Dani O. Gonzalez

Laparoscopic-Assisted Transversus Abdominis Plane Block for Postoperative Pain Control in Laparoscopic Ventral Hernia Repair: A Randomized Controlled Trial

BACKGROUND Laparoscopic ventral hernia repair (LVHR) is associated with considerable postoperative pain. Transversus abdominis plane (TAP) blocks have proven effective in controlling postoperative pain in a variety of laparoscopic abdominal operations. To date, no studies have focused on TAP blocks in LVHR. Our goal was to assess whether TAP blocks reduce opioid requirements and pain scores after LVHR. STUDY DESIGN Patients undergoing LVHR were randomly assigned to receive a TAP block or placebo injection. The primary end points were cumulative opioid use at 1, 3, 6, 12, 18, and 24 hours postoperatively and pain scores recorded at 1 and 24 hours postoperatively. RESULTS Patients in the experimental TAP group (n = 52) and control group (n = 48) were comparable with respect to patient demographics and clinical characteristics. In the postanesthesia care unit, the TAP group had significantly lower pain scores than the control group (p < 0.05). Patients in the TAP group used less opioids than the control group at each time point assessed after 6 hours postoperatively (p < 0.05). There was no significant difference in pain scores at 24 hours postoperatively (p > 0.05). CONCLUSIONS Transversus abdominis plane blocks given during LVHR significantly decrease both short-term postoperative opioid use and pain experienced by patients.

Role of non-operative management in pediatric appendicitis

Appendectomy is currently considered the standard of care for children with acute appendicitis. Although commonly performed and considered a safe procedure, appendectomy is not without complications. Non-operative management has a role in the treatment of both uncomplicated and complicated appendicitis. In uncomplicated appendicitis, initial non-operative management appears to be safe, with an approximate 1-year success rate of 75%. Compared to surgery, non-operative management is associated with less disability and lower costs, with no increase in the rate of complicated appendicitis. In patients with complicated appendicitis, initial non-operative management with interval appendectomy has been shown to be safe with reported success rates between 66% and 95%. Several studies suggest that initial non-operative management with interval appendectomy may be beneficial in patients with perforated appendicitis with a well-formed abscess or inflammatory mass. Recent data suggest that interval appendectomy may not be necessary after initial non-operative management of complicated appendicitis.

Predictors of Ventriculoperitoneal Shunt Failure in Children Undergoing Initial Placement or Revision.

Background: Ventriculoperitoneal (VP) shunt placement, the mainstay of treatment for hydrocephalus, can place a substantial burden on patients and health care systems because of high complication and revision rates. We aimed to identify factors associated with 30-day VP shunt failure in children undergoing either initial placement or revision. Methods: VP shunt placements performed on patients in the 2012-2013 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) Pediatric were identified. Results: VP shunts were placed in 3,984 patients either as an initial placement (n = 1,093) or as a revision (n = 2,891). Compared to the initial-placement group, the revision group was significantly more likely to experience shunt failure (14 vs. 8%, p < 0.0001). In the initial-placement group, congenital hydrocephalus was independently associated with shunt failure (OR 1.83; 95% CI 1.01-3.31, p = 0.047). In the revision group, cardiac risk factors (OR 1.38; 95% CI 1.00-1.90, p = 0.047), a chronic history of seizures (OR 1.33; 95% CI 1.04-1.71, p = 0.022), and a history of neuromuscular disease (OR 0.61; 95% CI 0.41-0.90, p = 0.014) were independently associated with shunt failure. Conclusions: Identifying the factors associated with VP shunt failure may allow the development of interventions to decrease failures. Further refinement of the collected variables in the NSQIP Pediatric specific to neurosurgical procedures is necessary to identify modifiable risk factors.

Effect of bladder augmentation on VP shunt failure rates in spina bifida

PURPOSE Most patients with spina bifida require ventriculoperitoneal (VP) shunt placement. Some also require bladder augmentation, which may increase the risk of VP shunt malfunction and/or failure. The aim of this study was to assess whether bladder augmentation affects the rate of VP shunt failure in this population. METHODS Using the Pediatric Health Information System, we studied patients with spina bifida born between 1992 and 2014 who underwent VP shunt placement. Using conditional logistic regression, we compared age- and hospital-matched patients who did and did not undergo a bladder augmentation to determine their difference in rates of VP shunt failure. RESULTS There were 4192 patients with spina bifida who underwent both surgical closure and VP shunt placement. Of these, 203 patients with bladder augmentation could be matched to 593 patients without bladder augmentation. VP shunt failure occurred within 2 years in 7.7% of patients, the majority of whom were in the group who underwent bladder augmentation (87%). After adjusting for confounders, undergoing bladder augmentation was independently associated with VP shunt failure (HR: 33.5, 95% CI: 13.15-85.44, p< 0.001). CONCLUSION Bladder augmentation appears to be associated with VP shunt failure. Additional studies are necessary to better define this relationship and identify risk-reduction techniques.

Management of benign ovarian lesions in girls: a trend toward fewer oophorectomies

Purpose of review The management of benign ovarian lesions in girls is currently a controversial topic in the pediatric surgical literature. The purpose of this review is to highlight the epidemiology of benign ovarian masses, outline preoperative risk stratification strategies, review the indications and importance of ovary-sparing surgery (OSS), and discuss the impact of management algorithms. Recent findings Efforts across the United States and Canada to promote OSS have improved awareness about the role and safety of OSS for the management of benign ovarian masses in pediatric and adolescent girls. Preoperative risk stratification techniques by a multidisciplinary team can improve the preoperative identification of lesions with a high likelihood of benign disease. Summary Avoiding oophorectomy may be associated with a number of benefits to individual patients and the overall population. The implementation of a management algorithm to guide the treatment of pediatric and adolescent girls with ovarian lesions can reduce the rate of inappropriate oophorectomies.