Laparoscopic pyloromyotomy can be performed safely by senior pediatric surgery trainees without supervision at high volume centers.

AIM OF THE STUDY: Pediatric surgery trainees at our institution perform 15 to 20 supervised laparoscopic pyloromyotomies during their junior year, and are allowed to perform the operation independently without supervision during their senior year. We reviewed the outcomes of laparoscopic pyloromyotomies performed by senior trainees operating without supervision and compared them to experienced pediatric surgeons. METHOD: We did a retrospective reviewed of all unsupervised laparoscopic pyloromyotomies (n = 90) performed by the last 12 pediatric surgery fellows (2012-2018) during their senior year, and the most recent 90 consecutive laparoscopic pyloromyotomies performed by 9 experienced pediatric surgeons. Statistical significance was determined by T-test and Fisher's exact test. Data is expressed as mean (SD) or median (range). A p value of ≤0.05 was considered significant. RESULTS: Mean age at surgery was 4.7 (SD: 1.6) and 5 (SD: 2.3) weeks in the trainees and surgeons group, respectively (p = 0.38). Mean operative time was 28 (SD: 13) minutes in the trainees group vs. 25 (SD: 10) minutes in the surgeons group (p = 0.09). Intraoperative complications occurred in 3 of 90 (2.7%) cases in the trainees group (three mucosal perforations, all detected during the operation, one repaired laparoscopically, two repaired open), and none in the surgeons group (p = 0.11). One postoperative complication requiring reoperation occurred in the trainees group (omentum eviscerated through an incision site), while none occurred in the surgeons group (p = 0.36). No incomplete pyloromyotomies occurred in either group. The median length of postoperative hospital stay was 1 (1 to 10) and 1 (1 to 6) days in the trainees and surgeons group, respectively (p = 0.63). CONCLUSION: Senior trainees at high-volume training programs can perform unsupervised laparoscopic pyloromyotomies safely as a mean to promote surgical autonomy without compromising patient outcomes. LEVEL OF EVIDENCE: III.

Laparoscopic appendectomy - Outcomes of senior trainees operating without supervision versus experienced pediatric surgeons.

AIM OF THE STUDY: Pediatric surgery trainees at our program are allowed to perform unsupervised laparoscopic appendectomies during their last year of training to promote independent operative decision-making skills. We reviewed the outcomes of laparoscopic appendectomies done by senior trainees without supervision and compared them to experienced pediatric surgeons. METHODS: We reviewed 500 laparoscopic appendectomies performed without supervision by the last 10 pediatric surgery trainees during their last year of training (first 50 cases of each trainee). We compared the outcomes of those 500 cases to the outcomes of 200 laparoscopic appendectomies performed by eight experienced pediatric surgeons (last 25 cases of each surgeon). Data are expressed as mean (SD), unless otherwise indicated. A P value of ≤0.05 was regarded as significant. MAIN RESULTS: Median age in the "trainees" and "surgeons" groups was 11 (range 2-22) and 12 (2-20) years, respectively (P = 0.35). The proportion of perforated appendicitis was similar: 98/500 (19.6%) in the trainees group and 42/200 (21%) in the surgeons group, respectively (P = 0.75). Mean operative time was 41 (SD 14.5) min in the trainees group vs. 39 (SD 16.1) min in the surgeons group (P = 0.05). Minor intraoperative complications occurred in 3/500 (0.6%) cases in the trainees group vs. 1/200 (0.5%) in the surgeons group (P = 0.69). No major complications occurred in either group. Mean hospital stay was 2 (range 0.5-26) and 2.3 (range 0.5-18) days in the trainees and surgeons groups, respectively (P = 0.25). There were 13/500 vs. 5/200 readmissions (P = 0.92), and 1/500 vs. 1/200 reoperations in the trainees and surgeons groups, respectively (P = 0.91). CONCLUSION: Allowing senior pediatric surgery trainees to perform laparoscopic appendectomies without supervision to stimulate surgical autonomy is safe and does not compromise patient outcomes. LEVEL OF EVIDENCE: III.

Surgical outcomes of pancreaticoduodenal injuries in children.

PURPOSE: To examine surgical outcomes of children with pancreaticoduodenal injuries at a Quaternary Level I pediatric trauma center. METHODS: We queried a prospectively maintained trauma database of a level one pediatric trauma center for all cases of pancreatic and/or duodenal injury from 2002 to 2017. Analysis was conducted using JMP 13.1.0. RESULTS: 170 children presented with pancreatic and/or duodenal injury. 13 (7.7%) suffered a combined injury and this group forms the basis for this report with mean ISS of 22.8 (± 15.1), RTS2 of 6.4(± 2.1), and median age of 6.6 (1.3-13.5) years. Child abuse (31%) and bicycle injuries (23%) were the most common mechanisms. 8/13 (61.5%) required operative intervention. Higher AAST pancreatic and duodenal injury grade (2.9 vs. 1.2, p = 0.05 and 3.6 vs. 1.4, p = < 0.01), lower RTS2 (7.84 vs. 5.49, p < 0.01), and lower GCS (9.6 vs. 15, p = 0.03) predicted operative intervention. 6/8 (75%) undergoing surgery survived to discharge with only (2/6) survivors suffering postoperative complications. Both mortalities were secondary to severe traumatic brain injury. CONCLUSION: Surgical management of complex pancreaticoduodenal injury is an uncommon traumatic event that is associated with high injury severity, but survival occurs in most scenarios.