Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016

Thoracoscopic Patch Repair of Congenital Diaphragmatic Hernia: Can Smaller Incisions Treat Larger Defects?

INTRODUCTION

Thoracoscopic CDH repair is increasingly performed for Type A and small Type B defects that are amenable to primary repair. However, the thoracoscopic approach is controversial for larger defects necessitating a patch due to technical complexity, intraoperative acidosis, and recurrence risk. We aim to compare clinical outcomes between thoracoscopic and open patch repair of Type B/C defects, using a standardized technique.

METHODS

This is a single-center retrospective review of thoracoscopic and open CDH patch repairs January 2017-December 2021. We excluded primary repairs, Type D hernias, repairs on ECMO, recurrent repairs. Various preoperative, intraoperative, and postoperative variables were compared. Primary outcome was recurrence rate. Secondary outcomes included intraoperative pH and pCO2, operative time, and complication rates.

RESULTS

Twenty-nine patients met inclusion criteria (open = 13, thoracoscopic = 16). The open cohort had lower o/e total fetal lung volume (29 vs 41.2%, p = 0.042), higher preoperative peak inspiratory pressures (24 vs 20 cm H2O, p = 0.007), were more frequently Type C defects (92.3 vs 31%, p = 0.002) and had liver "up" in left-sided hernias (46 vs 0%, p < 0.0001). Intraoperatively, median lowest pH and highest pCO2 did not differ; neither did overall median pH or pCO2. Operative times were similar (153 vs 194 min, p = 0.113). No difference in recurrence rates was identified, however postoperative complications were higher in the open group. There were no mortalities.

CONCLUSIONS

Although we demonstrate higher disease severity of patients undergoing open repair, thoracoscopic patch repair for Type B/C defects is safe and effective in patients with favorable physiologic status, alleviating concerns for intraoperative acidosis, operative length, and risk of recurrence.

LEVEL OF EVIDENCE

II.

Advances in Pediatric Surgery Simulation-Based Training

Pediatric surgery is the diagnostic, operative, and postoperative surgical care of children with congenital and acquired anomalies and diseases. The early history of the specialty followed the classic "see one, do one, teach one" philosophy of training but has since evolved to modern methods including simulation-based training (SBT). Current trainees in pediatric surgery face numerous challenges, such as the decreasing incidence of congenital disease and reduced work hours. SBT consists of several modalities that together assist in the acquisition of technical skills and improve performance in the operating room. SBT has evolved to incorporate simulator models and video gaming technology, in parallel with the development of simulation in other surgical and non-surgical pediatric fields. SBT has advanced to a level of sophistication that means that it can improve the skills of not only pediatric surgery trainees but also practicing attending surgeons. In this review, we will discuss the history of pediatric surgery, simulation in pediatric surgery training, and the potential direction of pediatric surgical simulation training in the future.

Nationwide trends of laparoscopic pyloromyotomy in patients with infantile hypertrophic pyloric stenosis in Germany: A slow path forward

Since its introduction, laparoscopic pyloromyotomy (LP), has become increasingly popular in many countries. We have noticed an attenuated trend in Germany. The aim of this study was to analyse the distribution of open and LP in Germany. The national database of administrative claims data of the Institute for the Remuneration System in Hospitals (InEK) was analysed regarding numbers of patients with pyloromyotomy in the years 2019-2021. The German quality reports of the hospitals of 2019 and 2020 were analyzed regarding the number of procedures performed per hospital and pediatric surgical department. A total of 2050 patients underwent pyloromyotomy. The incidence of hypertrophic pylorus stenosis (HPS) was 699 and 657 patients in 2019 and 2021, respectively. Regarding age, 31.1% were admitted before 28 days of age. LP gradually increased from 216 patients (30.9%) in 2019 to 239 patients (36.4%) in 2021. Thirty-three laparoscopic operations (4.8%) were converted to an open approach. In 24 of all patients, there was an injury to the stomach, in 20 patients to the duodenum, needing repair with sutures. Analysis of the quality reports indicated that 44% of pediatric surgical departments performed LP. Although LP has became more prevalent in Germany recently, about two thirds of patients still undergo an open procedure.

Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies

BACKGROUND

This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches.

METHODS

The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes.

RESULTS

12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5).

CONCLUSIONS

MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes.

MINI-ABSTRACT

In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair.

LEVEL OF EVIDENCE

III.

Global Health Challenges: Why the Four S's Are Not Enough

A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.

Feasibility of tracking in open surgical simulation

The aim of this study was to develop an adequate tracking method for open surgical training, using tracking of the instrument or hand motions.

An open surgical training model and the SurgTrac application were used to track four separate suturing tasks. These tasks were performed with colour markings of either instruments or fingers, to find the most promising setting for reliable tracking.

Four experiments were used to find the optimal settings for the tracking system. Tracking of instruments was not usable for knot tying by hand. Tracking of fingers seemed to be a more promising method. Tagging the fingers with a coloured balloon-tube, seemed to be a more promising method (1.2–3.0% right hand vs. 9.2–17.9% left hand off-screen) than covering the nails with coloured tape (1.5–3.5% right hand vs. 25.5–55.4% left hand off-screen). However, analysis of the videos showed that redness of the hand was seen as red tagging as well. To prevent misinterpreting of the red tag by redness of the hand, white surgical gloves were worn underneath in the last experiment. The off-screen percentage of the right side decreased from 1.0 to 1.2 without gloves to 0.8 with gloves and the off-screen percentage of the left side decreased from 16.9–17.9 to 6.6–7.2, with an adequate tracking mark on the video images.

This study shows that tagging of the index fingers with a red (right) and blue (left) balloon-tube while wearing surgical gloves is a feasible method for tracking movements during basic open suturing tasks.

Benchmarking utilization, length of stay, and complications following minimally invasive repair of major congenital anomalies

INTRODUCTION

Infants with newborn congenital anomalies are increasingly undergoing minimally invasive surgical (MIS) repair. Currently available data on outcomes are limited. This study provides national estimates for length of stay and 30-day complications following MIS for congenital anomalies.

METHODS

Using the ACS-NSQIP Pediatric (2013-2018), a retrospective analysis of MIS for congenital anomalies was performed. MIS repairs for the following diagnoses were included: pyloric stenosis (PS), congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung's disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), biliary atresia/choledochal cyst (HB), and intestinal atresia (IA). Postoperative LOS (pLOS) and complication rates were examined using multivariable analysis for risk factors after categorizing surgeries by complexity of care related to congenital anomaly: Simple (PS), Complex Group 1 (LL, MM, CM, and ARM), and Complex Group 2 (HD, CDH, TEF, HB, and IA).

RESULTS

Across 10 anomalies, 8,326 repairs were performed using an MIS approach. Procedure-specific median postoperative LOS (75th-percentile, 90th-percentile) for PS was 1 day (1, 3); LL was 3 (4, 7); MM was 2 (3, 5); CM was 4 (7, 14); ARM was 3 (5, 8); HD was 5 (8, 12); CDH was 8 (18, 31); HB was 5 (8, 12); TEF was 20 (31, 53); and IA was 17 (25, 40). The overall surgical complication rates (95% CI) were: PS, 5.1% (4.7%-5.6%); LL, 14.2% (12.3-16.4); MM, 8.4% (6.4-11.0); CM, 14.6% (11.9-17.9); ARM, 12.0% (7.1-19.5); HD, 22.1% (19.5-25.0); CDH, 21.1% (17.1-25.6); HB, 20.6% (13.7-29.7); TEF, 36% (27.5-45.5); and IA, 28.6% (19.3-40.1). Risk factors for increased pLOS and complications varied by procedure category and included patient-level and admission characteristics.

CONCLUSION

This study provides national benchmarks and risk factors for expected postoperative LOS and 30-day complications following MIS for congenital anomalies.

Paediatric Surgery training in South Africa: Trainees' perspectives

PURPOSE

There is very little documented evidence regarding the training of paediatric surgeons in South Africa since its inception as a formal speciality in 2007. This study aims to assess South African paediatric surgical trainees' perspectives regarding their training.

METHODS

A prospective study was conducted via an emailed electronic survey. The sample population included all current paediatric surgical trainees in South Africa. The questionnaire covered the trainees' demographics, exposure to different aspects of paediatric surgery, extent of after-hours clinical service, self-reported surgical competency and consultant supervision.

RESULTS

Forty one (95%) out of 43 trainees responded to the survey with 29 (71%) being female. Reported training deficits included lack of exposure to burn care in 12 trainees (30%), no urology exposure in 8 (20%), no paediatric trauma or minimally invasive surgery exposure in 6 (15%). Eighteen trainees (44%) reportedly worked more than 65 h per week with clinical responsibilities being the biggest hindrance to attending academic teaching. Trainees were more comfortable performing open procedures compared to laparoscopic but most respondents felt adequately supervised.

CONCLUSION

There exists a significant heterogeneity amongst the different training institutions with protected academic time and exposure to burns, urology and minimally invasive surgery remaining major obstacles in training.

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

The past 50 years have witnessed profound changes in the specialty of pediatric surgery in North America. There has been a marked increase in the number of both pediatric surgical training programs and practicing pediatric general and thoracic surgeons. Despite this trend, the population of children in the United States and the birth rate have recently remained relatively flat. Some pediatric surgeons have become "super specialists", concentrating their practices in oncology or colorectal surgery. This has the potential to result in a dilution of experience for both pediatric surgical trainees and practicing pediatric surgeons, thus limiting their ability to acquire and maintain expertise, respectively. Coincident with this, there has been a relative paradigm shift in recognition that "quality of life" is based more on maintaining a creative balance in lifestyle and is not "all about work". There has been a parallel growth in the number of practicing pediatric general and thoracic surgeons in urban settings, but we have not appreciated as much growth in rural and underserved areas, where access to pediatric surgical care remains limited and fewer pediatric general and thoracic surgeons practice. This is a complex issue, as some underserved areas are economically depressed and geographically sparse, but others are just underserved with adult providers taking care of children in settings that are often under resourced for pediatric surgical care. This problem may extend beyond the boundaries of pediatric general and thoracic surgery to other specialties. As the premier association representing all pediatric surgeons in the United States, the American Pediatric Surgical Association (APSA) has concluded that the quality of pediatric surgical care will likely decline should the status quo be allowed to continue. Therefore, APSA has initiated a Right Child/Right Surgeon initiative to consider these issues and propose some potential solutions. What follows is a brief statement of intent.

The Evolution of Surgical Management for Children and Young Adults With Spontaneous Pneumothorax

BACKGROUND

Few studies have analyzed pediatric spontaneous pneumothorax (SPTX) nationally. We sought to better define this patient population and explore the evolution of surgical management.

METHODS

Patients (10-20 y old) with an International Classification of Diseases, Ninth Revision diagnosis of SPTX were identified within the Kids' Inpatient Database for the years 2006, 2009, and 2012. Diagnoses and procedures were analyzed by International Classification of Diseases, Ninth Revision codes. National estimates were obtained using case weighting.

RESULTS

There were 11,792 pediatric SPTX hospitalizations, and patients were predominantly male (84.0%), non-Hispanic white (69.0%), with a mean age of 17.2 y (95% confidence interval, 17.2-17.3). Overall, 52.5% underwent tube thoracostomy as the primary intervention, and more than one-third had a major surgical procedure (34.9%). From 2006 to 2012, there was an increase in bleb excisions from 81.1% to 86.9% and an increase in mechanical pleurodesis from 64.2% to 69.0%. There was a significant change from a predominantly open thoracotomy approach in 2006 (76.1%) to a video-assisted thoracoscopic approach in 2012 (89.3%).

CONCLUSIONS

Pediatric admission for SPTX results in tube thoracostomy in more than half of the cases and surgery in approximately one-third of the cases. Surgical intervention has changed to a more minimally invasive approach during the last decade, and counseling to patients and their families should reflect these updated management strategies.

LEVEL OF EVIDENCE

III.

Who moved my fellow: changes to Accreditation Council for Graduate Medical Education fellowships in pediatric surgery and what may be yet to come

PURPOSE OF REVIEW

Over the past 15 years, the Accreditation Council for Graduate Medical Education (ACGME) has significantly altered the regulatory framework governing fellowship training in pediatric surgery. The daily experiences of pediatric surgical trainees have been impacted by these changes, but training program directors and faculty have not developed a consistent approach to managing this shift. This review highlights the changes, which have occurred, analyzes the current state of fellowship training, and proposes potential strategies for management.

RECENT FINDINGS

The implementation of work hour restrictions, increased supervision requirements, the milestone evaluation program and most recently, enforcement of required critical care experience, have caused significant changes in the curriculum. Pediatric surgical trainees record more total cases, and more minimally invasive surgical (MIS) cases, in particular, than ever before. A subset of this increase may result from trainees performing cases previously assigned to general surgery residents. Teaching cases performed by fellows have decreased. Although the relationship between these shifts in training experience and the didactic curriculum is not clear, we also note that the Pediatric Surgery Certifying Examination failure rate has increased, approaching 20% in recent years.

SUMMARY

It is unclear whether the changes in Pediatric Surgery training programs have been effective, or (conversely) have led to unintended consequences. Paradigm shifts in our training model may be required to address the changes in surgical education and skill acquisition, so that well tolerated, competent and skillful pediatric surgeons continue to enter the workforce.