Conclusion Overall, bipolar diathermy procedure for tonsillectomy was considered the best technique regarding primary and secondary bleeding outcomes, but the difference did not reach statistical significance. Coblation procedure for tonsillectomy was considered the best technique regarding intraoperative blood loss with significant difference except in comparison between bipolar diathermy and coblation the difference was not significant. Coblation technique also considered the best one regarding operative time with significant difference in direct comparison between coblation and cold, and insignificant in other comparisons. By systematic review on 21 studies coblation technique shows less postoperative pain than cold dissection and bipolar diathermy in the majority of studies comparing coblation with every technique. And there was no significant difference between studies compared cold dissection with bipolar diathermy regarding postoperative pain.

Opioid Use, Disposition, and Parent Satisfaction Following Common Pediatric Surgical Procedures.

There is wide variability in prescribing practices among providers, even for patients undergoing the same operations. Our study aims to analyze the variation in opioid prescription practices using a patient-centered approach to establish more appropriate prescribing guidelines for health care providers. We conducted phone surveys 30days after surgery to assess patient-reported opioid use. Over a two-year collection period, we identified patients that had undergone common outpatient pediatric surgery procedures in our 4-surgeon group. Included in the survey tool was the narcotic prescribed (if any), the amount used, and patient/family rating of pain control. We collected data for 189 separate procedures (88 umbilical hernias, 30 laparoscopic inguinal hernias, 2 open inguinal hernias, 41 appendectomies, 15 laparoscopic cholecystectomies, and 13 pectus bar removals). Patient age ranged from less than 1month to 246months. 83.5% of patients had a narcotic prescribed. The average number of doses used was 4, ranging from 0 (11.3%) to 30 (1.5%). 72.6% of families surveyed felt pain control was appropriate. However, 19.6% did feel they received too much pain medication. 10.6% reported completing their entire prescription; however, only 13.6% of families with excess narcotics reported proper disposal. Despite heightened awareness of the opioid epidemic, there is still a poor understanding of appropriate pain control regimens in the pediatric surgical population. We demonstrate that most patients are discharged home with excess opioids and that many families save the leftover pills/liquid. Further research and education are encouraged to limit the use of opioids in standard pediatric surgical procedures.

Changing Landscape of Routine Pediatric Surgery for Rural and Urban Children: A Report From the Child Health Evaluation of Surgical Services (CHESS) Group.

To describe the changes to routine pediatric surgical care over the past 2 decades for children living in urban and rural environments. A knowledge gaps exists regarding trends in the location where routine pediatric surgical care is provided to children from urban and rural environments over time. Children (age 0-18) undergoing 7 common surgeries were identified using State Inpatient Databases (SID, 2002-2017). Rural-Urban Commuting Area codes were used to classify patient and hospital zip codes. Multivariable regression models for distance traveled >60 miles and transfer status were used to compare rural and urban populations, adjusting for year, age, sex, race, and insurance status. Among 143,467 children, 13% lived in rural zip codes. The distance traveled for care increased for both rural and urban children for all procedures but significantly more for the rural cohort (eg, 102% vs 30%, P <0.001, cholecystectomy). Transfers also increased for rural children (eg, transfers for appendectomy increased from 1% in 2002 to 23% in 2017, P <0.001). Factors associated with the need to travel >60 miles included year [adjusted odds ratio (aOR)=2.18, 95% CI: 1.94-2.46: 2017 vs 2002], rural residence (aOR=6.55, 95% CI: 6.11-7.01), age less than 5 years (aOR=2.17, 95% CI: 1.92-2.46), and Medicaid insurance (aOR=1.35, 95% CI: 1.26-1.45). Factors associated with transfer included year (aOR=5.77, 95% CI: 5.26-6.33: 2017 vs 2002), rural residence (aOR=1.47, 95% CI: 1.39-1.56), age less than 10 years (aOR=2.34, 95% CI: 2.15-2.54), and Medicaid insurance (aOR=1.49, 95% CI: 1.42-1.46). Rural children, younger age, and those on Medicaid disproportionately traveled greater distances and were more frequently transferred for common pediatric surgical procedures.

Validity and Reliability of the Persian Version of Hypospadias Objective Penile Evaluation (HOPE) Questionnaire

Background and Objective: Surgical correction of hypospadias is one of the most common pediatric surgeries. Due to the several methods of hypospadias operations, the evaluation of results has always been challenging. Several questionnaires have been designed to reduce the discrepancy in the reports of hypospadias surgery, and the HOPE questionnaire is one of the most common. Based on our search, the reliability and validity of the Persian version of the HOPE (Hypospadias Objective Penile Evaluation) questionnaire have not been assessed yet. Materials and Methods: In this cross-sectional study, firstly, the questionnaire "Objective evaluation of penis in hypospadias" was translated by two urologists and an English language expert familiar with medical concepts according to the Backward-Forward translation method into Persian and then again into English, and finally, the questionnaire was sent to experts and compared with the original questionnaire. The quality of translation and content were finalized and corrected. Thereafter, in order to check the form and content validity, the questionnaire was sent to eight experts, and the content validity indices and its content validity ratio were calculated. In order to check the reliability-stability of the re-test, two questionnaires, including images after hypospadias surgery of 42 patients, were delivered to eight specialists in pediatrics, urology, and pediatric surgery to determine the score at a time interval of one week, and finally, the data were analyzed in SPSS software (version 23) using the test-retest method. The Intraclass Correlation Coefficient (ICC) index and its confidence interval were calculated by the scores obtained from twice answering the instrument for each factor and the entire questionnaire. In order to determine internal consistency and reliability, Cronbach's alpha coefficient was calculated for each factor and the entire questionnaire. Results: In our study, intraclass correlation coefficient values for inter-rater reliability in the HOPE score were calculated at 0.89, indicating the high reliability of this questionnaire in Persian. The internal consistency of the Persian version of the HOPE scale was confirmed, rendering a Cronbach's alpha coefficient of 0.98. Conclusion: The good validity and reliability of the HOPE scoring system in Persian support its use as a standard objective outcome measure of the cosmetic result after hypospadias surgery.

Impact of state legislation and institutional protocols on opioid prescribing practices following pediatric tonsillectomy.

Tonsillectomy is a common pediatric surgery, and pain is an important consideration in recovery. Due to the opioid epidemic, individual states, medical societies, and institutions have all taken steps to limit postoperative opioids, yet few studies have examined the effect of these interventions on pediatric otolaryngology practices. The primary aim of this study was to characterize opioid prescribing practices following North Carolina state opioid legislation and targeted institutional changes. This single center retrospective cohort study included 1552 pediatric tonsillectomy patient records from 2014 to 2021. The primary outcome was number of oxycodone doses per prescription. This outcome was assessed over three time periods: (1) Before 2018 North Carolina opioid legislation. (2) Following legislation, before institutional changes. (3) After institutional opioid-specific protocols. The mean (± standard deviation) number of doses per prescription in Periods 1, 2, and 3 was: 58 ± 53, range 4-493; 28 ± 36, range 3-488; and 23 ± 17, range 1-139, respectively. In the adjusted model, Periods 2 and 3 had lower doses by -41% (95% CI -49%, -32%) and -40% (95% CI -55%, -19%) compared to Period 1. After 2018 North Carolina legislation, dosage decreased by -9% (95% CI -13%, -5%) per year. Despite interventions, ongoing variability in prescription regimens remained in all periods. Legislative and institution specific opioid interventions was associated with a 40% decrease in oxycodone doses per prescription following pediatric tonsillectomy. While variability in opioid practices decreased post-interventions, it was not eliminated. 3.

A service evaluation of the impact of parental information provision on analgesia administration at home posttonsillectomy.

Tonsillectomy and adenotonsillectomy are together the most common pediatric surgical procedure and are increasingly performed as day cases. Postoperative pain is commonly severe for 1-2 weeks, but parental analgesia concerns lead to poor analgesia prescription compliance and under administration. This service evaluation assessed parental compliance with analgesia, elicited parental concerns, and obtained parental suggestions for improving the current written advice. Telephone questionnaires were completed on postoperative Days 3/4 and 7 with 42 parents of pediatric (adeno)-tonsillectomy patients over a 6-month period, peri-pandemic. The questionnaire collected categorical data on: analgesia prescribed and administered, the child's symptoms, and healthcare resource use. Qualitative data on barriers to analgesia administration and suggestions for written advice improvement were grouped thematically. Sore throats were reported by 93.3% parents between discharge and Day 3/4 but only 43.3% parents had 100% compliance with regular paracetamol and ibuprofen in the same time period. Parents frequently avoided morphine administration, expressing concerns about side effects, addiction, and previous experience. Parents were also concerned about using ibuprofen, discrepancies between weight-based and bottle instruction doses, and the length of the analgesia course. Parents would like further written information and reassurance on these topics as well as guidance on tapering or stopping analgesics and whether to wake their child at night. The breadth of unmet information needs identified in this service evaluation, alongside parental suggestions, will be used to improve the current written advice with the aim to improve the postoperative pain experience at home. These include information on length of analgesic course, safety of ibuprofen and paracetamol coadministration for analgesia, and details about morphine administration, including safety, side effects, and indication.