Factors Associated with Non-Completion of a Pediatric Metabolic and Bariatric Surgery Program.

BACKGROUND: Childhood obesity is a devastating disease process disproportionately affecting minority and low-income populations. Though bariatric surgery leads to durable weight loss and reversal of multiple obesity-related comorbidities, only a small fraction of pediatric patients undergoes the procedure. We sought to identify factors associated with non-completion in a pediatric bariatric surgery program. METHODS: Retrospective review of consecutive patients ≤18-years-old referred to an academic adolescent bariatric surgery program between 2017 and 2022 (n = 20 completers, 40 non-completers) was completed. Demographics and medical and psychosocial histories were summarized by completion status. RESULTS: Of the 33% (20/60; 85% female, 30% racial minorities) who successfully completed the program, the median age was 16 years [IQR 16, 17]. The median age of non-completers was 16 years [IQR 15, 17] (55% female, 56% racial minorities). Non-completion was associated with male gender (15% of completers vs 45% of non-completers, p = 0.022), neighborhood income <150% poverty level (0 completers vs 17.5% of non-completers, p = 0.047), and presence of environmental or family stressors (22% of completers vs 65% of non-completers, p = 0.008). Though not statistically significant, non-completers tended to be racial minorities (p = 0.054). CONCLUSIONS: Non-completion of the bariatric surgery pathway was more prevalent among male patients from lower-income neighborhoods with significant environmental or family stressors. These patients also tended to be racial and ethnic minorities. The findings underscore the need for further investigation into barriers to pediatric bariatric surgery. LEVEL OF EVIDENCE: Level III.

Surgery for chronic idiopathic constipation: pediatric and adult patients - a systematic review.

BACKGROUND: Chronic idiopathic constipation (CIC) is a substantial problem in pediatric and adult patients with similar symptoms and workup; however, surgical management of these populations differs. We systematically reviewed the trends and outcomes in the surgical management of CIC in pediatric and adult populations. METHODS: A literature search was performed using Ovid MEDLINE, Embase, Scopus, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov between January 1, 1995 and June 26, 2020. Clinical trials and retrospective and prospective studies of patients of any age with a diagnosis of CIC with data of at least 1 outcome of interest were selected. The interventions included surgical resection for constipation or antegrade continence enema (ACE) procedures. The outcome measures included bowel movement frequency, abdominal pain, laxative use, satisfaction, complications, and reinterventions. RESULTS: Adult patients were most likely to undergo resection (94%), whereas pediatric patients were more likely to undergo ACE procedures (96%) as their primary surgery. Both ACE procedures and resections were noted to improve symptoms of CIC; however, ACE procedures were associated with higher complication and reintervention rates. CONCLUSION: Surgical management of CIC in pediatric and adult patients differs with pediatric patients receiving ACE procedures and adults undergoing resections. The evaluation of resections and long-term ACE data in pediatric patients should be performed to inform patients and physicians whether an ACE is an appropriate procedure despite high complication and reintervention rates or whether resections should be considered as an initial approach for CIC.

Human serous cavity macrophages and dendritic cells possess counterparts in the mouse with a distinct distribution between species.

In mouse peritoneal and other serous cavities, the transcription factor GATA6 drives the identity of the major cavity resident population of macrophages, with a smaller subset of cavity-resident macrophages dependent on the transcription factor IRF4. Here we showed that GATA6+ macrophages in the human peritoneum were rare, regardless of age. Instead, more human peritoneal macrophages aligned with mouse CD206+ LYVE1+ cavity macrophages that represent a differentiation stage just preceding expression of GATA6. A low abundance of CD206+ macrophages was retained in C57BL/6J mice fed a high-fat diet and in wild-captured mice, suggesting that differences between serous cavity-resident macrophages in humans and mice were not environmental. IRF4-dependent mouse serous cavity macrophages aligned closely with human CD1c+CD14+CD64+ peritoneal cells, which, in turn, resembled human peritoneal CD1c+CD14-CD64- cDC2. Thus, major populations of serous cavity-resident mononuclear phagocytes in humans and mice shared common features, but the proportions of different macrophage differentiation stages greatly differ between the two species, and dendritic cell (DC2)-like cells were especially prominent in humans.

Medical student preparation for the operating room.

BACKGROUND: This study examines student perceptions of preparedness for the operating room (OR), resources used, and time spent in preparation. METHODS: Third-year medical and second-year physician assistant students across two campuses at a single academic institution were surveyed to assess perceptions of preparedness, time spent in preparation, resources used, and perceived benefits of preparation. RESULTS: 95 responses (response rate 49%) were received. Students reported being most prepared to discuss operative indications and contraindications (73%), anatomy (86%), and complications (70%), but few felt prepared to discuss operative steps (31%). Students spent a mean of 28 min preparing per case, citing UpToDate and online videos as the most used resources (74%; 73%). On secondary analysis, only the use of an anatomic atlas was weakly correlated with improved preparedness to discuss relevant anatomy (p = 0.005); time spent, number of resources or other specific resources were not associated with increased preparedness. CONCLUSION: Students felt prepared for the OR, though there is room for improvement and a need for student-oriented preparatory materials. Understanding the deficits in preparation, preference for technology-based resources, and time constraints of current students can be used to inform optimisation for medical student education and resources to prepare for operating room cases.

National Trends in Pediatric Metabolic and Bariatric Surgery: 2010-2017.

BACKGROUND: The childhood obesity epidemic has grown exponentially and is known to disproportionately affect minority groups. Successful treatment of this complex health issue requires a multidisciplinary approach including metabolic and bariatric surgery (MBS) for qualifying pediatric patients. This study examines current national trends in pediatric bariatric surgery from 2010 to 2017 using the National Inpatient Sample. METHODS: This study analyzed MBS among pediatric patients <19 years old using weighted discharge data from 2010 to 2017. The primary outcome was national procedure rates. Secondary analyses included procedure type, demographics, BMI, comorbidities, length of stay, and complication rates. RESULTS: From 2010 to 2017, annual bariatric procedure rates increased from 2.29 to 4.62 per 100 000 (P < .001). Laparoscopic sleeve gastrectomy outpaced Roux-en-Y gastric bypass and laparoscopic adjustable gastric band over time (0.31-3.99 per 100 000, P < .0001). The mean age was stable over time 18.10-17.96 (P = .78). The cohort was primarily female (76.5% to 75.4%), white (54.0% to 45.0%), and privately-insured (59.9% to 53.4%). Preoperative BMI increased from 2010 to 2017 (P < .001), whereas number of obesity-related comorbidities was stable (P > .05). Length of stay was <2 days (2.02-1.75, P = .04) and in-hospital complication rates were low (7.2% to 6.45%, P = .88). CONCLUSIONS: Pediatric MBS is underutilized nationally with disproportionately lower rates among minority groups. Despite incremental progress, further investigation into the racial and social determinants that limit access to pediatric weight loss surgery is critical.

Ethical Issues Related to the COVID-19 Pandemic That Have Influenced Pediatric Surgery.

The response of the health care system to pediatric surgical patients has been dramatically altered by the coronavirus disease 2019 pandemic. Such changes have affected children, families, and the clinicians who care for them. In this review, we highlight some of the ethical issues faced by pediatric surgical patients and pediatric surgeons during the coronavirus disease 2019 pandemic, including the transition to public health ethics, scarcity of resources, exacerbation of disparities, moral distress for pediatric surgeons, and shifting reliance on telemedicine and other remote means of communication. We discuss how these issues have prompted both favorable and unfavorable changes to the surgical care of children and consider which changes may have a lasting effect on pediatric surgery. [Pediatr Ann. 2022;51(8):e306-e310.].

The ethics of informed consent and shared decision-making in pediatric surgery.

Informed consent is a required feature in the practice of pediatric surgery. Surgeons cannot practice the trade without it and most of us learned to do it as part of our "apprenticeship" in surgical training. We were bystanders when the senior resident or attending spoke to the patient and family and we were silent witnesses to the signing of the document called a "consent." Intentional instruction about informed consent is rudimentary in most residencies. By the time we become surgical fellows, it is assumed that we have the requisite skill set to perform this "task" so we can get on with what we like to do best; operating. For many, it is viewed as a perfunctory step which, if done properly, will comply with hospital policies, might someday be exhibited during medical litigation, and ultimately it will occupy a tiny bit of memory in the hospital EMR system. However, this "thing" called the informed consent is much more than an item on a pre-op check list. The re-branding of the term "informed consent" into "shared decision-making" underscores the "re-evolution" that has occurred in thought and practice from the act of obtaining an individual's permission for treatment toward the process leading up to that act.1 It reflects some of our most important ethical values in healthcare and is still the source of scholarly inquiry and controversy. In this paper, the terms "informed consent" and "shared decision-making" will be used interchangeably but the intention is focused on the process of how physicians and their patients make choices together. If you have not thought about this topic recently, I encourage you to take a moment and explore some of the interesting and challenging questions which are still unanswered. Although the ethical principles underlying informed consent are shared by adult and pediatric medicine, there are many aspects which are unique to the medical care of children. This article highlights some of those challenges and controversies illustrated by two case studies and viewed through the lens of bioethics.

Ethics and multiculturalism in pediatric surgery.

The concept of culture includes many defining characteristics such race, ethnicity, gender, identity, socioeconomic status, beliefs, traditions, and habits. Multiculturalism is a concept that allows for respect, understanding and acknowledgement of a diversity of identities. The cases discussed in this manuscript indicate the importance of multiculturalism in the practice of pediatric surgery.

Video-assisted Thoracoscopic Resection of a Congenital Tracheobiliary Fistula in a Neonate: Technical Report and Review of the Literature.

BACKGROUND: Congenital tracheobiliary or bronchobiliary fistulae are rare developmental malformations associated with high morbidity and mortality primarily because of concomitant anomalies as well as delays in diagnosis. TECHNICAL REPORT: We report a case of a neonate who presented with bilious emesis and progressive respiratory failure requiring bronchoscopy and fluoroscopic bronchography for diagnosis with successful management through video-assisted thoracoscopic surgery. We also review the published literature on tracheobiliary fistula. CONCLUSION: Use of video-assisted thoracoscopic surgery for fistula resection has been reported in only one other neonate and provides a clinically less invasive option compared with open surgical ligation and resection. To our knowledge, this is the first English language report of thoracoscopic resection in a neonate with congenital tracheobiliary fistula.

Management and Microbiology of Perforated Appendicitis in Pediatric Patients: A 5-Year Retrospective Study.

INTRODUCTION: This study aims to assess the current epidemiology and microbiology of perforated appendicitis, how antibiotic choice and duration correlate with meaningful clinical outcomes, and whether serial white blood cell (WBC) counts provide clinical value. METHODS: Five-year retrospective cohort study, 2015-2019, among 333 consecutive children, ages 0-18 years, treated at St. Louis Children's Hospital for perforated appendicitis. Main outcomes included length of stay (LOS), postoperative abscess formation, and readmission. Statistical analysis was performed with uni- and multi-variate analyses. RESULTS: Intra-abdominal cultures most commonly grew Bacteroides fragilis (52%) and Escherichia coli (50%). Patients who initially received broad-spectrum antibiotics (meropenem, piperacillin-tazobactam, fourth-generation cephalosporins) for perforated appendicitis had greater rates of postoperative abscess formation (25% vs. 12%, p < 0.01) and LOS (7.0 vs. 5.7 days, p < 0.01). Similarly, antibiotics at time of discharge were associated with greater postoperative abscess formation (22% vs. 9%, p < 0.01) and LOS (6.4 vs. 5.6 days, p = 0.02). However, discharge with strictly oral antibiotics was not correlated with greater LOS, postoperative abscess formation, or readmission rates compared to discharge without antibiotics. Serial WBC counts had no predictive value for LOS, postoperative abscess formation, or readmission. CONCLUSIONS: Bacteroides fragilis and E. coli were the most common intra-abdominal microbes for perforated appendicitis among our cohort. In non-critically ill children, the routine use of broad-spectrum antibiotics or continuation of antibiotics beyond discharge was not correlated with improved clinical outcomes. Additionally, WBC counts were not correlated with meaningful clinical outcomes.

Extended sternotomy with lateral neck incision: An alternative approach for children with large apical chest masses with thoracic inlet involvement.

Pediatric tumors in the apex of the thoracic cavity are often diagnosed late due to the absence of symptoms. These tumors can be quite large at presentation with involvement of the chest wall, sympathetic chain, spine, and aortic arch. The tumors can also extend into the thoracic inlet and encircle the brachial plexus. Depending on the diagnosis, treatment may involve chemotherapy with subsequent surgery or require primary resection. Optimal exposure to resect large apical tumors with thoracic inlet extension is a surgical challenge. To date, several surgical techniques have been described to resect these tumors - including both anterior and posterior thoracic approaches. Each of these techniques can be limited by inadequate exposure of the mass. We describe an alternative approach to surgical resection of these masses that employs an extended sternotomy with a lateral neck incision. This report details two successful resections of large left apical masses with thoracic inlet involvement in children using this technique (Level of evidence 4).

Omental cyst: a case report and review of the literature.

BACKGROUND: Omental cysts are rare, predominantly occur in children, and often initially present with symptoms masquerading as other more common intra-abdominal pathologies. In this case report, we present the case of a child with an omental cyst that originated from the lesser sac. Due to the location of this cyst, resection presented unique technical challenges that have not been described in existing literature. CASE PRESENTATION: A 4-year-old male patient presented with symptoms initially concerning for appendicitis. Ultrasound showed a normal appendix but a large volume of complex intraperitoneal fluid. Computed tomography subsequently demonstrated a large cystic structure spanning from the stomach to the bladder. The patient was taken to the operating room where a large omental cyst was found to originate from the lesser sac. The resection was difficult due to the thin wall of the cyst and the intimate association of the superior-most aspect of the cyst with the tail of the pancreas, but was ultimately successful. CONCLUSIONS: Omental cysts are rarely suspected before detection on abdominal imaging. Surgical resection is the treatment of choice, and complete resection can result in a recurrence-free postoperative course. Laparoscopic resection has been reported, but laparotomy is reasonable when a minimally invasive approach may not allow for a safe resection without rupture of the cyst. Anatomical characteristics of the cyst, as demonstrated in our case, can present challenges in the treatment of this otherwise benign entity.

Fecal microbiota transplant rescues mice from human pathogen mediated sepsis by restoring systemic immunity.

Death due to sepsis remains a persistent threat to critically ill patients confined to the intensive care unit and is characterized by colonization with multi-drug-resistant healthcare-associated pathogens. Here we report that sepsis in mice caused by a defined four-member pathogen community isolated from a patient with lethal sepsis is associated with the systemic suppression of key elements of the host transcriptome required for pathogen clearance and decreased butyrate expression. More specifically, these pathogens directly suppress interferon regulatory factor 3. Fecal microbiota transplant (FMT) reverses the course of otherwise lethal sepsis by enhancing pathogen clearance via the restoration of host immunity in an interferon regulatory factor 3-dependent manner. This protective effect is linked to the expansion of butyrate-producing Bacteroidetes. Taken together these results suggest that fecal microbiota transplantation may be a treatment option in sepsis associated with immunosuppression.