Search

Background : One of the most competitive surgical sub-specialty fellowships remains Pediatric Surgery (PS), which requires candidates to develop a strong and research-oriented curriculum vitae. Although some objective factors of matriculation are known, factors for the interview selection and ranking per the program directors (PDs) have not been reviewed in over a decade. Methods : A web-based survey of US and Canadian PS program directors (PDs) (n=58) was used to evaluate a comprehensive list of factors in the selection criteria for PS fellowships. A mix of dichotomous, ranking, five-point Likert scale, and open-ended questions evaluated applicant characteristics, ABSITE scores, research productivity, interview day, and rank order criteria. Results : Fifty-five programs responded to the survey for a 95% participation rate. PDs desired an average of two years in dedicated research and weighted first authorship and total number of publications heavily. Only 38% of programs used an ABSITE score cutoff for offering interviews; however, the majority agreed that an overall upward trend was important. Quality letters of recommendation, especially from known colleagues, carried weight when deciding to offer interviews. Interview performance, being a team player, observed interpersonal interactions, perceived operative skills and patient care, and leadership were some of the notable factors when finalizing rank lists. Conclusions : A multitude of factors define a successful matriculant, including quality of letters of recommendation, quality and quantity of publications, supportive phone calls, observed interactions, interview performance, perceptions of being team player with leadership skills as well as perceptions of good operative skills and patient care.

BACKGROUND Intussusception, which is the prolapse of one section of intestine into another, is a common cause of small-bowel obstruction in pediatric patients. Bezoars are concretions of ingested foreign material. Trichobezoars, which are bezoars made of hair, occur in the context of trichotillomania, the compulsive pulling of hair, and trichophagia, the eating of hair. If gastric trichobezoars grow to sufficient size, an intestinal extension can serve as a lead point for intussusception to occur. Rarely, hair passes completely through the stomach and forms a trichobezoar within the small bowel. This obstruction can also create lead points and cause intussusception. This is one of the few reported cases of intussusception due to a primary intestinal bezoar. CASE REPORT We present the case of an 8-year-old boy with an unknown history of trichophagia and a preliminary diagnosis of appendicitis. Upon imaging, a bowel obstruction related to a small-bowel intussusception was discovered to be the probable cause. A diagnostic laparoscopy revealed an ileo-ileal intussusception caused by an ileal bezoar. Conversion to exploratory laparotomy assisted in removing the causative bezoar. The patient recovered without postoperative complications. CONCLUSIONS We report a case of an isolated intestinal trichobezoar causing intussusception in a boy. While intussusception secondary to a trichobezoar most commonly occurs due to 'Rapunzel syndrome,' this case shows that it is possible for an intestinal trichobezoar to form without the presence of 'Rapunzel syndrome.' This unique cause of intussusception presented as a small-bowel obstruction, requiring evacuation of the bezoar.

Introduction Incidentally found congenital pulmonary airway malformations (CPAM) in older children are extremely rare and have traditionally been managed with minimally invasive versus open lobectomy of the affected lobe. Presentation of case In this report, we present a 11-year-old male who presented with a recurrent spontaneous pneumothorax and was found to have a large symptomatic CPAM confined to a single segment of the right lower lobe. The patient was successfully treated with thoracoscopic segmentectomy without any residual disease seen on follow up imaging. Discussion Minimally invasive thoracoscopic approach has many advantages over open approach including better pain control, reduced hospital length of stay, and decreased intraoperative blood loss. With increasing use of minimally invasive approaches, lung-sparing surgery has demonstrated to be a viable and an attractive option for definitive resection of CPAM, without compromising resection margins and/or future lung function. Conclusion This report demonstrates that minimally invasive lung-sparing surgical treatment of a large CPAM is feasible in older children., Highlights • Older children with CPAM can present with a spontaneous pneumothorax. • CPAM confined to a segment of a single lobe should be managed with segmentectomy. • VATS segmentectomy for CPAM in older children can be successful.

Background/Purpose To identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy. Methods After IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1–18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval. The median time from pain onset to treatment initiation was 3 days (range: 1–14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence. Results Of 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57–0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81–0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity. Conclusion Younger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy. Level of evidence Treatment Study Level II.

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3–9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

The Big Five framework examines five factors that represent a description of human personality. These factors correlate with success measures and job satisfaction. The Big Five Inventory is a 44-item instrument designed to measure the Big Five framework. Our aim was to document the distribution of Big Five personality traits among Pediatric Surgery fellowship applicants, compare with community norms, surgical residents, between genders, and correlate to the fellowship match results.Forty Pediatric Surgery fellowship applicants at a university hospital completed the Big Five Inventory during the interview process. It was analyzed and compared with general surgery residents' results and community norms. The data were compared regarding gender and match results. Continuous variables were compared by unpaired t-tests and Mann-Whitney tests. A P value0.05 was considered significant.The 40 applicants were equally divided between male and female. When compared with general surgery residents and community norms, applicants of both genders scored higher on agreeableness (P 0.01), conscientiousness (P 0.01), and emotional stability (P 0.01). Applicants scored higher on openness when compared with surgical residents (P 0.01). Male applicants scored higher on emotional stability than females (P = 0.026). Matched applicants scored higher for conscientiousness than unmatched applicants (P = 0.016).Pediatric Surgery fellowship applicants expressed higher levels of desirable professional traits compared with general surgery residents and community norms. Male applicants demonstrated higher emotional stability than females. Conscientiousness was higher in matching applicants. This first reported experience with personality testing in Pediatric Surgery fellow selection demonstrated potential utility in applicant matching.

Lean Six Sigma (LSS) is a process improvement methodology that utilizes a collaborative team effort to improve performance by systematically identifying root causes of problems. Our objective was to determine whether application of LSS could improve efficiency when applied simultaneously to all services of an academic children's hospital.In our tertiary academic medical center, a multidisciplinary committee was formed, and the entire perioperative process was mapped, using fishbone diagrams, Pareto analysis, and other process improvement tools. Results for Children's Hospital scheduled main operating room (OR) cases were analyzed, where the surgical attending followed themselves.Six hundred twelve cases were included in the seven Children's Hospital operating rooms (OR) over a 6-month period. Turnover Time (interval between patient OR departure and arrival of the subsequent patient) decreased from a median 41min in the baseline period to 32min in the intervention period (p0.0001). Turnaround Time (interval between surgical dressing application and subsequent surgical incision) decreased from a median 81.5min in the baseline period to 71min in the intervention period (p0.0001).These results demonstrate that a coordinated multidisciplinary process improvement redesign can significantly improve efficiency in an academic Children's Hospital without preselecting specific services, removing surgical residents, or incorporating new personnel or technology.Prospective comparative study, Level II.

Purpose The aim was to review the respiratory failure causes and outcomes of infants with omphalocele or gastroschisis receiving ECMO and reported to the Extracorporeal Life Support Organization (ELSO). Methods Gastroschisis and omphalocele infants supported with ECMO and reported to the ELSO Registry between 1992 and 2015 were retrospectively reviewed. Clinical variables, diagnosis of respiratory failure (pulmonary hypertension (PHN), congenital heart defects (CHD), congenital diaphragmatic hernia (CDH), and sepsis), and outcomes were recorded. Univariate analysis was performed using Student's t -test for continuous or Fisher's exact test for categorical variables. Results Fifty-two infants with gastroschisis (41) (79%) or omphalocele (11) (21%) were identified. The survival to discharge rate of 51% for gastroschisis remained stable and was significantly higher ( P =0.05). The overall mortality rate for omphalocele was 82%. Omphalocele had significantly more PHN ( P P P =0.04) had significantly more sepsis ( P =0.02), and none had a CDH. Conclusion Infants with gastroschisis requiring ECMO support have significantly better survival than omphaloceles, and respiratory failure is significantly associated with sepsis. The majority of omphalocele infants die despite ECMO, and respiratory failure is associated PHN and CDH. The association of omphalocele, PHN, and CDH merits further investigation. Study type and evidence level Retrospective comparative study of Registry Database, Level 3.

Patient: Male, newborn Final Diagnosis: Fetiform teratoma Symptoms: Abdomen distension Medication:— Clinical Procedure: Surgical removal Specialty: Pediatrics and Neonatology Objective: Unknown etiology Background: Teratoma, a tumor containing a variety of tissues, is a broad diagnosis containing mature teratoma, immature teratoma, and teratomas with malignant transformation. The tumor forms during embryological development secondary to unsuccessful migration of primordial germ cells. A specific type of mature teratoma, containing human-like features, is called a fetiform teratoma. The fetiform teratoma is often compared and confused with fetus in fetu, a reabsorbed twin. While these tumors have commonly been described in the gonads, the retroperitoneal location finding on antenatal imaging is rare. The distinction between the aforementioned subtypes is not well established, proving a challenging diagnosis prior to resection. Case Report: We present a case of a newborn male with a prenatal diagnosis of retroperitoneal cystic mass. Although prenatal imaging was obtained, the diagnosis remained unclear. After birth, planned surgical excision on day of life 7 showed the suprarenal mass contained contiguous intestinal elements. Histopathology examination revealed a mature cystic teratoma with multiple tissue types, including colonic, brain, respiratory, lymphatics, and nerves, reminiscent of fetiform teratoma. This case report presents an interesting example of differentiating elements straddling the diagnoses mentioned above. Conclusions: This is the first reported case of fetiform teratoma diagnosed in a newborn and is especially unique for having the element of intestinal duplication within the retroperitoneal mass. The differentiating features of fetus in fetu and fetiform teratoma depend on subjective distinctions. The case provides an opportunity to discuss the differentials and management strategies.

The aim was to prospectively document the impact of early

Surgical trainees are expected to demonstrate family-centered care. However, it is unclear if residents know how to address psychosocial issues of pediatric patients and their families. Our aim was to evaluate surgical trainees’ knowledge of family dynamics. Over a six-month period, trainees (n = 16) were surveyed regarding their comfort and familiarity with the psychosocial aspects of patient care and family dynamics. Residents recorded their comfort level with managing various behaviors using a Likert scale, and indicated which family issues they felt least prepared to handle. Most trainees lacked knowledge of family adjustment phases (50%), relational triangles (78%), developmental stages of families (40%), ambiguous loss (75%), ABCX model of family stress (100%), and the SPIKES model (88%). Excluding anxiety and sadness, almost half of residents felt unprepared for dealing with a variety of challenging behaviors. Finally, trainees were least comfortable with breaking bad news. A Family Dynamics curriculum could potentially increase resident management skills and improve patient care.

Aim The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity. Materials and methods Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data. Results Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01). Conclusions Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability. Type of study Prospective study. Level of evidence Level II.

The mind-body connection is receiving increasing scrutiny in a large number of clinical settings, although research has lagged in the pediatric specialties. Psychoneuroimmunology (PNI) is a novel interdisciplinary scientific field that examines the relationship of the mind to the patient's neurologic, endocrine, and immune systems by examining critical parameters such as the effects of mental stress on wound healing and infection rates. Techniques that modify a patient's emotional and mental responses to illness and surgery have positive effects on their physiology resulting in improved recoveries and higher patient satisfaction rates. In the appropriate clinical settings, an awareness of PNI can enhance outcomes for pediatric surgical patients.

The objective of this study was to identify the incidence and factors associated with redo Nissen fundoplication in children.After Institutional Review Board approval (5100277), data for children under 18 years of age from two children's hospitals with fundoplication performed between January 1994 and December 2010 were reviewed. Children with one fundoplication were compared to those with redos to identify factors associated with redo. Variables were compared using t-tests for continuous and chi-square tests for categorical variables. Logistic regression evaluated for independence.There were 823 patients and 54.7% were male. A redo fundoplication was required in 100 (12.2% of cohort); 82 had 1 redo, 14 had 2 redos, and 4 had 3 redos. Follow-up ranged from 0.01 to 16.9 years (median: 2.9 years). Factors associated with redo were: younger age at first fundoplication, (p=0.002), hiatal dissection (p0.001), and male gender (p=0.008). Independent predictors of redo were: hiatal dissection at first fundoplication, OR: 8.45 (95% CI: 2.45-29.11), retching, OR: 3.59 (95% CI: 1.56-8.25) and younger age at first fundoplication, OR: 0.98 (95% CI: 0.97-0.98).The incidence of redo fundoplication in children is 12.2%. The risk of redo is significantly increased if patients are younger, have retching, and if the esophageal hiatus is dissected at the first fundoplication.

Background: Atropine has been used as a successful primary medical treatment for hypertrophic pyloric stenosis. Several authors have reported a higher rate of incomplete pyloromyotomy with the laparoscopic approach compared to open. In this study, we evaluated the use of atropine as a medical treatment for infants with emesis persisting greater than 48 hours after a laparoscopic pyloromyotomy.Materials and Methods: We performed a retrospective chart review of infants receiving a laparoscopic pyloromyotomy between November 1998 and November 2012. Infants with emesis that persisted beyond 48 hours postoperatively were given 0.01mg/kg of oral atropine 10 minutes prior to feeding. Infants remained inpatient until they tolerated two consecutive feedings without emesis.Results: 965 patients underwent laparoscopic pyloromyotomy; 816 (84.6%) male and 149 (15.4%) female. Twenty-four (2.5%) received oral atropine. The mean length of stay for patients who received atropine was 5.6 ± 2.6 days, an average of 3 additional days. They were discharged home with a one-month supply of oral atropine. Follow up evaluation did not reveal any complications from receiving atropine. The median follow up was 21 days. None returned to the operating room for incomplete pyloromyotomy. There were 17 (1.8%) operative complications in our series; 9 mucosal perforations, 2 duodenal perforations, and 6 conversions to open for equipment failure or poor exposure. There were 4 (0.4%) post-operative complications: 2 episodes of apnea requiring reintubation and 2 incisional hernias that required a second operation. There were no deaths.Conclusion: Oral atropine is a viable treatment for persistent emesis after a pyloromyotomy and reduces the need for a second operation due to incomplete pyloromyotomy.

Neonates exposed to common neonatal intensive care unit (NICU) procedures show alterations in heart rate, blood pressure, and oxygen saturation. However, it is unclear if these physiologic changes increase adenosine triphosphate (ATP) utilization, thus potentially increasing the risk for tissue hypoxia in medically fragile neonates. Plasma uric acid is a commonly used marker of increased ATP utilization because uric acid levels increase when ATP consumption is enhanced. To examine the effect of a common NICU procedure on plasma uric acid concentration, we developed a model that allows for acute monitoring of this biochemical marker in plasma in 7- to 9-day-old rabbits. In our pilot study, we exposed neonatal rabbits to a single heel lance 2.5 hr after catheter placement. We measured uric acid concentration before and 30 min after the heel lance and compared findings to levels in control animals not exposed to the heel lance. Our pilot data shows a significant difference in uric acid concentration over time between the control and heel lance groups (46.2 ± 7.1 μM vs. 54.7 ± 5.8 μM, respectively, p = .027). Calculation of percentage change from baseline showed uric acid concentration increasing in rabbits exposed to heel lance and decreasing in control rabbits (1.5 ± 4.7% vs. —16.1 ± 4.2%, respectively, p = .03). These data suggest that this animal model can be successfully used to examine the biochemical effect of common NICU procedures, such as heel lance, on markers of ATP breakdown and purine metabolism.

Purpose The purpose of this article was to identify factors associated with mortality after Nissen fundoplication in children. Methods After Institutional Review Board approval, children younger than 18 years, from two children's hospitals, with Nissen fundoplication performed between January 1994 and December 2010, were retrospectively reviewed. Inclusion required complete data and follow-up to October 2011. Survivors and nonsurvivors were compared, using t-tests for continuous and chi-square tests for categorical variables, to identify factors associated with mortality. Patient factors present before the first fundoplication were analyzed. Surgical factors were surgical complications, gastrostomy placement, operative technique, and redos. Logistic regression evaluated for independence of variables. Results A total of 823 children were identified, 412 were included and 63 died (15.3%). The median follow-up time for the cohort was 3.7 years (mean, 4.5 ± 3.2 years). For nonsurvivors, the median time to death after fundoplication was 6.0 months (mean, 13.2 ± 18.0 months). Significant factors after univariate analysis were surgical complications (p = 0.001), female gender (p = 0.001), neurological impairment (p = 0.010), and fundoplication performed before the age of 18 months (p = 0.035). Independent predictors were surgical complications, odds ratio (OR), 3.30 (95% confidence interval [CI], 1.31–8.29), neurological impairment, OR, 2.58 (95% CI, 1.38–4.83), fundoplication before the age of 18 months, OR, 2.46 (95% CI, 1.23–4.94), and female gender, OR, 2.25 (95% CI, 1.26–4.00). Conclusion After Nissen fundoplication in children, surgical complications, neurological impairment, fundoplication performed before the age of 18 months, and female gender are associated with mortality. The median time to death for nonsurvivors was 6 months.