Pediatric Surgery Practice Research Articles

National trends and variability in blood utilization in paediatric cardiac surgery.

Red blood cell transfusion is a common practice in paediatric cardiac surgery. Transfusion of red blood cells has been shown to be associated with an increase in morbidity in paediatric patients undergoing cardiac surgery. There is a huge variability in the practice of blood utilization within and across different practices. The aim of this study was to demonstrate the current variability and the trends over the past decade in blood usage among children's hospitals performing paediatric cardiac surgery. We performed a retrospective observational cohort study using the Paediatric Health Information System database from 43 participating paediatric hospitals in the USA. All discharge billing information for patients younger than 19 years of age who underwent cardiac surgery using cardiopulmonary bypass between 2005 and 2015 was investigated. Ten index diagnoses and procedures were investigated and analysed, based on age differences and on the Society of Thoracic Surgeon & European Association for Cardio-Thoracic Surgery mortality scores. Our main outcome variable was the unit(s) of homologous red blood cells charged for the first 24 h of admission for cardiac surgery. There was significant variability in red blood cell usage for a given diagnosis and procedural code across all the centres despite varied age ranges and complexity scores for the current and the last decade of paediatric cardiac surgical patients. We found a discernible variability in the current practice of blood utilization for a given procedure despite variability in the age and complexity of patients, with no changes in practice patterns for the last decade of paediatric cardiac surgery.

Off-Label Use of Medical Devices in Children.

Despite widespread therapeutic needs, the majority of medical and surgical devices used in children do not have approval or clearance from the Food and Drug Administration (FDA) for use in pediatric populations. The clinical need for devices to diagnose and treat diseases or conditions occurring in children has led to the widespread and necessary practice in pediatric medicine and surgery of using approved devices for "off-label" or "physician-directed" applications that are not included in FDA-approved labeling. This practice is common and often appropriate, even with the highest-risk (class III) devices. The legal and regulatory framework used by the FDA for devices is complex, and economic or market barriers to medical and surgical device development for children are significant. Given the need for pediatric medical and surgical devices and the challenges to pediatric device development, off-label use is a necessary and appropriate part of care. In addition, because of the relatively uncommon nature of pediatric conditions, FDA clearance or approval often requires other regulatory pathways (eg, Humanitarian Device Exemption), which can cause confusion among pediatricians and payers about whether a specific use, even of an approved device, is considered experimental. This policy statement describes the appropriateness of off-label use of devices in children; the use of devices approved or cleared through the FDA regulatory processes, including through the Humanitarian Device Exemption; and the important need to increase pediatric device labeling information for all devices and especially those that pose the highest risk to children.

Development of a multi-institutional clinical research consortium for pediatric surgery

BackgroundMulticenter clinical research studies in pediatric surgery have been largely limited to relatively small case-series and retrospective reviews because of the rarity of many of the diseases we treat and difficulty coordinating and executing multi-institutional studies. Creation of a collaborative research network can provide the needed patient population and infrastructure to perform high quality multi-institutional studies. MethodsIn 2013, eleven academic pediatric surgery centers within the United States formed a research consortium to develop and conduct multicenter clinical research projects to advance the practice of pediatric surgery. ResultsWe present our process for creating, developing, and maintaining this consortium including initial regional geographic limitation, charter development with by-laws and procedures for adopting studies, and research infrastructure including a central website for study monitoring and central reliance institutional review board process. ConclusionOur model could be reproduced or adapted by other institutions to develop or strengthen other research collaboratives. Level of evidenceType of study: retrospective, IV.

Routine preoperative laboratory testing in elective pediatric cardiothoracic surgery is largely unnecessary

ObjectiveRoutine preoperative laboratory testing (RLT) is common practice in pediatric cardiothoracic surgery and is associated with significant cost burden to patients and families. We sought to examine the value of RLT in patients undergoing elective pediatric cardiothoracic surgery. MethodsWe conducted a retrospective study of all scheduled elective pediatric cardiothoracic surgery at our institution from 2012 to 2014. Inpatients were excluded. Patient charts were reviewed to obtain preoperative laboratory values and determine relationship to case cancellation. RLT includes complete blood count, prothrombin time, partial thromboplastin time, urinalysis, 7 chemistry metabolic panel, electrocardiogram, and 2-view chest radiograph. ResultsRLT was completed for 1106 scheduled elective cases. Six (0.5%) cancellations were related to abnormal preoperative laboratory test results: 5 complete blood counts and 1 urinalysis. Hospital charge for RLT averaged $2064 per patient. Based on this incidence, we estimated that 184 routine preoperative laboratory tests, which generated a total hospital charge of $379,776, were required to capture 1 abnormal test significant enough to cancel surgery. An estimated charge of $2,169,552 was generated on prothrombin time, partial thromboplastin time, 7 chemistry metabolic panel, electrocardiogram, and 2-view chest radiograph, and none of these tests resulted in a cancellation. ConclusionsRLT does not significantly impact decision-making in elective pediatric cardiothoracic surgery. The decision to order a specific screening test should be clinically driven. Selective preoperative laboratory testing may have a positive impact on healthcare costs without affecting outcomes.

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.

Low-cost laparoscopic appendectomy in pediatric patients

Background/purpose: Laparoscopic appendectomy is widely practiced worldwide and has become one of the commonly performed procedures in pediatric surgery practice. However, the cost effectiveness of the procedure remains a major concern. The present study aimed to evaluate the safety and effectiveness of the operative techniques used to reduce the cost of the procedure. Patients and methods: A prospective study was conducted on patients undergoing laparoscopic appendectomy over a period of 2 years. The techniques used to reduce the cost of laparoscopic appendectomy were as follows: (i) using reusable trocars instead of disposable ones; (ii) using monopolar electrogoagualtion to seal the mesoappendix instead of staplers, LigaSure, or Harmonic scalpels; and (iii) using a handmade loop to secure the base of the appendix instead of using endoloops. Results: This study included 39 boys and 21 girls. The median age was 10 years. The mean duration of the operation was 56.5 min. No intraoperative complications were encountered. Two cases developed pelvic hematoma and were managed conservatively with success. The mean hospitalization stay was 2 days. Conclusion: Division of the mesoappendix using monopolar electrocautry and closing the base of appendix using handmade endloops during laporoscopic appendectomy appears to be a simple, effective, safe, and cost-efficient technique. Therefore, the use of more costly instruments, such as the endostapler, LigaSure, or Harmonic scalpel, seems unwarranted. Keywords: cost reduction, laparoscopic appendectomy, pediatric age

Current concepts in the management of inguinal hernia and hydrocele in pediatric patients in laparoscopic era

The surgical repair of inguinal hernia and hydrocele is one of the most common operations performed in pediatric surgery practice. This article reviews current concepts in the management of inguinal hernia and hydrocele based on the recent literature and the authors׳ experience. We describe the principles of clinical assessment and anesthetic management of children undergoing repair of inguinal hernia, underlining the differences between an inguinal approach and minimally invasive surgery (MIS). Other points discussed include the current management of particular aspects of these pathologies such as bilateral hernias; contralateral patency of the peritoneal processus vaginalis; hernias in premature infants; direct, femoral, and other rare hernias; and the management of incarcerated or recurrent hernias. In addition, the authors discuss the role of laparoscopy in the surgical treatment of an inguinal hernia and hydrocele, emphasizing that the current use of MIS in pediatric patients has completely changed the management of pediatric inguinal hernias.

What Evidence Underlies Clinical Practice in Paediatric Surgery? A Systematic Review Assessing Choice of Study Design.

ObjectiveIdentify every paediatric surgical article published in 1998 and every paediatric surgical article published in 2013, and determine which study designs were used and whether they were appropriate for robustly assessing interventions in surgical conditions.MethodsA systematic review was conducted according to a pre-specified protocol (CRD42014007629), using EMBASE and Medline. Non-English language studies were excluded. Studies were included if meeting population criteria and either condition or intervention criteria. Population: Children under the age of 18, or adults who underwent intervention for a condition managed by paediatric surgeons when they were under 18 years of age. Condition: One managed by general paediatric surgeons. Intervention: Used for treatment of a condition managed by general paediatric surgeons.Main Outcome MeasureStudies were classified according to whether the IDEAL collaboration recommended their design for assessing surgical interventions or not. Change in proportions between 1998 and 2013 was calculated.Results1581 paediatric surgical articles were published in 1998, and 3453 in 2013. The most commonly used design, accounting for 45% of studies in 1998 and 46.8% in 2013, was the retrospective case series. Only 1.8% of studies were RCTs in 1998, and 1.9% in 2013. Overall, in 1998, 9.8% of studies used a recommended design. In 2013, 11.9% used a recommended design (proportion increase 2.3%, 95% confidence interval 0.5% increase to 4% increase, p = 0.017).Conclusions and RelevanceA low proportion of published paediatric surgical manuscripts utilise a design that is recommended for assessing surgical interventions. RCTs represent fewer than 1 in 50 studies. In 2013, 88.1% of studies used a less robust design, suggesting the need for a new way of approaching paediatric surgical research.

Diagnostic and Therapeutic Implications of Cholelithiasis in Children

Introduction: Cholecystitis, for a long time considered as a disease of adults, has had an increased documented incidence of non-haemolitic cholelithiasis in the Pediatric Surgery practice in the last 20 years. Even though diseases of the gall bladder are rare in children, pediatric patients account for 4% of all cases with cholecystectomy. Cholecystitis and other diseases of the gall bladder should be considered in differential diagnosis in every patient with abdominal pain in the right upper quadrant, followed by jaundice, especially in children with history of hemolysis. Aim: The aim is to discuss the diagnostic and therapeutic modalities in 6 children with acute cholecystitis and cholelithiasis diagnosed and treated at the clinic of the authors. Patients and Methods: In the last 5 years, at UCCK, 6 patients under 12 years of age were operated, cholecystectomy was performed. The disease was more prevalent in female patients (66.66%—4 patients) than in male patients (33.33%—2 patients). Mean age was 8.6. Clinical manifestations presented: increased body temperature, abdominal pain and abdominal tenderness during examination. Other clinical manifestations included: vomiting in 4 patients (66.66%), jaundice in 2 patients (33.33%). Lab results showed leucosytosis in 3 patients (50%), disorders of the liver in 2 patients (33%). 2 patients were diagnosed with spherocytosis and splenomegaly, 1 patient had empyema of gall bladder (wall thickness of the gall bladder > 3.7 mm). Clinical diagnosis was confirmed with ultrasound. Ultrasound criteria are: gall bladder thickness (3.5 mm), stones ose sludge with acoustic shadow, and collection of liquid around gall bladder (pericholecystitis). Results: All patients were initially treated with naso-gastric tube (suction), fluids and antibiotics. Cholecystectomy was performed in 4 patients and cholecys-tectomy with splenectomy in 2 patients due to spherocytosis. Discussion and conclusion: Choleli-thiasis in children is most commonly associated with haemolitic and haemoglobin diseases (Hereditary Spherocytosis, Sideropenic Anaemia, Thalasemia etc.). The incidence of cholesterol stones is higher than pigment stones. Cholecystitis and cholelithiasis in children are more common than previously thought. Ultrasound confirms with great accuracy the presence of stones and acalculous cholesytitis. Treatment is usually surgical, laparoscopic or open surgery, depending on the stage of the disease and the experience of the surgeon.

Gynecologic concerns in patients with cloacal anomaly

Children with anorectal malformations (ARM) constitute a significant group within a pediatric surgery practice. It is important with female cases of anorectal malformations to consider the association of gynecologic anomalies, especially at the time of the definitive repair. However, it is critical to consider the association of such gynecologic anomalies when caring for patients with a cloacal anomaly. If not recognized, an opportunity to diagnose and treat such anomalies may be missed with the possibility of negative implications for future reproductive capacity. With the knowledge of the associated anomalies and long-term sequelae, surgeons can provide better care for girls and important counseling for parents. Knowledge of reproductive related issues in females with cloaca allows the pediatric surgeon an opportunity both, to provide optimal surgical management in infancy, childhood, and into young adulthood and to collaborate medically and surgically with an experienced gynecologist in patients with more complex anatomic variations. Appropriate counseling for patients and families about potential reproductive concerns that may develop many years after the definitive surgical repair allows preparation and planning to preserve future fertility.

Surgical Care of Pediatric Patients in the Humanitarian Setting

Little is known about the scope of practice and outcomes in pediatric surgery performed by humanitarian organizations in resource-poor settings and conflict zones. This study provides the largest report to date detailing such data for a major nongovernmental organization providing humanitarian surgical relief support in these settings. To characterize pediatric surgical care provision by a major nongovernmental organization in specialized humanitarian settings and conflict zones. A retrospective cohort study was conducted from August 15, 2014, to March 9, 2015, of 59,928 surgical interventions carried out from January 1, 2012, to December 31, 2013, by the Médecins Sans Frontières Operational Centre Paris (MSF-OCP) program in 20 locations, including South Sudan, Yemen, Syria, Gaza, Pakistan, Nigeria, Central African Republic, Democratic Republic of Congo, and the Philippines. Surgical interventions were primarily for general surgical, traumatic, and obstetric emergencies and were categorized by mechanism, type of intervention, American Society of Anesthesia risk classification, and urgency of intervention. Operative indications, type of intervention, and operative case mortality. Among all age groups, 59,928 surgical interventions were performed in dedicated trauma, obstetric, and reconstructive centers for 2 years. Nearly one-third of interventions (18,040 [30.1%]) involved preteen patients (aged <13 years) and 4571 (7.6%) involved teenaged patients (aged 13-17 years). The proportion of violence-related injuries in the preteen group was significantly lower than in the teenage group (4.8% vs 17.5%; P < .001). Burns (50.1%), other accidental injuries (16.4%), and infections (23.4%) composed the bulk of indications in the preteen group. Interventions in the teenage group were principally caused by trauma-related injuries (burns, 22.9%; traffic accidents, 10.1%; gunshot wounds, 8.0%). Crude perioperative case mortality rates were 0.07% in the preteen group, 0.15% in the teenage group, and 0.22% in the adult group (>17 years) (P = .001). One-third of the cases (33.4%) were deemed urgent, while most of the remaining cases (57.7%) were deemed semielective (surgical intervention to be performed within 48 hours). When examining surgical interventions in a population of pediatric patients cared for in the specialized setting of humanitarian aid and conflict zones, burns, other accidental injuries, and infection composed the bulk of indications in the preteen group; interventions in the teenage group were principally caused by trauma-related injuries. Crude perioperative case mortality rates in the preteen group were significantly lower than in the adult group. Further work is needed to examine long-term outcomes of pediatric operations in these settings and to guide context-specific surgical program development.

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 the surgeon of the week system in an academic pediatric surgery practice

BackgroundA pilot rounding surgeon of the week (SOW) program was implemented in our institution on July 2013 to improve patient care through focused attending rounds. The purpose of this study was to assess the impact of the SOW. MethodsWe performed a descriptive retrospective study from a single, large-volume academic center. Data were collected from July to December 2013 (post-SOW) and compared to July to December 2012 (pre-SOW). Outcomes included patient safety (safety reports) and team productivity (billing data). We also evaluated nursing satisfaction through a 10-point Likert scale survey. ResultsThe total number of patient safety complaints decreased after the SOW (37 pre-SOW versus 27 post-SOW). Work relative value units (wRVUs) increased by 8% while nonoperative billing increased by 15%. Twenty of the daytime nursing staff completed the survey and overall satisfaction with the SOW was 8.3. Twelve were employed prior to the SOW and, when analyzed independently, the proportion of employees satisfied with nursing to physician communication was higher after the SOW (55% pre-SOW vs. 83% post-SOW, p=0.13) as was perception of parental satisfaction (33% vs. 75%, p=0.04). ConclusionsThe SOW program appears to improve patient safety as evidenced by a decrease in patient safety events. Additionally, the SOW program led to higher ancillary staffing satisfaction and perceived parental satisfaction without decreasing revenue. This study suggests that the SOW may be a beneficial program that could be considered at other large-volume institutions.

Common Pediatric Congenital Conditions of the Hand.

After reading this article, the participant should be able to: 1. Accurately diagnose congenital differences that affect the hand. 2. Develop a surgical plan for syndactyly with regard to timing of intervention to prevent progressive deformity and principles to restore the commissure. 3. List the potential complications following polydactyly reconstruction. 4. State the indications for pollicization for thumb hypoplasia. Congenital conditions of the hand are commonly encountered in a pediatric hand surgery practice. The physician must be comfortable and have a sound understanding of the diagnosis and treatment algorithm. Certain diagnoses are inheritable and require genetic testing and/or genetic counseling. Appropriate referral is necessary to facilitate education about the congenital difference and its effect on subsequent generations. Syndactyly, polydactyly, thumb hypoplasia, and cleft hand are particularly commonplace and are discussed in this article. The treatment principles and surgical techniques are emphasized to maximize hand function and aesthetic outcome.

Anorectal malformation: the etiological factors.

Anorectal malformation (ARM) is a congenital anomaly commonly encountered in pediatric surgery practice. Although surgical procedures correct the anatomical anomalies, the post-operative bowel function is not universally satisfactory. The etiology of ARM remains unclear. In this review, we summarize the current understanding of the genetic and epigenetic factors contributing to the pathogenesis of ARM, based on published animal models, human genetics and epidemiological researches. Appreciation of these factors may be helpful in the management of ARM in the future.

Surgical checklist application and its impact on patient safety in pediatric surgery.

Background:Surgical care is an essential component of health care of children worldwide. Incidences of congenital anomalies, trauma, cancers and acquired diseases continue to rise and along with that the impact of surgical intervention on public health system also increases. It then becomes essential that the surgical teams make the procedures safe and error proof. The World Health Organization (WHO) has instituted the surgical checklist as a global initiative to improve surgical safety.Aims:To assess the acceptance, application and adherence to the WHO Safe Surgery Checklist in Pediatric Surgery Practice at a university teaching hospital.Materials and Methods:In a prospective study, spanning 2 years, the checklist was implemented for all patients who underwent operative procedures under general anesthesia. The checklist identified three phases of an operation, each corresponding to a specific period in the normal flow of work: Before the induction of anesthesia (“sign in”), before the skin incision (“time out”) and before the patient leaves the operating room (“sign out”). In each phase, an anesthesiologist,-“checklist coordinator”, confirmed that the anesthesia, surgery and nursing teams have completed the listed tasks before proceeding with the operation and exit. The checklist was used for 3000 consecutive patients.Results:No major perioperative errors were noted. In 54 (1.8%) patients, children had the same names and identical surgical procedure posted on the same operation list. The patient identification tag was missing in four (0.1%) patients. Mention of the side of procedures was missing in 108 (3.6%) cases. In 0.1% (3) of patients there was mix up of the mention of side of operation in the case papers and consent forms. In 78 (2.6%) patients, the consent form was not signed by parents/guardians or the side of the procedure was not quoted. Antibiotic orders were missing in five (0.2%) patients. In 12 (0.4%) cases, immobilization of the patients was suboptimal, which led to displacement of diathermy grounding pad. In 54 (1.8%) patients, the checklist was not used at all. In 76 (2.5%) patients the checklist was found to be incompletely filled.Conclusions:Our study supports the use of the checklist as an essential safety tool and reinforcement of the same. The checklist may act as a valuable prompt to focus the team, to ensure that even the simple things have been cared for.

Surgical Treatment Results In Gastroschisis Based On Preterm Delivery Within The 34th Week Of Gestation By Caesarean Section

The aim of the study was to assess the value of the today's appropriate approach, preterm delivery in the 34th week of gestation by Caesarean section and subsequent surgical intervention at the perinatal center, in daily practice of pediatric surgery with regard to early postoperative and mid-term outcome. Over the time period of 9 years, all consecutive cases diagnosed with gastroschisis at the perinatal center, University Hospital of Magdeburg, were born by Caesarean section within the 34th week of gestation followed by surgical intervention. The registered data were compared with those published by other groups. Overall, there were 19 cases through the investigation period from 01/01/2006 to 12/31/2014. The mean duration of gestation was 237.9 days. The mean birth weight was 2,276 g. In all individuals, a primary closure with no artificial material was achieved. The duration of postoperative artificial respiration was 2.3 days. Oral uptake could be initiated on the 10th postoperative day on average. The mean hospital stay was 37 days. There was no lethality. As complications, postoperative (iv catheter-associated) sepsis occurred in one case and relaparotomy became necessary in a further case because of no possible completion of enteral nutrition by 20 days after primary closure (complication and relaparotomy rate, 10.5% and 5.26%, respectively). The data indicate that in case of gastroschisis, primary closure can be more frequently achieved by section within the 34th week of gestation. Under the prediction of an optimal neonatological care, the risks of a preterm delivery by a planned section appear to be manageable.

The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients

BackgroundHispanics account for over 60% of the U.S. population growth and 25% speak little-to-no English. This language barrier adversely affects both access to and quality of care. Surgical specialties trail other medical fields in assessing the effects of language barriers to surgical clinical care and patient satisfaction. This study was designed to assess the effects of patient–provider language concordance on a pediatric surgery practice. MethodsA surgery-specific, 7-point Likert scale questionnaire was designed with 14 questions modeled after validated patient satisfaction surveys from the literature. Questions concerning provider–patient language concordance, quality of understanding, and general satisfaction were included. Surveys were administered to families of patients in the General Pediatric Surgery Clinic at our institution. Families were categorized into three groups: English-speaking, regardless of race/ethnicity; Spanish-speaking using interpreter services with an English-speaking medical team; and Spanish-speaking communicating directly with a Spanish-speaking medical team (Hispanic Center for Pediatric Surgery, HCPS). One-way analysis of variance was used to test for group differences. ResultsWe administered 226 surveys; 49 were removed due to lack literacy proficiency. Families in the HCPS group reported a higher level of satisfaction than the interpreter and English groups (p<0.01). The HCPS group also indicated improved understanding of the information from the visit (p<0.001). Spanish-speaking only families felt that communicating directly with their health care team in their primary language was more important than their English-speaking counterparts (p<0.001). ConclusionsIn a pediatric surgery clinic, language concordant care improves patient satisfaction and understanding for Hispanic families in comparison to language discordant care. Other clinics in other surgery sub-specialties may consider using this model to eliminate language barriers and improve patient satisfaction and understanding of surgical care.

Are paediatric operations evidence based? A prospective analysis of general surgery practice in a teaching paediatric hospital.

Paediatric surgical practice should be based upon solid scientific evidence. A study in 1998 (Baraldini et al., Pediatr Surg Int) indicated that only a quarter of paediatric operations were supported by the then gold standard of evidence based medicine (EBM) which was defined by randomized controlled trials (RCTs). The aim of the current study was to re-evaluate paediatric surgical practice 16 years after the previous study in a larger cohort of patients. A prospective observational study was performed in a tertiary level teaching hospital for children. The study was approved by the local research ethics board. All diagnostic and therapeutic procedures requiring a general anaesthetic carried out over a 4-week period (24 Feb 2014-22 Mar 2014) under the general surgery service or involving a general paediatric surgeon were included in the study. Pubmed and EMBASE were used to search in the literature for the highest level of evidence supporting the recorded procedures. Evidence was classified according to the Oxford Centre for Evidence Based Medicine (OCEBM) 2009 system as well as according to the classification used by Baraldini et al. Results was compared using Χ (2) test. P < 0.05 was considered statistically significant. During the study period, 126 operations (36 different types) were performed on 118 patients. According to the OCEBM classification, 62 procedures (49 %) were supported by systematic reviews of multiple homogeneous RCTs (level 1a), 13 (10 %) by individual RCTs (level 1b), 5 (4 %) by systematic reviews of cohort studies (level 2a), 11 (9 %) by individual cohort studies, 1 (1 %) by systematic review of case-control studies (level 3a), 14 (11 %) by case-control studies (level 3b), 9 (7 %) by case series (type 4) and 11 procedures (9 %) were based on expert opinion or deemed self-evident interventions (type 5). High level of evidence (OCEBM level 1a or 1b or level I according to Baraldini et al. PSI 1998) supported 75 (60 %) operations in the current study compared to 18 (26 %) in the study of 1998 (P < 0.0001). The present study shows that nowadays a remarkable number of paediatric surgical procedures are supported by high level of evidence. Despite this improvement in evidence-based paediatric surgical practice, more than a third of the procedures still lack sufficient evidence-based literature support. More RCTs are warranted to support and direct paediatric surgery practice according to the principals of EBM.

The timing of surgery for undescended testis - a retrospective multicenter analysis.

n Germany, it is recommended that the surgical treatment of an undescended testis should be carried out between the ages of 6 months and 1 year to lower the risks of subfertility and testicular carcinoma. Although this recommendation has appeared in the German guidelines from 2007 onward, orchidopexy is still frequently performed at later ages. We retrospectively analyzed data from seven pediatric surgical services in the German state of Baden-Württemberg on all boys who underwent orchidopexy from 2009 to 2012. We classified the timing of surgery as Age Group I (before the first birthday), Age Group II (between the first and second birthdays), and Age Group III (after the second birthday). We determined whether preoperative hormonal treatment was given and distinguished primary from secondary undescended testis. Among 2213 boys who underwent orchidopexy, 1850 had primary and 363 had secondary undescended testis. Of those with primary undescended testis, the percentages of boys who underwent surgery in Age Groups I, II, and III were (respectively, with 95% confidence intervals): 18.7% (17-20.6%), 24.4% (22.5-26.5%), and 57% (54.6-59.2%). A small percentage of boys in each group also received preoperative hormonal treatment. From 2009 to 2012, there was a secular trend favoring earlier orchidopexy. In 2012, 28 boys (14.2% [9.7-20.0%]) had orchidopexy in outpatient pediatric surgery practices before their first birthday, while 68 did on hospital inpatient services (40.7% [33.2-48.6%]). Most of the patients studied had surgery at a later age than recommended. Adherence to the guidelines in this respect is nonetheless relatively good in Germany compared to other countries, as studies from abroad have yielded findings that are just as bad or worse.