Pediatric Surgical Practice Research Articles

Evidence-based paediatric surgical oncology

Surgeons play a pivotal role in the decision-making and multidisciplinary management of childhood solid tumours.1 Evidence-based medicine—“aims to optimise decision making by emphasising on the use of best evidence from well-designed conducted research.” This article offers a brief overview in an effort to demonstrate how a selection of well-conducted, recently published studies can help address some topical and controversial themes in paediatric surgical oncology practice.

Pediatric Day Surgery: Evaluating Patient And Parental Anxiety.

Objective: A child’s pre-operative anxiety can result in adverse physiological reactions andpostoperative maladaptive behavioral changes. We investigated the child and the parent’s anxiety in response to day surgery and preoperative preparation, as a potential stressor during the surgical work-up. Patients and methods : All pediatric patients (3-17 years), having day-surgery procedures (from September 2014 to February 2015) and their parents were enrolled. Patient anxiety was evaluated using the Modified Yale Preoperative Anxiety Scale at preoperative preparation (T0), before surgery (T1), and discharge (T2). Parental anxiety was assessed using the State-Trait Anxiety Inventoryscale at T1 and T2. Results 63: children (33F/30M; 6.98±3.24 years) and their parentswere included. Children’s anxiety levels at T0 were higher compared with T1 and T2 (p<0.001). Parental anxiety state was higher at T1 in comparison with T2 (<0.001). The difference between state and trait anxiety levels at T1 and T2 were noted in the mothers (p<0.001) and fathers (p= 0.01 and p=0.02). Patient anxiety was not linked to parental anxiety and/or to the type of surgery. Conclusion Further efforts are needed to relieve children’s anxiety during the perioperative period, with attention to preoperative evaluation. An appropriate understanding and management of anxiety is mandatory to ameliorate patient care in today’s pediatric surgical practice.

Thirty-days readmissions in pediatric surgery: The first U.K. experience

IntroductionThe aim of this study was to investigate readmissions within 30days of operation (ReAd) in the setting of a tertiary pediatric surgical practice in the UK. MethodsUsing Hospital Episode Statistics, cases that were readmitted within 30days of primary operation were identified retrospectively. Demographics including age, gender, preexisting comorbidities, diagnosis on primary admission and the treatment, length of stay, and diagnosis on readmission with treatment, including further surgical intervention, were collected from discharge summaries and hospital notes. Neonates were excluded from this study. Comorbidities, involving one or more systems, were also identified for each case of readmission. ReAds were classified into emergency and elective cohort depending on the nature of the primary operation. Outcomes were compared between these two groups. Data were quoted as median (range) unless indicated otherwise. Data were analyzed using SPSS software Desktop 22.0, using Mann–Whitney U and Chi-Squared tests, with a consideration that a P≤0.05 was significant. ResultsA total of 2378 procedures were performed during the study period. Elective cases, including day cases, accounted for 77% (n=1837) of all cases. The remaining 23% (n=541) were emergency cases. Total unplanned readmission rate within 30days (ReAd) was 2%. Further surgical procedures were required in 38%. Having excluded neonates, the most common primary procedure leading to readmission within 30days was appendicectomy (26%). Overall, the most common cause for readmission within 30days was postoperative infection (30%). The ReAd in emergency cohort was 3.5% in comparison to 1.5% in elective, which was significantly different (P value=0.007). ConclusionReadmission within thirty days of primary procedure in pediatric surgery has little published data. An efficient discharge planning may play a vital role in preventing unwanted readmission. Elective operations had a significantly lower readmission rate than emergency operations. Having excluded neonates, appendicectomy was found to be the most common operation associated with readmission in the pediatric surgical practice. Although widely used as quality care indicator in adults, more studies are required to validate readmission rate as a quality of care indicator in pediatric surgery practice.

Pediatric appendectomy: the outcome differences between pediatric surgeons and general surgeons.

The aim of this study was to review our experience of pediatric appendectomy performed by either a general surgeon (GS) or a pediatric surgeon (PS) to determine any differences in outcomes. We reviewed the medical records of pediatric appendicitis patients, 4years before (GS group, 2007-2010) and after (PS group, 2011-2014) the introduction of a pediatric surgical practice. The records were reviewed for the following variables: operation time, length of hospital stay, complications, readmission in ≤30days, type of operation, negative for appendicitis, drainage, open conversion, and reoperation in ≤30days. Over 8years, 400 patients were operated on for acute appendicitis, with the PS group comprising 61% (N=244) of patients. The operation time (55.1 vs 43.2min, p=0.0001) and postoperative length of hospital stay (3.5 vs 2.7days, p=0.001) were shorter, more patients were treated by laparoscopy (61.3 vs 91.2%, p=0.0001), and a fewer patients required peritoneal drainage (29.5 vs 63.2%, p=0.023) in the PS group than in the GS group. The negative appendectomy rate was slightly lower in the PS group, but not to a statistically significant degree. The patients in the PS group enjoyed a reduced operation time and length of hospital stay, greater likelihood of laparoscopic operation, and less peritoneal drainage than the patients in the GS group.

Rates and burden of surgical site infections associated with pediatric colorectal surgery: insight from the National Surgery Quality Improvement Program

PurposeThe purpose of this study was to characterize the rates of surgical site infections (SSI) associated with colorectal procedures in children and the relative burden of these events within the scope of pediatric surgical practice. MethodsThe NSQIP-Pediatric Public Use File was queried for all pediatric surgery procedures captured from 50 hospitals during 2012—2013. Rates of incisional and deep organ/space SSIs (ISSI and OSI, respectively) were calculated for all procedures, and the relative burden of SSIs from the entire dataset attributable to colorectal procedures was determined. ResultsColorectal procedures accounted for 2.5% (2872/114,395) of the NSQIP-P caseload and contributed 7.1% of the SSI burden. The SSI rate for all colorectal procedures was 5.9% (ISSI:3.2%; OSI:2.7%), and the highest rates were associated with total abdominal colectomy (11.4%) partial colectomy (8.3%), and colostomy closure (5.0%). Inflammatory bowel disease contributed the greatest relative burden of SSIs among colorectal diagnoses (24.9%; ISSI:22%; OSI:28.6%), followed by Hirschsprung's Disease (14.2%; ISSI:15.4%; OSI:12.8%) and anorectal malformations (12.4%; ISSI:17.6%; OSI:6.4%). ConclusionColorectal procedures are responsible for a disproportionate burden of SSIs within pediatric surgery. The rate and relative burden of SSIs are particularly high for colostomy closure, partial colectomy, and procedures for inflammatory bowel disease. Efforts to reduce SSI burden may be best focused on this cohort of children.

Pediatric surgery – a changing field: national trends in pediatric surgical practice

BackgroundOver the last decade, our institution has experienced a relative increase in the number of mundane cases, such as appendectomy and incision and drainage of abscess, versus index (complex) cases. We sought to determine if this trend is present at the national level. MethodsA retrospective review of surgical case volume at 36 freestanding children's hospitals was performed between January 2004 and December 2013 using the Pediatric Health Information System (PHIS) database. Procedures were classified as “mundane” or “index”, and 10 procedures of each type were selected for analysis. Results were reported as a percentage of total cases. Statistical analysis of linear trends was performed with the Mann-Kendall test. ResultsOverall, index procedures had a significant downward trend (p<0.01), whereas mundane procedures had a significant upward trend (p<0.01). Individually, 5 mundane procedures had significant upward trends, and 3 had downward trends. Five index procedures had significant downward trends, and none had an upward trend. ConclusionThe field of pediatric surgery is undergoing change with mundane procedures constituting an increasing proportion of the surgical caseload, while complex procedures are proportionately decreasing. These trends may be useful to inform decisions regarding future pediatric surgery workforce planning.

Role of magnetic resonance imaging to detect occult spinal anomalies in anorectal malformations

Background: Anorectal malformations (ARM) are relatively frequently encountered anomalies that represent an important component of pediatric surgical practice. They are a complex group of malformations diagnosed at the time of birth, because of either the absence or an ectopic location of anus. The objective of the study is to determine the incidence of spinal anomalies in all types of anorectal malformations excluding cloaca in this part of country. Methods: All anorectal malformation patients attending surgery OPD and admitted to Surgery Department of UP RIMS & R who were completely investigated for associated anomalies during March 2015-Feb 2016 were completely investigated for associated anomalies during the above mentioned period were included in the study . Results: In our study we found that the incidence of spinal cord anomalies was 3 of 11 (27.2%) cases with low lesions and 12 of 39 (30.7%) cases with high lesions had spinal cord anomalies. Conclusions: MRI evaluation of spine should be performed in all patients of ARM irrespective of type of lesion.

Challenges with the establishment of congenital cardiac surgery centers in Nigeria: survey of cardiothoracic surgeons and residents

BackgroundThere are gaps in understanding the challenges with the establishment of pediatric cardiac surgical practices in Nigeria. The aim of this study was to examine the prospects and challenges limiting the establishment of pediatric cardiac surgical practices in Nigeria from the perspectives of cardiothoracic surgeons and resident doctors. MethodsA descriptive study was carried out to articulate the views of the cardiothoracic surgeons and cardiothoracic resident doctors in Nigeria. A self-administered questionnaire was used to generate information from the participants between December 2014 and January 2015. Data were analyzed using the SPSS version 21 statistical software package. ResultThirty-one of the 51 eligible participants (60.7%) took part in the survey. Twenty-one (67.7%) were specialists/consultants, and 10 (32.3%) were resident doctors in cardiothoracic surgical units. Most of the respondents, 26 (83.9%) acknowledged the enormity of pediatric patients with cardiac problems in Nigeria; however, nearly all such children were referred outside Nigeria for treatment. The dearth of pediatric cardiac surgical centers in Nigeria was attributed to weak health system, absence of skilled manpower, funds, and equipment. Although there was a general consensus on the need for the establishment of open pediatric cardiac surgical centers in the country, their set up mechanisms were not explicit. ConclusionsThe obvious necessity and huge potentials for the establishment of pediatric cardiac centers in Nigeria cannot be overemphasized. Nevertheless, weakness of the national health system, including human resources remains a daunting challenge. Therefore, local and international partnerships and collaborations with country leadership are strongly advocated to pioneer this noble service.

Structured intervention for management of pain following day surgery in children.

Ambulatory surgery forms a large part of pediatric surgical practice. Several studies indicate that postoperative pain is poorly managed with more than 30% of children having moderate to severe pain. In a busy outpatient clinic contact between healthcare professionals and the family is increasingly limited calling for a global and efficient pain management regime. The aim of this prospective observational cohort study was to determine postoperative pain intensity following day surgery in children after our structured intervention for pain management. A number of interventions in an effort to address barriers to effective postoperative pain management after day surgery were identified in the literature. By introducing our concept structured intervention, we aimed to address the majority if not all these barriers. Accordingly, we adapted postoperative pain management to each child using a multimodal approach consisting of surgery-specific analgesia with weight appropriate doses of acetaminophen and ibuprofen. Analgesics were handed out to the parents in formulations accepted by child and parent and after thorough information to the parents. Two hundred and forty-five children were scheduled for surgery during the 3-month period of which 149 children were available for analysis. The postoperative pain as assessed by the parents with a the Short Form of the Parents' Postoperative Pain Measure (PPPM-SF) was well managed exhibiting a median pain score of 4 on postoperative day 0 (POD0) and median 1 on postoperative day 1 (POD1) and a numeric rating scale (NRS) median pain score of 2 on POD0 and median 1 on POD1. We found a highly significant correlation between the PPPM-SF and the NRS scores. After thorough information of the parents we have successfully implemented a surgery-specific regime of primarily around-the-clock dosing of drug formulations acceptable for the specific child with dispensed medication ready available for the family.

Subspecialization within pediatric surgical groups in North America

PurposeThe purpose of this study was to assess the current status of subspecialization in North American pediatric surgical practices and to evaluate factors associated with subspecialization. MethodsA survey was sent to each pediatric surgical practice in the United States and Canada. For each of 44 operation types, ranging in complexity and volume, the respondents chose one of the following responses: 1. everyone does the operation; 2. group policy – only some surgeons do the operation; 3. group policy – anyone can do it but mentorship required; 4. only some do it due to referral patterns; 5. no one in the group does it. Association of various factors with degree of subspecialization was analyzed using nonparametric statistics with p<0.05 considered significant. ResultsResponse rate was 70%. There was significant variability in subspecialization among groups. Factors found to be significantly associated with increased subspecialization included free-standing children's hospitals, pediatric surgery training programs, higher number of surgeons, higher case volume, and greater volume of tertiary/quaternary cases. ConclusionsThere is wide variation in the degree of subspecialization among North American pediatric surgery practices. These data will help to inform ongoing debate around strategies that may be useful in optimizing pediatric surgical care and patient outcomes in the future.

Impact of Experience on Quality Outcomes in Single-incision Cholecystectomy in Children

Single-incision laparoscopic cholecystectomy (SILC) has been shown to be safe in children; however, factors that impact outcomes are not well understood. We report a retrospective review of 151 patients who underwent SILC between 2009 and 2013. Regression analysis was used to determine inflection of learning curve. Patients were grouped by early cases, late cases, and late case with surgical trainees. Mean age for all patients was 15 ± 3 years (5-20.5 year), and mean weight was 66.5 ± 21.3 kg (15-117 kg). There was a decrease in operative times between the early group (n = 15) and the late group (n = 100) (75.3 vs 56.1 minutes, P < 0.05). Surgical trainees were involved in 36 cases, and their introduction did not significantly increase operative times (56.1 vs 60.4 minutes, P = NS (Non-significant)). No difference in operative times between early cases and cases with trainees was identified (75.3 vs 60.4 minutes, P = NS). The complication was 6 per cent, with no significant differences between the groups. There were five conversions (3.3%). During the adoption of SILC, significantly decreased operative times were achieved after a short learning curve, and these were maintained with surgical trainees. Our results show that SILC can be safely introduced into a pediatric surgical practice.

Quality and Extent of Locum Tenens Coverage in Pediatric Surgical Practices

The prevalence and quality of locum tenens coverage in pediatric surgery have not been determined. An Internet-based survey of American Pediatric Surgical Association members was conducted: 1) practice description; 2) use and frequency of locum tenens coverage; 4) whether the surgeon provided such coverage; and 5) Likert scale responses (strongly disagree, disagree, neutral, agree, strongly agree) to statements addressing its acceptability and quality (two × five contingency table and χ(2) analyses, significance at P < 0.05). Three hundred sixteen of 1163 members (27.2% response rate) responded. One-fourth (24.1%) used a locum tenens regularly. Reasons were long-term inability to recruit a full-time surgeon (35.2%) and short-term vacancies (32.4%). One-fifth (20.4%) did locum tenens work; one-fourth (27.0%) plan to do so in the future. Two-thirds (64.2%) believe that surgical care in a locum tenens situation does not provide the same level of care as a full-time community-based surgeon. Most support locum tenens for short-term coverage (87.3%) and recruitment problems (72.1%), but not long-term vacancies (38.8%; P < 0.001) or permanent coverage (27.0%; P < 0.001). locum tenens coverage is an established feature of pediatric surgery. Most view it as a stopgap solution to the surgical workforce shortage.

The College of American Pathologists guidelines for whole slide imaging validation are feasible for pediatric pathology: a pediatric pathology practice experience.

Whole slide imaging (WSI) is rapidly transforming educational and diagnostic pathology services. Recently, the College of American Pathologists Pathology and Laboratory Quality Center (CAP-PLQC) published recommended guidelines for validating diagnostic WSI. We prospectively evaluated the guidelines to determine their utility in validating pediatric surgical pathology and cytopathology specimens. Our validation included varied pediatric specimen types, including complex or less common diagnoses, in accordance with the guidelines. We completed WSI review of 60 surgical pathology cases and attempted WSI review of 21 cytopathology cases. For surgical pathology cases, WSI diagnoses were highly concordant with glass slide diagnoses; a discordant diagnosis was observed in 1 of 60 cases (98.3% concordance). We found that nucleated red blood cells and eosinophilic granular bodies represented specific challenges to WSI review of pediatric specimens. Cytology specimens were more frequently discordant or failed for technical reasons, with overall concordance of 66.7%. Review of pediatric cytopathology specimens will likely require image capture in multiple focal planes. This study is the first to specifically evaluate WSI review for pediatric specimens and demonstrates that specimens representing the spectrum of pediatric surgical pathology practice can be reviewed using WSI. Our application of the proposed CAP-PLQC guidelines to pediatric surgical pathology specimens is, to our knowledge, the first prospective implementation of the CAP-PLQC guidelines.

Robotic Surgery may Not "Make the Cut" in Pediatrics.

Since the introduction of robotic surgery in children in 2001, it has been employed by select pediatric laparoscopic surgeons, but not to the degree of adult surgical specialists. It has been suggested that the technical capabilities of the robot may be ideal for complex pediatric surgical cases that require intricate dissection. However, due to the size constraints of the robot for small pediatric patients, the tight financial margins that pediatric hospitals face, and the lack of high level data displaying patient benefit when compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in pediatric surgical practice.

Circumcision: Is it worth it for 21st-century Australian boys?

Circumcision: Is it worth it for 21st-century Australian boys?

Minimally invasive surgery for paediatric inflammatory bowel disease: Personal experience and literature review

The incidence of paediatric inflammatory bowel disease (PIBD) has dramatically increased in the last 20 years. Although first reported in mid 1970s', diagnostic laparoscopy has started to be routinely adopted in paediatric surgical practice since late 1990s'. Minimally invasive surgery was first limited to diagnostic purposes. After 2002 it was also applied to the radical treatment of PIBD, either Crohn's disease (CD) or Ulcerative colitis. During the last decade minimally invasive approaches to PIBD have gained popularity and have recently became the "gold standard" for the treatment of such invalidating and troublesome chronic diseases. The authors describe and track the historical evolution of minimally invasive surgery for PIBD and address all available opportunities, including most recent advancements such as robotic surgery, single port approaches and minimally invasive treatment of perianal fistulising CD. A systematic review of all series of PIBD treated with minimally invasive approaches published so far is provided in order to determine the incidence and type of patients' complications reported up to present days. The authors also describe their experience with minimally invasive surgery for PIBD and will report the results of 104 laparoscopic procedures performed in a series of 61 patients between January 2006 and December 2014.

Surgical strategies in paediatric inflammatory bowel disease.

Inflammatory bowel disease (IBD) comprises two distinct but related chronic relapsing inflammatory conditions affecting different parts of the gastrointestinal tract. Crohn's disease is characterised by a patchy transmural inflammation affecting both small and large bowel segments with several distinct phenotypic presentations. Ulcerative colitis classically presents as mucosal inflammation of the rectosigmoid (distal colitis), variably extending in a contiguous manner more proximally through the colon but not beyond the caecum (pancolitis). This article highlights aspects of the presentation, diagnosis, and management of IBD that have relevance for paediatric practice with particular emphasis on surgical considerations. Since 25% of IBD cases present in childhood or teenage years, the unique considerations and challenges of paediatric management should be widely appreciated. Conversely, we argue that the organizational separation of the paediatric and adult healthcare worlds has often resulted in late adoption of new approaches particularly in paediatric surgical practice.

Efficiency of upper gastrointestinal endoscopy in pediatric surgical practice.

After the introduction of flexible fiber optic endoscopy to pediatric gastroenterology in the 1970s, upper gastrointestinal (UGI) endoscopy can be performed for the diagnosis and treatment of all age groups of children. We review indications, contraindications, preparation of patients for the procedure, and details of diagnostic and therapeutic UGI endoscopy used in pediatric surgery. We also discuss potential complications of endoscopy.

Early experience with laparoscopic surgery in children in Ile-Ife, Nigeria.

Background:Laparoscopy is not yet routinely employed in many Paediatric Surgical Units in Nigeria despite the advantages it offers. This study describes the preliminary experience with laparoscopic procedures in a single centre.Patients and Methods:A retrospective analysis of all children who had laparoscopic surgery between January 2009 and December 2013 at the Paediatric Surgical Unit of Obafemi Awolowo University Teaching Hospitals Complex Ile-Ife was carried out. Their sociodemographic, preoperative and intraoperative data along with postoperative records were subjected to descriptive analysis.Results:Eleven (44%) diagnostic and 14 (56%) therapeutic procedures were performed on 25 children whose age ranged from 5 months to 15 years (Median: 84 months, Mean: 103 ± 64.1 months), including eight (32%) females and 17 (68%) males. Indications included acute appendicitis in 12 (48%), intra-abdominal masses in six (24%), three (12%) disorders of sexual differentiation, two (8%) ventriculoperitoneal shunt malfunctions and impalpable undescended testes in two (8%) children. The procedures lasted 15-90 minutes (Mean = 54 (±21.6) minutes). Conversion rate was 17% for two patients who had ruptured retrocaecal appendices. No intra operative complications were recorded while three (12%) patients had superficial port site infections post-operatively. All diagnostic (11) and two therapeutic procedures were done as day case surgery. The mean duration of hospital stay was 3.1 (±3.3) days for those who had appendectomies.Conclusion:Laparoscopic surgery in children is safe and feasible in our hospital. We advocate increased use of laparoscopy in paediatric surgical practice in Nigeria and similar developing settings.

A randomized trial of laparoscopic versus open Nissen fundoplication in children under two years of age

AimsThe surgery of gastroesophageal reflux disease (GERD) is common in modern pediatric surgical practice. Any differences in perioperative and long-term clinical outcomes following laparoscopic (LN) or open Nissen (ON) fundoplication have not been comprehensively described in young children. This randomized, prospective study examines outcomes following LN versus ON in children <2years of age. MethodsFour surgeons at a single institution enrolled patients under 2years of age that required surgical management of GERD, who were then randomized to LN or ON between 2005 and 2012. A universal surgical dressing was employed for blinding. Analgesia and enteral feeding pathways were standardized. The primary outcome was postoperative length of stay. Perioperative outcomes and long-term follow up were collected as secondary outcomes and used to compare groups. ResultsOf 39 enrolled patients, 21 were randomized to ON and 18 to LN. Length of postoperative hospital stay, time of advancement to full enteral feeds, and analgesic requirements were not significantly different between treatment cohorts. The LN group experienced longer median operating times (173 vs 91min, P<0.001) and higher surgical charges ($4450 vs $2722, P=0.002). The incidence of post-discharge complications did not differ significantly between the groups at last follow-up (median 42months). ConclusionsThis randomized trial comparing postoperative outcomes following LN vs ON did not detect statistically significant differences in short- or long-term clinical outcomes between these approaches. LN was associated with longer surgical time and higher operating room costs. The benefits, risks, and costs of laparoscopy should be carefully considered in clinical pediatric surgical practice.