Search

Pectus arcuatum, also known as horns of steer anomaly or Currarino–Silverman Syndrome, is a distinct chest wall anomaly characterized by severe manubriosternal angulation, a shortened sternum, and mild pectus excavatum. The anomaly is typically repaired using open techniques, employing orthopedic fixation devices. Here, we report the results of a minimally invasive hybrid procedure to repair pectus arcuatum. The procedure combines a standard Nuss procedure to correct the depressed sternum with a short upper chest (in boys) or inter-mammary (in girls) incision for bilateral subperichondrial resection of the upper costal cartilages, osteotomy, and correction of the manubrial angulation. The medical records of all patients who underwent the procedure over the last 10 years were reviewed. Five patients, 3 boys and 2 girls, aged 14 to 17 years, underwent the procedure. Three patients had their pectus bars removed 3–4 years after repair. Follow-up after correction ranged from 6 months to 7 years. Good correction resulted in all patients achieving recovery without complications and recurrence. To date, all patients have been satisfied with their results. The minimally invasive hybrid procedure adequately corrects pectus arcuatum with minimal scarring and high satisfaction. [ABSTRACT FROM AUTHOR]

There is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness. A quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t -tests, Mann–Whitney, chi-square, or Fischer's exact test as appropriate. Phases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss. Educational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes. Non-Randomized Clinical Trial. II. [ABSTRACT FROM AUTHOR]

Data science approaches personalizing pediatric appendicitis management are hampered by small datasets and unstructured electronic medical records (EMR). Artificial intelligence (AI) chatbots based on large language models can structure free-text EMR data. We compare data extraction quality between ChatGPT-4 and human data collectors. To train AI models to grade pediatric appendicitis preoperatively, several data collectors extracted detailed preoperative and operative data from 2100 children operated for acute appendicitis. Collectors were trained for the task based on satisfactory Kappa scores. ChatGPT-4 was prompted to structure free text from 103 random anonymized ultrasound and operative records in the dataset using the set variables and coding options, and to estimate appendicitis severity grade from the operative report. A pediatric surgeon then adjudicated all data, identifying errors in each method. Within the 44 ultrasound (42.7%) and 32 operative reports (31.1%) discordant in at least one field, 98% of the errors were found in the manual data extraction. The appendicitis grade was erroneously assigned manually in 29 patients (28.2%), and by ChatGPT-4 in 3 (2.9%). Across datasets, the use of the AI chatbot was able to avoid misclassification in 59.2% of the records including both reports and extracted data approximately 40 times faster. AI chatbot significantly outperformed manual data extraction in accuracy for ultrasound and operative reports, and correctly assigned the appendicitis grade. While wider validation is required and data safety concerns must be addressed, these AI tools show significant promise in improving the accuracy and efficiency of research data collection. Level III. • What is known about this topic? The recently developed AI chatbots based on large language models (LLMs) have been shown to bring several benefits to healthcare professionals and potentially impact healthcare provision, training, and research. • What new information is contained in this article? The study shows for the first time how AI chatbots can facilitate clinical research and improve the accuracy of clinical data extraction when compared to trained human extractors. [ABSTRACT FROM AUTHOR]

The Canadian Association of Paediatric Surgeons launched a 10-year prospective assessment of the Canadian pediatric surgery workforce and training environment, beginning in 2013. The results of the first 5 years (2013–2017) were previously published. Here, we present the results of the last 5 years (2018–2022), and the cumulative results of the past decade. With IRB approval, a web-based survey was sent to all pediatric surgery division chiefs in Canada each year (2013–2022). The survey gathered workforce data on pediatric surgery practices, as well as data regarding fellowship graduates from Canadian training programs. Complete responses were received from all 18 divisions (100% response rate). Over the decade studied, the number of pediatric surgeons and full-time equivalent positions increased from 73 to 81, and 65 to 82, respectively. Thirty positions were vacated (15 retirement, 6 new Canadian practice, 8 leaving Canada, 1 other), and 38 were filled (20 new Canadian fellowship graduates, 8 Canadian surgeons moving from other sites in Canada, 10 surgeons coming from outside Canada). Seventy-five fellows completed training eligible for North American certification, including 34 Canadians, 31 Americans, and 10 non-North American foreign nationals (9 of whom left North America after training). The proportion of Canadian graduates who desired, but could not find, a Canadian position improved from 44% in the first 5 years to 20% in the second 5 years. The Canadian pediatric surgery workforce has experienced a modest increase over a decade. A mismatch still exists between Canadian pediatric surgery graduates and attending staff positions, but the situation has improved during the last 5 years. Survey. 5. [ABSTRACT FROM AUTHOR]

The discipline of pediatric surgery has honored many of the early giants through programs that bear their names. One of those programs is the M. James Warden Global Alliance Partnership, a landmark program celebrated at each annual meeting of the Pacific Association of Pediatric Surgeons since 1989. This article describes James Warden and his legacy as a surgeon and humanitarian and provides an update on the past, present, and future of the Global Alliance Partnership that bears his name. 5. [ABSTRACT FROM AUTHOR]

Consent conversations in pediatric surgery are essential components of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, and others in the healthcare system. The aim of this study is to explore expert consenting practice from the key stakeholders' perspective. Four senior attending pediatric surgeons obtained consent from a standardized mother of a child requiring surgery in two scenarios: a low-risk elective surgery (inguinal hernia repair – Video 1), and a high-risk emergency surgery (intestinal atresia – Video 2). All sessions were recorded. Families of children who had undergone minor or major surgery, families without medical or surgical background, and healthcare professionals were invited to view and evaluate the videos using a semi-structured questionnaire. Out of 251 distributed surveys, 56 complete responses were received. Thirty two participants (57.1%) evaluated video 1 and 24 (42.9%) evaluated. Overall, 22 (69%) respondents to video 1 and 20 (84%) respondents to video 2 were "very satisfied" with the recorded consent conversation. Qualitative responses shared common themes of valuing surgeon empathy, good surgeon communication, patient engagement, and adequate time and information. Suggestions for improvement included additional resources and visual aids, improved patient engagement, and discussion of post-operative expectations. Our data identifies strengths and gaps in the current consent process from the perspective of patient families and providers. Identified areas for improvement in the informed consent process based on multi-stakeholder input will guide the planned development of a consenting educational video resource. IV. • There is a need for better consent conversations in pediatric surgery informed by parents and healthcare providers. • Patients and families appreciate surgeon empathy, good surgeon communication, patient engagement, and adequate time for discussion and questions in a consent conversation. [ABSTRACT FROM AUTHOR]

Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are increasingly recognized as important health care quality indicators. PREMs measure patients' perception of the care they have received, differing from satisfaction ratings, which measure their expectations. The use of PREMs in pediatric surgery is limited, prompting this systematic review to assess their characteristics and identify areas for improvement. A search was conducted in eight databases from inception until January 12, 2022, to identify PREMs used with pediatric surgical patients, with no language restrictions. We focused on studies of patient experience but also included studies that assessed satisfaction and sampled experience domains. The quality of the included studies was appraised using the Mixed Methods Appraisal Tool. Following title and abstract screening of 2633 studies, 51 were included for full-text review, of which 22 were subsequently excluded because they measured only patient satisfaction rather than experience, and 14 were excluded for a range of other reasons. Out of the 15 included studies, questionnaires used in 12 studies were proxy-reported by parents and in 3 by both parents and children; none focused only on the child. Most instruments were developed in-house for each specific study, without patients' involvement in the process, and were not validated. Although PROMs are increasingly used in pediatric surgery, PREMs are not yet in use, being typically substituted by satisfaction surveys. Significant efforts are needed to develop and implement PREMs in pediatric surgical care, in order to effectively capture children's and families' voices. IV [ABSTRACT FROM AUTHOR]

• In a defined population of pediatric patients, laparoscopic inguinal hernia repair resulted in a modest decrease in the incidence of metachronous hernias at the cost of a signicant increase in recurrence. • The recurrence rate did not decrease with time. • The study reflects a "real world" experience with multiple surgeons, at different stages in their career, with variable laparoscopic skills, performing inguinal hernia repairs. • Pediatric surgeons adopting laparoscopic inguinal hernia repair should closely audit their outcomes. The optimal approach for pediatric inguinal hernia repair continues to be debated. We conducted a regional retrospective study to assess rates of recurrence and metachronous hernias after open repair (OPEN) and laparoscopic repair (LAP) A retrospective cohort study was conducted at two children's hospitals that serve a region of approximately 4 million people. All patients < 14 years old undergoing OPEN or LAP by pediatric surgeons during a 5-year period (2011 – 2015) were analyzed after a minimum follow up of 4 years. Cox proportional regression was used to compare the effect of surgical approach on hernia recurrence and metachronous contralateral hernias. A total of 1,952 patients, 587 female (30%) and 1365 male (70%), had 2305 hernias repaired. Median post operative follow up time was 6.6 years (range 4–9 years). OPEN and LAP were performed for 1827 (79%) and 478 (21%) hernias, respectively. There were no significant differences in rate of prematurity, age at repair, or frequency of emergent repair. LAP was associated with a lower incidence of metachronous contralateral hernias compared to OPEN (1.4% vs 3.8%, p = 0.047), and a higher incidence of recurrence (9% vs 0.9%, p < 0.001). After adjusting for confounders, LAP had a higher rate of recurrence than OPEN (hazard ratio 10.4, 95% CI 6–18.1).The recurrence rate did not decrease over the study period (p = 0.731). Laparoscopic inguinal hernia repair in children resulted in a modest decrease in the incidence of metachronous hernias, at the cost of a significant increase in recurrence. Retrospective Comparative Study. Level III. [ABSTRACT FROM AUTHOR]

• The Gastroschisis Prognostic Score (GPS) is a simple and accurate risk stratification and prognostic tool for gastroschisis. The GPS had never been tested previously in low- and middle-income countries. • In a Brazilian center, the GPS reliably predicted several important clinical outcomes, including duration of parenteral nutrition, mechanical ventilation, and length of stay. The Gastroschisis Prognostic Score (GPS) stratifies patients as high or low risk based on the visual assessment of intestinal matting, atresia, perforation, or necrosis. Despite being a simple score, its applicability to low and middle-income countries (LMICs) remains unknown. We tested the hypothesis that GPS can predict outcomes in LMICs, by assessing the prognostic value of the GPS in a middle-income country. This prospective study followed all newborns with gastroschisis in a Brazilian neonatal unit based in a public hospital from 2015–2019. Infants were stratified into low and high-risk cohorts based on the GPS. In addition to basic demographics, data collected included duration of parenteral nutrition (TPN), mechanical ventilation (MV), length of stay (LOS), suspicion of infection that led to the use of antibiotics, and mortality. Univariate and multivariate analyses were conducted to identify which outcomes the GPS independently predicted. Sixty-one newborns with gastroschisis were treated during the study period. The mean birth weight, gestational age, and 5ʼ Apgar score were 2258 g, 36 weeks, and 9. Twenty-four infants (39.3%) were identified as low-risk (GPS < 2) and 37 (60.7%) as high-risk (GPS > 2). The high-risk group presented with prolonged TPN use (p <0.001), MV (p <0.001), and LOS (p:0.002). GPS did not predict antibiotic therapy or mortality. In the first study in a middle-income country, the GPS predicted several important clinical outcomes. The GPS is a reliable tool for parental counseling and resource allocation in diverse settings. II.c (cohort prospective) [Display omitted] [ABSTRACT FROM AUTHOR]

Echocardiography (ECHO) and pulmonary function testing (PFT) are routinely performed during the preoperative evaluation of pectus excavatum (PE). We hypothesized that these investigations may be performed selectively based on patient symptoms and pectus severity. A retrospective review of all PE patients who underwent a Nuss procedure during a 15-year period (2004–2018) was conducted. Symptoms, clinical characteristics, ECHO, and PFT results were extracted from the medical chart. PE severity on computed tomography was measured using the Haller Index (HI) and Correction Index (CI), and reported as mean ± SEM. Logistic and linear regression assessed the ability of symptoms and indices to predict abnormal cardiopulmonary test results. Of 119 patients, 116 patients had symptom documentation, and 74 (64%) had one or more symptoms. HI and CI were 3.8 ± 1.0 and 31.6 ± 10.3, respectively. Of those with ECHO available (111), 14 (13%) were abnormal, and 12 of 14 required cardiology follow-up. Of those with PFT available (90), the results were abnormal in 15 (17%), including 9 (11%) obstructive, 4 (5%) restrictive, and 2 (2%) mixed. The presence of symptoms did not predict abnormal ECHO or PFT, but each standard deviation increase in the CI was associated with abnormal PFT and ECHO by a factor of 2.2 and 2.0 respectively. HI severity was only associated with ECHO. The rates of abnormal ECHO and PFT testing in PE patients are low, and do not correlate with symptoms. Routine ECHO is still recommended to detect anomalies requiring follow-up. Elevated CI severity may be used to guide selective PFT testing. Levels of evidence: Retrospective Study, Level III [ABSTRACT FROM AUTHOR]

• MIRPE generates severe and prolonged post-operative pain that is best managed with multimodal analgesia. • PE severity does not influence pain trajectory during the immediate post-operative period but seems to predict persistent pain at one year. • Pain modalities that offer analgesia beyond the immediate post-operative period would probably benefit patients with severe PE. Minimally Invasive Repair of Pectus Excavatum (MIRPE) is associated with significant postoperative pain. The objective of our study was to characterize the severity and duration of this pain, and to investigate possible associations with pectus severity. We conducted a retrospective cohort study of pediatric patients who underwent MIRPE from January 2014 to April 2018. Pectus excavatum (PE) severity was determined with 3 indices measured from computed tomography: Depression Index (DI), Correction Index (CI), and Haller index (HI). Mean pain scores for every 6-hour period and the presence of pain and intake of analgesics during follow-up were extracted from the medical record. The cohort included 57 patients with a mean age of 15.9 ± 1.3 years. All 3 severity indices were positively correlated, with a correlation coefficient of 0.8 between the DI and CI. The requirement for 2 bars was significantly associated with higher indices (95% CI:0.18–0.63, p = 0.01). Pain was managed with thoracic epidural analgesia for all but one patient. Growth linear modeling identified five different pain trajectory subgroups of patients up to post-operative day 5. None of the tested predictors (age, gender, body image, physical activity level, DI, CI, HI, difference deformity-epidural level) were significantly associated with class membership. Persistent pain at one-year follow-up was present in 18% of patients, all with severe deformity (DI≥0.8). Pain trajectory and intensity after MIRPE can be classified into discrete patterns but are not influenced by PE severity. Severe deformity seems to predict persistent pain at one year. [ABSTRACT FROM AUTHOR]

• We have identified the most frequently used PROMs in pediatric general surgery and their individual characteristics. • A conceptual understanding of FDH and QoL⁄HRQoL, prioritization of child self-reporting, and the inclusion of patients and family partners in PROMs development and selection are strongly recommended. • We discourage creating more in-house questionnaires for specific studies, and reinforce instead the further validationof quality existing PROMs, such as the EA-QOL and HAQL. With improved long-term survival rates, measuring the quality of surgical care has gradually shifted from clinical morbidity and mortality to patient-reported outcome measures (PROMs). Since the use of PROMs in pediatric surgery is still limited, we undertook a study to identify current PROMs, assess their characteristics, and identify gaps and areas for improvement. A search was conducted in eight databases from their inception until May 2021 to identify PROMs that have been used in pediatric surgical patients. PRISMA standards were followed, and screening was completed by two independent reviewers. The quality of the included studies was appraised using the AXIS and the Mixed Methods Appraisal Tool. Of 8282 studies screened, 101 articles met the inclusion criteria. Most of the studies (99%) were cross-sectional. We identified 85 different PROMs among the studies, 53 being disease-specific and the rest generic. The PedsQL™ was the most frequently used tool (42 studies). Almost half of the instruments (41 studies) were not validated, and 28% were developed ad hoc for each specific study. Significantly, all PROMs encountered were standardized (consisting of pre-determined domains), with no individualized tools currently in use. The overall quality of the included studies was good. PROMs are increasingly used in pediatric surgery. Disease-specific PROMs predominate the field, yet validated and especially individualized PROMs are notably absent. Future efforts are needed to develop robust tools that reflect individual patient and family needs, preferences, and values, with the aim of furthering family-centered pediatric surgical care. [ABSTRACT FROM AUTHOR]

• -Currently, little is known about the communication needs and preferences of patients and their families in elective pediatric surgery. • -Families value functional and quality of life PROs as much as clinical outcomes. While families prefer verbal discussions with clinicians, they are also seeking more contemporary means of risk communication such as email and SMS apps. Effective shared decision-making in pediatric surgery requires clarity regarding which surgical outcomes are most important to patients and their families, and how they prefer to receive the information. Despite how essential this is for effective risk communication, little is known about the communication needs and preferences of patients and their families in elective pediatric surgery. We administered a mailed and online cross-sectional survey in English and French to 548 families before or after surgery for hernia/hydrocele repair or tonsillectomy/adenoidectomy between July 2019 and February 2021. The survey consisted of 22 questions eliciting most valued patient-reported outcomes (PROs) across 4 domains: health-related quality of life (5), functional status (5), symptoms and symptom burden (5), health behaviours and patient experience (7), as well as overall impressions (3), surgical risks (5), communication preferences (4), and demographic questions (16). The survey was completed by 368 patient families (60 preoperative, 308 postoperative, response rate 67.2%). Most respondents (72%) indicated a significant desire to be informed on all listed PROs alongside surgical complications, and highly valued all functional and quality of life outcomes (92.9% & 89.8%, respectively). Preoperatively, patient families preferred to receive information in the form of pamphlets and websites, whereas postoperatively they preferred direct communication. Families value functional and quality of life PROs as much as clinical outcomes, and increasingly seek more contemporary (electronic) means of risk communication than we currently offer. This data will inform the development of mobile tools for personalized communication in pediatric surgery. [ABSTRACT FROM AUTHOR]

Recent studies have identified transanastomotic tubes (TATs) as a risk factor for the development of anastomotic strictures after repair of esophageal atresia with tracheoesophageal fistula (EATEF). We further investigated these findings in a multicenter study. We conducted a retrospective cohort study at three university-affiliated hospitals in the province of Quebec. All patients with types C and D EATEF who underwent primary repair between January 1993 and August 2018 were included. Anastomotic stricture was defined as clinical symptoms of stricture with confirmation on esophagram or endoscopy. Multivariate logistic regression and the Wilcoxon Rank-Sum test were used to evaluate the primary outcome of stricture within one year of surgery and secondary outcome of duration of postoperative total parenteral nutrition (TPN). 244 patients were included, of which 234 (96%) were type C and 10 (4%) were type D. The anastomotic stricture rate at 1 year was 30%. TATs were utilized in 61% of patients. Thirty-six percent of patients with TATs developed a stricture within one year, as compared to 19% of patients without TATs (p = 0.005). TATs were associated with stricture on univariate analysis (OR 2.49, p = 0.004, 95% CI: 1.37–4.69). On multivariate analysis, after adjusting for gestational age, birth weight, leak, long gap, anastomotic tension, and daily acid suppression, patients with TATs had 2.72 times higher odds of developing a stricture as compared to patients without TATs (p = 0.006, 95% CI: 1.35–5.74). The median duration of TPN was 9 days in both groups (p = 0.139, IQR 6–14 in patients with TATs versus IQR 7–16 in patients without). Transanastomotic tubes are associated with a significantly higher risk of postoperative stricture following repair of esophageal atresia with tracheoesophageal fistula and do not shorten the duration of total parenteral nutrition. III. [ABSTRACT FROM AUTHOR]

This study reports the incidence, severity, and predictors of musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, following thoracic procedures in children. Children younger than 14 years who had thoracic surgery between 1997 and 2012 and had no other predispositions to MD, underwent longitudinal follow-ups with dedicated musculoskeletal examination performed in an esophageal atresia, orthopedic, or research clinic. Incidence of MD was calculated, and logistic regression methods were used to determine independent predictors, including sex, gestational age, age at procedure, serratus anterior muscle division, and chest tube placement. The study cohort consisted of 104 patients followed for a median of 10.8 years (range 3–21). A total of 56 MD developed in 41 patients (39%), including scapular winging (24; 23%), scoliosis (17; 16%), and chest wall anomalies (15; 14%). The majority of MD were subclinical, with only 8 patients [8% (6 thoracotomies, 2 thoracoscopies)] requiring intervention. Among patients who underwent thoracotomies (93, 89%), serratus anterior muscle division was the only significant predictor of the development of MD [OR 8.9; 95% CI 2.8–32.6]. Musculoskeletal deformities develop in a significant proportion of children following thoracic surgery, but most are subclinical. A muscle-sparing technique decreases the incidence of these deformities. Prospective Cohort Study. Level II. [ABSTRACT FROM AUTHOR]

Low- and middle-income countries (LMICs) have only 19% of the global surgical workforce yet see 80% of worldwide deaths from noncommunicable diseases. We aimed to interrogate the correlation between pediatric surgical workforce density (PSWD) and survival from pediatric surgical conditions worldwide. A systematic review of online databases identified outcome studies for key pediatric surgical conditions (gastroschisis, esophageal atresia, intestinal atresia, and typhoid perforation) as well as PSWD data across low-income (LICs), middle-income (MICs), and high-income countries (HICs). PSWD was expressed as the number of PSs/million children under 15 years of age and we correlated this to surgical outcomes for our case series. PSWD ranged between zero (Burundi, The Gambia, and Mauritania) and 125.2 (Poland) across 86 countries. Outcomes for at least one condition were obtained in 61 countries: 50 outcomes in HICs, 52 in MICs and 8 in LICs. The mean survival in our case series was 42.3%, 69.4% and 91.6% for LICs, MICs, and HICs, respectively. A PSWD ≥ 4 PSs/million children under 15 years of age significantly correlated to odds of survival ≥ 80% (OR 16.8, p < 0.0001, 95% CI 5.66–49.88). Specifically in the studied LICs and MICs, increasing the PSWD to 4 would require training 1427 additional surgeons. Using a novel approach, we have established a benchmark for the scale-up of pediatric surgical workforce, which may support broader efforts to reduce childhood deaths from congenital disease. 2c – Outcomes Research. [ABSTRACT FROM AUTHOR]

Survival of newborns with gastroschisis is significantly higher in high-income versus low and middle-income countries. We reviewed treatment and outcomes of gastroschisis in a middle-income country setting with increasing protocolized management. All newborns with gastroschisis treated during the period 1989–2013 at a single Brazilian academic surgical service were studied retrospectively. Protocolized diagnosis, delivery, nutrition, medical interventions, and surgical interventions were introduced in 2002. Outcomes before and after protocol introduction were studied using univariate and multivariate analysis. One hundred fifty-six newborns were treated for gastroschisis: 35 (22.4%) and 121 (77.6%) before and after 2002, respectively. When compared to the earlier cohort, patients treated after 2002 had higher rates of prenatal diagnosis (90.9% vs. 60.0%, p < 0.001) , delivery at a tertiary center (90.9% vs. 62.9%, p < 0.001) , early closure (65.3% vs. 33.3%, p = 0.001), primary repair (55.4% vs. 31.4%, p = 0.013), monitoring of bladder pressure (62.0% vs. 2.9%, p = 0.001), PICC placement (71.1% vs. 25.7%, p < 0.001), early initiation of enteral feeding (54.5% vs. 20.0%, p < 0.001), and lower rates of electrolyte disturbances (53.7% vs. 85.7%, p = 0.001). Mortality decreased from 34.3% before 2002 to 24.8% (p =.27) after 2002 despite an increase in the complex gastroschisis rate from 11.4% to 15.7% during the same period. Gastroschisis outcomes in a middle-income country can be gradually improved through targeted interventions and management protocols. Therapeutic. III. [ABSTRACT FROM AUTHOR]

The importance of defining and implementing a culture of safety in pediatric surgery is being increasingly seen as essential to decreasing complications and improving outcomes. The concept of a safety culture is a universal one, but the elements of such a culture are different for every disease and anomaly treated. In this paper, I will review these elements as they pertain to the treatment of abdominal wall defects starting from fetal evaluation to post-discharge care. [ABSTRACT FROM AUTHOR]

Prolonged central vascular access is a source of significant morbidity in children with intestinal failure (IF). In an effort to decrease morbidity, our multidisciplinary IF team has primarily used peripherally inserted central catheters (PICCs) for these patients. We compared outcomes of PICCs to Broviacs®. A review of children with IF (2006–2018) at an academic children's hospital was conducted. Inclusion criteria: total parenteral nutrition duration > 42 days or small bowel length < 25% of total for gestational age. Complications/1000 catheter days were extracted, and a Poisson model was used to compare complications between PICCs and Broviacs®. Thirty-seven patients with IF were included, accounting for 19,452 catheter days. There were 209 PICCs (1.2–4F) and 39 Broviacs® (2.7–7F). The median duration of overall PICC access/patient was 166 days (range: 35 days–8 years). Incidences of central line associated blood stream infection and venous thrombosis were 3.95 and 0.55 per 1000 catheter days, respectively. There were no significant differences in complication rates per line per catheter day between PICCs and Broviacs® on multivariate analysis. Broviacs® showed a trend towards increased of catheter-related hospital admissions when compared to PICCs. PICCs in children with intestinal failure have similar complication rates to Broviacs® but may reduce catheter-related hospital admissions. Use of tunneled PICCs and increasing experience with this vascular access method may allow it to realize its potential advantages. Retrospective study, level III. [ABSTRACT FROM AUTHOR]

Boot camps seek to impart knowledge and skills for individuals entering new roles. We sought to evaluate knowledge, skills, and confidence of in-coming pediatric surgery trainees with a 2.5-day pediatric surgery boot camp. A curriculum included key aspects of pediatric surgery delivered during interactive lectures, small group discussions, and simulation. With REB approval, participant demographics were collected. Pre- and posttests assessed knowledge and trainee confidence. Comparative statistics and multivariate analysis of variance (MANOVA) were performed. Between 2017 and 2018, 16 individuals from North American pediatric surgery training programs participated in two boot camps. Ten had North American general surgery training, and eleven had no pediatric surgery exposure ≥ 1 year prior. All participants expressed increased confidence with course material after boot camp [F(18,11) = 3.137 ;p < 0.05]. Performance improved significantly (pre- vs. posttests, 47.0% vs. 62.4%; p < 0.05). MANOVA between faculty and trainees demonstrated agreement on the value of individual sessions [F(15,3) = 0.642 ;p = 0.76]. Neonatal bowel obstruction, gastrostomy tube complications, esophageal atresia, pain management, and informed consent were rated most useful. Trainees and teaching faculty considered the boot camp valuable. Trainees demonstrated significant improvements in core knowledge and confidence. The initial pediatric surgery boot camp experience shows promise in facilitating the transition to discipline for new trainees. Prospective treatment study. IV. [ABSTRACT FROM AUTHOR]

In 2014, a survey study of the Canadian pediatric surgery workforce predicted a need for 2 new pediatric surgeons/yr. in Canada. We sought to assess these predictions and evaluate the status of the workforce. With IRB approval, a web-based survey was sent to pediatric surgery division chiefs in Canada each year (2013–2017). The survey data included: number of practicing pediatric surgeons, full time equivalent (FTE) positions, and fellowship graduates. There was a 100% response rate (18 divisions). From 2013 to 2017, the number of practicing pediatric surgeons and FTE positions increased (73 to 78, and 64.6 to 67.5, respectively). Eleven positions were vacated (4 retirement, 7 new practice), and 18 were filled. Eight were filled by new Canadian graduates, 7 by Canadians previously working in Canada or abroad, and 3 by European surgeons. Thirty-eight fellows completed training in Canada, including 24 non-Canadians who all left Canada. Nine Canadians who started practicing immediately after fellowship took positions in Canada (5) and the US (4). Predictions made in 2014 were largely accurate. There has been modest growth in the Canadian pediatric surgery workforce over the last 5 years. A significant mismatch continues to exist between Canadian pediatric surgery graduates and attending staff positions. Survey. V [ABSTRACT FROM AUTHOR]

Effective antenatal counseling in congenital diaphragmatic hernia (CDH) relies on proper measurement of prognostic indices. This quality initiative audited the accuracy of prenatal imaging with postnatal outcomes at two tertiary pediatric referral centers. Prenatal lung–head ratio (LHR) and total fetal lung volume (TFLV) for CDH patients treated between 2006 and 2017 were retrieved. Study inclusion required at least one LHR or TFLV measurement between 24 and 32 weeks gestational age. Postnatal outcomes [mortality, extracorporeal life support (ECLS) need, patch repair, persistent pulmonary hypertension, oxygen requirement at 28 days] were abstracted from the Canadian Pediatric Surgery Network (CAPSNet) database and local chart review. Univariate and descriptive analyses were conducted. Eighty-two of 121 eligible CDH patients (68%) were included. Overall mortality, ECLS rates, and patch repair were 33%, 12.5%, and 45%, respectively. Lower LHR values correlated with increased rates of each outcome and persisted despite multiple measurements. Values obtained were higher than those in published schemata. LHR values > 45% were most associated with survival, avoidance of ECLS, and primary repair. TFLV values only correlated with mortality and patch repair. This audit confirms that LHR and TFLV values predict CDH outcomes. However, absolute values obtained require careful interpretation and internal review. IV. [ABSTRACT FROM AUTHOR]

Abstract Purpose Postoperative pain remains a considerable concern for patients and families. We assessed whether nebulized ropivacaine reduces morphine consumption and pain after laparoscopic appendectomy for uncomplicated appendicitis in children. Methods Patients 7–17 years old with uncomplicated appendicitis were randomized to ropivacaine (intervention arm) or saline nebulization (placebo arm) at the onset of laparoscopy. Nonconsenting individuals were treated with standard care and invited to provide clinical data (baseline arm). The primary outcome was in-patient morphine utilization. Secondary outcomes included pain scores at multiple time-points, markers of recovery, operative times, and surgeon satisfaction. The trial was registered (NCT02624089). Results Study enrollment was 116 patients over a 1-year period: Intervention (n = 43), Placebo (n = 39), Baseline (n = 34). No differences in baseline characteristics were noted between groups. No difference was noted in overall in-patient morphine consumption between randomized groups (0.31 vs. 0.35 mg/kg, p = 0.42) or between ropivacaine and baseline (0.31 vs. 0.277 mg/kg, p = 0.62). Although operative times were comparable between groups, 63% of surgeon respondents felt that nebulization obscured visualization. Conclusion Nebulized ropivacaine did not reduce postoperative morphine consumption or pain scores after laparoscopic appendectomy for simple appendicitis in children. Given that it decreases visualization and likely increases costs, nebulized administration of intraperitoneal analgesia does not appear warranted in this context. Type of study Treatment study. Level of evidence Level I. [ABSTRACT FROM AUTHOR]

Abstract Purpose Conservative treatment of pectus excavatum with a vacuum bell device may be an attractive alternative to surgical repair. We describe an early North American experience with this device. Methods Prospectively maintained chest wall clinic registries from two institutions were reviewed to identify pectus excavatum patients ≤ 21 years treated with the vacuum bell from 2013 to 2017. Multivariate linear regression was used to compare mean improvements in deformity-depth and Haller Index between groups of patients based on age and usage metrics (hours/day and days/week). Results Thirty-one patients with a median age of 14 years received treatment with the device. Mean follow-up duration was 18 months. Median depth and Haller Index at treatment onset were 2.3 cm and 3.9, respectively. Improvements in deformity-depth were superior with device usage > 2 h/day (p < 0.01) and daily use (p < 0.01). After adjusting for compliance, younger age of treatment onset was associated with greater improvement in Haller Index but not deformity depth. Conclusion Our prospective early North American experience found the vacuum bell to be a potential alternative to surgical treatment for pectus excavatum. Longer usage periods in a daily frequency are associated with best results. Type of study Treatment study; case series with no comparison group. Level of evidence Level IV. [ABSTRACT FROM AUTHOR]

Currently, the most important determinant of gastroschisis outcomes in high resource settings is whether the condition is associated with intestinal complications, such as atresia, necrosis, perforation, or volvulus. This form of the anomaly, known as complex gastroschisis, accounts for most of the mortality and a disproportionate burden of the morbidity from gastroschisis. There is some disagreement about what constitutes complex gastroschisis, and little consensus on the type and timing of surgical interventions. This article establishes a clear definition of complex gastroschisis. Surgical approaches to treatment of the diverse presentations of complex gastroschisis will be described and the timing of such interventions will be discussed. Contemporary outcomes of complex gastroschisis will be reviewed. Finally, a non-congenital intestinal complications that may arise in gastroschisis patients will be discussed. [ABSTRACT FROM AUTHOR]

Abstract Background The utility of magnetic resonance imaging (MRI) in the diagnosis and management of pediatric ovarian lesions has not been well defined. Methods A retrospective review of all girls who underwent MRI evaluation of ovarian masses during the period 2009–2015 was performed. The accuracy of MRI was evaluated by comparing results with surgical findings, pathology reports, and subsequent imaging. The influence of the MRI on the treatment plan was specifically explored. Results Eighteen girls, 12–17 years of age, underwent 27 MRIs, subsequent to ultrasound identification of ovarian lesions. Of 9 neoplastic lesions diagnosed on MRI, 8 (89%) were confirmed by surgical and pathological findings. Of 18 functional lesions, 17 (94.4%) were confirmed pathologically or by resolution on subsequent imaging. Twenty MRI exams (74%) directly influenced the treatment plan, by leading to appropriate operative intervention in 9 and appropriate observation in 11. The extent of ovarian resection was guided by MRI findings in 8 of 9 (89%) neoplastic lesions. For characterizing lesions as neoplastic, the sensitivity, specificity, negative predictive value, positive predictive value, and accuracy of MRI were 89%, 94%, 94%, 89%, and 93% respectively. Conclusions MRI can differentiate functional from neoplastic pediatric ovarian masses, and guide ovarian resection in appropriate cases. Level of study II [ABSTRACT FROM AUTHOR]

Introduction Parental presence at induction of general anesthesia (PPI) is highly desired by children and parents. However, it often faces resistance from medical personnel. We conducted a survey evaluating the perceptions of surgeons before and after establishment of a PPI program. Methods Internal web-based surveys using Likert Scale questions were administered to all members of a pediatric surgical department before and after the introduction of PPI at a freestanding children's hospital. Pre and post results were compared by Wilcoxon rank-sum tests. A p-value ≤ 0.0026 was considered significant due to the Bonferroni correction. Results The survey was sent to 59 surgeons 1 year before and 5 years after gradual implementation of PPI. Response rates were 46% and 54%, pre and post implementation, respectively. After implementation, there was a statistically significant increased level of agreement with the statement: “PPI improves the parents' level of satisfaction” (p = 0.0025) and a statistically significant decreased level of agreement with the statement “PPI lengthens the duration of induction” (p = 0.0001). Before initiation, 56% wanted to see PPI implemented, while after implementation, 97% wanted PPI to remain. Conclusions A majority of pediatric surgeons favored maintaining PPI after implementation. Resistance to initiation of PPI should not hinder implementation. Type of study Survey Level of evidence Not applicable [ABSTRACT FROM AUTHOR]

Background Total parenteral nutrition (TPN) is often used in children with perforated appendicitis, despite the absence of clear indications. We assessed the validity of specific clinical indications for initiation of TPN in this patient cohort. Methods Data were gathered prospectively on duration of nil per os (NPO) status and TPN use in a cohort of children treated under a perforated appendicitis protocol during a 19-month period. TPN was started in the immediate postoperative period in patients who had generalized peritonitis and severe intestinal dilatation at operation, or later per the discretion of the attending surgeon. At discharge, TPN was considered to have been used appropriately, according to consensus guidelines, if the patient was NPO ≥ 7 days or received TPN ≥ 5 days. Results During the study period, TPN was initiated in 31 (25.4%) of 122 patients operated for perforated appendicitis. Sixteen (51.6%) received TPN per operative finding indications and 15 (48.4%) for prolonged ileus. The operative indications demonstrated 47% sensitivity, 86% specificity, a positive predictive value (PPV) of 35%, and a negative predictive value (NPV) of 91%, when adherence to TPN consensus guidelines was considered the gold standard. Conclusion Patients without severe intestinal dilatation and generalized peritonitis at operation should not be placed on TPN in the immediate postoperative period. Refinement of selection criteria is necessary to further decrease inappropriate TPN use in children with perforated appendicitis. Type of study Diagnostic Test. Level of study II [ABSTRACT FROM AUTHOR]

Background/Purpose Intrathyroidal thymic tissue may be misinterpreted as a thyroid lesion in children, leading to invasive tests or resection. We sought to describe the characteristic imaging features of these lesions and to evaluate the safety of non-operative management. Methods A retrospective review of all patients less than 18 years old with intrathyroidal thymic tissue from 2000 to 2016 was performed. Data collection included patient demographics, imaging results, interventions, and outcomes. Results Eleven patients were identified using institutional radiology and pathology databases. Median patient age and lesion size at presentation were 5 years old (range 2 to 8 years old) and 0.9 cm (range 0.4 to 9.2 cm), respectively. Six lesions were incidentally identified, six were left-sided, and the most common location was the lower pole. Ultrasonographic features were reproducible and included well demarcated (10/11), hypoechoic lesions (11/11), containing punctate/linear internal echoes (11/11), and occasional mild hypervascularity (6/11). All cases demonstrated interval size and echotexture stability over a median surveillance period of 3 years (range 1 to 8 years). While 9 patients were simply observed, the first patient in this series underwent excision, while another had a fine needle aspiration to confirm pathology. Level of Evidence Study of diagnostic test, Level IV. Conclusion Intrathyroidal thymic tissue has typical clinical and sonographic characteristics which allow for appropriate diagnosis and avoids thyroid resection. [ABSTRACT FROM AUTHOR]

Calcifying fibrous tumor is a rare benign tumor that occurs in multiple locations, and originates from the subcutaneous and deep soft tissues. There are some reported adult cases of multiple or disseminated calcifying fibrous tumors of the pleura. We are reporting the first case of multiple calcifying fibrous tumors of the pleura in a 15 year old girl presenting with cyclical chest pain, with possible hormonal influence. [ABSTRACT FROM AUTHOR]

Purpose Despite a wide spectrum of severity, perforated appendicitis in children is typically considered a single entity in outcomes studies. We performed a prospective cohort study to define a risk stratification system that correlates with outcomes and resource utilization. Methods A prospective study was conducted of all children operated for perforated appendicitis between May 2015 and December 2016 at a tertiary free-standing university children's hospital. Surgical findings were classified into one of four grades of perforation: I. localized or contained perforation, II. Contained abscess with no generalized peritonitis, III. Generalized peritonitis with no dominant abscess, IV. Generalized peritonitis with one or more dominant abscesses. All patients were treated on a clinical pathway that involved all points of care from admission to final follow-up. Outcomes and resource utilization measures were analyzed using Fisher's exact test, Kruskal–Wallis test, One-way ANOVA, and logistic regression. Results During the study period, 122 patients completed treatment, and 100% had documented follow-up at a median of 25 days after operation. Grades of perforation were: I, 20.5%; II, 37.7%; III, 10.7%; IV, 31.1%. Postoperative abscesses occurred in 12 (9.8%) of patients, almost exclusively in Grade IV perforations. Hospital stay, duration of antibiotics, TPN utilization, and the incidence of postoperative imaging significantly increased with increasing grade of perforation. Conclusion Outcomes and resource utilization strongly correlate with increasing grade of perforated appendicitis. Postoperative abscesses, additional imaging, and additional invasive procedures occur disproportionately in patients who present with diffuse peritonitis and abscess formation. The current stratification allows risk-adjusted outcome reporting and appropriate assignment of resource burden. Level of evidence I (Prognosis Study). [ABSTRACT FROM AUTHOR]

Background The treatment of perforated appendicitis in children is characterized by significant variability in care, morbidity, resource utilization, and outcomes. We prospectively studied how minimization of care variability affects outcomes. Methods A clinical pathway for perforated appendicitis, in use for three decades, was further standardized in May 2015 by initiation of a disease severity classification, refinement of discharge criteria, standardization of the operation, and establishment of criteria for use of postoperative total parenteral nutrition, imaging, and invasive procedures. Prospective evaluation of all children treated for 20 months on the new fully standardized protocol was conducted and compared to a retrospective cohort treated over 58 months prior to standardization. Differences between outcomes before and after standardization were analyzed using regression analysis techniques to adjust for disease severity. Results Median follow-up time post discharge was 25 and 14 days in the post- and prestandardization groups, respectively. Standardization significantly reduced postoperative abscess (9.8% vs. 17.4%, p = 0.001) and hospital stay (p = 0.002). Standardization reduced the odds of developing a postoperative abscess by four fold. Conclusion Minimizing variability of care at all points in the treatment of perforated appendicitis significantly improves outcomes. Type of study Prospective Cohort Study. Level of evidence Level II. [ABSTRACT FROM AUTHOR]

Background Musculoskeletal deformities (MD), including scoliosis and chest wall anomalies, are potential long-term complications of neonatal thoracotomies. Methods We studied the incidence of MD in patients who underwent open repair of esophageal atresia between 1997 and 2012, had no other predisposition to MD, and subsequently received longitudinal follow-up in a multidisciplinary esophageal atresia clinic. Detailed chest wall and musculoskeletal exams were performed at each visit. Incident rate and incident rate ratios were used to determine the incidence of deformities. Logistic regression methods were used to test the effect of independent variables including sex, gestational age, muscle division, number of thoracotomies, and operative complications on the occurrence of MD. Results The study cohort consisted of 52 patients followed for a median of 8 (range 1–19) years. MD developed in 13 (25%), with an incident rate of 2.92 per 100 child-years. Division of the serratus anterior was associated with a significantly higher probability of developing MD (log-rank p = .0237) and was also a strong predictor of the same [OR 8.6 (95% CI 1.8–42.1)] after adjusting for possible confounders. Conclusions Musculoskeletal deformities develop in a significant proportion of neonates following thoracotomy. A muscle-sparing technique decreases the incidence of these deformities. Type of study Prospective Cohort Study. Level of evidence II. [ABSTRACT FROM AUTHOR]

Purpose We analyzed the determinants of outcomes in simple gastroschisis (GS) not complicated by intestinal atresia, perforation, or necrosis. Methods All simple GS patients enrolled in a national prospective registry from 2005 to 2013 were studied. Patients below the median for total parenteral nutrition (TPN) duration (26 days) and hospital stay (34 days) were compared to those above. Univariate and multivariate logistic and linear regression analyses were employed using maternal, patient, postnatal, and treatment variables. Results Of 700 patients with simple GS, representing 76.8% of all GS patients, 690 (98.6%) survived. TPN was used in 352 (51.6%) and 330 (48.4%) patients for ≤ 26 and > 26 days, respectively. Hospital stay for 356 (51.9%) and 330 (48.1%) infants was ≤ 34 and > 34 days, respectively. Univariate analysis revealed significant differences in several patient, treatment, and postnatal factors. On multivariate analysis, prenatal sonographic bowel dilation, older age at closure, necrotizing enterocolitis, longer mechanical ventilation, and central-line associated blood stream infection (CLABSI) were independently associated with longer TPN duration and hospital stay, with CLABSI being the strongest predictor. Conclusions Prenatal bowel dilation is associated with increased morbidity in simple GS. CLABSI is the strongest predictor of outcomes. Bowel matting is not an independent risk factor. Level of evidence 2c. [ABSTRACT FROM AUTHOR]

Background The Canadian 4-year native liver survival rate for biliary atresia (BA) after Kasai Portoenterostomy (KP) is 39%. The Canadian Biliary Atresia Registry (CBAR) was used to examine variability of surgical and medical management of BA. Methods Gastroenterologists and surgeons in all 14 Canadian pediatric tertiary centers were invited to complete an online survey of their BA management practices. Results Of gastroenterologists, diagnostic procedures included liver biopsy (92%), HIDA scan (58%), and percutaneous cholangiogram (46%). Surgeons reported Roux-en-Y lengths of 20–50 cm with 78% avoiding diathermy at the portal plate; 16% performed laparoscopic exploration, but none laparoscopic KP. Postoperative corticosteroids and antibiotics were used by 24% and 85% of gastroenterologists, respectively, with similar rates for surgeons. At discharge, gastroenterologists prescribed oral antibiotics (80%), and ursodeoxycholic acid (95%), while surgeons reported lower rates (62% and 55%). Considerable variation existed in follow-up monitoring. No center had a standard protocol for evaluating suspected cholangitis. There was a lack of consensus for defining failed KP and referral criteria for transplant evaluation. Conclusion In Canada, treatment of BA is not centralized, and there is variability in diagnostic approaches and management. Collaboration through CBAR will allow for implementation and evaluation of standardized surgical and medical management with a goal to improve outcomes. Level of evidence Survey study. Level IV evidence. [ABSTRACT FROM AUTHOR]

Background African pediatric surgery (PS) faces multiple challenges. Information regarding existing resources is limited. We surveyed African pediatric surgeons to determine available resources and clinical, educational, and collaborative needs. Methods Members of the Pan-African Pediatric Surgical Association (PAPSA) and the Global Pediatric Surgery Network (GPSN) completed a structured email survey covering PS providers, facilities, resources, workload, education/training, disease patterns, and collaboration priorities. Results Of 288 deployed surveys, 96 were completed (33%) from 26 countries (45% of African countries). Median PS providers/million included 1 general surgeon and 0.26 pediatric surgeons. Median pediatric facilities/million included 0.03 hospitals, 0.06 ICUs, and 0.17 surgical wards. Neonatal ventilation was available in 90% of countries, fluoroscopy in 70%, TPN in 50%, and frozen section pathology in 35%. Median surgical procedures/institution/year was 852. Median waiting time was 40 days for elective procedures and 7 days? for emergencies. Weighted average percent mortality for key surgical conditions varied between 1% (Sierra Leone) and 54% (Burkina Faso). Providers ranked collaborative professional development highest and direct clinical care lowest priority in projects with high-income partners. Conclusions The broad deficits identified in PS human and material resources in Africa suggest the need for a global collaborative effort to address the PS gaps. Level of evidence Level 5, expert opinion without explicit critical appraisal. [ABSTRACT FROM AUTHOR]

Purpose The GPS enables risk stratification for gastroschisis and helps discriminate low from high morbidity groups. The purpose of this study was to revalidate GPS's characterization of a high morbidity group and to quantify relationships between the GPS and outcomes. Methods With REB approval, complete survivor data from a national gastroschisis registry was collected. GPS bowel injury scoring was revalidated excluding the initial inception/validation cohorts (> 2011). Length of stay (LOS), 1st enteral feed days (dFPO), TPN days (dTPN), and aggregate complications (COMP) were compared between low and high morbidity risk groups. Mathematical relationships between outcomes and integer increases in GPS were explored using the entire cohort (2005–present). Results Median (range) LOS, dPO, and dTPN for the entire cohort (n = 849) was 36 (26,62), 13 (9,18), and 27 (20,46) days, respectively. High-risk patients (GPS ≥ 2; n = 80) experienced significantly worse outcomes than low risk patients (n = 263). Each integer increase in GPS was associated with increases in LOS and dTPN by 16.9 and 12.7 days, respectively (p < 0.01). COMP rate was also increased in the high-risk cohort (46.3% vs. 22.8%; p < 0.01). Conclusion The GPS effectively discriminates low from high morbidity risk groups. Within the high risk group, integer increases in GPS produce quantitatively differentiated outcomes which may guide initial counseling and resource allocation. Level of evidence IIb. [ABSTRACT FROM AUTHOR]

Background This study sought to establish factors that can prognosticate outcomes of bracing for pectus carinatum (PC). Methods Prospective data were collected on all patients enrolled in a dynamic bracing protocol from July 2011 to July 2015. Pressure of correction (POC) was measured at initiation of treatment, and pressure of treatment (POT) was measured pre- and post-adjustment at every follow-up visit. Univariate and Cox regression analysis tested the following possible determinants of success and bracing duration: age, sex, symmetry, POC, and POT drop during the first two follow-up visits. Results Of 114 patients, 64 (56%) succeeded, 33 (29%) were still in active bracing, and 17 (15%) failed or were lost to follow-up. In successful patients, active and maintenance bracing was 5.66 ± 3.81 and 8.80 ± 3.94 months, respectively. Asymmetry and older age were significantly associated with failure. Multivariable Cox proportional hazard analysis of time-to-maintenance showed that asymmetry (p = 0.01) and smaller first drop in POT (p = 0.02) were associated with longer time to reach maintenance. Conclusions Pressure of correction does not predict failure of bracing, but older age, asymmetry, and smaller first drop in pressure of treatment are associated with failure and longer bracing duration. Level of evidence Prospective Study/Level of Evidence IV. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background Care of infants with gastroschisis is centralized in Canada and noncentralized in the United States. We conducted an outcomes comparison between the two countries and analyzed the determinants of such outcomes. Methods Inpatient mortality and hospital stay of gastroschisis patients from the Canadian Pediatric Surgery Network prospective clinical database for the period 2005-2013 were compared with those from the US Kids Inpatient Database for the period 2003-2012. Potential outcome determinants were analyzed using univariate and multivariate analyses. Results A comparison was made between 695 Canadian patients and 5216 American patients. Complex gastroschisis was found in 16.0% and 13.7% of patients in Canada and the US, respectively; P = 0.11. Canada had less premature births, more normal birth weight (BW) infants, less cesarean section deliveries, and more inborn patients compared to the US. For simple gastroschisis, Canadian mortality was lower (1.4% vs. 3.4%; P = .008) and hospital stay was longer (45 ± 38 vs. 41 ± 32 days; P = .04). US mortality correlated strongly with low BW (P = .002) and marginally with cesarean section delivery (P = .08). A longer Canadian hospital stay was associated with lower gestational age (P = 0.01) and western region (P = 0.04), while a longer American hospital stay was associated with medium neonatal intensive care unit gastroschisis volume (P = .03), low socioeconomic status (P = .06), low BW (P = 0.06), and public insurance (P = 0.07). Outcomes for complex gastroschisis did not differ between Canada and the US. Conclusions Mortality for simple gastroschisis is higher in the US than in Canada, whereas no outcome differences exist for complex gastroschisis. Outcome determinants are different between the 2 countries. [ABSTRACT FROM AUTHOR]

Perineal hernias can occur primarily or secondary to a pelvic operation. Among primary perineal hernias, the congenital type is very rare, with less than 10 cases reported in the literature. This is a case report of a healthy female child presenting with a congenital posterior perineal hernia who underwent successful delayed operative repair using a perineal approach. Level of evidence Level V – case report. [ABSTRACT FROM AUTHOR]

In the last 2 years, a coalescence of forces has brought the needs of surgical patients in low resource settings to the top of the international healthcare policy agenda. This same dynamic has propelled academic global surgery, and particularly education, to the forefront. The proportion of surgical trainees seeking global surgical experiences, and interested in incorporating global surgery into their clinical and academic career, has risen sharply. International surgical electives are now allowed in a number of surgical residency programs, if they meet strict criteria. However, the Accreditation Council for Graduate Medical Education (ACGME) currently does not allow international electives during pediatric surgical training. This decision has not been contested by the American Board of Surgery (ABS) or the Association of Pediatric Surgery Training Program Directors (APSTPD). Valid concerns exist regarding international pediatric surgical electives. In this article, the authors address these concerns and exhort the APSTPD, the ABS, and the ACGME to re-examine their position on the value of pediatric global surgery electives. Level of evidence 5. [ABSTRACT FROM AUTHOR]

Introduction Congenital paraesophageal hernia (CPEH) is the least common congenital diaphragmatic hernia. We performed an extensive review to further define this entity. Methods A retrospective study of children with CPEH (types II–IV hiatal hernias) treated at two children’s hospitals over a 25-year period (1988–2013) was performed. Results Fourteen patients were diagnosed at a median age of 35 days (range 0–500), with one prenatal diagnosis. The most common symptoms were emesis in type II hernias (50%), and respiratory distress in types III and IV hernias (75% and 50%, respectively). Gastroesophageal reflux was concomitantly diagnosed in 50%, while concurrent congenital anomalies existed in 36%. A correct initial diagnosis was made in only 29% of cases. The diagnosis was most often established by UGI study (64%). The method of repair was laparoscopy in 21%, and laparotomy in 71%. An antireflux procedure was done in 13 (93%) patients. Long-term follow up data was available for 86% of patient. During follow-up, one patient recurred and one required sequential pneumatic esophageal dilations. There were no mortalities. Conclusions CPEH is a rare entity often associated with gastroesophageal reflux disease and other congenital anomalies. Prognosis is excellent, but awareness of this anomaly may lead to earlier diagnosis. [ABSTRACT FROM AUTHOR]

Purpose We performed a population-based study to analyze the trends, associations, and outcomes of laparoscopic appendectomy (LA) in the Canadian universal health care setting. Methods Children younger than 18 years coded for urgent appendectomy in the discharge abstract database of the Canadian Institute of Health Information during 2004–2010 were analyzed. The Cochran–Armitage test, logistic regression, and quintile regression were used to perform the necessary analyses. Results 41,405 children were studied. LA incidence steadily increased from 28.8% to 66.4%, p < .0001. Conversion rates significantly decreased, while LA for perforated appendicitis significantly increased. LA occurred significantly less in younger patients [OR 0.24 (< 5 years), OR 0.45 (6–11 years)], males [OR 0.79], and operations by a general surgeon [OR 0.33]. Rural domicile, socioeconomic status, and hospital type had no effect. LA decreased hospital stay for simple appendicitis by one day beginning in 2006, and by variable durations for perforated appendicitis throughout the study period. Conclusions The incidence of LA in Canada has more than doubled. Older children, females, and patients treated by pediatric surgeons are more likely to receive LA, while domicile, socioeconomic status, and hospital type have no effect. LA reduced hospital stay for both simple and perforated appendicitis. [ABSTRACT FROM AUTHOR]

Background We previously demonstrated feasibility, safety, and a reproducible histologic bulking effect after injection of dextranomer hyaluronic acid copolymer (DxHA) into the gastroesophageal junction of rabbits. In the current study, we investigated the potential for DxHA to augment the lower esophageal sphincter (LES) in a porcine model of gastroesophageal reflux disease (GERD). Methods Twelve Yucatan miniature pigs underwent LES manometry and 24-hour ambulatory pH monitoring at baseline, after cardiomyectomy, and 6 weeks after randomization to endoscopic injection of either DxHA or saline at the LES. After necropsy, the foregut, including injection sites, was histologically examined. Results Pigs in both groups had similar weight progression. Cardiomyectomy induced GERD in all animals, as measured by a rise in the median % of time pH < 5 from 0.6 to 11.6 (p = 0.02). Endoscopic injection of DxHA resulted in a higher median difference in LES length (1.8 cm vs. 0.4 cm, p = 0.03). In comparison with saline injection, DxHA resulted in 120% increase in LES pressure, and 76% decrease in the mean duration of reflux episodes, but these results were not statistically significant. Injection of DxHA induced a foreign body reaction with fibroblasts and giant cells. Conclusions Porcine cardiomyectomy is a reproducible animal GERD model. Injection of DxHA may augment the LES, offering a potential therapeutic effect in GERD. [ABSTRACT FROM AUTHOR]

Abstract: Background: There is significant lack of information regarding the Canadian pediatric surgery workforce. Methods: An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012. Results: The survey was completed by 98% of practicing surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs. Conclusions: The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada. [Copyright &y& Elsevier]

Abstract: Background: Outcomes of appendicitis may be influenced by access to healthcare. We investigated the determinants of pediatric appendicitis outcomes in the single-payer Canadian healthcare system. Methods: Children coded for urgent appendectomy by the Canadian Institute of Health Information during the period 2004–2010 were analyzed. Misdiagnosis rate, perforated appendicitis rate, and hospital stay were the outcomes studied. Analyzed variables included age, gender, domicile, socioeconomic status, surgeon’s specialty, hospital type, region, and operative approach. Logistic regression analysis was used to examine associations, and a quintile regression model examined the effect on median hospital stay. Results: 41,702 patients were studied. A higher rate of perforated appendicitis was associated with lower age [OR 2.66], male gender [OR 1.18], pediatric surgeon [OR 1.25], and treatment outside the Maritimes. A higher rate of misdiagnosis was associated with lower age [OR 1.53], female gender [OR 2.29], non-children’s hospital [OR 1.33], and western Canada [OR 1.22]. A significantly longer hospital stay was associated with open appendectomy, pediatric surgeon, and the Territories for simple appendicitis, and open appendectomy, pediatric surgeon, children’s hospital, and the Maritimes for perforated appendicitis. Conclusions: In Canada, outcomes of pediatric appendicitis are associated with regional and treatment-level factors. Rural domicile and socioeconomic status do not affect outcomes. [Copyright &y& Elsevier]