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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Global Health Challenges: Why the Four S's Are Not Enough. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121867. [PMID: 36553311 PMCID: PMC9777240 DOI: 10.3390/children9121867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/22/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022]
Abstract
A well-known tenant of global health is the need for the four-S's to be successful in providing care in any context; Staff, Stuff, Space and Systems. Advanced thoracoscopy is slow to gain traction in low- and middle-income countries (LMICs). To our knowledge, no pediatric advanced thoracoscopy had been attempted previously in either LMIC. Therefore, we report the challenges associated with the adoption of the first advanced thoracoscopic procedures in two LMIC hospitals by a visiting surgeon. To further identify aspects of care in promoting the introduction of advanced thoracoscopy, we added a fifth S as an additional category-Socialization. A key to accomplishing goals for the patients as a visiting surgeon, particularly when introducing an advanced procedure, is acceptance into the culture of a hospital. Despite facing significant obstacles in caring for complex thoracic pathology with heavy reliance on disposable and reusable instrumentation provided through donation and limitations in staff such as access to neonatologists and pediatric surgeons, many obstacles have been overcome. In this perspective article, we show that a "fifth S" is also integral-having local surgeons and anesthesiologists eager to learn with acceptance of the visiting surgeon's expertise opens a path towards attempting advanced procedures in limited-resource settings.
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Menzenbach J, Layer YC, Layer YL, Mayr A, Coburn M, Wittmann M, Hilbert T. The level of postoperative care influences mortality prediction by the POSPOM score: A retrospective cohort analysis. PLoS One 2021; 16:e0257829. [PMID: 34587207 PMCID: PMC8480745 DOI: 10.1371/journal.pone.0257829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 09/11/2021] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND The Preoperative Score to Predict Postoperative Mortality (POSPOM) assesses the patients' individual risk for postsurgical intrahospital death based on preoperative parameters. We hypothesized that mortality predicted by the POSPOM varies depending on the level of postoperative care. METHODS All patients age over 18 years undergoing inpatient surgery or interventions involving anesthesia at a German university hospital between January 2006, and December 2017, were assessed for eligibility for this retrospective study. Endpoint was death in hospital following surgery. Adaptation of the POSPOM to the German coding system was performed as previously described. The whole cohort was divided according to the level of postoperative care (normal ward vs. intensive care unit (ICU) admission within 24 h vs. later than 24 h, respectively). RESULTS 199,258 patients were finally included. Observed intrahospital mortality was 2.0% (4,053 deaths). 9.6% of patients were transferred to ICU following surgery, and mortality of those patients was increased already at low POSPOM values of 15. 17,165 patients were admitted to ICU within 24 h, and these patients were older, had more comorbidities, or underwent more invasive surgery, reflected by a higher median POSPOM score compared to the normal-ward group (29 vs. 17, p <0.001). Mortality in that cohort was significantly increased to 8.7% (p <0.001). 2,043 patients were admitted to ICU later than 24 h following surgery (therefore denoted unscheduled admission), and the median POSPOM value of that group was 23. Observed mortality in this cohort was highest (13.5%, p <0.001 vs. ICU admission <24 h cohort). CONCLUSION Increased mortality in patients transferred to high-care wards reflects the significance of, e.g., intra- or early postoperative events for the patients' outcome. Therefore, scoring systems considering only preoperative variables such as the POSPOM reveal limitations to predict the individual benefit of postoperative ICU admission.
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Affiliation(s)
- Jan Menzenbach
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yannik C Layer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Yonah L Layer
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Andreas Mayr
- Institute of Medical Biometrics, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Mark Coburn
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Maria Wittmann
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
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Laparoscopic Splenectomy: Has It Become the Standard Surgical Approach in Pediatric Patients? J Surg Res 2019; 240:109-114. [PMID: 30925411 DOI: 10.1016/j.jss.2019.02.045] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/05/2019] [Accepted: 02/22/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Splenectomy is often required in the pediatric population as part of the treatment of hematologic disorders and can be performed laparoscopically or open. We evaluated the comparative effectiveness of laparoscopic (LS) and open (OS) splenectomies using the American College of Surgeons National Surgical Quality Improvement Program Pediatric (NSQIP-P) data set. METHODS The NSQIP-P data set was used to identify children who underwent elective splenectomy between January 2012 and December 2016. Thirty-day outcomes between OS and LS, and LS alone and concurrent LS and cholecystectomy were compared using univariate and multivariate analysis. RESULTS Most of the splenectomies (91%) were performed laparoscopically. There was no difference in overall complications between OS (n = 60) and LS (n = 613), although OS had a higher risk of perioperative transfusion (OR 3.19, 95% CI 1.52-6.69). LS was associated with a shorter median hospital length of stay (2 versus 4 d, P < 0.001) and similar mean operative times compared to OS (120 versus 133 min, P = 0.559). There was no difference in outcomes of children undergoing LS versus LS and concurrent cholecystectomy (n = 129). CONCLUSIONS LS has become the standard approach for elective splenectomies in the pediatric population and has minimal morbidity, and when indicated, concurrent cholecystectomies do not increase the risk of complications. LEVELS OF EVIDENCE III.
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Criss CN, Ralls MW, Johnson KN, Awtar S, Jarboe MD, Geiger JD. A Novel Intuitively Controlled Articulating Instrument for Reoperative Foregut Surgery: A Case Report. J Laparoendosc Adv Surg Tech A 2017; 27:983-986. [PMID: 28727949 DOI: 10.1089/lap.2017.0107] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The field of laparoscopic surgery has continued to grow exponentially over the years, prompting new innovative technologies. Despite substantial advancements, standard laparoscopic tools have undergone little design changes and fail to optimize mobility in limited spaces. Advancements in robotics have attempted to address this, allowing for increasing degrees of freedom and articulation of instruments. Even so, this system has proven to be cumbersome with questionable cost-effectiveness. In this study, we present the first use of a solely mechanical intuitively controlled articulating laparoscopic needle driver. The ability to naturally articulate allowed for ease during suturing and knot tying during the critical portions of the operation. The FlexDex surgical instrument demonstrates promise in the field of foregut surgery in addition to other areas of minimally invasive specialties.
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Affiliation(s)
- Cory N Criss
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
| | - Matthew W Ralls
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
| | - Kevin N Johnson
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
| | - Shorya Awtar
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
| | - Marcus D Jarboe
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
| | - James D Geiger
- Section of Pediatric Surgery, C.S. Mott Children's Hospital , Ann Arbor, Michigan
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Sattarova V, Eaton S, Hall NJ, Lapidus-Krol E, Zani A, Pierro A. Laparoscopy in pediatric surgery: Implementation in Canada and supporting evidence. J Pediatr Surg 2016; 51:822-7. [PMID: 26944184 DOI: 10.1016/j.jpedsurg.2016.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 02/07/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to assess the diffusion of laparoscopy usage in Canadian pediatric centers and the relationship between uptake of laparoscopic surgery and the level of evidence supporting its use. METHODS National data on four pediatric laparoscopic operations (appendectomy, pyloromyotomy, cholecystectomy, splenectomy) were analyzed using the Canadian Institute for Health Information Discharge Database (2002-2013). The highest level of evidence to support the use of each procedure was identified from Cochrane, Embase, and Pubmed databases. Chi-square test for trend was used to determine significance and time to plateau. RESULTS There were 28,843 operations (open: 12,048; laparoscopic: 16,795). Use of laparoscopic procedures increased over time (p<0.0001). A plateau was reached for cholecystectomy (2006), splenectomy (2007), and appendectomy (2012), but not for pyloromyotomy. Laparoscopic pyloromyotomy in 2013 remains less diffused than the other procedures (p<0.0001). Laparoscopic appendectomy and pyloromyotomy are supported by level-1a evidence in children, whereas cholecystectomy and splenectomy are supported by level-1a evidence in adults but level-3 in children. CONCLUSIONS In Canada, it has taken a long time to reach high-level implementation of laparoscopic surgery in children. Laparoscopic cholecystectomy first reached plateau, whereas laparoscopic pyloromyotomy continues to increase but remains low despite high level of evidence in support of its usage compared to open surgery.
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Affiliation(s)
- Victoria Sattarova
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Simon Eaton
- UCL Institute of Child Health, London, United Kingdom
| | - Nigel J Hall
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Eveline Lapidus-Krol
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Augusto Zani
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.
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Jackson HT, Shah SR, Hathaway E, Nadler EP, Amdur RL, McGue S, Kane TD. Evaluating the impact of a minimally invasive pediatric surgeon on hospital practice: comparison of two children’s hospitals. Surg Endosc 2015; 30:2281-7. [DOI: 10.1007/s00464-015-4227-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 02/21/2015] [Indexed: 02/07/2023]
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Acker SN, Garcia AJ, Ross JT, Somme S. Current trends in the diagnosis and treatment of pyloric stenosis. Pediatr Surg Int 2015; 31:363-6. [PMID: 25672283 DOI: 10.1007/s00383-015-3682-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2015] [Indexed: 12/27/2022]
Abstract
AIM We hypothesized that recent trends towards earlier diagnosis of hypertrophic pyloric stenosis continued throughout the early part of the 21st century. METHODS We reviewed the medical records of patients with HPS at a single institution during two periods: 1/03-12/05 and 4/09-7/13. RESULTS A total of 433 patients with hypertrophic pyloric stenosis who underwent pyloromyotomy were included (modern cohort = 259; historic = 174). The two cohorts did not differ in terms of age, weight, or median time from symptom onset to physician (5 vs 6.5 days; p = 0.3) or surgeon (7 days for both) evaluation. The percentage of patients who presented late (>7 days of symptoms) (27 % modern vs 25 % historic; p = 0.15) or with an elevated serum bicarbonate (22 % for both; p = 0.8) did not change over time. There was a shift to laparoscopic procedures: 99 % modern vs 57 % historic (p < 0.0001) with no associated change in operative length (28 vs. 27 min; p = 0.06), or operative (3 % for both, p = 0.8) or respiratory (4 vs 2 %, p = 0.4) complications. CONCLUSION Most infants with hypertrophic pyloric stenosis are diagnosed early, prior to significant electrolyte abnormalities; however, continued improvement in awareness is necessary given that a fourth of patients are diagnosed after over 1 week of symptoms.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, 12631 E 17th Ave, C302, Aurora, CO, 80045, USA,
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