Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee.

INTRODUCTION: The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations. METHODS: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS: The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management. CONCLUSIONS: Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy. LEVEL OF EVIDENCE: Level 3-4. TYPE OF STUDY: Systematic Review of Level 3-4 Studies.

Screening and Prophylaxis for Venous Thromboembolism in Pediatric Surgery: A Systematic Review.

OBJECTIVE: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis. METHODS: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature. RESULTS: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin. CONCLUSIONS: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations. TYPE OF STUDY: Systematic Review of level 2-4 studies. LEVEL OF EVIDENCE: Level 3-4.

Prenatal presentation of a hyperfunctioning thyroid nodule.

OBJECTIVES: Fetal and neonatal hyperthyroidism are most commonly seen in patients whose mothers have Graves' disease. Rarely, it can be caused by non-autoimmune conditions. As these conditions are rare, the workup and treatment is not uniform and can lead to persistent symptoms and long-term negative health effects. CASE PRESENTATION: This report describes a patient with congenital hyperthyroidism from a toxic adenoma presenting with fetal tachycardia. The patient was initially managed medically after birth, but was eventually treated with thyroidectomy. CONCLUSIONS: This case report highlights an additional, important, differential diagnosis for fetal hyperthyroidism when maternal Graves' disease has been ruled out.

Practice Patterns in the Operative Management of Pediatric Thyroid Disease Across Surgical Specializations.

BACKGROUND: Multiple surgical specializations are involved in the operative management of pediatric thyroid disease, but current practice patterns remain unknown. The objective of this study was to examine current practice patterns in the operative management of pediatric thyroid disease, specifically comparing practices across different surgical specializations including pediatric surgery, pediatric otolaryngology, general surgery, adult otolaryngology, and endocrine-focused general surgery. METHODS: Children 0-18 years-old undergoing thyroid surgery from 2015 to 2019 were identified using the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases across 6 states. Surgeon specialization was determined for all included surgeons. Patient and hospital characteristics were compared across surgical specializations. Clinical outcomes including hypocalcemia/hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, and wound infection were assessed. RESULTS: A total of 1241 pediatric thyroidectomies performed by 363 surgeons were included. Procedures were most frequently performed by pediatric surgeons (34.9%). Only 7.2% of procedures were performed by adult general surgeons. There were statistically significant differences in patient age, sociodemographics, surgical indications, and type of procedure performed between specializations (p < 0.05). Endocrine-focused general surgeons had the highest average annual thyroid procedure volume with 78.2 cases/year, and pediatric surgeons and pediatric otolaryngologists had the lowest volumes with 0.7 and 0.6 cases/year, respectively. Overall complication rates were low. CONCLUSIONS: Operative management of pediatric thyroid disease was most frequently performed by pediatric surgery. Pediatric specializations are more likely to operate on low-income, minority children with public insurance and patients with Graves' disease. Overall complications were low. LEVEL OF EVIDENCE: III.

Pediatric surgery milestones 2.0: A primer.

More than twenty years ago, the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties began the conversion of graduate medical education from a structure- and process-based model to a competency-based framework. The educational outcomes assessment tool, known as the Milestones, was introduced in 2013 for seven specialties and by 2015 for the remaining specialties, including pediatric surgery. Designed to be an iterative process with improvements over time based on feedback and evidence-based literature, the Milestones started the evolution from 1.0 to 2.0 in 2016. The formation of Pediatric Surgery Milestones 2.0 began in 2019 and was finalized in 2021 for implementation in the 2022-2023 academic year. Milestones 2.0 are fewer in number and are stated in more straightforward language. It incorporated the harmonized milestones, subcompetencies for non-patient care and non-medical knowledge that are consistent across all medical and surgical specialties. There is a new Supplemental Guide that lists examples, references and links to other assessment tools and resources for each subcompetency. Milestones 2.0 represents a continuous process of feedback, literature review and revision with goals of improving patient care and maintaining public trust in graduate medical education's ability to self-regulate. LEVEL OF EVIDENCE: V.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Design and Evaluation of Haptic Constraints for Laparoscopic Instrument Handling.

Learning and mastering laparoscopic skills is an involved and complicated process, especially in the case of pediatric surgery due to extremely fragile tissues and small spaces. Given these constraints, precise, controlled, and gentle laparoscopic tool motions are essential. Proper handling and ergonomics of laparoscopic tool handling are often overlooked when training novice surgeons. Novice surgeons tend to overgrip the tool, which may lead to applying excessive amounts of force and potential surgical complications. We have developed two constraint mechanisms to enable proper tool handling: one mechanism is a passive kinematic constraint which physically prevents the user from over-gripping the tool. The second mechanism operates under dynamic resistive control. An elastic silicone membrane, secured by a hard plastic clip to the finger loop of the laparoscopic tool, actively resists the user's overgrip. These constraint devices were tested in a series of human subject studies with novice learners. The resulting data shows a both a significant reduction in over-grip and overall task completion time when using the passive constraint. The left index, right middle, and right ring fingers are shown to have the least amount of over-grip, as well as the lowest time of non-contact with the tool, indicating the importance of these fingers for laparoscopic tool control.

Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease.

OBJECTIVE: To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications. BACKGROUND: H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications. METHODS: A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary children's hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed. RESULTS: We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation. CONCLUSIONS: There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered. THE LEVEL OF EVIDENCE RATING: Level IV.

The impact of goal setting and goal orientation on performance during a clerkship surgical skills training program.

BACKGROUND: The purpose of this study was to integrate relevant goal-setting theory and to identify if trainees' goal orientations have an impact on the assigned goals-performance relationship. METHODS: Trainees attended 1 of the 3 goal-training activities (do your best, performance, or learning goals) for knot tying (KT) and camera navigation (CN) during the 3rd-year clerkship rotation. Questionnaires and pretests and/or post-tests were completed. RESULTS: One twenty-seven 3rd-year medical students (age: 25 ± 2.6; 54% women) participated in the training program. Pretraining to post-training performance changes were significant for all groups on both tasks (P < .01), but the increase was significantly greater (P < .01) for the learning goals group (do your best: KTΔ = 2.14, CNΔ = 1.69; performance: KTΔ = 2.49, CNΔ = 2.24; learning: KTΔ = 3.04 CNΔ = 2.76). Correlations between goal orientations and improvement were examined, revealing a unique role of goal orientation for performance improvement. CONCLUSIONS: These data indicate that consideration of goal type and trainee goal orientation must be considered during curriculum development to maximize educational value.