Emily T. Durkin

The impact of work hour restrictions on surgical resident education.

OBJECTIVE Resident work-hour restrictions were instituted in July 2003 based on ACGME mandates. The American Board of Surgery In-Training Examination (ABSITE), American Board of Surgery Qualifying Examination (ABSQE), and operative volume traditionally have been measures of surgical resident education and competency. The objective of this study was to determine the effect of reduced work hours on resident standardized test scores and operative volume at our institution. DESIGN We reviewed ABSITE scores, ABSQE scores, and operative logs from 1997 to 2005 of all general surgery residents. Linear mixed-effects models were fitted for each component ABSITE score (total, basic science, and clinical management), and they were compared using a chi-squared likelihood ratio. Operative logs of graduating residents were compared before and after the work restrictions and were evaluated for association with ABSITE score. p-values less than 0.05 were considered significant. RESULTS The program was compliant with ACGME mandates within 6 months of institution. ABSITE scores improved significantly after the restriction of work hours in both basic science (p = 0.003) and total score (p = 0.008). Clinical management scores were not affected. The number of major cases recorded by graduating residents did not change. A positive correlation was found between number of cases performed during residency and clinical management ABSITE scores (p = 0.045). ABSQE scores were not impacted by operative volume during residency. CONCLUSIONS ABSITE scores improved significantly after the restriction of resident work hours. Resident operative experience was not affected. An unexpected consequence of work-hour restrictions may be an improvement in surgical resident education.

Age-Related Differences in Diagnosis and Morbidity of Intestinal Malrotation

BACKGROUND Intestinal malrotation in adulthood may present with a variety of chronic symptoms. Surgical intervention frequently leads to other complications in these patients. We hypothesized that the chronic nature of malrotation in adults could cause a delay in diagnosis and increased perioperative complications. STUDY DESIGN All patients diagnosed with intestinal malrotation from July 2002 through July 2006 were included. IRB approval was obtained. Outcomes in patients less than 16 years of age were compared with outcomes from those older than 16. Presenting symptoms, initial diagnosis, results of imaging data, and time to diagnosis were evaluated. Surgical management, resulting complications, and rate of reoperation were analyzed. RESULTS Twenty-four patients with intestinal malrotation were identified (age range, 10 days to 89 years old; 10 adults, 14 children). Seventy percent of adults experienced chronic symptoms for 6 months or more before the diagnosis of malrotation was made (children, 14%, p = 0.017). No patients in the adult group were initially diagnosed with malrotation, although 57% of children were correctly diagnosed at the time of presentation of symptoms (p=0.006). Postoperative complications occurred in 60% of adults, but in only 29% of children, though this did not reach significance (p=0.211). Forty percent of adult patients required reoperation (p=0.020). CONCLUSIONS Intestinal malrotation in adults is often associated with a delay in diagnosis and increased morbidity. Enhanced awareness of this entity in adults may enhance patient counseling and improve therapeutic outcomes in these patients.

Early laparoscopic fundoplication and gastrostomy in infants with spinal muscular atrophy type I

BACKGROUND/PURPOSE Spinal muscular atrophy (SMA) in children leads to progressive muscle weakness, dysphagia, aspiration, and death. We hypothesized that early laparoscopic fundoplication and gastrostomy in infants with SMA type I could be performed safely perhaps leading to fewer aspiration events and improved nutritional status. METHODS Children diagnosed with SMA type I from 2002 through 2005 were included (n = 12). All children underwent laparoscopic Nissen fundoplication with gastrostomy shortly after diagnosis. Postoperative respiratory management and discharge criteria were standardized. RESULTS All patients were extubated immediately postoperatively. There were no significant complications. Average time to full feeding and inpatient length of stay were 42 +/- 4.9 hours (range, 30-48 hours) and 78 +/- 22.5 hours (range, 44-120 hours), respectively. Mean weight-for-length percentile was doubled at 1 year postoperatively (P = .03). The number of respiratory-related hospitalizations in the cohort decreased by almost 50% in the ensuing 12 months after surgery, although this did not reach statistical significance in this small cohort (P = .34). CONCLUSIONS Early laparoscopic fundoplication and gastrostomy is safe and is associated with improved nutritional status. A trend toward fewer significant long-term aspiration-related events was seen after fundoplication. To better assess the long-term benefits of performing an antireflux procedure in these high-risk patients, a larger prospective trial comparing current nutritional support practices is needed.

What is the optimal treatment for children with primary hyperparathyroidism

PURPOSE Little information exists regarding the optimal surgical treatment of pediatric primary hyperparathyroidism. We hypothesized that primary hyperparathyroidism in children, in the absence of a family history, is caused by single-gland disease and is amenable to minimally invasive parathyroidectomy (MIP). METHODS We reviewed the records of individuals younger than 25 years who underwent parathyroidectomy in a prospectively collected database at a single tertiary hospital from 2003 to 2009. RESULTS Twenty-five patients were identified, with a mean (SD) age of 19 (3.7) years. Sixty percent had single-gland disease (n = 15). Familial disease was present in 6 patients. All of the children younger than 18 years without a family history of disease (9/9) were found to have a single-gland disease (P < .001). Seventy-eight percent of patients without a family history were successfully treated without a bilateral exploration. Average length of stay was less than 1 day with no complications or recurrences. CONCLUSIONS Primary hyperparathyroidism in patients younger than 18 years without a family history was uniformly caused by single-gland disease. Minimally invasive parathyroidectomy was successful in these patients and avoided the morbidity of bilateral exploration. We recommend MIP be used in pediatric patients at large referral centers with prior successful institutional experience with the technique.

Recent Advances and Controversies in Pediatric Laparoscopic Surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Regulation of the earliest immune response to In Utero Hematopoietic Cellular Transplantation

In Utero Hematopoietic Cellular Transplantation (IUHCT) is a promising intervention to treat a wide range of congenital disease. Through the presentation of donor cells to the immature immune system, mixed hematopoietic chimerism and donor-specific tolerance can be achieved. However, the failure of engraftment in prenatal recipients in which no immunodeficiency exists suggests the existence of a fetal immune barrier to transplantation. Although the possible barriers include effectors of the adaptive and innate immune system, our recent findings and ongoing investigations indicate that the barrier most likely resides in the developing NK cells. A chimerism level above a certain threshold during NK cell development is necessary to overcome rejection. Clinically, this transplantation barrier might also exist in early human fetal NK cells. Understanding the fetal immune barrier to allotransplantation is essential in advancing clinical application of IUHCT. Herein, we provide a short summary and new evidence for the earliest immune response to prenatal transplantation.

Pediatric blunt abdominal aortic injury and the use of intra-operative aortic ultrasound for surgical decision making

Traumatic injury has been the most common cause of morbidity and mortality in the pediatric population, but injuries to the abdominal aorta are rare. We reviewed 2 children who underwent exploratory laparotomy for blunt aortic injury in which intra-operative ultrasound guided the surgical approach. Intra-operative ultrasound allowed us to minimize resection of normal aorta and achieve primary repair. In the pediatric population, achieving primary repair is ideal, as synthetic grafts will likely need future revisions as children grow. Here we present the use of intra-operative ultrasound in maximizing the chance at primary repair of the aorta following blunt injury.

Trogocytosis as a mechanistic link between chimerism and prenatal tolerance

In utero hematopoietic cellular transplantation (IUHCT) holds great promise for the treatment of congenital diseases of cellular dysfunction such as sickle cell disease, immunodeficiency disorders and inherited metabolic disorders. However, repeated failures in clinical cases of IUHCT that do not involve an immunodeficiency disease force a closer examination of the fetal immune system. While the mechanisms regulating T cell tolerance have been previously studied, the educational mechanisms leading to NK cell tolerance in prenatal chimeras remain unknown. As a low level of donor cells (1.8%) is required to induce and maintain this tolerance, it is likely that these mechanisms employ indirect host-donor interaction. This report examines donor-to-host MHC transfer (trogocytosis) as an intrinsic mechanism regulating the development and maintenance of NK cell tolerance in prenatal chimeras. The findings demonstrate that phenotypically tolerant host NK cells express low levels of transferred donor MHC antigens during development and later as mature cytotoxic lymphocytes. Further study is needed to understand how the cis-recognition of transferred donor MHC ligand influences the selection and maintenance of tolerant NK cells in prenatal chimeras.

KIR receptor-ligand incompatibility predicts killing of osteosarcoma cell lines by allogeneic NK cells.

The effectiveness of killer immunoglobulin‐like receptor (KIR) incompatible, alloreactive natural killer (NK) cells has been primarily documented in hematological malignancies following stem‐cell transplant. This effect has not been thoroughly evaluated for pediatric solid tumors. In this study, we evaluated KIR receptor‐ligand incompatibility of NK cells against osteosarcoma cell lines.

Operative indications in recurrent ileocolic intussusception

BACKGROUND Air-contrast enema (ACE) is standard treatment for primary ileocolic intussusception. Management of recurrences is less clear. This study aimed to delineate appropriate therapy by quantifying the relationship between recurrence and need for bowel resection, pathologic lead points (PLP), and complication rates. METHODS After IRB approval, a single institution review of patients with ileocolic intussusception from 1997 to 2013 was performed, noting recurrences, outcomes, and complications. Fishers exact and t-tests were used. RESULTS Of 716 intussusceptions, 666 were ileocecal. Forty-four underwent bowel resection, with 29 PLPs and 9 ischemia/perforation. Recurrence after ACE occurred in 96 (14%). Recurrence did not predict PLP (P=0.25). Recurrence (≥3) was associated with higher resection rate (P=0.03), but not ischemia/perforation (P=0.75). ACE-related complications occurred in 4 (0.5%) patients. Successful initial ACE had 98% negative predictive value for resection and PLP (e.g., after successful ACE, 2% had resections, 2% PLP). After failed initial ACE, 36% received resection, and 23% had PLP (P<0.001). CONCLUSIONS Recurrence is associated with a greater risk of resection but not PLP or ACE-complication. Failed ACE is associated with increased risk for harboring PLP and receiving resection. ACE should be the standard treatment in recurrent intussusception, regardless of number of recurrences.