Elective procedures and anesthesia in children: pediatric surgeons enter the dialogue on neurotoxicity questions, surgical options, and parental concerns

SHapley Additive exPlanations (SHAP)-based, multivariate machine-learning techniques with external validation: Construction of a preoperative interpretable predictive model for intestinal resection of incarcerated inguinal hernia

BACKGROUND

Currently, there are a lack of effective tools for preoperative risk assessment of intestinal resection in patients with inguinal incarcerated hernia. The purpose of this study is to investigate the variable characteristics associated with intestinal resection and develop an interpretable preoperative prediction model, aiming to assist clinicians in preoperative risk for intestinal resection in patients with inguinal incarcerated hernia.

METHODS

The data from 2 medical institutions were retrospectively collected, and they were grouped according to whether intestinal resection was performed intraoperatively and the pathologic results. Lasso and multifactor logistic regression screened variables, and 10 machine-learning algorithms built and validated the model, with evaluation using the confusion matrix and SHapley Additive exPlanations value.

RESULTS

Lasso regression and multifactorial logistic regression analyses showed that peritonitis, intestinal obstruction, neutrophil count, C-reactive protein, and preoperative total protein were the key characteristic variables. The area under curve of models constructed by 10 algorithms in the external validation set were all above 0.8, and the k-nearest neighbor algorithm had the most comprehensive model performance. The constructed model exhibits good predictive performance on the external validation set.

CONCLUSION

Accurate preoperative prediction of intraoperative intestinal ischemia in patients with incarcerated inguinal hernia is crucial. This study identified peritonitis, intestinal obstruction, neutrophil count, C-reactive protein, and preoperative total protein as characteristic variables for predicting intraoperative intestinal ischemia in these patients. The constructed prediction model can assist clinicians in more accurately assessing intestinal viability during surgery, offering valuable insights for evaluating intestinal resection risk.

Preoperative evaluation of biliary atresia

Biliary atresia can be a challenging diagnosis to make as there is no single definitive diagnostic laboratory or imaging study available and no single agreed upon diagnostic algorithm. The purpose of this article is to review the complex puzzle of clinical, laboratory, and imaging studies that aid in the evaluation of infants suspected of having biliary atresia. We have reviewed historical and current manuscripts and society guidelines, added our own experience in evaluating infants for biliary atresia, and then summarized the findings to provide a concise review of what we feel is the modern approach to diagnosis of biliary atresia.

Impact of the Age at Distal Hypospadias Surgery on Behavioral Problems, Somatic Symptoms and Irritability Levels in Children

BACKGROUND

To assess the effect of age at hypospadias surgery on emotional and behavioural problems, somatic symptoms, irritability, and penile perception.

METHODS

We retrospectively identified the patients who underwent single distal hypospadias surgery and age-matched healthy controls were included. There were two further subgroups according to the age at the time of hypospadias repair (<2 vs. >2 years). The Strengths and Difficulties Questionnaire (SDQ), Revised Children's Anxiety and Depression Scale (RCADS), Affective Reactivity Index (ARI), Level 2 Somatic Symptom Scale, and Penile Perception Score (PPS) scale were used. The groups were compared using multivariate variance analysis (MANOVA).

RESULTS

Both groups consisted of 70 patients (mean age 14.0 ± 0.2 years, for both), while there were 34 patients in the hypospadias groups who underwent surgery at <2 years of age. Depressive, panic, separation anxiety, social phobia, and somatic complaint symptom scores of the hypospadias group were lower than those of the control group. Obsessive-compulsive symptom levels were significantly higher in patients who underwent hypospadias surgery at >2 vs. <2 years of age. Additionally, PPSs rated by the surgeon were significantly higher in the former. A multivariate linear regression model indicated that panic disorder symptom scores predicted child PPS in the hypospadias group. Limitations include retrospective design.

CONCLUSIONS

Single hypospadias surgery seems not to have a negative impact on emotional and behavioural status. Children who underwent distal hypospadias surgery after 2 years of age had higher levels of obsessive-compulsive symptoms. Following emotional status may help the early diagnosis of future psychopathologies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Contemporary Assessment of Long-Term Survival Rates in Patients With Stage I Nonseminoma Germ-Cell Tumor of the Testis: Population-Based Comparison Between Surveillance and Active Treatment After Initial Orchiectomy

BACKGROUND

Historical data demonstrated similar survival outcomes in patients with stage I nonseminoma germ-cell tumor of the testis (NSGCTT) subjected to either surveillance or active treatment (AT) after orchiectomy. However, data with long-term follow-up are unavailable. We tested contemporary treatment rates and their effect on cancer-specific mortality (CSM) and other-cause mortality (OCM) relative to surveillance, as well as after stratification between chemotherapy (CHT) versus retroperitoneal lymph node dissection (RPLND).

PATIENTS AND METHODS

We identified patients with stage I NSGCTT with initial orchiectomy within the Surveillance, Epidemiology, and End Results (SEER) database (1988-2015). Subsequent surveillance versus CHT versus RPLND use rates were reported. Cumulative incidence plots and multivariable competing-risks regression (CRR) models were used after propensity score (PS) matching. These tests first compared surveillance versus AT (CHT vs. RPLND) and subsequently CHT versus RPLND.

RESULTS

Of 5034 patients with stage I NSGCTT, 61.2%, 24.9%, and 13.9%, respectively, underwent surveillance, CHT, and RPLND. Between 1988 and 2015, surveillance (estimated annual percentage change [EAPC]: +1.1%, P < .001) and CHT (EAPC: +2.3%, P < .001) rates increased. RPLND rates decreased (EAPC: -5.7%; P < .001). After PS matching, CRR models failed to identify AT as an independent predictor of lower mortality relative to surveillance. However, after PS matching, CRR models identified RPLND as an independent predictor of lower CSM (hazard ratio, 0.26; P = .002) relative to CHT. No difference in OCM rates was recorded (hazard ratio, 1.25; P = .2).

CONCLUSION

Surveillance and CHT use rates increased while RPLND decreased in the last two decades. Virtually the same outcomes were recorded between surveillance and AT. However, within AT, RPLND was associated with lower CSM than CHT.

Cause analysis, prevention, and treatment of postoperative restlessness after general anesthesia in children with cleft palate

Cleft palate is one of the most common congenital malformations of the oral and maxillofacial region, with an incidence rate of around 0.1%. Early surgical repair is the only method for treatment of a cleft lip and palate. However, because of the use of inhalation anesthesia in children and the physiological characteristics of the cleft palate itself combined with the particularities of cleft palate surgery, the incidence rate of postoperative emergence agitation (EA) in cleft palate surgery is significantly higher than in other types of interventions. The exact mechanism of EA is still unclear. Although restlessness after general anesthesia in children with cleft palate is self-limiting, its effects should be considered by clinicians. In this paper, the related literature on restlessness after surgery involving general anesthesia in recent years is summarized. This paper focuses on induction factors as well as prevention and treatment of postoperative restlessness in children with cleft palate after general anesthesia. The corresponding countermeasures to guide clinical practice are also presented in this paper.

Adverse Events and Resource Utilization After Spinal and General Anesthesia in Infants Undergoing Pyloromyotomy

BACKGROUND AND OBJECTIVES

Interest in spinal anesthesia (SA) is increasing because of concern about the long-term effects of intravenous (IV) and inhaled anesthetics in young children. This study compared SA versus general anesthesia (GA) in infants undergoing pyloromyotomy.

METHODS

Between 2000 to 2013, the University of Vermont Medical Center almost exclusively used SA for infant pyloromyotomy surgery, whereas Columbia University Medical Center relied on GA. Outcomes included adverse events (AEs) within 48 hours of surgery, operating room (OR) time, and postoperative length of stay (LOS). Regression was used to evaluate the association between anesthesia technique and outcomes, accounting for demographic and clinical covariates.

RESULTS

We studied 218 infants with SA at the University of Vermont Medical Center and 206 infants with GA at Columbia University Medical Center. In the SA group, 96.3% of infants had adequate initial analgesic levels, but 35.8% required supplemental IV or inhaled anesthetic agents. Compared with GA, the risk of AEs in SA (adjusted odds ratio, 0.60; 95% confidence interval [CI], 0.27-1.36) did not significantly differ, but SA was associated with shorter OR times (17.5 minutes faster; 95% CI, 13.5-21.4 minutes) and shorter postoperative LOS (GA is 1.19 times longer; 95% CI, 1.01-1.40).

CONCLUSIONS

Infants undergoing pyloromyotomy with SA had shorter OR times and postoperative LOS, no significant differences in AE rates, and decreased exposure to IV and inhaled anesthetics, although SA infants often still required supplemental anesthetics. Whether these differences result in any long-term benefit is unclear; further studies are needed to determine the risk of rare AEs, such as aspiration.

Use of Anesthesia for Imaging Studies and Interventional Procedures in Children

Ongoing investigation from the Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study hopes to examine the long-term effect on cognitive and language development of a single anesthetic exposure in children undergoing inguinal hernia repair. The fifth PANDA Symposium, held in April 2016, continued the mission of previous symposia to examine evidence from basic science and clinical studies on potential neurotoxic effects of anesthetics on developing brain. At the 2016 Symposium, a panel of specialists from nonsurgical pediatric disciplines including anesthesiology, radiology, neurology, gastroenterology, oncology, cardiology, and critical care reviewed use of anesthesia in their practices, including how concern over possible neurodevelopmental effects of early childhood anesthetic exposure has changed discussion with patients and families regarding risks and benefits of imaging studies and interventional procedures involving sedation or anesthesia. This paper summarizes presentations from nonsurgical pediatric specialists at the 2016 PANDA Symposium.

Anesthesia in children: perspectives from nonsurgical pediatric specialists

The Pediatric Anesthesia NeuroDevelopment Assessment (PANDA) study investigates the potential neurotoxicity of anesthetics in the pediatric population. At a recent symposium, a panel of nonsurgical physicians from the disciplines of radiology, neurology, cardiology, and critical care discussed the role anesthesia plays in their respective practices. To execute diagnostic studies and/or therapeutic interventions in each of these disciplines, general anesthesia is oftentimes required for pediatric patients. Given recent publications in the literature suggesting the potential for neurotoxicity following anesthesia in pediatric patients, physicians, parents, and other stakeholders are now challenged to continue to balance safety with efficacy in caring for children. This paper summarizes the panelist presentations and the ensuing discussion at the 2014 PANDA symposium.

Anesthesia for the young child undergoing ambulatory procedures: current concerns regarding harm to the developing brain

PURPOSE OF REVIEW

Sedation and anesthesia are often necessary for children at any age, and are frequently provided in ambulatory settings. Concerns have mounted, based on both laboratory studies including various mammalian species and retrospective human clinical studies, that the very drugs that induce sedation and anesthesia may trigger an injury in the developing brain, resulting in long-lasting neurobehavioral consequences.

RECENT FINDINGS

New retrospective studies further augment these concerns. Specifically, recent studies support that a single anesthesia exposure before age 3 may increase the risk for long-term disabilities in language acquisition and abstract reasoning, and that exposure to two or more anesthetics before age 2 nearly doubles the risk for an attention-deficit hyperactivity disorder diagnosis by age 19. However, methodological limitations preclude final conclusions or change in practice based on these reports, as retrospective studies cannot prove causation. Ongoing prospective clinical studies such as 'General Anesthesia and Apoptosis Study', 'Pediatric Anesthesia NeuroDevelopment Assessment', and 'Mayo Safety in Kids' trials will offer more answers in the future. Meanwhile, laboratory experiments continue to describe differential morphologic injury to individual structures in the neuropil, and have identified mitochondrial dysfunction and neuroinflammation as potential links in the injury process. Additionally, concepts for protection against anesthesia-induced neurotoxicity continue to be tested in the laboratory.

SUMMARY

Results from ongoing prospective clinical trials and translational research will help clarify whether anesthesia-associated neurotoxicity affects the developing human brain, including whether it causes long-term disability, and may further identify the injury mechanisms and potential strategies for protection. Currently, the available evidence does not support a change in practice.

Report of the third PANDA symposium on "Anesthesia and Neurodevelopment in Children"

The Pediatric Anesthesia and NeuroDevelopment Assessment (PANDA) Project team organized its third biennial scientific symposium on "Anesthesia and Neurodevelopment in Children" at the Children's Hospital of New York on April 21, 2012. The event was co-sponsored by the New York-Presbyterian/Morgan Stanley Children's Hospital (MS-CHONY) and the Department of Anesthesiology of Columbia University. The day-long program included updates of recent research in anesthetic neurotoxicity in the developing brain from preclinical studies to clinical and patient-oriented outcome research. It also provided a forum for discussion among many different stakeholders in this important public health issue.