Robert Baird

A systematic review and meta-analysis of gastrostomy insertion techniques in children.

BACKGROUND Gastrostomy tubes are inserted via multiple techniques to provide a route for enteral feeding in the pediatric population. This review compares the rate of major complications and resource utilization associated with the various insertion techniques. METHODS Major electronic databases were queried for comparative studies of two or more insertion techniques, including open, laparoscopic, percutaneous endoscopic, or fluoroscopic guided. Major complications were defined as reoperation within 1 year or death. Screening of eligible studies, data extraction, and assessment of methodological quality were conducted independently by two reviewers. Forest and funnel plots were generated for outcomes using Revman 5.1, with p<0.05 considered significant. RESULTS Twenty-two studies with a total of 5438 patients met inclusion criteria. No differences in major complications were noted in studies comparing open versus laparoscopic approaches or open versus PEG. Studies comparing laparoscopic gastrostomy and PEG revealed a significantly increased risk in major complications with PEG (n=10 studies, OR 0.29, 95% CI: 0.17-0.51, p<0.0001). The number needed to treat to reduce one major complication by abandoning PEG is 45. CONCLUSIONS PEG is associated with an increased risk of major complications when compared to the laparoscopic approach. Advantages in operative time appear outweighed by the increased safety profile of laparoscopic gastrostomy insertion.

Gangrenous appendicitis in children: a prospective evaluation of definition, bacteriology, histopathology, and outcomes

INTRODUCTION The definition and treatment of gangrenous appendicitis are not agreed upon. We performed a prospective study in children to evaluate an objective definition of gangrenous appendicitis, as well as associated bacteriology, histopathology, and outcomes. METHODS Five staff pediatric surgeons prospectively enrolled patients in the study at the time of appendectomy if the following five criteria were met: gray or black discoloration of the appendiceal wall; absence of fecalith outside the appendix; absence of visible hole in the appendix; absence of gross purulence or fibrinous exudate remote from the appendix; and absence of intraoperative appendiceal leak. Peritoneal fluid was cultured, and a standard histopathologic review was undertaken. Persistence of fever (>37.5°C) and ileus was documented daily. Patients were continued postoperatively on ampicillin, gentamicin, and metronidazole until they tolerated diet, manifested a 24-h afebrile period, and had a normal leukocyte count. Hospital stay, readmissions, and infectious complications were recorded. The study took place over a 12-mo period. RESULTS Thirty-eight patients were enrolled, representing 17% of all patients with appendicitis treated during the year. Average age was 10.8 ± 3.5 y. Peritoneal cultures were positive in 53% of cases. Gangrene was documented histologically in 61% of specimens. Hospital stay was 3.2 ± 1.1 d. There were no postoperative infectious complications or readmissions related to the disease. Neither culture results nor histologic gangrene had a statistically significant effect on hospital stay. CONCLUSIONS An objective definition of gangrenous appendicitis is reproducible and has good histopathologic association. Recovery from gangrenous appendicitis is not influenced by culture or pathology results, and postoperative complications are rare. Limiting postoperative antibiotics to 24 h in gangrenous appendicitis may significantly decrease the cost of treatment without increasing morbidity.

A risk-stratified comparison of fascial versus flap closure techniques on the early outcomes of infants with gastroschisis

BACKGROUND While fascial closure is traditionally used in gastroschisis (GS), flap closure (skin or umbilical cord) has gained popularity. We evaluated early outcomes and complications of the two techniques. METHODS A national, population-based gastroschisis data registry was analyzed from 2005 to 2011. We compared fascial to flap closures and stratified patients into low or high-risk groups using the Gastroschisis Prognostic Score (GPS), a validated marker of post-natal bowel injury. Demographic and outcome data, including length of stay, complications, and markers of resource utilization were analyzed using Fishers exact and Students t-tests for categorical and continuous variables, respectively (p<0.05 significant). RESULTS The analyzed dataset included 436 fascial closures (344 [78.8%] low-risk, 92 high-risk) and 129 flap closures (112 [86.7%] low-risk, 17 high-risk; p=0.06). Demographics and birth weight did not differ between groups. In patients with low GPS, flap closure demonstrated significant decreases in resource utilization and failure of closure, without differences in complication rates. Analysis of high-risk patients revealed no statistically significant differences in outcome. CONCLUSION Flap closure was not associated with an increase in patient morbidity and seemed suitable as a definitive closure method for gastroschisis patients irrespective of disease severity. Furthermore, flap closure reduced several markers of resource utilization in patients with low-risk disease.

Pectus carinatum treatment in Canada: current practices ☆

BACKGROUND Multiple treatment options currently exist for the correction of pectus carinatum (PC). We performed a survey of Canadian pediatric surgeons to define current practices. METHODS All active members of Canadian Association of Paediatric Surgeons were surveyed online during winter 2011 through the Canadian Association of Paediatric Surgeons Web site. The survey assessed multiple facets of PC evaluation and treatment, with particular emphasis on the practice of bracing. RESULTS Forty-five active members (85%) responded, of whom 32 (71%) currently treat PC. Fifty-three percent of practices are low volume (<5 patients annually). In terms of preferred or most used treatment modality, 69% of surgeons used bracing, 25% performed Ravitch repairs, 3% performed open minimal cartilage resections, and 3% performed reverse Nuss procedures. Of 23 surgeons (72%) who used bracing, 83% used it for most or the patients. Fifty-seven percent judged their bracing results as good or excellent, and 74% felt that most or all patients braced were satisfied; 80% and 88% agreed or strongly agreed that bracing was generally preferable to surgical repair and that bracing should be first line treatment, respectively. CONCLUSIONS Bracing is the preferred treatment for PC by most Canadian pediatric surgeons, despite lack of prospective outcome data. This presents an opportunity for a multicenter prospective study.

The use of laparoscopy in ventriculoperitoneal shunt revisions

INTRODUCTION Ventriculoperitoneal shunts (VPSs) are routinely placed in children with hydrocephalus. However, they often encounter problems, and revisions are frequent. We sought to evaluate our institutional experience with laparoscopic-assisted VPS revisions. METHODS With institutional review board approval, a retrospective chart review of 17 consecutive patients who underwent 19 laparoscopic-assisted VPS revisions was conducted. Data extracted included patient demographics, indications for laparoscopic-assisted revision, complications, and shunt outcomes. RESULTS The median age at revision was 12 years (0.4-20 years). Ten children (58.8%) had 2 or more previous VPS revisions. Indications for laparoscopic revision included adhesive obstruction, broken shunt retrieval, cerebrospinal fluid pseudocyst, diagnostic laparoscopy, and conversion from ventriculoatrial shunt to VPS. Three patients required repeat VPS revision for distal shunt failure, whereas 2 patients required repeat VPS revision for proximal dysfunction. Failures occurred 5 to 258 days after laparoscopic-assisted revision. Median follow-up was 21 weeks (interquartile range, 6-57 weeks). No patients developed abdominal infections postoperatively. CONCLUSION Laparoscopy is useful in select patients with distal VPS failure. Patients with multiple previous revisions, prior abdominal surgery, previous intraperitoneal infections, broken devices, or cerebrospinal fluid pseudocysts may benefit from this approach. Further prospective studies with long-term follow-up are needed to determine which patients benefit most from the laparoscopic-assisted approach.

Success in the Pediatric Surgery Match: a survey of the 2010 applicant pool

BACKGROUND/PURPOSE Traditionally, basic science research and publication record have led to a successful Pediatric Surgery Match. With changing applicant research backgrounds, we evaluated if these or other factors still apply. METHODS A SurveyMonkey questionnaire was distributed to 57 applicants with known contact information. We assessed demographic/financial data, application details and match results, research experience, publications, presence of a pediatric surgery fellowship at their home program, and applicant ranking criteria. RESULTS Forty-three (75%) responses were received. Twenty-five candidates matched, 12 (48%) to 1 of their first 3 choices. The median number of programs applied to was similar for matched and unmatched candidates (30), but matched candidates attended more interviews (21 vs 14.5; P = .03). Matched applicants had more publications (9.5 vs 5.1; P = .03), although research experience was similar to unmatched candidates. Research focus for matched vs total applicants included basic science (5 vs 12), clinical (4 vs 6), and both (11 vs 16). Five candidates matched without research experience. Ten (40%) applicants matched to institutions where they completed residency/research/fellowship training. Twelve (49%) applicants matched from programs without a fellowship program. CONCLUSION A strong publication record remains important, although clinical research is being valued more. Candidates from nonfellowship programs can be successful. This information may be useful to mentor future applicants and lays the foundation for a critical evaluation of the match process.

The correlation between the time spent in utero and the severity of bowel matting in newborns with gastroschisis

BACKGROUND Optimal timing of delivery in fetuses with gastroschisis (GS) is unknown. Some favor early induced delivery to prevent bowel injury. This study evaluates the correlation between bowel injury and the gestational age at birth using the Gastroschisis Prognostic Score (GPS). METHODS A national database was analyzed from 2005 to 2013. Patients were pooled based on their gestational age at birth. The mean GPS and % of patients with severe bowel matting were tabulated for each week in utero. Regression modeling was used to evaluate the relationship between the dependent (severe matting and GPS) and independent (gestational age) variables and the R(2) coefficient of determination was derived to evaluate model strength. Additional factors influencing the timing of delivery were evaluated. RESULTS Of 780 cases, 88 were excluded because of missing data. A linear relationship is seen between increasing gestational age and decreasing bowel matting (R(2)=0.66) and GPS (R(2)=0.72). For every week in utero, the % of patients with severe matting decreases by 3.6%. CONCLUSION Early induced delivery simply to protect the bowel from ongoing in utero damage appears unfounded and should be reserved for evidence of closing gastroschisis or traditional obstetrical/fetal indications.

Comparative outcome analysis of the management of pediatric intussusception with or without surgical admission

BACKGROUND Controversy persists about the need to admit patients after successful reduction of intussusception. Our hypothesis is that pediatric intussusception can be managed with discharge from the emergency department (ED) after reduction without increasing morbidity, yielding significant cost savings. METHODS A chart review over 10 years was performed at two Canadian institutions. Data abstracted included: demographics, length of stay (LOS), initial and recurrence management. Primary outcome was early recurrence and resultant management, including LOS and need for operative intervention. Costs were calculated using hospital-specific data. RESULTS 584 patient records were assessed: 329 patients were managed with admission after reduction, 239 as outpatients. In the admission group, 28 patients had at least one recurrence (8.5%), with 8 after discharge. In the outpatient group, 21 patients had at least one recurrence (8.8%), with 19 after discharge. The difference post-discharge was significant (p=0.004). Outcomes of recurrence did not differ, with 2 patients in each group requiring operative intervention. Average LOS in the admission group was 90 h, with additional average cost of

Partnership in fellowship: Comparative analysis of pediatric surgical training and evaluation of a fellow exchange between Canada and Kenya

1771 per non-operated patient. CONCLUSIONS Pediatric intussusception can be safely managed as an outpatient with reliable follow up. Discharge from the ED reduces hospital charges without increasing morbidity. This approach should be considered in managing patients with intussusception.

Flap versus fascial closure for gastroschisis: a systematic review and meta-analysis

BACKGROUND In pediatric surgery, significant differences in education and practice exist between developed and developing nations. We compared the training of senior fellows in a Canadian and a Kenyan pediatric surgery training program, and evaluated a fellow exchange between the programs. METHODS The study was performed six years after creation of the exchange program. Areas studied included case volume and distribution, length of training, curriculum, work hours, and an estimate of service to education ratio. Perceived strengths and challenges of the exchange were investigated using questionnaires. RESULTS Fellows at each site performed approximately 450 cases/year. Significant differences in case distribution were noted, with plastic surgery, urology and neurosurgery procedures being significantly more frequent in the Kenyan center, and neonatal, minimally invasive, and vascular access procedures being significantly more frequent in the Canadian center. All participants identified educational value in the exchange, although logistical challenges were significant. CONCLUSION Differences exist in the training experiences of pediatric surgical fellows in Canada and Kenya, reflecting the differences in health care environment, education, and surgical practice in the two countries. The exchange program of pediatric surgical fellows tapped into this rich diversity and may be applicable to other medical and surgical specialty training programs.