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Anderson C, Duggan B, Colgate C, Bhatia M, Gray B. How far We Go For Surgery: Distance to Pediatric Surgical Care in Indiana. J Pediatr Surg 2024; 59:1444-1449. [PMID: 38582703 DOI: 10.1016/j.jpedsurg.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/26/2024] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
INTRODUCTION Despite increasing numbers of pediatric surgery training programs, access to pediatric surgical care remains limited in non-academic and rural settings. We aimed to characterize demographic and patient factors associated with increased distance to selected pediatric surgical procedures in Indiana. METHODS This IRB-approved retrospective review analyzed pediatric patients undergoing appendectomy, cholecystectomy, umbilical hernia repair, pyloromyotomy, and video assisted thoracic surgery (VATS) procedures from 2019 through 2021. Data was obtained from an electronic medical record warehouse and the Indiana Hospital Association. Travel distance was calculated as driving distance between patient address and hospital ZIP codes. Statistics were performed in R, with p < 0.05 indicating significance. RESULTS There were 6835 operations performed, and half of all operations (46%) were performed at institutions with fellowship-trained pediatric surgeons. The median travel distance for all operations was 13 miles (range 0-182); the shortest was for laparoscopic appendectomy (9 miles, IQR[0-20]). The longest distances were for pyloromyotomy (51 miles, IQR[14-84]) and VATS procedures (57 miles, IQR[13-111]), of which, nearly all were performed at tertiary pediatric care centers (97% and 93%, respectively). There was a significant linear and quadratic effect of age on travel distance (p < 0.001), with younger patients requiring farther travel. On multivariable linear regression, age and procedure type had the largest effect on travel distance (Eta squared 0.03, p < 0.001). CONCLUSION Younger age and more specialized procedures, including VATS and pyloromyotomy, were associated with increased travel distance. This highlights regionalization of these procedures to urban areas with pediatric care centers, while others are performed closer to home. LEVEL OF EVIDENCE III TYPE OF STUDY: Retrospective comparative study.
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Affiliation(s)
- Cassandra Anderson
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, 46202-3082, USA; Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN, 46202, USA.
| | - Ben Duggan
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, 46202-3082, USA
| | - Cameron Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, 410 W 10th Street, HITS, Suite 2000, Indianapolis, IN, 46202, USA
| | - Manisha Bhatia
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, 46202-3082, USA; Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN, 46202, USA
| | - Brian Gray
- Indiana University School of Medicine, 340 West 10th Street, Fairbanks Hall, Suite 6200, Indianapolis, IN, 46202-3082, USA; Section of Pediatric Surgery, Riley Hospital for Children, 705 Riley Hospital Drive RI2500, Indianapolis, IN, 46202, USA
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Eakes AM, Burkbauer L, Purcell LN, Akinkuotu AC, McLean SE, Charles AG, Phillips MR. Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review. Am Surg 2023; 89:3739-3744. [PMID: 37150834 DOI: 10.1177/00031348231173943] [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] [Indexed: 05/09/2023]
Abstract
Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.
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Affiliation(s)
- Ali M Eakes
- School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura Burkbauer
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Laura N Purcell
- Department of Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adesola C Akinkuotu
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sean E McLean
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anthony G Charles
- Department of Surgery, Division of General and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Michael R Phillips
- Department of Surgery, Division of Pediatric Surgery, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Ma W, Gao H, Liu X, Chang M, Jia C, Sun F. An exploration into the application of specialty-orientated CBL pedagogy in undergraduate teaching in pediatric surgery. Front Pediatr 2022; 10:948853. [PMID: 36405829 PMCID: PMC9671942 DOI: 10.3389/fped.2022.948853] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE This study aims to identify whether the specialty-oriented case-based learning (CBL) pedagogy contributes to the teaching of basic theory and practical operation in undergraduate clinical teaching in pediatric surgery, and to assess the satisfaction of undergraduates. METHODS A total of 72 undergraduates in Grade 2016 who interned at Qilu Hospital of Shandong University were enrolled in this study. All these undergraduates voluntarily participated in this experimental study. They were randomly divided into the experimental group (the CBL group, n = 36) and the control group [the traditional lecture-based learning (LBL) group, n = 36] with the assistance of random number tables. In the control group, a traditional pedagogy was adopted and the knowledge in the textbook was explained according to the syllabus. In the experimental group, a specialty-oriented CBL pedagogy was adopted under the guidance of clinical instructors. After the teaching, a comparison was drawn between both groups in respect of the theoretical exam and practical exam scores. In addition, the teaching results were evaluated by a questionnaire survey. RESULTS The average theoretical exam scores and comprehensive scores of undergraduates in the CBL group were higher than those in the LBL group (P < 0.05). There was no significant difference in the practical exam scores between the CBL group and the LBL group (P > 0.05). However, those undergraduates in the CBL group attained higher scores in doctor-patient communication and perioperative diagnosis and treatment (P < 0.05). According to the questionnaire survey, the undergraduates in the CBL group had higher satisfaction than those in the LBL group. Besides, this specialty-oriented CBL pedagogy had higher performance in improving their ability to solve problems independently and cultivating and expanding their knowledge compared with the traditional pedagogy. Meanwhile, this specialty-oriented CBL pedagogy can cultivate the critical thinking of undergraduates, which could increase their learning efficiency and improve their interest in learning. CONCLUSION This specialty-oriented CBL pedagogy could improve the mastery of professional knowledge, course satisfaction, doctor-patient communication ability in clinical practice, and perioperative diagnosis and treatment ability of these undergraduates. Therefore, it is worthwhile to recommend and popularize this pedagogy in undergraduate clinical teaching in pediatric surgery.
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Affiliation(s)
- Wenyue Ma
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Hongjie Gao
- Department of Pediatrics, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xiaoya Liu
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Mengmeng Chang
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Changlin Jia
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, China
| | - Fengyin Sun
- Department of Pediatric Surgery, Qilu Hospital of Shandong University, Jinan, China
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Sogbodjor LA, Singleton G, Davenport M, Walker S, Moonesinghe SR. Quality metrics for emergency abdominal surgery in children: a systematic review. Br J Anaesth 2021; 128:522-534. [PMID: 34895715 DOI: 10.1016/j.bja.2021.10.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/07/2021] [Accepted: 10/13/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND There is variation in care quality and outcomes for children undergoing emergency abdominal surgery, such as appedectomy. Addressing this requires paediatric-specific quality metrics. The aim of this study was to identify perioperative structure and process measures that are associated with improved outcomes for these children. METHODS We performed a systematic review searching MEDLINE, Embase, CINAHL, Cochrane Library, and Google Scholar for articles published between January 1, 1980 and September 29, 2020 about the perioperative care of children undergoing emergency abdominal surgery. We also conducted secondary searching of references and citations, and we included international professional publications. RESULTS We identified and analysed 383 peer-reviewed articles and 18 grey literature publications. High-grade evidence pertaining to the perioperative care of this patient group is limited. Most of the evidence available relates to improving diagnostic accuracy using preoperative blood testing, imaging, and clinical decision tools. Processes associated with clinical outcomes include time lapse between time of presentation or initial assessment and surgery, and the use of particular analgesia and antibiotic protocols. Structural factors identified include hospital and surgeon caseload and the use of perioperative care pathways. CONCLUSIONS This review summarises the structural and process measures associated with outcome in paediatric emergency abdominal surgery. Such measures provide a means of evaluating care and identifying areas of practice that require quality improvement, especially in children with appendicitis. CLINICAL TRIAL REGISTRATION PROSPERO CRD42017055285.
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Affiliation(s)
- Lisa A Sogbodjor
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK; Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK.
| | - Georgina Singleton
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Mark Davenport
- Department of Paediatric Surgery, King's College Hospital, London, UK
| | - Suellen Walker
- Department of Anaesthesia and Pain Medicine, Great Ormond Street Hospital NHS Foundation Trust, London, UK; Clinical Neurosciences, UCL Great Ormond St Institute of Child Health, London, UK
| | - S Ramani Moonesinghe
- Centre for Perioperative Medicine, Research Department for Targeted Intervention, UCL Division of Surgery and Interventional Science, London, UK; UCLH Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College London Hospitals NHS Foundation Trust, London, UK; Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, London, UK
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Oh C, Lee S, Chang HK, Ahn SM, Chae K, Kim S, Kim S, Seo JM. Analysis of Pediatric Surgery Using the National Healthcare Insurance Service Database in Korea: How Many Pediatric Surgeons Do We Need in Korea? J Korean Med Sci 2021; 36:e116. [PMID: 33975393 PMCID: PMC8111040 DOI: 10.3346/jkms.2021.36.e116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 03/25/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND In the past, general surgeons (GSs) without a pediatric surgical subspecialty often performed surgery on children and, even now, GSs are performing many pediatric surgeries. We aimed to investigate the involvement of pediatric surgeons (PSs) and GSs in pediatric surgery, compare the outcomes of surgery in the neonatal intensive care unit (NICU), and estimate the appropriate PS workforce in Korea. METHODS We used surgical data from the National Health Insurance Service database that was collected from patients under the age of 19 years in hospitals nationwide from January 2002 to December 2017. In this database, we found 37 hospitals where PSs worked by using the index operation (congenital diaphragmatic hernia, esophageal atresia, hypertrophic pyloric stenosis, Hirschsprung's disease, abdominal wall defect, jejunoileal atresia, malrotation, anorectal malformation, and biliary atresia). It was assumed that the surgery in the 37 hospitals was performed by PS and that the surgery in other hospitals was performed by GS. Mortality was analyzed to compare the outcomes of acute abdominal surgery in the NICU. We estimated the number of PS currently needed in Korea for each situation under the assumption that PS would perform all operations for the index operation, main pediatric diseases (index operation + gastroesophageal reflux disease, choledochal cyst, inguinal hernia, and appendicitis), acute abdominal surgery in the NICU, and all pediatric surgeries. Additionally, we estimated the appropriate number of PS required for more advanced pediatric surgery in the future. RESULTS The number of pediatric surgeries from 2002 to 2017 increased by 124%. Approximately 10.25% of the total pediatric surgeries were performed by PSs, and the percentage of the surgery performed by PSs increased from 8.32% in 2002 to 15.92% in 2017. The percentage of index operations performed by PSs annually was 62.44% in average. It was only 47.81% in 2002, and increased to 88.79% in 2017. During the last 5 years of the study period, the average annual number of surgeries for main pediatric diseases was approximately 33,228. The ratio of the number of surgeries performed by PS vs. GS steadily increased in main pediatric diseases, however, the ratio of the number of surgery performed by PS for inguinal hernia and appendicitis remained low in the most recent years. The percentage of the number of acute abdominal surgery performed by PS in the NICU was 44% in 2002, but it had recently risen to 89.7%. After 30 days of birth, mortality was significantly lower in all groups that were operated on by PS, rather than GS, during the last 5 years. In 2019, 49 PSs who were under the age of 65 years were actively working in Korea. Assuming that all pediatric surgeries of the patients under the age of 19 years should be performed by PS, the minimum number of PS currently required was about 63 if they perform all of the index operations, the main pediatric surgery was about 209, the NICU operation was about 63, and the all pediatric surgeries was about 366. Additionally, it was determined that approximately 165 to 206 PS will be appropriate for Korea to implement more advanced pediatric surgery in the future. CONCLUSION The proportion of the pediatric surgery performed by PS rather than GS is increasing in Korea, but it is still widely performed by GS. PSs have better operative outcomes for acute abdominal surgery in the NICU than GSs. We believe that at least the index operation or the NICU operation should be performed by PS for better outcome, and that a minimum of 63 PSs are needed in Korea to do so. In addition, approximately 200 PSs will be required in Korea in order to manage main pediatric diseases and to achieve more advanced pediatric surgery in the future.
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Affiliation(s)
- Chaeyoun Oh
- Department of Pediatric Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sanghoon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Kyung Chang
- Department of Pediatric Surgery, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Korea
| | - Soo Min Ahn
- Department of Pediatric Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyunghee Chae
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sujeong Kim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sukil Kim
- Department of Preventive Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Meen Seo
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Rolle U, Fahlenbach C, Heidecke CD, Heller G, Meyer HJ, Schuler E, Waibel B, Jeschke E, Günster C, Maneck M. Rates of Complications After Appendectomy in Children and Adolescents: Pediatric Surgical Compared to General Surgical Hospitals. J Surg Res 2020; 260:467-474. [PMID: 33272597 DOI: 10.1016/j.jss.2020.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 10/08/2020] [Accepted: 11/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Appendectomies in children and adolescents are performed in Germany in pediatric surgical (PS) or general surgical hospitals (GS). The aim of this study is to evaluate whether the surgery in a PS or GS hospital has an influence on the postoperative course after appendectomy in children and adolescents. MATERIALS AND METHODS Nationwide routine data from children and adolescents aged 1-17 y insured by the Local Health Insurance Fund who underwent appendectomy between 2014 and 2016 were analyzed (cohort study). Descriptive statistics were calculated both overall and in the two groups (PS and GS). Patients were additionally examined by age (1-5, 6-12, and 13-17 y), treatment (laparoscopic, open surgical, and conversion), and appendicitis type (nonacute: K36/K37/K38/R10, acute simple: K35.30/K35.8, and acute complex: K35.2/K35.31/K35.32). The influence of surgeon specialization on 90-d secondary surgery and 90-d general complications was assessed by multiple logistic regression. RESULTS Altogether, 25,065 patients who underwent surgery in 83 PS and 906 GS hospitals were included. Logistic regression analysis revealed that PS was associated with a reduced risk of interventions in the 1-5- and 6-12-y age groups (odds ratio: 0.44, 0.62). Acute complex appendicitis, comorbidities, and open surgery significantly increased the risk for reintervention. PS was associated with an increased risk for complications in the 13-17-y age group (odds ratio: 1.66). CONCLUSIONS PS and GS hospitals provided safe appendectomies in children and adolescents with low reintervention and complication rates. PS hospitals demonstrated advantages for patients in the 1-5- and 6-12-y age groups and GS hospitals for patients 13-17 y.
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Affiliation(s)
- Udo Rolle
- Department of Paediatric Surgery and Paediatric Urology, University Hospital, Goethe University, Frankfurt/Main, Germany.
| | | | - Claus-Dieter Heidecke
- Department of General, Visceral, Thoracic and Vascular Surgery, University Medicine Greifswald, Greifswald, Germany
| | - Günther Heller
- Department of Medicine, University Marburg, Marburg, Germany
| | | | - Ekkehard Schuler
- Department of Quality Management, Helios Hospital, Berlin, Germany
| | - Beate Waibel
- Medical Review Board of the Social Health Insurance Funds, Freiburg, Germany
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The Right Child/Right Surgeon initiative: A position statement on pediatric surgical training, sub-specialization, and continuous certification from the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:2566-2574. [PMID: 32950245 PMCID: PMC7423589 DOI: 10.1016/j.jpedsurg.2020.08.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/12/2020] [Accepted: 08/01/2020] [Indexed: 12/11/2022]
Abstract
The past 50 years have witnessed profound changes in the specialty of pediatric surgery in North America. There has been a marked increase in the number of both pediatric surgical training programs and practicing pediatric general and thoracic surgeons. Despite this trend, the population of children in the United States and the birth rate have recently remained relatively flat. Some pediatric surgeons have become "super specialists", concentrating their practices in oncology or colorectal surgery. This has the potential to result in a dilution of experience for both pediatric surgical trainees and practicing pediatric surgeons, thus limiting their ability to acquire and maintain expertise, respectively. Coincident with this, there has been a relative paradigm shift in recognition that "quality of life" is based more on maintaining a creative balance in lifestyle and is not "all about work". There has been a parallel growth in the number of practicing pediatric general and thoracic surgeons in urban settings, but we have not appreciated as much growth in rural and underserved areas, where access to pediatric surgical care remains limited and fewer pediatric general and thoracic surgeons practice. This is a complex issue, as some underserved areas are economically depressed and geographically sparse, but others are just underserved with adult providers taking care of children in settings that are often under resourced for pediatric surgical care. This problem may extend beyond the boundaries of pediatric general and thoracic surgery to other specialties. As the premier association representing all pediatric surgeons in the United States, the American Pediatric Surgical Association (APSA) has concluded that the quality of pediatric surgical care will likely decline should the status quo be allowed to continue. Therefore, APSA has initiated a Right Child/Right Surgeon initiative to consider these issues and propose some potential solutions. What follows is a brief statement of intent.
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Bos C, Doumouras AG, Akhtar-Danesh GG, Flageole H, Hong D. A population-based cohort examining factors affecting all-cause morbidity and cost after pediatric appendectomy: Does annual adult procedure volume matter? Am J Surg 2018; 218:619-623. [PMID: 30580933 DOI: 10.1016/j.amjsurg.2018.12.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/04/2018] [Accepted: 12/13/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to examine factors affecting morbidity and cost after pediatric appendectomy and particularly the role of adult surgical volume. MATERIALS AND METHODS This was population-based study including all pediatric patients who underwent appendectomy for appendicitis in Canada (excluding Quebec) from 2008 to 2015. All-cause morbidity was the main outcome of interest. Cost of the index admission (in 2014 Canadian dollars) was a secondary outcome. Hierarchal linear and logistic regressions were used to model the outcomes. RESULTS Overall, 41,512 patients were identified. After adjustment, younger patients (OR = 0.98/year, 95%CI 0.97-0.99, p < 0.001), patients with comorbidities (OR = 2.20, 95%CI 1.96-2.46, p < 0.001), and those with perforated appendicitis (OR = 5.95, 95%CI 5.44-6.50, p < 0.001) were more susceptible to morbidity. Annual pediatric appendectomy volume was a significant predictor of reduced morbidity (OR = 0.85/20 cases, 95%CI 0.76-0.93, p < 0.001) as was the use of laparoscopy (OR = 0.81, 95%CI 0.72-0.91, p = 0.001). Conversely, annual adult appendectomy volume conferred no benefit nor did pediatric surgery specialty training. CONCLUSION Outcomes after pediatric appendectomy are influenced by pediatric case volume, regardless of specialty training, but extra adult surgical volume confers no benefit.
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Affiliation(s)
- Cecily Bos
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | | | | | - Helene Flageole
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of Pediatric Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Dennis Hong
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada; Division of General Surgery, St. Joseph's Healthcare, Hamilton, Ontario, Canada.
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Trauma surgeon performance of appendectomy in 5-year- to 10-year-old children is safe and decreases length of hospital stay. J Trauma Acute Care Surg 2018; 85:118-121. [PMID: 29554038 DOI: 10.1097/ta.0000000000001902] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Boo YJ, Lee EH, Lee JS. Comparison of surgical outcomes among infants in neonatal intensive care units treated by pediatric surgeons versus general surgeons: The need for pediatric surgery specialists. J Pediatr Surg 2017; 52:1715-1717. [PMID: 28189454 DOI: 10.1016/j.jpedsurg.2017.01.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/19/2017] [Accepted: 01/21/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE This study compared the outcomes of infants who underwent surgery in neonatal intensive care units by pediatric surgeons and by general surgeons. METHODS This was a retrospective study of infants who underwent surgery in neonatal intensive care units between 2010 and 2014. A total of 227 patients were included. Of these patients, 116 were operated on by pediatric surgeons (PS) and 111 were operated on by general surgeons (GS). The outcome measures were the overall rate of operative complications, unplanned reoperation, mortality rate, length of stay, operative time, and number of total number of operative procedures. RESULTS The overall operative complication rate was higher in the GS group compared with the PS group (18.7% vs. 7.0%, p=0.0091). The rate of unplanned reoperations was also higher in the GS group (10.8% vs. 3.5%, p=0.0331). The median operation time (90min vs. 75min, p=0.0474) and median length of stay (24days vs. 18days, p=0.0075) were significantly longer in the GS group. The adjusted odd ratios of postoperative complications for GS were 2.9 times higher than that of PS (OR 2.90, p=0.0352). CONCLUSIONS The operative quality and patient outcomes of the PS group were superior to those of the GS group. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Yoon Jung Boo
- Division of Pediatric Surgery, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea.
| | - Eun Hee Lee
- Department of Pediatrics, Korea University College of Medicine, Seoul, Republic of Korea
| | - Ji Sung Lee
- Department of Medical Statistics, Asan Medical Center, Seoul, Republic of Korea
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Han SB, Kim J, Moon SB. Jejunal perforation as an unusual presentation of total colonic aganglionosis in a neonate: A case report. Int J Surg Case Rep 2017; 41:117-120. [PMID: 29073546 PMCID: PMC5653242 DOI: 10.1016/j.ijscr.2017.10.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/03/2017] [Accepted: 10/11/2017] [Indexed: 11/15/2022] Open
Abstract
Untreated distal bowel obstruction eventually leads to perforation near the obstruction. Total colonic aganglionosis can present as a proximal jejunal perforation. Distal bowel should also be sought in cases of proximal bowel perforation. Appendiceal biopsy can be a reliable tool for suspecting total colonic aganglionosis. Multiple colon and rectal biopsies are necessary to diagnose total colonic aganglionosis.
Introduction Neonatal intestinal perforation usually occurs at distal small bowel secondary to distal bowel obstruction. The aim of this report is to describe an unusual case of total colonic aganglionosis with an initial presentation of proximal jejunal perforation. Presentation of case A male newborn presented with jejunal perforation on the fifth day of life and was treated by laparoscopic primary repair. Abdominal distention persisted postoperatively, and radiological examination revealed an obstruction near the terminal ileum. Laparotomy showed a transition zone 30-cm proximal to the ileocecal valve, and diverting ileostomy and appendiceal biopsy was performed. Permanent section demonstrated the complete absence of ganglion cells in the appendix and total colonic aganglionosis was strongly suspected. Discussion Contrary to the classic teaching, proximal bowel perforation can occur in case of far distal obstruction, and careful distal evaluation would direct more appropriate surgical treatment option. Conclusions Total colonic aganglionosis can present as a proximal bowel perforation. Careful distal evaluation can provide diagnostic clues in cases of proximal intestinal perforation. Appendiceal biopsy is a reliable tool for evaluating suspected total colonic aganglionosis, but multiple colonic and rectal biopsies should be obtained to confirm the diagnosis.
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Affiliation(s)
- Sang Beom Han
- Department of Ophthalmology, Kangwon Natinoal University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Jiha Kim
- Department of Neurosurgery, Kangwon National University Hospital, Kangwon National University School of Medicine, Chuncheon, Republic of Korea.
| | - Suk-Bae Moon
- Department of Surgery, Kangwon Natinoal University Hospital, Kangwon National University School of Medicine, Chuncheon, 24289, Republic of Korea.
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Khoshhal Z, Canner J, Schneider E, Stem M, Haut E, Schlottmann F, Barbetta A, Mungo B, Lidor A, Molena D. Impact of Surgeon Specialty on Perioperative Outcomes of Surgery for Benign Esophageal Diseases: A NSQIP Analysis. J Laparoendosc Adv Surg Tech A 2017; 27:924-930. [PMID: 28594583 DOI: 10.1089/lap.2017.0083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Surgery for benign esophageal disease is mostly performed either by general surgeons (GS) or cardiothoracic surgeons (CTS) in the United States. The purpose of this study was to evaluate the effect of surgeon specialty on perioperative outcomes of surgery for benign esophageal diseases. MATERIALS AND METHODS We have conducted a retrospective analysis using the ACS-NSQIP during the period of 2006-2013. Patients who underwent paraesophageal hernia (PEH) repair, gastric fundoplication, or Heller esophagomyotomy were divided into two groups according to the specialty of the surgeon (GS or CTS). Outcomes compared between the two groups using multivariable logistic regression included 30-day mortality, overall morbidity, discharge destination, hospital length of stay (LOS), and readmission rates. RESULTS Most of the surgeries were performed by general surgeons (PEH: 97.1%; fundoplication: 97.6%; Heller: 91.6%). Patients had lower comorbidities, better physical condition, and underwent a laparoscopic approach more frequently in the GS group. Regression analysis showed that GS group had a lower mortality rate (operating room, 0.44; 95% confidence interval [CI]: 0.23-0.86; P = .017), shorter LOS, and more home discharge for patients undergoing PEH repair. Mortality, morbidity, readmission, LOS, and home discharge were comparable between GS and CTS in fundoplication and Heller esophagomyotomy. CONCLUSION GS perform most of esophageal surgeries for benign diseases. GS group has better outcomes in PEH repair compared with CTS, whereas there is no difference in the overall outcomes between GS and CTS in fundoplication and Heller esophagomyotomy. These results show that specialization is not always the answer to better outcomes. Difference in outcomes, however, might be related to disease severity, approach needed, or case volume.
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Affiliation(s)
- Zeyad Khoshhal
- 1 Epidemiology and Biostatistics Concentration, Johns Hopkins Bloomberg School of Public Health , Baltimore, Maryland.,2 Department of Surgery, Taibah University School of Medicine , Madinah, Saudi Arabia .,3 Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Joseph Canner
- 3 Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Eric Schneider
- 3 Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Miloslawa Stem
- 4 Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Elliott Haut
- 3 Department of Surgery, Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine , Baltimore, Maryland.,4 Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Francisco Schlottmann
- 5 Department of Surgery, Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Arianna Barbetta
- 5 Department of Surgery, Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center , New York, New York
| | - Benedetto Mungo
- 4 Department of Surgery, Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Anne Lidor
- 6 Department of Surgery, University of Wisconsin , Madison, Wisconsin
| | - Daniela Molena
- 5 Department of Surgery, Thoracic Surgery Service, Memorial Sloan Kettering Cancer Center , New York, New York
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Khoushhal Z, Canner J, Schneider E, Stem M, Haut E, Mungo B, Lidor A, Molena D. Influence of Specialty Training and Trainee Involvement on Perioperative Outcomes of Esophagectomy. Ann Thorac Surg 2016; 102:1829-1836. [PMID: 27570158 DOI: 10.1016/j.athoracsur.2016.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/29/2016] [Accepted: 06/13/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitals' and surgeons' volume-outcome relationship have been reported in several esophagectomy studies with an inverse association of mortality and volume. The purpose of our study was to evaluate the outcomes of esophagectomy in the United States relative to the surgeon's specialty. METHODS This was a retrospective analysis using the American College of Surgeons National Surgical Quality Improvement Program database (2006 to 2013). All patients (18 years of age and older) who underwent esophagectomy were divided into 2 groups according to whether the operation was performed by a general surgeon (GS) or a cardiothoracic surgeon (CTS). A comparison of intraoperative and postoperative outcomes between the groups was conducted. The primary outcome was 30-day mortality. Secondary outcomes included overall and serious morbidity, discharge destination, and length of hospital stay. RESULTS Of the 5,142 esophagectomies identified, 70.3% were performed by GS and 29.7% by CTS. Overall, CTS patients had significantly higher comorbidities and cancer rates (61% versus 53%). Both specialties preferred the transthoracic approach (59.41% for CTS versus 44.90% for GS). Trainee involvement was higher for CTS. There was no significant difference in mortality or overall morbidity. Patients operated on by GS had higher rates of wound infection, sepsis, shock, prolonged or unplanned intubation, and a longer hospital stay, whereas patients operated on by CTS had higher chance for bleeding and return to the operating room. Trainees' involvement in esophagectomy was not associated with worse outcome. CONCLUSIONS Our study showed that a large number of esophagectomies in the United States are performed by GS, with the transthoracic approach being the most popular among both specialties. Trainees' involvement in esophagectomy did not significantly affect patients' outcomes. However CTS specialty was associated with lower incidence of infection and a shorter hospital stay.
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Affiliation(s)
- Zeyad Khoushhal
- Epidemiology and Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Surgery, Taibah University School of Medicine, Madinah, Saudi Arabia; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Joseph Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Eric Schneider
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Miloslawa Stem
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Elliott Haut
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Benedetto Mungo
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Anne Lidor
- Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Daniela Molena
- Division of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, New York.
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Kim Y, Jung K, Ryu YJ, Moon SB. Pediatric appendectomy: the outcome differences between pediatric surgeons and general surgeons. Surg Today 2016; 46:1181-6. [PMID: 27142973 DOI: 10.1007/s00595-016-1343-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/19/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE The aim of this study was to review our experience of pediatric appendectomy performed by either a general surgeon (GS) or a pediatric surgeon (PS) to determine any differences in outcomes. METHODS We reviewed the medical records of pediatric appendicitis patients, 4 years before (GS group, 2007-2010) and after (PS group, 2011-2014) the introduction of a pediatric surgical practice. The records were reviewed for the following variables: operation time, length of hospital stay, complications, readmission in ≤30 days, type of operation, negative for appendicitis, drainage, open conversion, and reoperation in ≤30 days. RESULTS Over 8 years, 400 patients were operated on for acute appendicitis, with the PS group comprising 61 % (N = 244) of patients. The operation time (55.1 vs 43.2 min, p = 0.0001) and postoperative length of hospital stay (3.5 vs 2.7 days, p = 0.001) were shorter, more patients were treated by laparoscopy (61.3 vs 91.2 %, p = 0.0001), and a fewer patients required peritoneal drainage (29.5 vs 63.2 %, p = 0.023) in the PS group than in the GS group. The negative appendectomy rate was slightly lower in the PS group, but not to a statistically significant degree. CONCLUSION The patients in the PS group enjoyed a reduced operation time and length of hospital stay, greater likelihood of laparoscopic operation, and less peritoneal drainage than the patients in the GS group.
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Affiliation(s)
- Younglim Kim
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea
| | - Kyuwhan Jung
- Department of Surgery, Seoul National University Bundang Hospital, Songnam, South Korea
| | - Young-Joon Ryu
- Department of Pathology, Kangwon National University School of Medicine, Chuncheon, South Korea
| | - Suk-Bae Moon
- Department of Surgery, Kangwon National University School of Medicine, Chuncheon, 200-722, South Korea.
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Optimal Time to Surgery for Patients Requiring Laparoscopic Appendectomy: An Integrative Review. AORN J 2016; 103:198-211. [DOI: 10.1016/j.aorn.2015.12.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Revised: 12/07/2014] [Accepted: 12/10/2015] [Indexed: 01/30/2023]
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Risk factors for complications and readmission after operative fixation of pediatric femur fractures. J Child Orthop 2015; 9:307-11. [PMID: 26238610 PMCID: PMC4549346 DOI: 10.1007/s11832-015-0672-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 07/20/2015] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Operative fixation of pediatric femur fractures with intramedullary implants has grown in popularity in recent decades. However, risk factors for short-term adverse events and readmission have not been well studied. METHODS Pediatric patients who underwent intramedullary nailing of a femur fracture between 2012 and 2013 were identified from the American College of Surgeons National Surgical Quality Improvement Program database. Risk factors for any adverse event (AAE) and readmission after intramedullary nailing were evaluated using univariate and multivariate analysis. RESULTS A total of 522 pediatric patients who underwent intramedullary nailing of the femur during the study period were identified. The mean age of this patient cohort was 10.2 ± 3.8 years. Review of the cases revealed that 18 (3.4 %) patients had AAE and that 20 (3.8 %) patients were readmitted, of whom 13 (2.5 %) underwent a reoperation. Independent risk factors for AAE were a cardiac comorbidity [odds ratio (OR) 12.7, 95 % confidence interval (CI) 1.5, 103.7], open fracture (OR 10.2, 95 % CI 1.4, 74.4), and prolonged operative time (OR 17.5, 95 % CI 6.1, 50.5). Independent risk factors for readmission were a central nervous system disorder (OR 4.5, 95 % CI 1.3, 16.2) and a seizure disorder (OR 4.9, 95 % CI 1.0, 23.5). CONCLUSIONS The results of the multivariate analysis suggest that cardiac comorbidities, open fractures, and prolonged operative time increase the risk for AAE and that central nervous system disorders and seizure disorders may increase the risk for readmission. Surgeons should be aware of these risk factors and counsel the families of pediatric patients who undergo intramedullary nailing of femur fractures.
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Healy DA, Doyle D, Moynagh E, Maguire M, Ahmed I, Ahmed AS, Caldwell M, O'Hanrahan T, Walsh SR. Systematic Review and Meta-Analysis on the Influence of Surgeon Specialization on Outcomes Following Appendicectomy in Children. Medicine (Baltimore) 2015; 94:e1352. [PMID: 26266388 PMCID: PMC4616707 DOI: 10.1097/md.0000000000001352] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The aim of this study is to assess the influence of surgeon specialization on outcomes following appendicectomy in children.General surgeons and pediatric surgeons manage appendicitis in children; however, the influence of subspecialization on outcomes remains unclear.Two authors searched Medline and Embase to identify relevant studies. Eligible studies were comparative and provided data on children who had appendicectomy while under the care of general or pediatric surgical teams. Two authors initially screened titles and abstracts and then full text manuscripts were evaluated. Data were extracted by 2 authors using an electronic spreadsheet. Pooled risk ratios and pooled mean differences were used in analyses.We identified 9 relevant studies involving 50,963 children who were managed by general surgery teams and 15,032 children who were managed by pediatric surgery teams. A normal appendix was removed in 4660/48,105 children treated by general surgery units and in 889/14,760 children treated by pediatric units (pooled risk ratio 1.79; 95% confidence interval [CI] 1.26-2.54; P = 0.001). Children managed in general units had shorter mean hospital stays compared with children managed in pediatric units (pooled mean difference -0.70 days; 95%CI -1.09 to -0.30; P = 0.0005). There were no significant differences regarding wound infections, intra-abdominal abscesses, readmissions, or mortality.We found that children who were managed by specialized pediatric surgery teams had lower rates of negative appendicectomy although mean length of stay was longer. Our article is based upon a group of heterogeneous and mostly retrospective studies and therefore there is little external validity. Further studies are needed.
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Affiliation(s)
- Donagh A Healy
- From the Department of General Surgery, The Mall, Sligo Regional Hospital, Sligo (DAH, DD, EM, MM, IA, ASA, MC, TO); and Department of Surgery, National University of Ireland Galway, Galway, Ireland (SRW)
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