The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association

How We Do It: Video-Based Assessment Conference for Intraoperative Decision Making in Pediatric Surgery

OBJECTIVE

To demonstrate our experience with establishing a video-based assessment conference (VBA) for rare and complex procedures in a pediatric surgery fellowship program.

DESIGN

We share our experience in establishing a VBA conference in our Division of Pediatric Surgery from case selection, methods of operative video recording, equipment, and editing, and the structure of how cases are presented in conference.

SETTING

Pediatric Surgery Fellowship at the Johns Hopkins Children's Center in Baltimore, MD.

PARTICIPANTS

Pediatric surgery faculty, pediatric surgery fellows, general surgery residents, medical students, and nurse practitioners at Johns Hopkins participated in the conferences. Medical students and faculty were responsible for video recording and editing.

CONCLUSIONS

Allowing VBA of operative cases can improve comprehensive learning in technically challenging and rare cases seen in pediatric surgery. Our paper shares one methodology of establishing a successful VBA conference.

Rural General Surgeons' Perspectives Regarding the Provision of Surgical Care to Children

OBJECTIVE

The volume of surgical care provided to children by general surgeons has decreased over time, which disproportionally impacts rural children. This study aimed to understand factors that influence rural general surgeons' decisions regarding provision of surgical care to children.

DESIGN

Cross-sectional survey of 55 items conducted between February 2023 and March 2024 SETTING: Survey distributed at meetings, ACS communities, social media.

PARTICIPANTS

162 nonpediatric surgery trained general surgeons practicing in rural communities across North America.

RESULTS

Among respondents, median age was 58 years, and 75.9% identified as male and 87.7% as White/Caucasian. While a majority of respondents operated on children, most performed < 20 surgeries per year. Factors reported by surgeons to be most influential regarding their decision to operate on children were personal experience/expertise/training. Availability of a pediatric inpatient unit and proximity to a children's hospital/pediatric surgeons were the next most influential factors. The amount of pediatric surgery exposure during training, feeling this training was adequate, and a greater number of years in practice since completion of training all significantly correlated with comfort in operating on younger patients. The amount of pediatric surgery exposure during training also correlated with the number of surgeries performed per year in children. > 90% of respondents reported that they would have completed additional training in pediatric surgery if it had been available during or after completion of residency. About 3 to 6 months was reported by most respondents as the optimal duration of additional pediatric surgery exposure.

CONCLUSIONS

New training paradigms that increase exposure to pediatric surgery during residency may facilitate rural surgeons' provision of routine surgical care to children and minimize the travel burden currently experienced by rural children who require surgical care.

Geographic Differences in Pediatric Surgical Mortality in Canada: A Retrospective Cohort Study

OBJECTIVE

This study describes differences in postoperative mortality for pediatric patients in rural communities compared to urban communities.

BACKGROUND

Canada has the second largest land mass in the world, with a population density of 4 people per km2. There are 18 children's hospitals in Canada offering pediatric surgical services, all in urban centres, yet nearly one-fifth of the population lives in rural or remote communities. Children who live in rural settings may have worse surgical outcomes, including mortality rates, compared with urban populations.

METHODS

Pediatric patients, from birth to 18 years old, who had surgery from January 1, 2011, to December 31, 2021, at a single Children's Hospital were included in the study. Data was obtained from the provincial Operating Room Information System (ORIS) database. Postal code, rural and urban status, distance to children's hospital (0-50 km, 51-100 km, 101-150 km, 151-200 km, and >200 km), and procedure urgency were collected. 30-day mortality for all procedures was collected.

RESULTS

85,998 surgical procedures were performed at ACH between 2011 and 2021. 17,773 (20.7%) of patients lived >50 km or more from the hospital - 5,329 (6.2%) 51- 100 km, 4,053 (4.7%) 101-150 km, n=2,323 (2.7%) 151-200 km, and 6,070 (7.1%) >200 km. Rural patients had higher 30-day mortality rates than urban patients, with an odds ratio of mortality (rural vs urban) of 2.30 (95% CI, 0.95 to 5.60). When stratified by distance, patients living closer to the hospital (0-50 km) had lower odds of mortality.

CONCLUSIONS

Canadian Rural patients have higher operative mortality risks than urban patients. This study identifies a vulnerable group of patients who do not have equal access to care and may experience worse outcomes.

Impact of Locum Tenens Providers on Delivery of Pediatric Surgical Care

INTRODUCTION

We sought to understand the impact of locum tenens surgeons on pediatric surgical care delivery.

METHODS

We conducted a cross-sectional survey of Children's Hospital Association pediatric surgical practices. Anonymous electronic surveys were used to investigate locum tenens utilization, primary reason for use, limitations on clinical activities, and variations in practice standards or quality. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between practice characteristics and locum tenens use.

RESULTS

Of 172 practices, 71% (n = 122) completed the survey. Median hospital size was 203 beds (interquartile range = 130-350). Median number of surgeons per practice was 5 (interquartile range = 3-8). Thirty-seven practices (30%) employed locum tenens at primary (n = 27) or satellite (n = 12) sites. Locum tenens utilization was higher in suburban (odds ratio [OR] = 3.78, P = 0.006) and rural (OR = 4.96, P = 0.041) locations and lower at sites with a level 4 neonatal intensive care unit (OR = 0.35, P = 0.035). Most (51%) used locum tenens ≥ 1 time monthly but < 1 time weekly and for ongoing or interim coverage (87%). In total, 14% of practices reported clinical restrictions for locum tenens surgeons, including limitations on extracorporeal membrane oxygenation, neonatal index cases, and operative trauma. Most (76%) practices using locum tenens reported variations in practice standards or quality; all were perceived as negative (57%) or neutral (43%).

CONCLUSIONS

Locum tenens providers are utilized most commonly in suburban and rural sites and hospitals without the highest level of neonatal intensive care. While locum tenens surgeons may help maintain access to pediatric surgical care where gaps exist, there may be a need to improve the quality and reliability of care rendered.

Readiness of Graduating General Surgery Residents To Perform Common Pediatric Surgery Procedures

OBJECTIVE

Up to 40% of pediatric surgery procedures occur at adult hospitals. We aim to evaluate how competent graduating general surgery residents are to perform common pediatric surgery procedures.

DESIGN

Pediatric and adult inguinal (IH) and umbilical (UH) hernia operative evaluations were collected. Ratings were analyzed using Bayesian generalized linear mixed models. The primary outcome was graduating residents' estimated probability of being competent to perform an IH or UH repair.

SETTING

This study was conducted using operative assessment data from general surgery programs in the Society for Improving Medical and Professional Learning (SIMPL) collaborative.

PARTICIPANTS

113,621 evaluations (2,924 UH, 5,555 IH) from 7,032 categorical general surgery residents were analyzed from 2015-2023.

RESULTS

Graduating residents had an adjusted probability of being competent to perform an adult IH of 94.3% (Interquartile Range [IQR] 83.4%-98.3%). In contrast, competence probabilities were 79.5% (IQR 52.7%-93.3%) for a <6 month old, 89.6% (IQR 72.1%-96.9%) for a 6 month to 5 year old, and 89.9% (IQR 71.9%-96.9%) for a >5 year old. For UH repairs, competence probabilities were similar for adult (97.6%, IQR 92.4%-99.3%) and pediatric procedures (97.3% for <5 years old [IQR 91.4%-99.2%]; 97.6% for >5 years old [IQR 92.3%-99.3%]).

CONCLUSIONS

Nearly all graduating general surgery residents are competent to perform pediatric UH repairs. However, there is variability in competence of general surgery residents performing pediatric IH repairs, especially in children <6 months old.

Effect of physician specialty training on pediatric appendectomy outcomes: an NSQIP-P analysis

PURPOSE

Appendectomies are the most common abdominal emergency surgery in pediatric patients. Both pediatric and general surgeons are credentialed to perform this procedure, however pediatric surgeons are specialized in pediatrics. This study seeks to determine differences in pediatric appendectomy outcomes between general and pediatric surgeons.

METHODS

Pediatric patients undergoing appendectomies between 2015 and 2020 were identified in the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database. Multivariable logistic regression models examined association of surgeon specialty with readmission, postoperative complications, reoperation, non-home discharge destination, operative time, etc. Adjusted odds ratios (AOR) and 95% confidence intervals (CI) were calculated.

RESULTS

Average ages of pediatric patients undergoing appendectomy by pediatric and general surgeons were 11.2 (n = 68,638) and 12.3 (n = 3,986) years, respectively (p < .001). General surgeons were not more likely to have adverse outcomes [AOR: 1.00 (0.99-1.01), p = 0.57], readmissions [AOR: 0.995 (0.98-1.00), p = 0.11], reoperations [AOR: 1.00 (0.99-1.00), p = 0.54], or non-home discharges [AOR: 0.99 (0.99-1.00), p = 0.94].

CONCLUSIONS

Similar outcomes arise in pediatric appendectomies performed by general surgery at a children's hospital or hospitals with a pediatric wing. Significant limitations to using the NSQIP-P database persist. Further research including hospitals contributing to both adult and pediatric databases can provide a clearer picture of post-surgical outcomes in appendectomies.

Unveiling patterns in pediatric appendectomy: A comparative study on healthcare resource capacity and surgical decisions in Brazil

BACKGROUND

Appendicitis is the most prevalent surgical emergency in children. This study examined hospital infrastructure, surgical techniques, patient demographics, and hospitalization parameters to assess the provision of safe and adequate care within the Brazilian public healthcare system.

METHODS

Pediatric hospitalizations for acute appendicitis in 2022 were extracted from the Brazilian national database. We included all hospitalizations for patients aged 0-16 years with a primary ICD-10 diagnosis of acute appendicitis who underwent an operation. Parameters of interest were the type of surgical approach, mortality, and total cost of hospitalization. Facilities were defined as basic-facility, full-facility, and pediatric according to the level of pediatric resources available.

RESULTS

In 2022, there were 29,983 pediatric appendectomies due to acute appendicitis. Of these, 90.2% were open appendectomies. Most occurred in basic-facility general hospitals (53.0%), followed by full-facility (35.2%) and pediatric hospitals (11.8%). Full-facility hospitals had a higher median cost (USD126.3, IQR 99.5-154.4) compared to basic (USD96.8, IQR 87.6-130.1) and pediatric hospitals (USD103.0, IQR 91.9-117.5), though the cost difference between basic and pediatric was not significant (p = 0.367). Death was a rare event across all levels of hospital infrastructure and for all types of procedures performed.

CONCLUSIONS

The majority of hospitalizations for acute appendicitis occurred in hospitals with minimal pediatric infrastructure. Open appendectomies remain the most predominant procedure across all hospital types.

Locum Tenens and Pediatric Surgery: A Position Statement and Practice Guidelines From the American Pediatric Surgical Association (APSA)

The American Pediatric Surgical Association (APSA) Practice Committee endorsed by the Board of Governors presents a Position Statement on the role of locum tenens in the practice of pediatric surgery. The Practice Committee also presents a set of guidelines for locum tenens practice. These recommendations highlight safe practice and quality care that protects the patient as well as the pediatric surgeon by offering best practice standards, defining optimal resources and establishing parameters by which hospitals and locum tenens agencies should abide. These guidelines are intended to foster discussion and contract negotiation as well as inform decision making for a) pediatric surgeons considering locum tenens opportunities, b) host organizations (hospitals and practices) seeking the coverage of a pediatric surgeon, and c) locum tenens companies vetting both surgeons and hospitals for appropriateness of such coverage. This Position Statement and foundational set of guidelines align with APSA's Vision (all children receive the highest quality surgical care) and Mission (to provide the best surgical care to our patients and families by supporting an inclusive community through education, discovery and advocacy).

Interfacility Transfer of Children With Time-Sensitive Surgical Conditions, 2002-2017

Importance

Surgical care for children in the United States has become increasingly regionalized among fewer centers over time. The degree to which regionalization may be associated with access to urgent surgical care for time-sensitive conditions is not clear.

Objective

To investigate whether transfers and travel distance have increased for 4 surgical conditions, and whether changes in transfers and travel distance have been more pronounced for rural vs urban children.

Design, Setting, and Participants

This retrospective cross-sectional study analyzed data from 9 State Inpatient Databases from 2002 to 2017. Participants included children aged younger than 18 years undergoing urgent or emergent procedures for malrotation with volvulus, esophageal foreign body, and ovarian and testicular torsion.

Exposure

Residential and hospital zip codes were categorized as rural or urban. Hospitals were categorized as pediatric hospitals, adult hospitals with pediatric services, and adult hospitals without pediatric services.

Main Outcomes and Measures

Primary outcomes were transfer for care and travel distance between patients' home residences and the hospitals where care was provided. Transfer and travel distance were analyzed using multivariable regression models.

Results

Among the 5865 children younger than 18 years undergoing procedures for malrotation with volvulus, esophageal foreign body, ovarian torsion, or testicular torsion, 461 (7.9%) resided in a rural area; 1097 (20.5%) were Hispanic, 1334 (24.9%) were non-Hispanic Black, and 2255 (42.0%) were non-Hispanic White; 2763 (47.1%) were covered by private insurance and 2535 (43.2%) were covered by Medicaid; and the median (IQR) age was 9 (2-14) years. Most care was provided at adult hospitals (73.4% with and 16.9% without pediatric services); the number of hospitals providing this care decreased from 493 to 292 hospitals (2002 vs 2017). Transfer was associated with rural residence (adjusted odds ratio [aRR], 2.3 [95% CI, 1.8-3.0]; P < .001) and increased over time (2017 vs 2002: aOR, 2.8 [95% CI, 2.0-3.8]; P < .001). Similarly, travel distance was associated with rural residence (adjusted risk ratio [aRR], 4.4 [95% CI, 3.9-4.8]; P < .001) and increased over time (2017 vs 2002: aRR, 1.3 [95% CI, 1.2-1.4]; P < .001). Rural children were more frequently transferred (2017 vs 2002) for esophageal foreign body (48.0% [12 of 25] vs 7.3% [4 of 55]; P < .001), ovarian torsion (26.7% [4 of 15] vs 0% [0 of 18]; P = .01), and testicular torsion (18.2% [2 of 11] vs 0% [0 of 16]; P = .04). Travel distance for rural children increased the most for torsions, from a median (IQR) of 19.1 (2.3-35.4) to 43.0 (21.6-98.8) miles (P = .03) for ovarian torsion and from 7.3 (0.4-23.7) to 44.5 (33.1-48.8) miles (P < .001) for testicular torsion.

Conclusions and Relevance

In this cross-sectional study of children with time-sensitive surgical conditions, the number of hospitals providing urgent surgical care to children decreased over time. Transfers of care, especially among rural children, and travel distance, especially for those with ovarian and testicular torsion, increased over time.

Barriers to diffusion and implementation of pediatric minimally invasive surgery in Brazil

BACKGROUND

The main barriers to the broad implementation of pediatric minimally invasive surgery (MIS) are technological, technical, and epistemological barriers, as well as the rarity of certain pathologies. These issues are presumed to be more significant in low- and middle-income countries. This study aimed to identify and analyze the factors limiting the diffusion and implementation of pediatric MIS in Brazil.

METHODS

A nationwide cross-sectional survey was conducted via an online questionnaire in Brazil from January 2022 to July 2022. The sample was taken by convenience from the population of pediatric surgeons in Brazil. A total of 187 surgeons were included. The collected data were divided into three sections to evaluate technological, technical, and epistemological limitations to pediatric MIS implementation.

RESULTS

Although 85% of the participants had previous training, a lack of adequate training was identified as a significant limiting factor, particularly among those who had taken only short courses (42.3% vs. 64.3%, p = 0.033). Only 14% of the participants reported performing MIS for major pediatric procedures. With respect to intracorporeal suturing, 38.1% of the surgeons with extensive training considered it a limiting factor compared with 60.7% (p = 0.029) of those without prior training. Among those without previous training, 61% cited a lack of financial support or encouragement from their department as the reason. Additionally, 65% of the surgeons considered the lack of basic instruments a limiting factor. Although 95% of the participants agreed that simulation training is indispensable, pediatric surgery fellowship programs in Brazil do not include a standardized curriculum or mandatory training in MIS, and only 47% reported providing training space for their current fellows.

CONCLUSION

A combination of technological, technical, and epistemological barriers hinders the implementation of pediatric MIS. Despite its limitations, this study serves as a foundational guide for future analysis and overcoming the identified barriers.

How far We Go For Surgery: Distance to Pediatric Surgical Care in Indiana

INTRODUCTION

Despite increasing numbers of pediatric surgery training programs, access to pediatric surgical care remains limited in non-academic and rural settings. We aimed to characterize demographic and patient factors associated with increased distance to selected pediatric surgical procedures in Indiana.

METHODS

This IRB-approved retrospective review analyzed pediatric patients undergoing appendectomy, cholecystectomy, umbilical hernia repair, pyloromyotomy, and video assisted thoracic surgery (VATS) procedures from 2019 through 2021. Data was obtained from an electronic medical record warehouse and the Indiana Hospital Association. Travel distance was calculated as driving distance between patient address and hospital ZIP codes. Statistics were performed in R, with p < 0.05 indicating significance.

RESULTS

There were 6835 operations performed, and half of all operations (46%) were performed at institutions with fellowship-trained pediatric surgeons. The median travel distance for all operations was 13 miles (range 0-182); the shortest was for laparoscopic appendectomy (9 miles, IQR[0-20]). The longest distances were for pyloromyotomy (51 miles, IQR[14-84]) and VATS procedures (57 miles, IQR[13-111]), of which, nearly all were performed at tertiary pediatric care centers (97% and 93%, respectively). There was a significant linear and quadratic effect of age on travel distance (p < 0.001), with younger patients requiring farther travel. On multivariable linear regression, age and procedure type had the largest effect on travel distance (Eta squared 0.03, p < 0.001).

CONCLUSION

Younger age and more specialized procedures, including VATS and pyloromyotomy, were associated with increased travel distance. This highlights regionalization of these procedures to urban areas with pediatric care centers, while others are performed closer to home.

LEVEL OF EVIDENCE

III TYPE OF STUDY: Retrospective comparative study.

Principles and Practice in Pediatric Vascular Trauma: Part 1: Scope of Problem, Team Structure, Multidisciplinary Dynamics, and Solutions

As of 2020, penetrating injuries became the leading cause of death among children and adolescents ages 1-19 in the United States. For the patients who initially survive and receive advanced medical care, vascular injuries are a significant cause of morbidity and additionally trigger notable trauma team angst. Moreover, penetrating injuries can lead to life-threatening hemorrhage and/or limb-threatening ischemia if not addressed promptly. Vascular injury management demands timely and unique expertise, particularly for pediatric patients. As the frequency of vascular injuries requiring operative management increases, it becomes clear that an ad hoc approach is not ideal. An integrated team would provide the best approach for rapid hemorrhage control and revascularization, but the structure of vascular response teams at children's hospitals is highly variable. In part 1 of this review, we will evaluate the scope and extent of the epidemic of traumatic vascular injuries in pediatric patients, review current evidence and outcomes, discuss various challenges and advantages of different team structures, and outline potential outcome targets and pediatric vascular trauma response solutions. LEVEL OF EVIDENCE: n/a.

Temporal Trends of Neonatal Surgical Conditions in Texas and Accessibility to Pediatric Surgical Care

INTRODUCTION

Texas consistently accounts for approximately 10% of annual national births, the second highest of all US states. This temporal study aimed to evaluate incidences of neonatal surgical conditions across Texas and to delineate regional pediatric surgeon accessibility.

METHODS

The Texas Birth Defects Registry was queried from 1999 to 2018, based on 11 well-established regions. Nine disorders (30,476 patients) were identified as being within the operative scope of pediatric surgeons: biliary atresia (BA), pyloric stenosis (PS), Hirschsprung's disease, stenosis/atresia of large intestine/rectum/anus, stenosis/atresia of small intestine, tracheoesophageal fistula/esophageal atresia, gastroschisis, omphalocele, and congenital diaphragmatic hernia. Annual and regional incidences were compared (/10,000 births). Statewide pediatric surgeons were identified through the American Pediatric Surgical Association directory. Regional incidences of neonatal disorder per surgeon were evaluated from 2010 to 2018 as a surrogate for provider disparity.

RESULTS

PS demonstrated the highest incidence (14.405/10,000), while BA had the lowest (0.707/10,000). Overall, incidences of PS and BA decreased significantly, while incidences of Hirschsprung's disease and small intestine increased. Other diagnoses remained stable. Regions 2 (48.24/10,000) and 11 (47.79/10,000) had the highest incidence of neonatal conditions; Region 6 had the lowest (34.68/10,000). Three rural regions (#2, 4, 9) lacked pediatric surgeons from 2010 to 2018. Of regions with at least one surgeon, historically underserved regions (#10, 11) along the Texas-Mexico border consistently had the highest defect per surgeon rates.

CONCLUSIONS

There are temporal and regional differences in incidences of neonatal conditions treated by pediatric surgeons across Texas. Improving access to neonatal care is a complex issue that necessitates collaborative efforts between state legislatures, health systems, and providers.

Comparing pediatric femoral shaft fracture repair patient outcomes between pediatric and non-pediatric orthopedic surgeons

INTRODUCTION

While pediatric femoral shaft fractures account for less than 2% of all fractures in children, they are the most common pediatric fracture requiring hospitalization. Management of pediatric femoral shaft fractures is challenging, with various treatment options relating to severity and patient age. The last few decades have seen an increased supply of pediatric orthopedic surgeons (POS) along with increased referral rates. However, there continues to be a maldistribution of POS throughout the country. This study sought to determine outcomes following femoral shaft fracture repair by POS compared to non-pediatric trained orthopedic surgeons.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was queried to identify pediatric patients who underwent open treatment of femoral shaft fracture from 2012 to 2019. Differences in patient demographics, comorbidities, and postoperative complications were assessed and compared between patients who were treated by pediatric subspecialty-trained orthopedic surgeons and those treated by non-pediatric orthopedic surgeons. Bivariate and multivariable regression analyses were utilized.

RESULTS

Of the 5862 pediatric patients who underwent femoral shaft fracture treatment, 4875 (83.2%) had their surgeries performed by a POS whereas 987 (16.8%) were operated on by a non-pediatric surgeon. POS were more likely to operate on patients with a higher American Society of Anesthesiologists classification (p < 0.001) and those with medical comorbidities, including gastrointestinal (p = 0.022) and neurological (p < 0.001). After controlling for baseline patient characteristics on multivariable regression analysis, patients treated by non-pediatric orthopaedic surgeons are at an increased risk of prolonged hospital stay (OR 2.595; p < 0.001) when compared to patients operated on by POS.

CONCLUSION

The results indicated that patients undergoing surgical treatment for a femoral shaft fracture by a non-pediatric trained orthopedic surgeon were at increased risk of a prolonged hospital stay compared to those being treated by POS. Additionally, POS were more likely to operate on more difficult patients with increased comorbidities.

Location of Treatment Among Infants Requiring Complex Surgical Care

INTRODUCTION

Rural children have worse health outcomes compared to urban children. One mechanism for this finding may be decreased access to specialized care at children's hospitals. The objective of this study was to evaluate the hospital types where complex surgical care in infants is performed nationally.

METHODS

This study examined infants (<1 y old) in the Kids' Inpatient Database from 2009 to 2019 who underwent surgery for one of the following conditions: esophageal atresia, gastroschisis, omphalocele, Hirschsprung disease, anorectal malformation, pyloric stenosis, small bowel atresia, congenital diaphragmatic hernia, and necrotizing enterocolitis. The relationship between patient residence (rural versus urban) and location of surgical care (children's hospital versus other) was compared in relation to other covariates using multivariable logistic regression models.

RESULTS

Among 29,185 infants undergoing these operations, 16.0% lived in a rural area. Rural infants were more frequently White (64.8% versus 43.4% P < 0.001), from the lowest two income quartiles (86.5% versus 52.0%, P < 0.001), and from the South or Midwest regions (P < 0.001). Surgical care was predominantly (94.1%) provided at urban teaching hospitals but frequently not at children's hospitals, especially among rural infants. After adjusting for other covariates, rural infants were significantly less likely to undergo care at a children's hospital for both 2009 (adjusted odds ratio 0.66, P < 0.001) and 2012-2019 (adjusted odds ratio 0.78, P < 0.001).

CONCLUSIONS

A sizable portion of complex surgical care in infants is performed outside children's hospitals, especially among those from rural areas. Further work is necessary to ensure adequate access to children's hospitals for rural children.

Surgical Simulation of Posterior Sagittal Anorectoplasty for Rectovestibular Fistula: Low-Cost High-Fidelity Animal-Tissue Model

PURPOSE

To provide a high-fidelity, animal tissue-based model for the advanced surgical simulation of a Posterior Sagittal Anorectoplasty (PSARP) for rectovestibular fistula in anorectal malformation (ARM).

MATERIALS AND METHODS

A chicken cadaver was used to assess the feasibility of simulating a PSARP for rectovestibular fistula in ARM. No modification was required to implement the surgical simulation.

RESULTS

A detailed description of the high-fidelity surgical simulation model is provided. The PSARP can be simulated while providing realistic anatomy (e.g. common wall between rectovestibular fistula and vagina), adequate rectal size, location and placement of the rectovestibular fistula, and proximity to the vagina. Haptic conditions of the tissue resemble human tissue and operative conditions as well.

DISCUSSION

Concerning the decreased exposure of index cases of pediatric surgical trainees and pediatric surgeons in practice, simulation-based training can provide means to acquire or maintain the necessary skills to perform complex surgical procedures [1-5] Surgical simulation models for ARM are limited. Few low-cost trainers are available with predominant artificial and mostly unrealistic tissue [6-8] Animal models have the advantage of realistic multilayer tissue haptic feedback [6].

CONCLUSION

We provide a low-cost, high-fidelity model for correcting a rectovestibular fistula in a child with ARM, a complex operative procedure with low incidence but high-stake outcomes. The described tissue model utilizing the chicken cloaca anatomy provides a high-fidelity model for operative correction of rectovestibular ARM. For simulation purposes in the treatment of ARM, this model appears to be promising in terms of providing realistic pathology and haptic feedback in pediatric dimensions.

LEVEL OF EVIDENCE

V.

Characterizing rural families' experiences receiving pediatric surgical care: A qualitative study

PURPOSE

Access to pediatric surgical care is influenced by multiple factors, including proximity to care and financial resources. There is limited understanding regarding the process by which rural children acquire surgical care. We qualitatively explored rural families' experiences seeking surgical care for their children at a major children's hospital.

METHODS

Parents or legal guardians ≥18 years of age with children who received general surgical care at a major children's hospital and who lived in rural areas were included. Operative logs from 2020 to 2021 and postoperative clinic visits were used to identify families. Semi-structured interviews explored rural families' experiences receiving surgical care. Interviews were inductively and deductively analyzed to create codes and identify thematic domains. Twelve interviews (with 15 individuals) were conducted before thematic saturation was reached.

FINDINGS

Children were predominantly White (92%) and lived a median of 98.3 mi (interquartile range 49.4-147.0 mi) from the hospital. Four thematic domains were identified: (1) Accessing surgical care included difficulties with referral processes and travel/lodging burdens; (2) surgical care processes involved treatment details and provider/hospital expertise; (3) resources for navigating care encompassed families' employment status, financial burden, and technology use; and (4) social support included family situations, emotions and stress, and coping with diagnoses.

CONCLUSIONS

Rural families experienced difficulties with obtaining referrals, challenges with travel and employment, and the benefits of technology use. These findings can be applied to the development of tools that can ease challenges faced by rural families whose children require surgical care.

Association of Rural Residence With Surgical Outcomes Among Infants at US Children's Hospitals

OBJECTIVES

Disparities in pediatric health outcomes are widespread. It is unclear whether rurality negatively impacts outcomes of infants with surgical congenital diseases. This study compared outcomes of rural versus urban infants requiring complex surgical care at children's hospitals in the United States.

METHODS

Rural and urban infants (aged <1 year) receiving surgical care at children's hospitals from 2016 to 2019 for esophageal atresia, gastroschisis, Hirschsprung's disease, anorectal malformation, and congenital diaphragmatic hernia were compared over a 1-year postoperative period using the Pediatric Health Information System. Generalized linear mixed effects models compared outcomes of rural and urban infants.

RESULTS

Among 5732 infants, 20.2% lived in rural areas. Rural infants were more frequently white, lived farther from the hospital, and lived in areas with lower median household income compared with urban infants (all P < .001). Rural infants with anorectal malformation and gastroschisis had lower adjusted hospital days over 1 year; rural infants with esophageal atresia had higher adjusted odds of 30-day hospital readmission. Adjusted mortality, hospital days, and readmissions were otherwise similar between the 2 groups. Outcomes remained similar when comparing urban infants to rural infant subgroups with the longest hospital travel distance (≥60 miles) and lowest median household income (<$35 000).

CONCLUSIONS

Despite longer travel distances and lower financial resources, rural infants with congenital anomalies have similar postoperative outcomes to urban infants when treated at children's hospitals. Future work is needed to examine outcomes for infants treated outside children's hospitals and to determine whether efforts are necessary to increase access to children's hospitals.

A Contemporary Review of Surgical Approach and Outcomes in Pediatric Hypertrophic Pyloric Stenosis

INTRODUCTION

In order to define optimal resources and outcome standards for infant pyloromyotomy, we sought to perform a contemporary analysis of surgical approach (laparoscopic versus open) and outcomes.

METHODS

The National Surgical Quality Improvement Project Pediatrics Participant Use File (NSQIP PUF) was queried from 2016 to 2020. Utilization of laparoscopy was trended over time. Complication rates and length of stay were compared by operative approach.

RESULTS

9752 pyloromyotomies were included in the analysis. The utilization of laparoscopy steadily increased over the study time period (66% to 79%) and was associated with a shorter operative time. On multivariate regression, the utilization of laparoscopy was associated with a lower risk of overall complications, length of stay, and superficial surgical site infections. Overall complication rates were lower than previously reported (2.02%). The most common complication was superficial infection (1.2%).

CONCLUSIONS

In facilities reporting to pediatric National Quality Improvement Project, utilization of laparoscopy has steadily increased, and complication rates are lower than previously reported. Complication rates and length of stay were lower with the laparoscopic approach in this contemporary cohort. These results offer benchmarks for quality improvement initiatives. The laparoscopic approach should be standard in facilities performing this procedure.

Pediatric Liver and Transplant Surgery: Results of an International Survey and Expert Consensus Recommendations

BACKGROUND

Pediatric liver surgery is a complex and challenging procedure and can be associated with major complications, including mortality. Best practices are not established. The aims of this study were to evaluate surgeons' individual and institutional practices in pediatric liver surgery and make recommendations applicable to the management of children who require liver surgery.

METHODS

A web-based survey was developed, focusing on the surgical management of children with liver conditions. It was distributed to 34 pediatric surgery faculty members of the Biliary Atresia and Related Disorders (BARD) consortium and 28 centers of the European Reference Network-Rare Liver. Using the Delphi method, a series of questions was then created to develop ideas about potential future developments in pediatric liver surgery.

RESULTS

The overall survey response rate was 70.6% (24/34), while the response rate for the Delphi questionnaire was 26.5% (9/34). In centers performing pediatric liver surgery, most pediatric subspecialties were present, although pediatric oncology was the least present (79.2%). Nearly all participants surveyed agreed that basic and advanced imaging modalities (including ERCP) should be available in those centers. Most pediatric liver surgeries were performed by pediatric surgeons (69.6%). A majority of participants agreed that centers treating pediatric liver tumors should include a pediatric transplant program (86%) able to perform technical variant grafts and living donor liver transplantation. Fifty-six percent of responders believe pediatric liver transplantation should be performed by specialized pediatric surgeons.

CONCLUSION

Pediatric liver surgery should be performed by specialized pediatric surgeons and should be centralized in regional centers of excellence where all pediatric subspecialists are present. Pediatric hepatobiliary and transplant training needs to be better promoted amongst pediatric surgery fellows to increase this subspecialized workforce.

Distribution of acute appendicitis care in children: A statewide assessment of the surgeons and facilities providing surgical care

BACKGROUND

Pediatric appendicitis is managed by general and pediatric surgeons at both children's hospitals and non-children's hospitals. A statewide assessment of surgeons and facilities providing appendicitis care was performed to identify factors associated with location of surgical care.

METHODS

Children aged <18 years undergoing appendectomy for appendicitis in Wisconsin from 2018-2020 were identified through the International Classification of Diseases, 10th revision, and Current Procedural Terminology codes using Wisconsin Hospital Association data. Patient residence and hospital locations were used to determine travel distance, rurality, and neighborhood-level socioeconomic status.

RESULTS

Among 3,604 children with appendicitis, 36.0% and 12.8% had an appendectomy at 2 major children's hospitals and 4 other children's hospitals, respectively, and 51.2% had an appendectomy at 99 non-children's hospitals. Pediatric surgeons performed 76.1% of appendectomies at children's hospitals and 2.9% at non-children's hospitals. Only 32.2% of patients received care at the hospital closest to their homes. Non-children's hospitals disproportionally cared for older, non-Hispanic White, and privately insured children, those with uncomplicated appendicitis, and those living in rural areas, in mid-socioeconomic status neighborhoods, and greater distances from children's hospitals (all P < .001). After multivariable adjustment, receipt of care at children's hospitals was associated with younger age, minority race, complicated appendicitis, shorter distance to children's hospitals, and urban residence.

CONCLUSION

Over half of surgical care for pediatric appendicitis occurred at non-children's hospitals, especially among older children and those living in rural areas far from children's hospitals. Future work is necessary to determine which children benefit most from care at children's hospitals and which can safely receive care at non-children's hospitals to avoid unnecessary time and resource utilization associated with travel to children's hospitals.

Bariatric surgery practice patterns among pediatric surgeons in the United States

BACKGROUND

Metabolic and bariatric surgery (MBS) in adolescents has been shown to be safe and effective, but current practice patterns are variable and poorly understood. The aim of this study is to assess current MBS practice patterns among pediatric surgeons in the United States.

METHODS

American Pediatric Surgical Association members were surveyed on current bariatric surgery practices.

RESULTS

Four hundred and three (40%) surgeons out of a total of 1013 pediatric surgeons responded to the survey. Only 2 respondents had additional training in MBS (0.5%). One hundred thirty-two (32.6%) report that their practice participates in metabolic and bariatric surgery, with 123 (30.4%) having a specific partner specializing in MBS. Most respondents (92%) stated that they believe high volume is associated with better outcomes with regard to MBS. Only 17 (4.2%) surgeons performed a metabolic and bariatric surgery in the last year. All routinely perform sleeve gastrectomy as their primary procedure. Most (82%) perform procedures with an additional surgeon, either another pediatric surgeon (47%) or an adult bariatric surgeon (47%). All pediatric bariatric surgeons responded that they believe high volume led to better outcomes. Adolescent MBS programs most commonly included pediatric nutritionists (94%), pediatric psychologists (94%), clinical nurses (71%), clinical coordinators (59%), pediatric endocrinologists (59%), and exercise physiologists (52%).

CONCLUSION

Only 17 (4.2%) respondents had performed a metabolic and bariatric surgery in the past year, and few of those had additional training in MBS. Future work is necessary to better understand optimal practice patterns for adolescent metabolic and bariatric surgery.

TYPE OF STUDY

Review article.

LEVEL OF EVIDENCE

Level III.

Environmental impact of telehealth use for pediatric surgery

BACKGROUND

The healthcare sector is responsible for 10% of US greenhouse gas emissions. Telehealth use may decrease healthcare's carbon footprint. Our institution introduced telehealth to support SARS-CoV-2 social distancing. We aimed to evaluate the environmental impact of telehealth rollout.

METHODS

We conducted a retrospective cohort study of pediatric patients seen by a surgical or pre anesthesia provider between March 1, 2020 and March 1, 2021. We measured patient-miles saved and CO₂ emissions prevented to quantify the environmental impact of telehealth. Miles saved were calculated by geodesic distance between patient home address and our institution. Emissions prevented were calculated assuming 25 miles per gallon fuel efficiency and 19.4 pounds of CO₂ produced per gallon of gasoline consumed. Unadjusted Poisson regression was used to assess relationships between patient demographics, geography, and telehealth use.

RESULTS

60,773 in-person and 10,626 telehealth encounters were included. This represented an 8,755% increase in telehealth use compared to the year prior. Telehealth resulted in 887,006 patient-miles saved and 688,317 fewer pounds of CO₂ emitted. Demographics significantly associated with decreased telehealth use included Asian and Black/African American racial identity, Hispanic ethnic identity, and primary language other than English. Further distance from the hospital and higher area deprivation index were associated with increased telehealth use (IRR 1.0006 and 1.0077, respectively).

CONCLUSION

Incorporating telehealth into pediatric surgical and pre anesthesia clinics resulted in significant CO₂ emission reductions. Expanded telehealth use could mitigate surgical and anesthesia service contributions to climate change. Racial and linguistic minority status were associated with significantly lower rates of telehealth utilization, necessitating additional inquiry into equitable telemedicine use for minoritized populations.

LEVEL OF EVIDENCE

Level IV.

Geographic barriers to children's surgical care: A systematic review of existing evidence

BACKGROUND

Ensuring that children have access to timely and appropriate surgical care is a vital component of comprehensive pediatric care. This study systematically reviews the existing evidence related to geographic barriers in children's surgery.

METHODS

Medline and Scopus databases were searched for any English language studies that examined associations between geographic burden (rural residence or distance to care) and a quantifiable outcome within pediatric surgical subspecialties. Two independent reviewers extracted data from each study.

RESULTS

From 6331 studies screened, 22 studies met inclusion criteria. Most studies were retrospective analyses and conducted in the U.S. or Canada (14 and three studies, respectively); five were conducted outside North America. In transplant surgery (seven studies), greater distance from a transplant center was associated with higher waitlist mortality prior to kidney and liver transplantation, although graft outcomes were generally similar. In congenital cardiac surgery (five studies), greater travel was associated with higher neonatal mortality and older age at surgery but not with post-operative outcomes. In general surgery (eight studies), rural residence was associated with increased rates of perforated appendicitis, higher frequency of negative appendectomy, and increased length of stay after appendectomy. In orthopedic surgery (one study), rurality was associated with decreased post-operative satisfaction. No evidence for disparate outcomes based upon distance or rurality was identified in neurosurgery (one study).

CONCLUSIONS

Substantial evidence suggests that geographic barriers impact the receipt of surgical care among children, particularly with regard to transplantation, congenital cardiac surgery, and appendicitis.

Employment search, initial employment experience, and career preferences of recent pediatric surgical fellowship graduates: An APSA survey, part of the right child/right surgeon initiative

BACKGROUND

APSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce.

METHODS

Using APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email.

RESULTS

144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were "location or geography" (71%), "available mentorship" (53%), and "compensation and benefits" (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted.

CONCLUSION

In our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.

The "chicken-leg anastomosis": Low-cost tissue-realistic simulation model for esophageal atresia training in pediatric surgery

INTRODUCTION

Shifting the training from the operating room (OR) to simulation models has been proven effective in enhancing patient safety and reducing the learning time to achieve competency and increase the operative efficiency. Currently the field of pediatric surgery only offers few low-cost trainers for specialized training and these feature predominantly artificial and often unrealistic tissue. The aim of this study was to develop an easy access low-cost tissue-realistic simulation model for open training of esophageal atresia and to evaluate the acceptance in trainees and junior pediatric surgeons.

MATERIALS AND METHODS

The model is fashioned using reconfigured chicken skin from a chicken leg. To create a model of esophageal atresia, the chicken skin is dissected off the muscle and reconfigured around a foley catheter balloon to recreate the proximal pouch and a feeding tube to recreate the distal pouch. Surrounding structures such as the tracheo-esophageal fistula and the azygos vein can be easily added, obtaining a realistic esophageal atresia (Type C) prototype. Evaluation of model construction, usage and impact on user were performed by both a self-assessment questionnaire with pre- and post-training questions as well as observer-based variables and a revised Objective Structured Assessment of Technical Skills (OSATS) score.

RESULTS

A total of 10 participants were constructing and using the model at two different timepoints. OSATS score for overall performance was significantly higher (p = 0.005, z = -2.78) during the second observational period [median (MD): 4,95% confidence interval CI: 3.4, 5.1] compared to the first (MD: 3, 95% CI 2.4, 4.1). Self-reported boost in confidence after model usage for performing future esophageal atresia (EA) repair and bowel anastomosis (BA) in general was significantly higher (EA: U = 1, z = -2.3, p = 0.021, BA: U = 1, z = -2.41, p = 0.016) in participants with more years in training/attending status (EA MD:5, BA MD: 5.5) compared to less experienced participants (EA MD: 1.5, BA: 1).

CONCLUSION

Our easy access low-cost simulation model represents a feasible and tissue realistic training option to increase surgical performance of pediatric surgical trainees outside the OR.

Development of a Standardized Program for the Collaboration of Adult and Children's Surgeons

BACKGROUND

Children's hospitals within larger hospitals (CH/LH) have the specific clinical advantage of easily facilitated collaboration between adult and children's surgeons. These collaborations, which we have termed hybrid surgical offerings (HSOs) are often required for disease processes requiring interventions that fall outside the customary practice of children's surgeons. Formal models to describe or evaluate these practices are lacking.

METHODS

HSOs within a CH/LH were identified. Principles of systems-engineering were used to develop a standardized model (Children's Hybrid Enhanced Surgical Services [CHESS]) to describe and evaluate HSOs. Face validity was established via unstructured interviews of CH leaders and HSO surgeons. Areas for improved system-wide standardization and programmatic development were identified.

RESULTS

HSOs were identified in collaboration with adult bariatric, minimally invasive, advanced endoscopic, endocrine, thoracic, and orthopedic trauma surgical services. The CHESS framework encompassed: 1) quality improvement metrics, 2) credentialing and oversight, 3) transitions of care, 4) pediatric family-centered care, 5) maintenance of the cycle of expertise, 6) continuing medical education, 7) scholarship. While HSOs fulfilled the majority of aforementioned programmatic domains across all six HSO-providing services, areas for improvement included maintaining a cycle of expertise (33%), quality improvement metrics (50%), and pediatric family-centered care (66%).  Additional noted advantages included faster translation of adult innovation to pediatric care and facilitation of emergency interdisciplinary care.

CONCLUSION

Formal evaluation of HSOs is necessary to standardize and improve the quality of children's surgical care. Development of a structured framework such as CHESS addresses gaps in quality oversight and provides a basis for performance improvement, patient safety, and programmatic development.