Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Study objectiveTo determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.DesignA systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.SettingPreoperative assessment.PatientsOlder patients (≥ 60 years) undergoing non-cardiac surgery.MeasurementsOutcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.ResultsFifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).ConclusionsPreoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.     

Income Disparities in Nationwide Outcomes of Malrotation with Midgut Volvulus

BackgroundMalrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent with timely diagnosis and treatment, but the development of bowel ischemia is associated with many negative consequences.MethodsThe Nationwide Readmissions Database was used to identify patients 0–18 years (excluding newborns) with malrotation and midgut volvulus from 2010 to 2014. Demographics, procedures, and outcomes were compared by income group (highest quartile vs. lowest quartile) using standard statistical tests. Results were weighted for national estimates.ResultsEmergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd's procedure, while 14% required bowel resection and/or ostomy. Patients in the lowest income quartile were more likely to require bowel resection (18% vs. 8%, p = 0.03) or ostomy (9% vs. 2%, p = 0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged hospital stay (8 [5-13] days vs. 6 [4-8] days, p<0.001) and experience complications including infections (19% vs. 5%, p = 0.002), endotracheal intubation (18% vs. 4%, p<0.001), and blood transfusions (13% vs. 3%, p = 0.003).ConclusionIncome disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists. Patients from lower-income communities are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigations of practices to mitigate risk for low-income patients.Level of evidenceLevel III: Retrospective comparative study     

Delayed versus early repair of inguinal hernia in preterm infants: A systematic review and meta-analysis

ObjectivesTo evaluate the clinical outcomes of herniotomy in preterm infants undergoing early versus delayed repair, the risk factors for complications, and to identify best timing of surgery.MethodsMedline, Embase and Central databases were searched from inception until 25 Jan 2021 to identify publications comparing the timing of neonatal inguinal hernia repair between early intervention (before discharge from first hospitalization) and delayed (after first hospitalisation discharge) intervention. Inclusion criteria was preterm infants diagnosed with inguinal hernia during neonatal intensive care unit admission. Results were analyzed using fixed and random effects meta-analysis (RevManv5.4).ResultsOut of 721 articles found, six studies were included in the meta-analysis. Patients in the early group had lower odds of developing incarceration [odds ratio (OR) 0.43, 95% confidence interval (CI) 0.34–0.55, I² = 0%, p < 0.001]; but higher risk of post-operative respiratory complications (OR 4.36, 95% CI 2.13–8.94, I² = 40%, p < 0.001). No significant differences were reported in recurrence rate (OR 3.10, 95% CI 0.90–10.64, I² = 0%, p = 0.07) and surgical complication rate (OR 0.94, 95% CI 0.18–4.83, I² = 0%, p = 0.94) between early and delayed groups.ConclusionWhile early inguinal hernia repair in preterm infants reduces the risk of incarceration, it increases the risk of post-operative respiratory complications compared to delayed repair. Surgeons should discuss the risks and benefits of delaying inguinal hernia repair with the caregivers to make an informed decision best suited to the patient physiology and circumstances.Level of evidenceTreatment study, level 3.     

Factors influencing enteral autonomy after autologous gastrointestinal reconstructive surgery: A two-centre UK perspective

Background and AimsThe implementation of multidisciplinary care and improvements in parenteral nutrition (PN) in patients with short bowel syndrome (SBS) have led to better outcomes and higher survivability. Autologous gastrointestinal reconstructive (AGIR) surgery can reduce the duration on PN and lead to earlier enteral autonomy (EA). Our aim was to investigate the effect of SBS aetiology and other predictors on the achievement of enteral autonomy following AGIR surgery.MethodsRetrospective review of all patients undergoing AGIR surgery in two tertiary paediatric surgical units, between 2010 and 2021. Continuous data is presented as median (range).ResultsTwenty-seven patients underwent 29 AGIR procedures (20 serial transverse enteroplasties (STEP), 9 longitudinal intestinal lengthening and tailoring (LILT)) at an age of 6.6 months (1.5 – 104.5). EA rate was 44% at 13.6 months after surgery (1 – 32.8). AGIR procedures achieved an increase in small bowel length of 70% (pre-operative 46.5 vs 77 cm, p = 0.003). No difference was found between STEP and LILT (p = 0.84). Percentage of expected small bowel length (based on the child's weight) was a strong predictor of EA (bowel length >15% – EA 80% vs bowel length ≤15% – EA 17%, p = 0.008). A diagnosis of gastroschisis showed a negative non-significant correlation with the ability to achieve EA (25% vs 60%, p = 0.12). Overall survival rate was 96%.ConclusionAGIR surgery is an important tool in the multidisciplinary management of children with SBS. Percentage of expected small length and aetiology of SBS are likely predictors of achievement of EA in patients undergoing AGIR surgery.Level of Evidence: IVRetrospective Case-Series     

Initial experience of Chinese surgical robot “Micro Hand S″-assisted versus open and laparoscopic total mesorectal excision for rectal cancer: Short-term outcomes in a single center

BackgroundA Chinese surgical robot, Micro Hand S, was introduced for clinical use as a novel robotic platform. This study aimed to comprehensively compare the early experience of the Micro Hand S robot-assisted total mesorectal excision (TME) with conventional approaches.MethodsBetween May 2017 and April 2018, 99 consecutive patients who underwent open, laparoscopic and Micro Hand S robot-assisted TME (O-/L-/RTME) for rectal cancer were included. Clinical and pathological outcomes were retrospectively analyzed. Surgical success as the primary endpoint was defined as the absence of (i) conversion, (ii) incomplete TME, (iii) involved circumferential and distal resection margins (CRM/DRM), (iv) severe complications.ResultsThe rate of surgical success was similar (89.7 vs. 86.4 vs. 84.6%, p = 0.851) in the three groups and the respective incidences were as follows: conversion (not applicable, 4.5 vs. 2.3%, p = 1.000), incomplete TME (6.9 vs. 6.8 vs. 3.8%, p = 0.980), involved CRM/DRM (0 vs. 2.3 vs. 3.8%, p = 0.592), severe complications (3.4 vs. 4.5 vs. 7.7%, p = 0.844). Compared with open and laparoscopic surgery, the robotic surgery was associated with longer operative time, less blood loss, earlier first flatus time and liquid intake time, and shorter length of hospital stay (p < 0.05).ConclusionsThe Micro Hand S assisted TME is safe and feasible, showing comparable outcomes than conventional approaches, with superiority in blood loss, recovery of bowel function, length of hospital stay, but with increased operative time.     

Association between Kasai portoenterostomy at low caseload centres and transplant complications in children with biliary atresia

BackgroundKasai portoenterostomy (KPE) is the preferred treatment for biliary atresia (BA) patients. It has been shown that the center caseload of KPE impacts on native liver survival. We aimed to define the impact of KPE caseload on complications at the time of liver transplantation (LT).MethodsRetrospective data collection of LT for BA performed in our tertiary center between 2010 and 2018. The patients were grouped according to the caseload of the center that performed KPE: Group A (≥5 KPE/year) and Group B (<5 KPE/year). We analyzed total transplant time (TTT), hepatectomy time, amount of plasma and red blood cell (RBC) transfusions, occurrence of bowel perforations at LT.ResultsAmong 115 patients, Group A (n 44) and Group B (n 71) were comparable for age, sex, PELD score, TTT. The groups differed for: median hepatectomy time (57 min, IQR = 50–67; vs 65, IQR 55–89, p = 0.045); RBC transfusions (95 ml, IQR 0–250; vs 200 ml, IQR 70–500, p = 0.017); bowel perforations (0/44 vs 15/71, p = 0.001). One-year graft loss in Group A vs Group B was 1/44 vs 7/71 (p = 0.239), whereas deaths were 0/44 vs 5/71 respectively (p = 0.183); 5/15 patients who had a perforation eventually lost the graft.ConclusionsThis study found an association between KPE performed in low caseload center and the incidence of complications at LT. These patients tend to have a worse outcome. The centralization of KPE to referral center represents an advantage at the time of LT.Mini abstractWe studied the impact of Kasai portoenterostomy (KPE) caseload on complications at the time of liver transplantation (LT), in 115 patients. We found an association between KPE performed in low caseload center and increased bowel perforations and blood transfusions. We suggest to centralize to experienced center all children requiring KPE.     

Is colostomy closure without mechanical bowel preparation safe in pediatric patients? A randomized clinical trial

BackgroundMechanical bowel preparation (MBP) is largely used worldwide prior to colostomy closure in children, although its benefits are questioned by scientific evidence, and its use can cause adverse reactions. We hypothesized that colostomy closure procedures in children are not associated with increased complications (surgical site infection [SSI] and anastomotic leakage) when performed without MBP. Thus, we conducted a noninferiority trial to compare the safety and efficacy of colostomy takedown with and without MBP.MethodsA randomized noninferiority clinical trial was conducted at Hospital Infantil de Mexico in Mexico City from 2015 to 2019, in which the experimental group did not receive MBP prior to colostomy closure. A total of 79 patients were analyzed, and the primary outcomes were safety-related. Data were analyzed using the chi-squared test, Student's t-test, or Mann–Whitney U test as appropriate.ResultsThe demographics in both groups were comparable. Statistical analysis revealed equivalence in safety outcomes (superficial SSI, 22.5% vs 15.3% p = 0.420; deep SSI, 7.5% vs 0% p = 0.081; reoperation, p = 0.320; intestinal occlusion, p = 0.986); no anastomotic leakage was observed in any group. Secondary outcomes such as fasting time and length of hospital stay after surgery were also similar between the groups. However, patients who received MBP were admitted 2 days before surgery.ConclusionsOur findings indicate that withholding MBP prior to colostomy takedowns in children is not associated with increased complications. Omitting MBP also leads to less discomfort and shortens hospital length of stay, suggesting that it has safer and more effective procedures.Level of evidenceRandomized controlled clinical trial with adequate statistical power.     

Increased CMV disease and “severe” BK viremia with belatacept vs. sirolimus three-drug maintenance immunosuppression

ObjectivesBelatacept may provide benefit in delayed graft function, but its association with infectious complications is understudied. We aim to assess the incidence of CMV and BK viremia in patients treated with sirolimus or belatacept as part of a three-drug immunosuppression regimen after kidney transplantation.Materials and methodsKidney transplant recipients from 01/01/2015 to 10/01/2021 were retrospectively reviewed. Maintenance immunosuppression was either tacrolimus, mycophenolate and sirolimus (B⁰) or tacrolimus, mycophenolate, and belatacept (5.0 mg/kg monthly) (B¹). Primary outcomes of interest were BK and CMV viremia which were followed until the end of the study period. Secondary outcomes included graft function (serum creatinine, eGFR) and acute rejection through 12 months.ResultsBelatacept was initiated in patients with a higher mean kidney donor profile index (B⁰:0.36 vs. B¹:0.44, p = .02) with more delayed graft function (B⁰:6.1% vs. B¹:26.1%, p < .001). Belatacept therapy was associated with more “severe” CMV viremia >25,000 copies/mL (B⁰:1.2% vs. B¹:5.9%, p = .016) and CMV disease (B⁰:0.41% vs. B¹:4.2%, p = .015). However, there was no difference in the overall incidence of CMV viremia >200 IU/mL (B⁰:9.4% vs. B¹:13.5%, p = .28). There was no difference in the incidence of BK viremia >200 IU/mL (B⁰:29.7% vs. B¹:31.1%, p = .78) or BK-associated nephropathy (B⁰:2.4% vs. B¹:1.7%, p = .58), but belatacept was associated with “severe” BK viremia, defined as >10,000 IU/mL (B⁰:13.0% vs. B¹:21.8%, p = .03). The mean serum Cr was significantly higher with belatacept therapy at 1-year follow up (B⁰:1.24 mg/dL vs. B¹:1.43 mg/dL, p = .003). Biopsy-proven acute rejection (B⁰:1.2% vs. B¹:2.6%, p = .35) and graft loss (B⁰:1.2% vs. B¹:0.84%, p = .81) were comparable at 12 months.ConclusionsBelatacept therapy was associated with an increased risk of CMV disease and “severe” CMV and BK viremia. However, this regimen did not increase the overall incidence of infection and facilitated comparable acute rejection and graft loss at 12-month follow up.     

Erector spinae plane block for postoperative analgesia in breast and thoracic surgery: A systematic review and meta-analysis

Study objectiveThe erector spinae plane block (ESPB) is a newly defined regional anesthesia technique first introduced in 2016. The aim of this study is to determine its analgesic efficacy compared with non-block care and thoracic paravertebral block (TPVB).DesignWe systematically searched PubMed, Web of Science citation index, Embase, the Cochrane Library, Google Scholar, and ClinicalTrials.gov register searched up to March 2020. We conducted a meta-analysis of randomized controlled trials (RCTs) that compared an ESPB to non-block care or TPVB for postoperative analgesia in breast and thoracic surgery patients. Primary outcome was 24-hour postoperative opioid consumption. Risk of bias was assessed using Cochrane methodology.Results14 RCTs that comprised 1018 patients were included. Seven trials involved thoracic surgery patients and seven included breast surgery patients. Meta-analysis revealed that ESPB significantly reduced 24-hour opioid consumption compared with the non-block groups (−10.5 mg; 95% CI: −16.49 to −3.81; p = 0.002; I² = 99%). Similarly, the finding was consistent in subgroup analysis between the breast surgery (−7.75 mg; 95%CI −13.98 to −1.51; p = 0.01; I² = 97%) and thoracic surgery (−14.81 mg; 95%CI −21.18 to −8.44; p < 0.001; I² = 96%) subgroups. The ESPB significantly reduced pain scores at rest or movement at various time points postoperatively compared with non-block group, and reduced the rate of postoperative nausea and vomiting (OR 0.48; 95%CI 0.27 to 0.86; p = 0.01; I² = 0%). In contrast, there were no significative differences reported in any of the outcomes for ESPB versus TPVB strata.ConclusionsESPB improved analgesic efficacy in breast and thoracic surgery patients compared with non-block care. Furthermore, current literature supported the ESPB offered comparable analgesic efficacy to a TPVB.     

Impact of Hepatitis B virus infection on postoperative complications and length of stay in elderly patients with hip fracture: A retrospective cohort study

BackgroundOsteoporosis and subsequent fractures are common in the chronic hepatitis B (CHB) population, especially in the elderly. This study investigated the effects of hepatitis B virus (HBV) infection on postoperative outcomes following hip fracture surgery.MethodsThe study identified elderly patients who underwent hip fracture surgery at three academic tertiary care centres between January 2014 and December 2020. Propensity score matching was performed to compare the outcomes of 1,046 patients with HBV infection to 1,046 controls.ResultsThe seroprevalence of HBV among elderly patients undergoing hip surgery was 4.94%. The HBV cohort had significantly higher rates of medical complications (28.1 vs. 22.7%, p = 0.005), surgical complications (14.0 vs. 9.7%, p = 0.003), and unplanned readmissions (18.9 vs. 14.5%, p = 0.03) within 90 days of surgery. Patients with HBV infection were more likely to have increased length of stay (6.2 vs. 5.9 days, p = 0.009) and in-hospital charges (¥52,231 vs. ¥49,832, p < 0.00001). Multivariate logistic regression suggested that liver fibrosis and thrombocytopenia were independent risk factors for major complications and extended LOS.ConclusionPatients with HBV infection were at greater risk of adverse postoperative outcomes. We should pay more attention to the considerable burden of perioperative management of CHB patients. Due to the high proportion of undiagnosed patients in the Chinese elderly population, universal HBV screening should be considered preoperatively.     

Perioperative dexmedetomidine administration to prevent delirium in adults after non-cardiac surgery: A systematic review and meta-analysis

Study objectiveTo evaluate the efficacy of perioperative dexmedetomidine (DEX) administration for preventing delirium in adults after non-cardiac surgery.DesignSystematic review and meta-analysis of randomized controlled trials (RCTs).InterventionsPerioperative administration of DEX to prevent delirium in adults following non-cardiac surgery.MeasurementsThe incidence of postoperative delirium (POD).MethodsThe databases of PubMed, Embase and Cochrane Central Register were searched from inception to Mar 4, 2021 for all available RCTs that assessed DEX for POD in adults after non-cardiac surgery. Risk ratio (RR) with a 95% confidence interval (CI) was calculated for dichotomous data. Standardized mean difference (SMD) was calculated for continuous data. Risk of bias was assessed using the second version of the Cochrane risk-of-bias tool for RCTs (RoB 2.0), and the level of certainty for main outcomes were assessed by the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology.Main resultsThirteen studies, including the meta-analysis with a total of 4015 patients (DEX group: 2050 patients; placebo group: 1965 patients), showed that DEX significantly reduced the incidence of POD in adults after non-cardiac surgery compared with control group (RR: 0.60; 95%CI: 0.46 to 0.77, P = 0.0001, I² = 55%, GRADE = moderate). Meanwhile, there was a statistical difference by the subgroup analysis between the mean age ≥ 65 years group and the mean age<65 years group. There were no statistical differences in length of hospital stay following surgery (SMD: -0.36; 95%CI: −0.80 to 0.07, P = 0.1, I² = 97%, GRADE = low) and all-cause mortality rate (RR:0.57; 95%CI: 0.25 to 1.28, P < 0.17, I² = 0%, GRADE = moderate) compared with placebo group. However, Meta-analysis showed that DEX administration significantly resulted in intraoperative bradycardia when compared with placebo group (RR: 1.39; 95%CI: 1.14 to 1.69, P = 0.0009, I² = 0%, GRADE = high), and as well as intraoperative hypotension (RR: 1.25; 95%CI: 1.11 to 1.42, P = 0.0004, I² = 0%, GRADE = high).ConclusionThis systematic review and meta-analysis suggests that perioperative administration of DEX could significantly reduce the incidence of POD in patients elder than 65 years following non-cardiac surgery. However, there was no definite evidence that perioperative DEX could reduce the incidence of POD in patients younger than 65 years of age after non-cardiac surgery. In addition, perioperative DEX administration was associated with an elevated risk of bradycardia and hypotension.     

Limb salvage surgery has a higher complication rate than amputation but is still beneficial for patients younger than 10 years old with osteosarcoma of an extremity

Background/PurposeLimb preserving surgery for the treatment of patients with osteosarcoma younger than 10 years old is challenging and some authors have advocated amputation to reduce the risk of complications. The aim of this study was to compare the clinical outcomes and surgical complications of patients with osteosarcoma of the extremity aged <10 years old who were treated with limb salvage and amputation.Patients and methodsRetrospective review of patients aged <10 years old who were treated for primary osteosarcoma of bone between 2000 and 2018.ResultsWe analyzed 82 consecutive patients (32 males, 50 females; median age 8, range 3–9 yrs). Limb-salvage surgery (LSS; n = 65, 79%) and amputation (n = 17, 21%) were performed. Fourteen patients had metastasis at surgery. In patients without metastasis at surgery, the metastasis-free and overall survival rates at 5 years following LSS vs. amputation were 75% vs. 58% (p = 0.162) and 71% vs. 55% (p = 0.516), respectively. The 2-year and 5-year OS rates of the LSS and amputation groups of patients with metastasis at surgery were 88% versus 83% and 50% versus 0%, respectively (p = 0.180). The overall complication rates were 46% post-LSS with 31% requiring re-operation versus 12% post-amputation, with 6% requiring re-operation (p = 0.010).ConclusionThe prognosis of patients with localized osteosarcoma aged <10 years undergoing LSS is similar to those treated with amputation, but LSS is associated with a higher risk of complications and subsequent re-operation.Level of evidenceLevel III     

Variability,outcomes and cost associated with the use of parenteral nutrition in children with complicated appendicitis: A hospital-level propensity matched analysis

Background/PurposeTo examine the influence of parenteral nutrition (PN) on clinical outcomes and cost in children with complicated appendicitis.MethodsRetrospective study of 1,073 children with complicated appendicitis from 29 hospitals participating in the NSQIP-Pediatric Appendectomy Pilot Collaborative (1/2013–6/2015). Mixed-effects regression was used to compare 30-day postoperative outcomes between high and low PN-utilizing hospitals after propensity matching on demographic characteristics, BMI and postoperative LOS as a surrogate for disease severity.ResultsOverall PN utilization was 13.6%, ranging from 0–10.3% at low utilization hospitals (n = 452) and 10.3–32.4% at high utilization hospitals (n = 621). Outcomes were similar between low and high utilization hospitals for rates of overall complications (12.3% vs. 10.5%, OR: 0.80 [0.46,1.37], p = 0.41), SSIs (11.3% vs. 8.8%, OR: 0.72 [0.40,1.32], p = 0.29) and revisits (14.7% vs. 15.9%, OR: 1.10 [0.75,1.61], p = 0.63). Adjusted mean 30-day cumulative hospital cost was 22.9% higher for patients receiving PN ($25,164 vs. $20,478, p < 0.01) after controlling for postoperative LOS.ConclusionFollowing adjustment for patient characteristics and postoperative length of stay, higher rates of PN utilization in children with complicated appendicitis were associated with higher cost but not with lower rates of overall complications, surgical site infections or revisits.Level of Evidence Level III: Treatment study - Retrospective comparative study     

Most children experience resolution of idiopathic pediatric rectal prolapse with bowel management alone

BackgroundRecent studies in children with idiopathic rectal prolapse report up to 48% require surgical intervention to manage refractory disease. We sought to examine outcomes of our non-surgical approach to managing rectal prolapse using a bowel management program.MethodsA retrospective review was performed for all children with the diagnosis of rectal prolapse between 2011 and 2020. Children with a rectal polyp or hemorrhoid were excluded.Results47 children with rectal prolapse were identified (median age at diagnosis of 4 years (IQR 3,7.75); age ≤ 4 years n = 30; age > 4 years n = 17). Associated diagnoses included constipation (n = 45, 96%) and psychiatric diagnoses (n = 7, 14%). Children underwent a bowel management program including stimulant laxatives in 44 (94%) and osmotic laxatives in 2 (4%). Median follow-up time was 181 days (IQR 77, 238). Median time to resolution of rectal prolapse was 9 months (IQR 4, 13) with a maximum time to resolution of 31 months. We compared children ≤ 4 years old (Group A) to those > 4 years old (Group B). Psychiatric diagnoses were less common in Group A (3.5 vs. 38.9%, p = 0.003). Median time to spontaneous resolution was 6.5 months (IQR 3.5, 9.5) in Group A versus 13.5 (IQR 4, 16) months in Group B, p = 0.13. No differences in surgical intervention were identified. Three (6.4%) patients required surgery for prolapse.ConclusionsA bowel management program is an effective treatment for most children with rectal prolapse. This data suggests that surgical intervention is unnecessary in most children.Level of evidenceIII.     

Effect of COVID-19 on pediatric appendicitis presentations and complications

PurposeAppendicitis is the most common surgical emergency in children. This study aims to examine how the COVID-19 pandemic affected pediatric patients with acute appendicitis with regards to presentation and complications.MethodsAfter obtaining ethics approval, we performed a chart review of pediatric patients admitted with a diagnosis of appendicitis from March 1, 2019 to June 30, 2019 and March 1, 2020 to June 30, 2020. Data collection included a post-operative period of 30 days. The primary outcome of interest was complication rates post-appendectomy. Secondary outcomes included time to presentation, symptoms, time to surgery, and rate of perforation.ResultsOverall, 205 patients were included with 115 in the pre-pandemic group and 90 in the pandemic group. There was no significant difference in complication rates (16% pre-pandemic vs. 13.3% pandemic). In the pandemic group, time from symptom onset to presentation was significantly longer (1.87 days vs. 2.42 days, p = 0.01), more patients presented with emesis (70% vs. 55%, p<0.05), more patients had perforated appendicitis (47% vs. 32%, p<0.05), more patients were likely to be tachycardic (46% vs. 32%, p = 0.05)  and waited less time for surgery (5.75 h vs. 4.15 h, p = 0.05) which both approached significance.ConclusionSignificant delays in pediatric appendicitis presentation, and higher rates of tachycardia and perforation were seen during the pandemic. This did not result in increased complication rates but could suggest pandemic patients were more ill than their pre-pandemic counterparts.     

Long-term surgical and patient-reported outcomes of Hirschsprung Disease

BackgroundInformation is needed regarding the complex relationships between long-term functional outcomes and health-related quality of life (HRQoL) in Hirschsprung's Disease (HSCR). We describe long-term outcomes across multiple domains, completing a core outcome set through to adulthood.MethodsHSCR patients operated at a single center over a 35-year period (1978–2013) were studied. Patients completed detailed questionnaires on bowel and urologic function, and HRQOL. Patients with learning disability (LD) were excluded. Outcomes were compared to normative data. Data are reported as median [IQR] or mean (SD).Results186 patients (median age 28 [18–32] years; 135 males) completed surveys. Bowel function was reduced (BFS 17 [14–19] vs. 19 [19–20], p < 0•0001;$\eta$² = 0•22). Prevalence and severity of fecal soiling and fecal awareness improved with age (p < 0•05 for both). Urinary incontinence was more frequent than controls, most of all in 13–26y females (65% vs. 31%,p = 0•003). In adults, this correlated independently with constipation symptoms (OR 3.18 [1.4–7.5],p = 0.008). HRQoL outcomes strongly correlated with functional outcome: 42% of children demonstrated clinically significant reductions in overall PedsQL score, and poor bowel outcome was strongly associated with impaired QOL (B = 22•7 [12•7–32•7],p < 0•001). In adults, GIQLI scores were more often impacted in patients with extended segment disease. SF-36 scores were reduced relative to population level data in most domains, with large effect sizes noted for females in General Health (g = 1.19) and Social Wellbeing (g = 0.8).ConclusionFunctional impairment is common after pull-through, but bowel function improves with age. Clustering of poor functional outcomes across multiple domains identifies a need for early recognition and long-term support for these patients.     

Comparison of 2K and 4K imaging systems for laparoscopic repair of choledochal cyst in children

AimThe safety and success of laparoscopic choledochal cyst surgery (LapCC) depends upon two critical elements during the hepaticojejunostomy anastomosis (HJA). These may be termed the Difficulty of Differentiation (DOD) and the Difficulty of Suturing (DOS). The type of imaging system (2 or 4 K) used may influence either of these. We compared outcomes of LapCC using 2 or 4 K imaging systems.MethodsLapCC were performed at a single institution by the same team using a 2 K system (2009–2018; n = 26) and a 4 K system (2018–2019; n = 11) were compared. 4 K cases were chosen to match 2 K cases to minimize bias. Five independent senior pediatric surgeons scored DOD and DOS blindly from intraoperative video recordings of LapCC using a subjective 5-point scale (5: impossible, 4: difficult, 3: tedious, 2: slow, and 1: easy) and rated their over all impression as +1 if 4 K was better, 0 if they were the same, and -1 if 4 K was worse. Total HJA anastomosis time (TAT) and TAT/suture were also calculated.ResultsLapCC was performed in 37 age/weight/HJA diameter matched children. Scores for DOD (p<0.001) were lower with 4 K with less variance, although there was no difference in DOS (p = 0.08). Operative time (p = 0.03) and duration of hospitalization (p < 0.001) were significantly shorter with 4 K. 4 K was rated +1 unanimously. There was no difference in TAT (p = 0.17) and TAT/suture (p = 0.22).There was one HJA leak with 2 K (3.8%) and no complications with 4 K.ConclusionsImproved resolution with 4 K improved the progress of surgery as reflected by shorter operative time and duration of hospitalization, enhancing the performance of LapCC in children.Level of evidenceIII.     

Complications in the Management of Displaced Intra-articular Calcaneal Fractures: A Systematic Review and Network Meta-Analysis of 2538 Patients

The purpose of this study was to compare the complication risk of different treatments for displaced intra-articular calcaneal fractures (DIACFs). Randomized controlled trials comparing interventions for DIACFs were included: (1) interventions with conservative treatment, surgery with a minimally invasive approach (MIA) (sinus tarsi or small longitudinal), surgery with a percutaneous approach (PA) and open surgery with the extensive “L” lateral approach (ELA), and (2) complications and wound infections were also assessed. Twenty-six published trials met the inclusion criteria. The trials involved a total of 2538 patients surgically treated for acute DIACFs. For total complications, the mean incidence rate in the ELA was significantly higher than the rates in other treatments (conservative treatment vs ELA: odds ratio (OR), 0.36; p < .001; MIA vs ELA: OR, 0.23; p = .002; and PA vs ELA: OR, 0.18; p < .001). For wound infections, there were no significant differences among the groups (MIA vs PA: OR, 0.98; 95% CI, 0.32-3.01; p = .977; MIA vs ELA: OR, 0.45; 95% CI, 0.19-1.10; p = .081; and PA vs ELA: OR, 0.46; 95% CI, 0.19-1.11; p = .085). According to the surface under the cumulative ranking curve, the PA was most likely to be the best management for minimizing complications (surface under the cumulative ranking curve = 86.2). The ELA was significantly related to a higher risk of complications among all management methods. The PA was most likely to be the ideal choice when only complications were considered.     

The efficacy and safety of tranexamic acid in foot and ankle surgery: A systematic review and meta-analysis of comparative clinical studies

BackgroundA comprehensive review of the current evidence investigating the potential therapeutic effects of tranexamic acid (TXA) and its safety in foot and ankle surgery is provided in this research study.MethodsWe followed the PRISMA guidelines to conduct a systematic review on TXA administration in foot and ankle surgeries. MEDLINE/PubMed, EMBASE, SCOPUS, Web of Science, and Cochrane Library were searched comprehensively from inception to June 2022, as well as hand searching to include level I and III studies. A total of 970 records were reviewed, and seven comparative studies with a total of 514 patients were included in two groups: intervention (n = 257) and control (n = 257). Two studies used local TXA, and five studies used intravenous TXA. Three studies included calcaneal fractures, three included total ankle arthroplasty (TAA), and one had all ambulatory foot and ankle surgeries. Outcome variables were postoperative blood loss, hemoglobin change, and postoperative complications.ResultsPooled mean difference (MD) of postoperative blood loss after 24 h was ? 142.08 ml (95% CI, ?177.92 to ?106.24; P < 0.001; I² = 14%) showing a significant decrease in blood loss due to TXA use in both TAA and calcaneal fracture. Also hemoglobin drop was significantly lower in TXA group with a pooled MD of 0.56 g/dL (95% CI, 0.34–0.77; P < 0.001; I² = 73%). The odds ratio of wound complication after using TXA was 0.71 (95% CI, 0.42–1.21; P = 0.21; I² = 9.4%), revealing no significant correlation between TXA use and wound complications. Moreover our meta-analysis revealed no correlation between TXA use and thromboembolic events [OR = 0.67; P = 0.71; I² = 0% ).ConclusionsThe use of TXA has been demonstrated to reduce blood loss during foot and ankle surgery in an effective and safe manner. The optimum time of administration, optimum dosage, and the administration way (local vs. IV) should be researched in future studies.Level of evidenceIII     

Pull through for Hirschsprung disease without planned rectal decompression is safe

AimsDefinitive surgery for Hirschsprung disease (HD) is typically deferred to allow rectal washouts. In contrast, we have performed pull through on the next available operating list following diagnostic biopsy. Our aims are to compare outcomes of surgery without planned decompression vs. surgery where the timing of pull through was deferred.MethodsA consecutive series undergoing pull-through. Timing of surgery was at surgeon's discretion and classified as either no planned decompression surgery or other. Outcomes were i) complications graded >3b Clavien-Dindo (CD) within 30d, or ii) a need for a revisional pull through or iii) a post-pull-through stoma. We excluded total colonic aganglionosis.Results156 children (116 boys) underwent pull-through. 71 had surgery without planned decompression. The indications for timing in the other 85 were: planned after home washouts (n = 28), planned after stoma (n = 29), diagnostic error (n = 19), prematurity (n = 3), late presentation (n = 2) and other (n = 4). The mean age at surgery in the surgery without planned decompression group was 18 days (range 1–49 days) vs. 310 days (range 14–4084 days).5/72 (7%) undergoing surgery without planned decompression experienced a complication of ≥CD 3b, compared to 7/85 (8%) of delayed surgery (p = 0.8). 3/71 (4%) of the surgery without planned decompression group required a stoma following pull through compared to 11/83 (13%) of the delayed group (p = 0.059). 5/71 (7%) of the surgery without planned decompression group required revisional pull through compared to 13/85 (15%) of the delayed surgery group (p = 0.1).ConclusionsSurgery without planned rectal decompression for HD leads to no increase in significant complications, requirement for stoma or revision. Early definitive surgery is safe, and the use of pre-operative stoma or rectal washouts is not always necessary.Level of EvidenceIII