Same-day discharge for pediatric laparoscopic gastrostomy

BackgroundLaparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy.MethodsWe performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017–September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education.ResultsSixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9–4.1], and the median weight was 10.5 kg [IQR 7.6–15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16–29]. The median time to initiation of feeds was 4.4 h [IQR 3.4–5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7–10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room < 30 days at a median 5 days [IQR 3–12] post-operatively, primarily for mechanical complications.ConclusionSame-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits.Type of studyProspective Observational Study.Level of EvidenceLevel II.     

Same-day trial of void and discharge following standard vs. MOSESTM holmium laser enucleation of the prostate: A single-center experience

IntroductionWe aimed to compare perioperative and postoperative outcomes and to assess the safety and feasibility of same-day trial of void (TOV) in patients who underwent standard holmium laser enucleation of the prostate (HoLEP) vs. MOSES^TM HoLEP (MoLEP).MethodsWe conducted a retrospective review of prospectively collected data of patients that underwent HoLEP (100 W) or MoLEP (120 W) with same-day catheter removal three hours postoperatively at our institution from August 2018 to September 2021. Patient demographics, intraoperative parameters, and postoperative outcomes were analyzed. Data were compared as means with standard deviation and medians with interquartile range (IQR) or numbers and percentages. Continuous and categorical variables were assessed using the Mann-Whitney U test and Chi-squared test, respectively. Predictors of shorter enucleation time and failed same-day TOV were investigated.ResultsOf the 90 patients included, 28 underwent HoLEP while 62 had MoLEP. There was no significant difference between the groups in terms of the successful TOV (23 [82%] vs. 58 [93.5%], p=0.1) and readmission rate (3 [10.7%] vs. 1 [1.6%], p=0.08); however, the MoLEP group had a significantly shorter mean enucleation time (p<0.001), mean hemostasis time (p<0.001), mean morcellation time (p=0.003), and lower mean energy used (p<0.001). On the logistic regression model, MoLEP (odds ratio [OR] 0.03, 95% confidence interval [CI] 0.007–0.19, p<0.001), lower preoperative prostate-specific antigen (PSA) test (OR 1.25, 95% CI 1.01–1.55, p=0.03), and smaller prostate size (OR 1.06, 95% CI 1.02–1.09, p<0.001) were independent predictors of shorter enucleation time. History of preoperative retention was the only significant factor associated with a failed same-day TOV (p=0.04). There was no difference in intraoperative or postoperative complication rates or postoperative functional outcomes between the two technologies.ConclusionsSame-day TOV and discharge are feasible following standard HoLEP and MoLEP, with comparable outcomes; however, the use of MOSES^TM technology offered better enucleation efficiency with excellent hemostatic potential. Preoperative retention was the only predictor of failed same-day TOV.     

Minimally invasive Nuss technique allows for repair of recurrent pectus excavatum following the Ravitch procedure: report of 12 cases

This work aimed to determine the efficacy of recurrent pectus excavatum repair using a minimally invasive Nuss procedure. We performed a secondary repair in 12 patients with recurrent pectus excavatum by using the minimally invasive Nuss procedure. Prior repairs had been performed using the Ravitch procedure in all cases. The values obtained in preoperative pulmonary function tests were less than 80% of the normal values. The median duration of surgery was slightly longer than that of the primary surgeries. The procedural complications included hemothorax (16.7%) and pleural effusion (25.0%). None of the patients developed a pneumothorax, pericarditis, pneumonia, wound infection, or immune rejection. There were no deaths or cardiac perforations. Exercise tolerance increased in 7 of the 12 cases. We achieved excellent results from surgical correction using the Nuss procedure in these 12 patients who showed recurrent pectus excavatum after failed repair surgery using the Ravitch procedure.     

When patients choose: comparison of Nuss, Ravitch, and Leonard procedures for primary repair of pectus excavatum

Background/Purpose

Pectus excavatum is a common chest wall deformity, and several procedures have been developed for its correction. We allow patients to choose among Leonard, Nuss, and Ravitch procedures. This study aimed to determine which procedure most patients select and the resultant outcomes.

Methods

Charts were reviewed of all pectus excavatum repairs performed for 4 years by a practice covering a university-based children's hospital. Procedure choice, operative time, length of stay, analgesia, fees, and complications were recorded.

Results

The Ravitch procedure was chosen by 60.9% of our patients, Leonard procedure by 23.9%, and Nuss procedure by 15.2%. Operative times were not significantly different among the groups. The mean length of stay was 2.2 days (Ravitch), 1.5 days (Leonard), and 3.9 days (Nuss) (P < .005). Epidural analgesia/patient-controlled analgesia pump requirements were 50% (Ravitch), 5% (Leonard), and 100% (Nuss). The mean charges were $27,414 (Ravitch), $18,094 (Leonard), and $43,749 (Nuss) (P < .05). The overall complication rate was 16.3%. The complications among each group were as follows: Ravitch, 14.3%; Leonard, 9.1%; and Nuss, 35.7%.

Conclusions

We allow patients to choose among Leonard, Ravitch, and Nuss procedures for repair of pectus excavatum. Most select the Ravitch procedure. Length of stay, fees, analgesic needs, and complication rate were highest among patients in the Nuss group; all of these variables were lowest in the Leonard group.     

A simple technique for preventing bar displacement with the Nuss repair of pectus excavatum

BACKGROUND/PURPOSE: The most common complication of the minimally invasive technique for repair of pectus excavatum (MIRPE) is bar displacement, which has been reported to occur in 9.5% of all cases, particularly in teenaged patients. The use of a lateral stabilizing bar has improved stability but has not eliminated the occurrence of this problem. The authors report a new technique added to the standard MIRPE that creates an additional third point of fixation of the pectus bar to prevent displacement. METHODS: The technique requires the simple placement, via a spinal needle, of a nonabsorbable suture next to the sternum, encircling a rib and the bar, using a single 3-mm stab wound and thoracoscopic guidance. The suture simply is buried under the skin. Since 1998, this technique has been applied to 20 patients who underwent MIRPE. RESULTS: The average age was 14 years; 80% were boys. Average operating time was 75 minutes, and all patients had thoracoscopy with the MIRPE. A lateral stabilizing bar also was used in 14 patients. Four patients had 2 struts placed. Average length of stay was 5.5 days. There were no early complications. Mean follow-up was 12 months. Bar displacement occurred in 1 patient early in the series in which an absorbable suture was used for fixation. One patient had a prolonged hospital stay of 7 days because of postoperative pain. CONCLUSIONS: This modification to the original technique of MIRPE creates a 3-point fixation system that minimizes the risk of bar shifting even in teenaged patients. It does not add any significant time or cost to the operation, and it is fairly simple to perform. The authors believe that this technique decreases the occurrence of bar displacement, and they recommend its use for all patients with pectus excavatum considered candidates for the Nuss repair.     

A comparison of epidural bupivacaine-fentanyl and bupivacaine-clonidine in children undergoing the Nuss procedure

The administration of epidural opioids, though effective for producing analgesia, has severe side effects in most patients. It is unknown whether clonidine can effectively replace opioids and cause fewer side effects. We compared, in this randomized trial, the incidence of vomiting and pruritus as well as the analgesic profile of three different combinations of bupivacaine, fentanyl, and clonidine administered epidurally in patients undergoing the Nuss procedure: bupivacaine + fentanyl, bupivacaine + clonidine, bupivacaine + fentanyl + clonidine. The incidence of side effects was significantly less in the bupivacaine + clonidine group (33%) compared with the bupivacaine + fentanyl (92%) and bupivacaine + fentanyl + clonidine (73%) groups (P = 0.004). Quality of postoperative analgesia was similar in the three groups. No significant complications were observed. In conclusion, clonidine is an effective and safe alternative to epidural opioids.     

Pain during sexual activity and ejaculation following hernia repair: A retrospective comparison of transabdominal preperitoneal versus Lichtenstein repair

Pain during sexual activity and ejaculation are the unspoken long-term complications of groin hernia repair. Laparoscopic surgical techniques are associated with decreased post-operative pain and earlier return to daily activities, but its effect on these complications is unclear. This study aims to investigate the effect of transabdominal preperitoneal repair (TAPP) on de-novo pain during sexual intercourse and ejaculation and to compare with open repair. For this reason, two groups were determined according to the surgical technique: the Lichtenstein repair and the TAPP groups and a questionnaire was sent to the patients a minimum of 6 months following the surgery. A total of 317 patients included, as 115 in TAPP and 202 in Lichtenstein repair group. No significant difference was observed concerning pre-operative pain during sexual activity and ejaculation in both groups (p = .75, p = .56). Following the surgery, the number of patients experiencing painful sexual activity was significantly higher in the Lichtenstein repair group compared to the TAPP group (19.3% vs. 11.3%, respectively, p = .03). The post-operative painful ejaculation rate was also significantly lower for the TAPP group (p = .04). The lower rates of post-operative dysejaculation and pain during sexual activity can be achieved with the advantage of laparoscopic surgery.     

Same-day discharge after total thyroidectomy: the value of 6-hour serum parathyroid hormone and calcium levels

BACKGROUND: The purpose of this study was to determine whether patients who undergo total thyroidectomy will have postoperative hypocalcemia develop when they reach the critical 6-hour serum levels defined as parathyroid hormone (PTH) > or =28 ng/L and simultaneous corrected calcium > or =2.14 mmol/L. METHODS: This was a prospective study involving 70 consecutive total thyroidectomy patients. There were 51 women and 19 men involved in the study. The mean age was 49.3 years (range, 21-76 years). Patients who had completion thyroidectomy or neck dissections were excluded. Patients undergoing parathyroidectomy at the time of thyroidectomy were also excluded. PTH and corrected calcium levels were measured postoperatively at 6, 12, and 20 hours. RESULTS: Hypocalcemia developed in 24% (17 of 70) of the patients. Of the 53 patients who remained normocalcemic, 68% (36 of 53) reached the 6-hour critical level. None of the hypocalcemic patients (0 of 17) attained the 6-hour critical level (chi-square test p < .0001). This translates into a specificity of 100% (95% confidence interval [CI], 80.5% to 100%) and a positive predictive value of 100% (95% CI, 90.1% to 100%). CONCLUSIONS: The simultaneous evaluation of PTH and corrected calcium levels 6 hours after thyroidectomy allows for an accurate prediction of the trend of serum calcium. This study enables us to confidently consider same-day discharge for most of our thyroidectomy patients.     

Erratum to: Same-day discharge after craniotomy for supratentorial tumour surgery: a retrospective observational single-centre study

Canadian Journal of Anesthesia/Journal canadien d'anesthésie -     

Comparison of the Nuss and the Ravitch procedure for pectus excavatum repair: a meta-analysis

Purpose

Pectus excavatum is the most common chest wall deformity in children. Two procedures are widely applied—the Nuss and the Ravitch. Several comparative studies are published evaluating both procedures with inconsistent results. Our objective was to compare the Nuss procedure to the Ravitch procedure using systematic review and meta-analysis methodology.

Methods

All publications describing both interventions were sought through the Cochrane Central Register of Controlled Trials (CENTRAL) database, MEDLINE, and EMBASE. The statistical analysis was performed using RevMan 5 software. Odds ratios (OR) and weighted mean differences (WMDs) with 95% confidence intervals are presented.

Results

No randomized trials were identified. Nine prospective and retrospective studies were identified and were included in this study. There was no significant difference in overall complication rates between both techniques (OR, 1.75 (0.62-4.95); P = .30). Looking at specific complications, the rate of reoperation because of bar migration or persistent deformity was significantly higher in the Nuss group (OR, 5.68 (2.51-12.85); P = .0001). Also, postoperative pneumothorax and hemothorax were higher in the Nuss group (OR, 6.06 [1.57-23.48]; P = .009 and OR, 5.60 [1.00-31.33]; P = .05), respectively. Duration of surgery was longer with the Ravitch (WMD, 69.94 minutes (0.83-139.04); P = .05). There was no difference in length of hospital stay (WMD, 0.4 days (−2.05 to 2.86); P = .75) or time to ambulation after surgery (WMD, 0.33 days [−0.89 to 0.23]; P = .24). Among studies looking at patient satisfaction, there was no difference between both techniques.

Conclusions

Our results suggest no differences between the Nuss procedure vs the Ravitch procedure with respect to overall complications, length of hospital stay, and time to ambulation. However, the rate of reoperation, postoperative hemothorax, and pneumothorax after the Nuss procedure were higher compared to the Ravitch procedure. No studies showed a difference in patient satisfaction.     

Submuscular bar,multiple pericostal bar fixation,bilateral thoracoscopy: A modified Nuss repair in adolescents

Background/Purpose: Thoracoscopic Nuss repair of funnel chests is used increasingly, but has a high bar dislocation rate. The authors intended to reduce this by technical modifications of the original Nuss technique. Methods: In 40 patients from 12.3 to 42.1 years of age (mean, 17.6 [plusmn] 5.8) the bars were placed directly on the ribs in a submuscular position and fixed by a minimum of 14 absorbable figure of 8 sutures around the bar and the underlying rib placed under bilateral thoracoscopy. Two stabilizers were used in all patients, the bar was introduced from the left in severe cases, and a second bar was implanted in most beyond 16 years of age. All patients underwent follow-up to date in a prospective observation study. Results: There was no bar or stabilizer dislocation, no prolonged pain or neuralgia, but one traumatic seroma, one pleural, and one pericardial effusion. One bar was easily removed after 13 months. Conclusions: Submuscular position provides a far better bar fixation and soft tissue coverage of Nuss implants. The technique is technically more demanding but safe and has reduced the incidence of bar dislocation to zero in this early experience of 40 adolescent patients, although no sportive restrictions were imposed on the patients at all. J Pediatr Surg 37:1276-1280.     

Infectious complications after the Nuss repair in a series of 863 patients

Purpose

A nemesis of surgical implants is infection. We evaluated the various infectious complications after Nuss repair of pectus excavatum in 863 patients over 18 years.

Methods

After institutional review board approval, a retrospective review of a prospectively gathered database of patients was performed who underwent minimally invasive repair of pectus excavatum and developed an infection. All patients received intravenous antibiotics before surgery continuing until discharge. Patients with a persistent fever after operation were discharged with oral antibiotics.

Results

From January 1987 to September 2005, 863 patients underwent a minimally invasive pectus excavatum repair and 13 (1.5%) developed postoperative infections. These included 6 bar infections, 4 cases of cellulitis, and 3 stitch abscesses. Cellulitis was defined as erythema and warmth which responded to a single course of antibiotics. Bar infections were defined as an abscess in contact with the bar. Surgical drainage and long-term antibiotics resolved 3 of these abscesses, whereas 3 patients required early bar removal (1 after 3 months and 2 after 18 months). Cultures identified a single organism in each case and Staphylococcus aureus was the most common organism (83%) identified, and all being methicillin sensitive. All infections occurred on the side of the stabilizer if a stabilizer had been placed.

Conclusions

Infectious complications after Nuss repair are uncommon and occurred in 1.5% of our patients. Published rates of postoperative infection range from 1.0% to 6.8%. Superficial infections responded to antibiotics alone. Bar infection occurred in only 0.7% and required surgical drainage and long-term antibiotics. Only 3 of these (50% of bar infections and 0.34% overall) required early bar removal at 3 and 18 months because of recurring infections. Early bar removal should be a rare morbidity with the Nuss repair.     

A comparison of three methods of skin closure following repair of Achilles tendon rupture

Meticulous skin closure is required to avoid wound problems after Achilles tendon surgery. The purpose of our study was to compare postoperative complication rate, operation time, clinical outcome and patient satisfaction with the wound among two topical skin adhesives (2-octyl cyanoacrylate and n-butyl cyanoacrylate) and conventional nylon skin sutures in Achilles tendon repair surgery. We retrospectively reviewed the records 122 consecutive patients (40 patient in nylon skin suture, 43 patients in 2-octyl cyanoacrylate and 39 patients in n-butyl cyanoacrylate) who underwent surgical repair for acute Achilles tendon rupture between 2012 and 2016. The primary outcome measure was the development of complications in the wound. Secondary outcome measures included the operative time, the Achilles Tendon Total Rupture Score (ATRS) and patient satisfaction with the wound. There was no difference in complication rate in the wound (p = 0.694) and in ATRS (p = 0.824) among patients in the three groups. Mean operative time in nylon skin suture group was significantly longer than in the 2-octyl cyanoacrylate group and n-butyl cyanoacrylate group (p = 0.018 and p = 0.002, respectively). Patient satisfaction in the 2-octyl cyanoacrylate and n-butyl cyanoacrylate groups was significantly higher than in the nylon skin suture group (p = 0.015 and 0.018, respectively). The use of 2-octyl cyanoacrylate and n-butyl cyanoacrylate topical skin adhesives for skin closure following repair of Achilles tendon rupture has equivalent effectiveness and safety compared to conventional nylon skin suture, but higher patient satisfaction. Despite its higher cost, these topical skin adhesives are viable alternatives for wound closure in patients who regard cosmetic outcomes as important.