Pediatric Surgical Team Research Articles

Ergonomics analysis of pediatric surgical team in dedicated endoscopic surgery suites

Ergonomics analysis of pediatric surgical team in dedicated endoscopic surgery suites

Transitional Care in Anorectal Malformation and Hirschsprung's Disease: A Systematic Review of Challenges and Solutions

BackgroundThe literature on transitional care in anorectal malformation (ARM) and Hirschsprung's disease (HD) is diverse and heterogeneous. There is a lack of standards and guidelines specific to transitional care in these conditions. We aim to establish and systematically categorize challenges and solutions related to colorectal transition care. MethodsSystematic review of qualitative studies from MEDLINE, EMBASE, PubMed and Scopus databases (2008–2022) was conducted to identify the challenges and solutions of healthcare transition specific to ARM and HD. Thematic analyses are reported with reference to patient, healthcare provider and healthcare system. ResultsSixteen studies from 234 unique articles were included. Fourteen themes related to challenges and solutions, each, are identified. Most challenges identified are patient related. The key challenges pertain to: (1) patient's lack of understanding of their disorder, resulting in over-reliance on the pediatric surgical team and reluctance towards transitioning to adult services; (2) a lack of education and awareness among adult colorectal surgeons in caring for pediatric colorectal conditions and inadequate communication between pediatric and adult teams; and (3) a lack of structured transition program and joint-clinic to meet the needs of the transitioning patients. The key solutions are: (1) fostering young adult patient's autonomy and independence; (2) conducting joint pediatric-adult transition clinics; and (3) ensuring a structured and coordinated transition program is available using a standardized guideline. ConclusionA comprehensive framework related to barriers and solutions for pediatric colorectal transition is established to help benchmark care quality of transitional care services. Level of EvidenceIV. Type of StudySystematic review without meta-analysis.

Remote cadaveric minimally invasive surgical training.

The aim of the study is to discuss the efficacy of live vs. remote cadaver surgical training (CST) for minimally invasive surgery (MIS). A cohort of 30 interns in their first and second years of training were divided into three groups: live observers (n = 12), live participants (n = 6), and remote observers: (n = 12). The interns had the opportunity to either observe or actively participate in two different surgical procedures, namely, laparoscopic lower anterior resection, performed by a colorectal surgical team, and laparoscopic fundoplication, performed by a pediatric surgical team. The procedures were conducted either at a base center or at a remote center affiliated with the institute. Some of the interns interacted directly with the surgical teams at the base center, and others interacted indirectly with the surgical teams from the remote center. All interns were administered questionnaires before and after completion of the CST in order to assess their understanding of various aspects related to the operating room layout/instruments (called "design"), accessing the surgical field (called "field"), understanding of anatomic relations (called "anatomy"), their skill of dissection (called "dissection"), ability to resolve procedural/technical problems (called "troubleshooting"), and their skill in planning surgery (called "planning") according to their confidence to operate using the following scale: 1 = not confident to operate independently; 4 = confident to operate with a more senior trainee; 7 = confident to operate with a peer; and 10 = confident to operate with a less experienced trainee. A p < 0.05 was considered statistically significant. All scores improved after CST at both the base and remote centers. The following significant increases were observed: for remote observers: "field" (2.67→4.92; p < .01), "anatomy" (3.58→5.75; p < .01), "dissection" (3.08→4.33; p = .01), and "planning" (3.08→4.33; p < .01); for live observers: "design" (3.75→6.17; p < .01), "field" (2.83→5.17; p < .01), "anatomy" (3.67→5.58; p < .01), "dissection" (3.17→4.58; p < .01), "troubleshooting" (2.33→3.67; p < .01), and "planning" (2.92→4.25; p < .01); and for live participants: "design" (3.83→6.33; p = .02), "field" (2.83→6.83; p < .01), "anatomy" (3.67→5.67; p < .01), "dissection" (2.83→6.17; p < .01), "troubleshooting" (2.17→4.17; p < .01), and "planning" (2.83→4.67; p < .01). Understanding of "design" improved significantly after CST in live observers compared with remote observers (p < .01). Understanding of "field and "dissection" improved significantly after CST in live participants compared with live observers (p = .01, p = .03, respectively). Out of the 12 remote observers, 10 participants (83.3%) reported that interacting with surgical teams was easy because they were not on-site. Although all the responses were subjective and the respondents were aware that observation was inferior to hands-on experience, the results from both centers were equivalent, suggesting that remote learning could potentially be viable when resources are limited.

Comparative Analysis of Outcomes and Complications of Pediatric Trauma Surgeries Performed by General Surgeons Versus Specialized Pediatric Trauma Surgeons: A Review of the Literature.

Pediatric trauma surgeries require specialized expertise to ensure optimal outcomes and minimize complications. This review aims to compare the outcomes and complications of pediatric trauma surgeries performed by general surgeons versus specialized pediatric trauma surgeons, based on the analysis of relevant papers. A literature search was conducted, and 10 papers were chosen for analysis. The selected papers included comparative data on outcomes and complications between general and specialized pediatric trauma surgeons. Specialized pediatric trauma surgeons consistently demonstrated superior outcomes compared with general surgeons. They had lower mortality rates and improved functional outcomes, shorter hospital stays, and lower complication rates. Multidisciplinary collaboration among specialized pediatric trauma surgical teams enhanced communication and patient management. The findings support the advantages of specialized pediatric trauma surgeons, who possess specific training in pediatric anatomy, physiology, and surgical techniques. Their expertise enables them to address the unique challenges of pediatric trauma and tailor interventions accordingly. The multidisciplinary approach facilitated by specialized teams further enhances outcomes. Specialized pediatric trauma surgeons offer distinct advantages over general surgeons in pediatric trauma surgeries. Their expertise, tailored interventions, and multidisciplinary collaboration contribute to improved outcomes and reduced complications. Efforts should be directed towardestablishing specialized pediatric trauma surgical teams and enhancing access to specialized expertise.

Ten Years Analysis of Parental Counselling-in-Continuum in Paediatric Surgery: Psychosocial and Medico-legal Outcome.

Parents are anxious and apprehensive about the health of their children. A standardised, reproducible and meticulous parental counselling is helpful to both the parents and the treating doctors, as well as markedly reduces instances of scrimmage and medico-legal litigations. The aim of this study is to assess the psychosocial and medico-legal outcomes of parental counselling-in-continuum (PCiC) in paediatric surgery. The study was conducted at two government-run Tertiary Healthcare Centres in North India. The study design involves prospective feedback-based study. It included all the admitted paediatric surgery patients. Periodic multisession PCiC was done for each patient by three paediatric surgery teams from 2011 to 2021. At the time of discharge, feedback was taken to assess the psychosocial outcome of PCiC, and the medico-legal outcome was calculated based on the number of litigations. A total of 22,353 admissions were done in paediatric wards at these institutes. 1574 cases were managed conservatively and 20,779 patients who underwent surgeries were included in the study. 4758 (22.89%) were emergency procedures and 16,021 (77.11%) were elective procedures. Parents rated the counselling efforts excellent in 18,285 (81.80%), good in 3162 (14.14%), satisfactory in 876 (3.91%) and poor in 30 (0.13%) cases with zero medico-legal litigations and 12 incidents of scrimmage. PCiC, being a novel concept, should form a centerpiece of paediatric surgical management as it maximally enhances the patient satisfaction level and protects the treating paediatric surgical team from scrimmage and medico-legal litigations.

Met and Unmet Need for Pediatric Surgical Access in Uganda: A Country-Wide Prospective Analysis

IntroductionChildren's surgical access in low and low-middle income countries is severely limited. Investigations detailing met and unmet surgical access are necessary to inform appropriate resource allocation. Materials and methodsSurgical volume, outcomes, and distribution of pediatric general surgical procedures were analyzed using prospective pediatric surgical databases from four separate regional hospitals in Uganda. The current averted burden of surgical disease through pediatric surgical delivery in Uganda and the unmet surgical need based on estimates from high-income country data was calculated. ResultsA total of 8514 patients were treated at the four hospitals over a 6-year period corresponding to 1350 pediatric surgical cases per year in Uganda or six surgical cases per 100,000 children per year. The majority of complex congenital anomalies and surgical oncology cases were performed at Mulago and Mbarara Hospitals, which have dedicated pediatric surgical teams (P < 0.0001). The averted burden of pediatric surgical disease was 27,000 disability adjusted life years per year, which resulted in an economic benefit of approximately 23 million USD per year. However, the average case volume performed at the four regional hospitals currently represents 1% of the total projected pediatric surgical need. ConclusionsThis investigation is one of the first to demonstrate the distribution of pediatric surgical procedures at a country level through the use of a prospective locally created database. Significant disease burden was averted by local pediatric and adult surgical teams, demonstrating the economic benefit of pediatric surgical care delivery. These findings support several ongoing strategies to increase pediatric surgical access in Uganda.

551. Antibiotic Use Among Surgical Patients in the Neonatal Intensive Care Unit (NICU): The NO-More-AntibioticS and Resistance in Surgery (NO-MAS-R-S) Study

Abstract Background Although antibiotic exposure among infants in the NICU is associated with short- and long-term adverse effects, the burden of antibiotic use in neonatal surgical patients has not been well described. The pediatric surgical team at Nationwide Children’s Hospital (NCH) provides all surgical consultations for central Ohio in the level 4 outborn referral NICU at NCH. Our objective was to quantify the total use of antibiotics in surgical NICU patients and thus inform antimicrobial stewardship opportunities. Methods This was a prospective observational study of all infants in the NCH NICU who underwent pediatric surgical evaluation and received antibiotic therapy from 1/3/2022 to 4/29/2022. The pediatric surgery fellow informed the neonatal clinical pharmacist about all consultations and provided qualitative data on antibiotic prescribing (diagnosis, indication and reasoning for antibiotic selection, dosing, and duration) using a set questionnaire. Pertinent demographic maternal/infant data were obtained from the electronic health records. Results During the 4-month study period, 59 infants (median gestational age, 35 wks, IQR 28-35 wks; median birth weight, 2275 g, IQR 1085-3107 g) underwent surgical evaluation at a median postnatal age of 2 days (IQR, 1-12 d). 33 (56%) infants were male; 9 (22%) had antibiotic exposure for &amp;gt;48 hours before surgical consultation. Of the 59 infants, 28 (47%) had a surgical procedure performed (Figure 1) with indications for antibiotic use provided in Figure 2. 34 (58%) infants had antibiotics started by surgical team for a median treatment duration of 7 days (IQR, 5-14). Surgeons considered 74% (20/27) of antibiotic initiation courses to be evidence-based. Of the 59 infants, the most commonly used antibiotics were gentamicin (32%), ampicillin-sulbactam (29%), cefazolin (19%), and piperacillin-tazobactam (14%). The most frequent blood isolate was E. coli (n=4). Mortality was 2% (n=1) and was not infection-related. Figure 1Surgical procedures performed in 28 of 59 infants who underwent surgical evaluation. Figure 2 Indications for antibiotic use in 59 infants who underwent surgical evaluation Conclusion Antibiotics were utilized in the majority of infants who had surgical consultation. Surgical prophylaxis was the main indication and may serve as a potential opportunity for ongoing surgical stewardship efforts. (Supported by Merck &amp; Co research grant) Disclosures Debra A. Goff, Pharm.D, FIDSA, FCCP, Merck Sharp &amp; Dohme (MSD): Grant/Research Support Alexandra K. Medoro, MD, Merck: Grant/Research Support Pavel Prusakov, PharmD, Merck Sharp &amp; Dohme: Grant/Research Support.

Lessons learned from early experience of per oral endoscopic myotomy in children

Background/AimsAchalasia cardia (AC) is rare in children, and the standard treatment is open or Laparoscopic Heller's myotomy with or without fundoplication if pneumatic dilatation has failed. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with good results in adults. We report POEM in four children and the outcome with special emphasis on the technique and management of intra-operative complications. MethodFour children aged 7–15 years presenting with progressive dysphagia, cough, night-time aspirations, and weight loss of six months to one year were investigated with upper GI contrast study, flexible endoscopy and biopsy, oesophageal manometry, and a diagnosis of Type 1 & 2 AC was made. An experienced adult endoscopist in collaboration with the paediatric surgical team performed POEM. ResultsPOEM was performed successfully using ERBE HYBRID knife setup and waterjet injection for the submucosal tunnelling. Operative time was 25–40 min (mean 31 min). The hospital stay was 3–8 days with last 3 patients discharged on day three. No major intraoperative or post-operative complications were seen. The Eckardt score changed from above 4 to 0 at one-month follow-up. All four are well at one year post-operatively and beyond. Two patients had subcutaneous emphysema post-operatively. One developed pneumoperitoneum intra-operatively. ConclusionPOEM was successfully performed with only minor adverse events in experienced hands. Anticipation and preparation for potential intraoperative complications and assigned responsibilities to each team helped the safe completion in the shortest time. Rectifying pneumoperitoneum concurrently without interruption of the operation exemplified teamwork. Level of EvidenceIII

Neonatal Surgical Emergencies Immediate Referral

Background: This study was conducted to explore the circumstances around which neonates are referred to the pediatric surgical team of Liaquat University Hospital. This influences the surgical management of neonatal emergencies outcome which also turns on awareness of the conditions early diagnosis, proper resuscitation, excellent nursing care, and refer to the proper center, main requirement is the application of a basic neonatal transport unit, whenever necessary these neonates are referred to these centers from wherever they are born. Methods: It is a retrospective descriptive study carried out at Liaquat University Hospital Hyderabad Sindh. This study included every referral neonatal surgical emergency managed by the pediatric surgical team from June 2017 to May 2019. Data were obtained from the patient's files and operation theatre register. This study was conducted over two years from June 2017 to May 2018 in the department of pediatric surgery, Liaquat University of medical health sciences Jamshoro. All the neonates presenting with surgical emergencies were included irrespective of gender, mode of referral, and causes that warrant surgical exploration using sampling of convenience. However, neonates whose carers did not consent to be a part of the study were not included. Inform consent was taken from either of the parents reassuring them about confidentiality, as well as the treatment being unaffected had they chosen to withdraw from a study at any time. The study variables included age, sex, weight, and referral pattern, later data was analyzed using SPSS version 21. Results: Fifty-three neonates were operated in July 2017 to June 2020. Out of 53 neonates, 32 were male and 21 female. The male to female ratio is 1.5:1. Anorectal Malformation 12 (22.6%) Intestinal Atresia 6 (11.3%) and Pneumoperitoneum 5 (9.4%) Hirschsprung's disease 9 (13.2%). Neonates with low birth weight were 5 (9.4%). The basic neonatal referral &amp; transport system was poorer. Age at the time of presentation ranges from 1 to 20 days, a median age was 3 days. Dehydration in mild, moderate, and severe was noted in 38 (71.6%) of the referral neonates. The leading cause of morbidity and mortality was sepsis, mortality was 7 (13.2%). Conclusion: Management of neonatal emergencies the morbidity and mortality were not as high compared to other developing countries. However, improvement in the outcomes will require awareness, early referral to the concerned department, and overcoming difficulties by providing a well-equipped hospital that will provide an outstanding nursing facility and a well-equipped neonatal transportation system. Keywords: Neonatal transport unit, Basic resuscitation, Good nursing care, Neonatal intensive care unit

Pediatric Surgical Care During the COVID-19 Lockdown: What Has Changed and Future Perspectives for Restarting in Italy. The Point of View of the Italian Society of Pediatric Surgery.

Background:The coronavirus disease 2019 (COVID-19) time exacerbated some of the conditions already considered critical in pediatric health assistance before the pandemic. A new form of pediatric social abandonment has arisen leading to diagnostic delays in surgical disorders and a lack of support for the chronic ones. Health services were interrupted and ministerial appointments for pediatric surgical healthcare reprogramming were postponed. As a result, any determination to regulate the term “pediatric” specificity was lost. The aim is, while facing the critical issues exacerbated by the COVID-19 pandemic, to rebuild future perspectives of pediatric surgical care in Italy.MethodsEach Pediatric Society, including the Italian Society of Pediatric Surgery (SICP), was asked by the Italian Federation of Pediatric Associations and Scientific Societies to fill a questionnaire, including the following the main issues: evaluation of pre-pandemic criticalities, pediatric care during the pandemic and recovery, and current criticalities. The future care model of our specialty was analyzed in the second part of the questionnaire.ResultsChildren are seriously penalized both for surgical treatment as well as for the diagnostic component. In most centers, the pediatric surgical teams have been integrated with the adult ones and the specificity of training the pediatric operating nursing is in danger of survival. “Emotional” management of the child is not considered by the general management and the child has become again an adults patient of reduced size.ConclusionA new functional pediatric surgical model needs to be established in general hospitals, including activities for day surgery and outpatient surgery. To support the care of the fragile child, a national health plan for the pediatric surgery is required.

VP10.08: Fetal cleft lip palate: sonographic diagnosis and postnatal outcomes

Orofacial clefts (OCs) is one of the most common congenital anomalies with an incidence of 1:700 to 1:1000. They can be isolated entities or parts of genetic syndromes. Early diagnosis of OCs is of great significance for etiological testing and parental decision making. We sought to examine the diagnostic and prognostic implications of the finding of left lip and or palate on routine obstetric ultrasound exam. This was a descriptive study observational developed in the Maternity and Neonatology Center, department in order to investigate facial cleft described at a sonographic scan in the first and second trimester. This study included 238 women who underwent ultrasonographic exam from January 2019 to December 2020. Then we reviewed the details of each case referring to our local pediatric surgical unit and perinatal pathology department to obtain outcomes. We identified 17 cases with the diagnosis of facial clefting. Fifteen cases were diagnosed in the second trimester, 2 at the first trimester. All fetuses were karyotyped, 15 (88%) had a normal karyotype, however, 2 (12%) had a trisomy 13. Of the 17 confirmed facial clefts, 9 had associated structural abnormalities and the remaining 8 were not found to have any other anomaly. Of the multiple structural anomaly cases, 7 underwent termination, 10 got birth at term. From those born 2 died soon after birth, 7 were referred to the pediatric surgical team. Facial clefts are often associated with other structural anomalies. It is important to detect cleft lip and palate because it can be an indicator of other syndromic congenital anomalies or chromosomal abnormalities. A multidisciplinary approach is essential for proper management.

Impaired Health of Children Treated for Hirschsprung’s Disease

Impaired Health of Children Treated for Hirschsprung’s Disease

Clinical Presentation, Treatment, and Challenges in the Management of Child Sexual Assault at a Tertiary Care Referral Center in India.

Child Sexual Assault (CSA) is not an uncommon but an under-reported crime. Along with social and psychological critical issues, there are multiple challenges faced by the surgical team for the treatment of complex perineal injuries associated with CSA. This study was conducted to find clinical presentation and management of CSA along with its problems and challenges encountered by the pediatric surgical team. This was a retrospective study from 2010 to 2019, conducted in the department of pediatric surgery at a tertiary referral center. All-female patients with a definitive history of sexual assault were included in the study. Seven patients fulfilled the inclusion criteria and the mean age was 5.3years. After a primary survey, all patients were taken up for examination under anesthesia (EUA). Three patients were managed by the primary repair of the wound and did well during follow-up. Four patients had grade 4 perineal injury and required stage reconstruction. As a first stage, repair of rectal tear, vaginal tear, and the perineal body reconstruction was done along with diversion colostomy. One patient required redo repair of the perineal body and one had developed a rectovaginal fistula. Three patients completed all stages and they are fully continent. The spectrum of injuries varies widely in CSA and more chances of high-grade perineal injuries in children due to distinctive local anatomy. EUA is crucial to assess the extent of the injury and to decide the course of management. Meticulous anatomical repair and diversion stoma is the key for successful complex repair and excellent long-term outcomes in terms of continence for the severe grade of perineal injuries.

Collaboration pédiatre-adulte dans la chirurgie des tumeurs musculosquelettiques

Orthopaedic surgery I has a key role on the medical pathway of adolescent and young-adult (AYA) patients with musculo-skeletal tumor from diagnosis, tumor resection, musculo-skeletal immediate or delayed reconstruction, to dealing with late complications and sequelae following reconstruction during childhood. Administrative authorizations, organization by health authorities as well as training courses are quite different for adult and pediatric surgery. However, surgery for musculo-skeletal tumors in AYA patients have neither adult nor pediatric specifities; resection-reconstruction rules and technics are the same for adult or pediatric patients, with nevertheless lower complication rate and more biologic reconstructions for the youngest, and more prosthetic reconstructions for the oldest. Late complications after bone and soft-tissue reconstructions in childhood and musculo-skeletal deformation after surgery and/or radiotherapy in childhood need the vision from "adult" orthopaedic teams for long and very long term success of the surgical project with a good knowledge of pediatric technics previously used. Thus, formal shared time and transition care are necessary between pediatric and adult surgical teams to prepare long-term follow-up of these childhood cancer survivors. Participation to the same specialized Multi-Disciplinary Board, scientific society gathering adult and pediatric surgeons, clinical trials with no age-limitation might help to erase barriers and to ease collaboration between adult and pediatric ortho-oncologic teams.

Frontonasal Dysplasia in Yangon, Myanmar

Frontonasal dysplasia (FND) is an uncommon congenital anomaly affecting the eyes, nose and forehead. In this case report, a baby of a 22-year-old mother was diagnosed with a midline facial cleft, bifid nose and hypertelorism during an ultrasound scan at 29th week of gestation. Besides a history of miscarriage on first pregnancy, no other abnormalities findings were found in laboratory or radiological examination of the newborn. Counselling about abnormality and psychological support were given by both obstetrician and neonatologist during the antenatal period. The patient delivered vaginally at 36th week with spontaneous labour and no complication was observed. Further interventions including corrective treatment have been planned as they often interfere with important functions such as breathing and feeding. Thus, the paediatric surgical team decided to do the operation when the baby reaches one year old as then tissues have been developed to 90% of their eventual form to give optimal treatment results. Further life expectancy depends on the severity of the malformation and whether or not surgical intervention can improve the associated health problems. This case report raises the importance of awareness on the nutritional value of pregnant mothers especially carotene and folic acid intake which may be associated with the organ maldevelopment. Overall, this report outlined the management of this rare condition experienced by the patient, particularly in a resource-limited setting like Yangon in Myanmar and also reviewed the literature about the presentation and classification of this condition.

Experience of teamwork between pediatric surgical team and pediatric intensive care team in management of pediatric ICU patients

Experience of teamwork between pediatric surgical team and pediatric intensive care team in management of pediatric ICU patients

Possible cytokine biomarkers in pediatric acute appendicitis

BackgroundDiagnosis of acute appendicitis (AA) and decisions about its treatment remain among the most common dilemmas of pediatric surgical teams. Monitoring of immune response may be of importance for this purpose. Our aim was to measure and analyze serum and peritoneal fluid cytokines, in children who had undergone surgery for suspected AA.MethodsProspective investigation of serum and peritoneal fluid cytokine values was performed in 127 consecutive patients. According to the pathohistological findings, patients were divided into three groups: normal/early, uncomplicated and complicated AA. Determination of cytokine concentrations for 20 different cytokines was done using a commercial flow cytometry kit: Human Inflammation 20 plex BMS 819.ResultsStatistically significant differences in serum cytokine values between pathohistological groups were found for IP-10, MIP-1α and IL-10. Preoperative cut-off values of IP-10, MIP-1α and IL-10 between groups were obtained using ROC curve analysis. Positive correlations between serum and peritoneal concentrations were recorded for most of the analyzed cytokines.ConclusionIP-10, MIP-1α and IL-10 showed potential in assessment of AA in children. Confirmatory studies with a larger number of patients are required to prove reliability of these biomarkers.

Separation of omphalopagus conjoined twins with ruptured omphalocele, complex biliary sharing and a choledochal cyst

Abstract Separating conjoined twins requires a multidisciplinary team to manage all the phases of care. These phases include initial resuscitation, managing the often discordant physiology between each twin prior to separation, planning for and carrying out the separation operation, and postoperative management. Each phase has unique challenges. The decision on timing of separation is critical in achieving success and is influenced by the stability of each infant, the confidence and experience of the team and full preoperative understanding of the shared anatomy to the extent possible. We successfully separated omphalopagus conjoined twins complicated by complex sharing of the biliary tree and the presence of an infected choledochal cyst. Preoperative optimization, MRI and MRCP, intraoperative US along with an experienced pediatric surgical team proved critical to successful separation and survival of each twin.

The Pediatric Surgical Team: a Model for Increased Surgeon Index Case Exposure

Background/PurposeHigh surgical volume for both surgeons and hospital systems has been linked to improved outcomes for many surgical problems, yet case volumes per pediatric surgeon are diminishing nationally in complex pediatric surgery. We therefore sought to review our experience in a geographically isolated setting where a surgical team approach has been used to improve per-surgeon exposure to index pediatric surgical cases. MethodsAs a surgical group, we incorporated a surgical team approach to complex pediatric surgical cases in 2010. We obtained institutional review board approval to review our pediatric surgeon index case volume experience. We then compared our surgeon experience to published surgical volumes for complex pediatric surgical cases. ResultsA surgical team approach (2 or 3 board certified pediatric surgeons/urologists working as co-surgeons or assistant surgeon) was used in the majority of cases for tracheoesophageal fistula/esophageal atresia (77%), congenital pulmonary airway malformation (73.5%), cloaca (75%), anorectal malformation (43.6%) biliary atresia (77.8%), Hirschsprung's disease (51.9%), congenital diaphragmatic hernia (67.6%), robotic choledochal cyst (100%), and complex oncology (adrenal tumors, neuroblastoma, Wilms tumor and Hepatoblastoma surgery) (85–100%). Over the 5-year period, surgeon index case exposure for all index pediatric surgical cases was above the published national median for pediatric surgeons, except for in splenic operations when contrasted to published experience. ConclusionsA surgical team approach to complex pediatric surgery may help maintain exposure to adequate index case volumes. This model may be useful for maintaining competence in geographically-isolated practice settings and low-volume pediatric hospitals that provide surgical care; the model has implications for systems development and workforce allocation within pediatric surgery. Level of Evidence4

Neutrophil myeloperoxidase index in pediatric acute appendicitis

Background/Aim. Diagnosis of acute appendicitis (AA) remains the most common dilemma of pediatric surgical team. Our aim was to determine whether the neutrophil myeloperoxidase index (MPXI), in combination with other laboratory and clinical parameters, can be useful in diagnosis and follow-up of AA in children. Methods. A prospective investigation of MPXI values in 117 consecutive patients, planned for the surgical intervention due to AA, was performed. The patients were stratified into three groups according to the intraoperative finding: the normal/early, uncomplicated and complicated AA. Laboratory analyses were done preoperativly, on the 1st and on the 3rd postoperative days. Results. The statistically significant difference of MPXI values between the uncomplicated and complicated appendicitis before surgery and the positive correlations between the MPXI and C-reactive protein, as well as interleukin- 6, before surgery were found. Postoperatively, in the group of uncomplicated, as well as complicated AA, a significant decrease of MPXI was recorded. Conclusion. The MPXI may be used as an informative biomarker in the follow- up of AA in children. A wide reference range for the MPXI and individual differences in the values of MPXI in the healthy children, generate difficulties for its use for the initial diagnosis of acute appendicitis. Usefulness of MPXI determination decreases with a delayed diagnosis.