Fluoroscopy-based percutaneous posterior screw placement in the lateral position using the tunnel view technique: technical note

Purpose

Lumbar fusion using lateral single position surgery (LSPS) gained popularity during the last few years. While prone percutaneous pedicle screw placement is well described, placing percutaneous pedicle screws with the patient in the lateral position is considered the most complicated part of LSPS. In this article we describe the fluoroscopy navigated technique for lateral percutaneous screw placement using the tunnel view technique.

Methods

The radiologic background and principles of the tunnel view technique are described. In addition, the special positioning of the patient, the C-arm and the surgical technique is discussed in detail.

Results

This technique is used as the standard for percutaneous screw placement in the prone or lateral positions in our department since 2017. Since the introduction of this technique we have had 0% reoperation rate for symptomatic malpositioned pedicle screws.

Conclusion

The tunnel view technique simplifies pedicle screw placement while allowing for permanent observation of pedicle walls and the superior joint surface during placement of the Jamshidi needle. It also allows for confirmation of intrapedicular position of the screw after its implantation. This technique is safe and feasible in our clinical experience.

     

Lateral decubitus single position anterior posterior surgery improves operative efficiency,improves perioperative outcomes,and maintains radiological outcomes comparable with traditional anterior posterior fusion at minimum 2-year follow-up

BACKGROUND CONTEXTThe advantages of lateral single position surgery (LSPS) in the perioperative period has previously been demonstrated, however 2-year postoperative outcomes of this novel technique have not yet been compared to circumferential anterior-posterior fusion (FLIP) at 2-years postoperatively.PURPOSEEvaluate the safety and efficacy of LSPS versus gold-standard FLIPSTUDY DESIGN/SETTINGMulticenter retrospective cohort review.PATIENT SAMPLEFour hundred forty-two patients undergoing lumbar fusion via LSPS or FLIPOUTCOME MEASURESLevels fused, operative time, estimated blood loss, perioperative complications, and reasons for reoperation at 30-days, 90-days, 1-year, and 2-years. Radiographic outcomes included lumbar lordosis (LL), pelvic incidence (PI), pelvic tilt (PT), PI-LL mismatch, and segmental lumbar lordosis.METHODSPatients were grouped as LSPS if anterior and posterior portions of the procedure were performed in the lateral decubitus position, and FLIP if patients were repositioned from supine or lateral to prone position for the posterior portion of the procedure under the same anesthetic. Groups were compared in terms of demographics, intraoperative, perioperative and radiological outcomes, complications and reoperations up to 2-years follow-up. Measures were compared using independent samples or paired t-tests and chi-squared analyses with significance set at p<.05.RESULTSFour hundred forty-two patients met inclusion, including 352 LSPS and 90 FLIP patients. Significant differences were noted in age (62.4 vs 56.9; p≤.001) and smoking status (7% vs 16%; p=.023) between the LSPS and FLIP groups. LSPS demonstrated significantly lower Op time (97.7min vs 297.0 min; p<.001), fluoro dose (36.5mGy vs 78.8mGy; p<.001), EBL (88.8mL vs 270.0mL; p<.001), and LOS (1.91 days vs 3.61 days; p<.001) compared to FLIP. LSPS also demonstrated significantly fewer post-op complications than FLIP (21.9% vs 34.4%; p=.013), specifically regarding rates of ileus (0.0% vs 5.6%; p<.001). No differences in reoperation were noted at 30-day (1.7%LSPS vs 4.4%FLIP, p=.125), 90-day (5.1%LSPS vs 5.6%FLIP, p=.795) or 2-year follow-up (9.7%LSPS vs 12.2% FLIP; p=.441). LSPS group had a significantly lower preoperative PI-LL (4.1° LSPS vs 8.6°FLIP, p=.018), and a significantly greater postoperative LL (56.6° vs 51.8°, p = .006). No significant differences were noted in rates of fusion (94.3% LSPS vs 97.8% FLIP; p=.266) or subsidence (6.9% LSPS vs 12.2% FLIP; p=.260).CONCLUSIONSLSPS and circumferential fusions have similar outcomes at 2-years post-operatively, while reducing perioperative complications, improving perioperative efficiency and safety.     

Student attitudes toward the International Clinical and Professional Chiropractic Education Position Statement and Evidence-based practice: a survey of UQTR chiropractic students

ObjectiveThe aim of this study is to describe the attitude of Université du Québec à Trois-Rivières (UQTR) chiropractic students toward the International Clinical and Professional Chiropractic Education Position Statement and evidence-based practice (EBP) beliefs.MethodsA cross-sectional survey was administered to all the UQTR chiropractic students. Using a five-point Likert scale, students were asked to rate their level of agreement with the position statement (10 items), EBP (2 items), interprofessional collaboration (2 items) and vitalistic philosophy (2 items).ResultsSurvey response rate was 71%. Students most frequently reported strong agreement with the position statement, EBP and interprofessional collaboration. They also most frequently disagreed with vitalistic philosophy. The attitude toward the position statement was positively correlated with the year of study in the program (r=0.10, p=0.019), EBP (r=0.56, p<0.001) and interprofessional collaboration (r=0.45, p <0.001).ConclusionsUQTR chiropractic students demonstrate high levels of agreement with EBP and the Education Position Statement.     

Impact of previous lumbar spine surgery on the outcome of lumbar total disc replacement: analysis of prospective 5-year follow-up study data

Purpose

It is sometimes anticipated that patients with prior spine surgery will have a compromised outcome from future procedures. The purpose of this study was to compare TDR outcomes in patients with prior lumbar spine surgery to those with no previous surgery.

Methods

Post hoc analysis was performed on 5-year follow-up data collected prospectively in the multi-centre FDA-regulated trial for the activL® Artificial Disc which involved 376 patients treated for single-level symptomatic disc degeneration. Clinical outcome measures included the Oswestry Disability Index (ODI), visual analog scales (VAS) assessing back and leg pain, SF-36, adverse events, and re-operations. Radiographic outcomes included flexion/extension range of motion (ROM) and translation of the operated segment. Patients were divided into two groups: Prior Lumbar Surgery (PLS, n = 92) and No Prior Lumbar Surgery (NPLS, n = 284).

Results

Baseline demographics were similar in the two groups. ODI, VAS, and SF-36 Physical Component Scale scores improved significantly (p < 0.05) from baseline in both groups with improvements maintained through 5-year post-TDR with no significant differences between groups. There were no statistically significant differences in rates of serious device-related events, procedure-related events, or re-operations. While ROM was significantly less prior to TDR surgery in the PLS group, there was no significant difference in ROM at post-operative points.

Conclusion

Prior lumbar spine surgery was not associated with compromised outcomes following TDR. These results are in line with reports from earlier studies with shorter follow-up, finding that non-destabilizing prior surgery is not a contra-indication for TDR provided that selection criteria are met.

Level of Evidence I

Diagnostic: individual cross-sectional studies with the consistently applied reference standard and blinding.

     

Proton pump inhibitor prophylaxis after Roux-en-Y gastric bypass: A national survey of surgeon practices

BackgroundProton pump inhibitors (PPIs) are frequently used after Roux-en-Y gastric bypass (RYGB) to prevent marginal ulceration. The optimal duration of PPI treatment after surgery to minimize ulcer development is unclear.ObjectivesAssess bariatric surgeon practice variability regarding postoperative PPI prophylaxis.SettingSurvey of medical directors of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited centers.MethodsMembers of the American Society for Metabolic and Bariatric Surgery research committee developed and administered a web-based anonymous survey in November 2021 to bariatric surgeons of Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited programs detailing questions related to surgeons’ use of PPI after RYGB including patient selection, medication, dosage, and treatment duration.ResultsThe survey was completed by 112 surgeons (response rate: 52.6%). PPIs were prescribed by 85.4% of surgeons for all patients during their hospitalization, 3.9% for selective patients, and 10.7% not at all. After discharge, 90.3% prescribed PPIs. Pantoprazole was most often used during hospitalization (38.5%), while omeprazole was most prescribed (61.7%) after discharge. The duration of postoperative PPI administration varied; it was 3 months in 43.6%, 1 month in 20.2%, and 6 months in 18.6% of patients. Finally, surgeons’ practice setting and case volume were not associated with the duration of prophylactic PPI administration after RYGB.ConclusionsPPI administration practices vary widely among surgeons after RYGB, which may be related to the limited comparative evidence and guidelines on best duration of PPI administration. Large prospective clinical trials with objective outcome measures are needed to define optimal practices for PPI prophylaxis after RYGB to maximize clinical benefit.     

What is the value of 3D virtual reality in understanding acetabular fractures?

Background

Acetabular fractures are difficult to classify owing to the complex three-dimensional (3D) anatomy of the pelvis. 3D printing helps to understand and reliably classify acetabular fracture types. 3D-virtual reality (VR) may have comparable benefits. Our hypothesis is that 3D-VR is equivalent to 3D printing in understanding acetabular fracture patterns.

Methods

A total of 27 observers of various experience levels from several hospitals were requested to classify twenty 3D printed and VR models according to the Judet–Letournel classification. Additionally, surgeons were asked to state their preferred surgical approach and patient positioning. Time to classify each fracture type was recorded. The cases were randomized to rule out a learning curve. Inter-observer agreement was analyzed using Fleiss’ kappa statistics (κ).

Results

Inter-observer agreements varied by observer group and type of model used to classify the fracture: medical students: 3D print (κ = 0.61), VR (κ = 0.41); junior surgical residents: 3D print (0.51) VR (0.54); senior surgical residents: 3D print (0.66) VR (0.52); junior surgeons: 3D print (0.56), VR (0.43); senior surgeons: 3D print (κ = 0.59), VR (κ = 0.42).

Using 3D printed models, there was more agreement on the surgical approach (junior surgeons κ = 0.23, senior surgeons κ = 0.31) when compared with VR (junior surgeons κ = 0.17, senior surgeons 0.25). No difference was found in time used to classify these fractures between 3D printing and VR for all groups (P = 1.000).

Conclusions

The Judet–Letournel acetabular classification stays difficult to interpret; only moderate kappa agreements were found. We found 3D-VR inferior to 3D printing in classifying acetabular fractures. Furthermore, the current 3D-VR technology is still not practical for intra-operative use.

     

Employment search,initial employment experience,and career preferences of recent pediatric surgical fellowship graduates: An APSA survey,part of the right child/right surgeon initiative

BackgroundAPSA's Right Child/Right Surgeon Initiative addresses issues concerning patient access to appropriate pediatric surgical care and workforce distribution. The APSA Workforce Committee sought to understand the experiences and motivations of recent graduates of Pediatric Surgery Training Programs entering the workforce.MethodsUsing APSA membership databases, we identified members who completed fellowship training from 2010 to 2019. An online survey was created using Survey Monkey, and invitations to participate were sent via email.Results144 of 447 invited participants responded (32% response rate). 91% of respondents participated in dedicated research prior to fellowship, but only 64% perform research during their employment. 23% completed an additional clinical fellowship, but only 54% currently practice within the second field. When asked to identify the top three factors used to choose a position, the most common responses were “location or geography” (71%), “available mentorship” (53%), and “compensation and benefits” (37%). Describing their first position, 77% reported working in an academic institution, 78% reported working in a metropolitan/urban area, and 55% reported working in a free-standing children's hospital. 94% participate in General Surgery resident education, and 49% are faculty within a Pediatric Surgery fellowship. Overall, 92% of respondents were able to find the type of employment position that they had wanted.ConclusionIn our survey the overwhelming majority of young pediatric surgeons found the type of job they desired. Most report beginning their practice in more populated, urban areas within academic institutions. Geographic location and work environment played heavily into their employment decisions. These preferences could contribute to continued disparity in access to pediatric surgeons between urban and rural America and to dilution of experience for urban surgeons. Possible solutions include alternative incentive programs for employment in less populated areas or new training models for general surgeons in rural areas to train in fundamentals of Pediatric Surgery.     

Nonhemorrhagic Cord Contusion After Percutaneous Fiducial Placement: Case Report and Surgical Recommendations

Abstract

Study Design: Single case report and extensive literature review.

Objectives: To present the first such report of cervical cord contusion after the percutaneous placement of gold-seed fiducials. The pathomechanics and surgical recommendations are reviewed.

Background: Spinal cord injuries are well documented in the medical literature. These injuries range from cord contusion to transection and result primarily from trauma. A single case report of a patient who was found to have a nonhemorrhagic cervical spinal cord contusion after percutaneous fiducial implantation is presented.

Methods: Single case report.

Results: The patient underwent percutaneous placement of fiducials for stereotactic radiosurgery for a nerve sheath tumor. Postoperatively she had primarily sensory complaints; no motor deficits were detected on neurological examination. Neuroimaging studies demonstrated nonhemorrhagic cervical cord contusion. She was treated conservatively and had complete resolution of her symptoms.

Conclusions: The likely mechanism for the contusion was neck hyperextension during thrusting maneuvers during fiducial implantation. This is yet another report of normal intraoperative-evoked potentials with postoperative neurological sequelae. A dedicated team approach involving ancillary staff, anesthesiologists, and surgeons should be utilized to avert this potentially devastating complication.     

The role of occlusion and micro-incontinence in the pathogenesis of penile lichen sclerosus: an observational study of pro-inflammatory cytokines’ gene expression

Purpose

To assess the expression of selected cytokines in penile lichen sclerosus (PLS) and associate them with the occurrence of micro-incontinence (MI) in different stages of PLS.

Methods

The skin biopsies from 49 PLS affected, and 13 from nonlesional foreskins (healthy control adult males undergoing circumcision due to phimosis caused by short frenulum) were obtained. All specimens were used for RNA extraction and RT-qPCR. Quantitative assessment of the gene expression of interleukin 1-A (IL-1A), interleukin 1-B (IL-1B), interleukin 1 receptor antagonist (IL-1RN), interleukin 6 (IL-6), transforming growth factor β1 (TGF-β1), and interferon-gamma (INF-γ) was performed. To determinate the presence of MI, the patients were asked about voiding patterns, especially leaking tiny drops of urine from the urethral meatus after urination.

Results

IL-1A, IL-6, and INF-γ mRNA levels were approximately 150, 16, and 59 times higher in PLS than in control samples, respectively. The highest IL-1A mRNA levels were observed in early PLS (n?=?13), INF-γ in moderate PLS (n?=?32), while IL-6 in severe PLS (n?=?4). MI was noted in 45 PLS patients vs. 0 in control (p?<?0.0001). IL-1A and IL-6 vs control ratios were concentration (ca.) 400 and 30 times higher, respectively, in MI PLS samples than in PLS without MI.

Conclusion

Occlusion and irritating urine effect are associated with the clinical progression of penile LS with increased mRNA expression of IL-1A, INF-γ, and IL-6 pro-inflammatory cytokines in the foreskin.

     

Malleolar tips as reference points for positioning of syndesmotic screw: A preliminary CT based analysis

PurposeThe risk of malpositioning of the syndesmotic screws is very high. A lack of standard radiological or physical references for accurate syndesmotic screw placement is a potential contributing factor in syndesmotic screw malpositioning. Malleolar tips are clinically as well as radiologically appreciable bony references. The purpose of this preliminary CT based study was to investigate the axial relations of the central syndesmotic axis with the malleolar tips.MethodsCT based studies of uninjured adult ankle joints with intact syndesmosis, conducted over a six months period were analysed. The axial differences between the coronal plane along the malleolar tips and that along the central syndesmotic axis in the axial plane were measured. Gender-based variations were also analyzed.ResultsA total of 70 CT studies were analyzed, and the axial difference between the malleolar tips based coronal plane and that along the central syndesmotic axis was observed to be 3.70 ± 5.61°. The male and female measurements were comparable.ConclusionBeing in a static relation to the syndesmosis independent of the foot position and the limb rotation, the malleolar tips can be reliably used as references for directing syndesmotic screw in the axial plane. A knowledge of this axial difference between malleolar tips and central syndesmotic axis can help surgeons in an accurate syndesmotic screw placement.     

Hepatic artery pseudoaneurysm,bronchobiliary fistula in a patient with liver trauma

Background

A wide variety of hemostats are available as adjunctive measures to improve hemostasis during surgical procedures if residual bleeding persists despite correct application of conventional methods for hemorrhage control. Some are considered active agents, since they contain fibrinogen and thrombin and actively participate at the end of the coagulation cascade to form a fibrin clot, whereas others to be effective require an intact coagulation system. The aim of this study is to provide an evidence-based approach to correctly select the available agents to help physicians to use the most appropriate hemostat according to the clinical setting, surgical problem and patient’s coagulation status.

Methods

The literature from 2000 to 2016 was systematically screened according to PRISMA [Preferred Reporting Items for Systematic Reviews and Meta-Analyses] protocol. Sixty-six articles were reviewed by a panel of experts to assign grade of recommendation (GoR) and level of evidence (LoE) using the GRADE [Grading of Recommendations Assessment, Development and Evaluation] system, and a national meeting was held.

Results

Fibrin adhesives, in liquid form (fibrin glues) or with stiff collagen fleece (fibrin patch) are effective in the presence of spontaneous or drug-induced coagulation disorders. Mechanical hemostats should be preferred in patients who have an intact coagulation system. Sealants are effective, irrespective of patient’s coagulation status, to improve control of residual oozing. Hemostatic dressings represent a valuable option in case of external hemorrhage at junctional sites or when tourniquets are impractical or ineffective.

Conclusions

Local hemostatic agents are dissimilar products with different indications. A knowledge of the properties of each single agent should be in the armamentarium of acute care surgeons in order to select the appropriate product in different clinical conditions.

     

An international survey of pelvic trauma surgeons on the management of pelvic ring injuries

IntroductionThere exists substantial variability in the management of pelvic ring injuries among pelvic trauma surgeons. The objective of this study was to perform a comprehensive survey on the management of pelvic ring injuries among an international group of pelvic trauma surgeons to determine areas of agreement and disagreement.MethodsA 45-item questionnaire was developed using an online survey platform and distributed to 30 international pelvic trauma surgeons. The survey consisted of general questions on the acute management of pelvic ring injuries and questions regarding 5 cases: Lateral compression (LC) type 1 injury, LC-3, Anterior-posterior compression (APC) type 3 injury, a combined vertical shear (VS) injury through the sacrum, and VS injury through sacroiliac joint. Respondents were shown blinded anteroposterior pelvis radiographs and axial computed tomography (CT) images for each case and asked if the injury needed fixation, the type of fixation, the order of fixation, and postoperative weight-bearing status. The Kappa statistic was calculated to assess agreement between respondents for each question.ResultsNineteen out of 30 pelvic trauma surgeons completed the survey. Respondents practiced in Brazil (n = 1), Germany (n = 1), India (n = 1), Italy (n = 1) United Kingdom (n = 1), and the United States (n = 14). Of the 45 questions in this survey, 38 (84%) had minimal to no agreement among the respondents. There was moderate agreement, for performing lumbopelvic fixation when indicated, for anterior and posterior fixation of the LC-3 injury, and on forgoing EUA or stress X-rays for the APC-3 injury. There was strong agreement for open reduction and internal fixation of the anterior pelvic ring in the APC-3 injury and the VS injury through the SI joint. In contrast, LC-1 injury and combined VS pelvic ring injury through the sacrum had no areas of moderate to strong agreement.DiscussionThis study identified specific areas of pelvic ring injury management with minimal to no agreement among pelvic trauma surgeons. Future research should target these areas with a lack of agreement to decrease practice variability and improve patient outcomes.     

Survey of hand surgeons’ and therapists’ perceptions of the benefit of common surgical procedures of the hand

Objective: The objectives of this survey were (1) to study if surgeons’ perceptions of the benefit of six surgical procedures differ if they consider themselves as patients instead of treating a patient, (2) to evaluate the role of five predetermined factors that may influence decision-making, and (3) to assess how uniformly hand surgeons and hand therapists perceive the benefits of the surgical treatments.

Methods: The members of the national societies for Hand Surgery and Hand Therapy were asked to participate in the survey. Six patient cases with hand complaint (carpal tunnel syndrome, flexor tendon injury, dorsal wrist ganglion, thumb amputation, boxer’s fracture, and mallet fracture) and a proposed operative procedure were presented, and the respondents rated the procedures in terms of the expected benefit. Half of the surgeons were advised to consider themselves as patients when filling out the survey.

Results: A survey was completed by 56 surgeons (61%) and 59 therapists (20%). Surgeons who considered themselves as patients had less confident perception on the benefit of carpal tunnel release compared with surgeons, who considered treating patients. Hand surgeons and hand therapists had similar perception of the benefits of surgery. The expected functional result was regarded as the most important factor in directing the decision about the treatment.

Conclusions: Surgeons tended to be more unanimous in their opinions in cases, where there is limited evidence on treatment effect. The agreement between surgeons and therapists implies that the clinical perspectives are similar, and probably reflect the reality well.     

Documentation of fracture severity with the AO classification of pediatric long-bone fractures

Background?The AO comprehensive pediatric longbone fracture classification system describes the localization and morphology of fractures, and considers severity in 3 categories: (1) simple, (2) wedge, and (3) complex. We evaluated the reliability and accuracy of surgeons in using this rating system.

Material and methods?In a first validation phase, 5 experienced pediatric (orthopedic) surgeons reviewed radiographs of 267 prospectively collected pediatric fractures (agreement study A). In a second study (B), 70 surgeons of various levels of experience in 15 clinics classified 275 fractures via internet. Simple fractures comprised about 90%, 99% and 100% of diaphyseal (D), metaphyseal (M), and epiphyseal (E) fractures, respectively.

Results?Kappa coefficients for severity coding in D fractures were 0.82 and 0.51 in studies A and B, respectively. The median accuracy of surgeons in classifying simple fractures was above 97% in both studies but was lower, 85% (46–100), for wedge or complex D fractures.

Interpretation?While reliability and accuracy estimates were satisfactory as a whole, the ratings of some individual surgeons were inadequate. Our findings suggest that the classification of fracture severity in children should be done in only two categories that distinguish between simple and wedge/complex fractures.     

Status of venous thromboembolism prophylaxis among bariatric surgeons: have we changed our practice during the past decade?

BackgroundVenous thromboembolism (VTE) is considered one of the principal causes of morbidity and mortality in patients requiring bariatric surgery. A survey to all members of the American Society for Metabolic and Bariatric Surgery was conducted in 1998 and published in 2000 in the journal “Obesity Surgery.”MethodsA survey was repeated to all physician members of the American Society for Metabolic and Bariatric Surgery to determine the current practices for VTE prophylaxis. The results were compared with those of the previous study.ResultsOf the members, 35% completed the survey for a total of 332 responses. The number of cases annually per surgeon almost doubled since 1998 (145 versus 85). Laparoscopic gastric bypass has replaced open gastric bypass as the most common procedure performed, followed by laparoscopic gastric banding as the second most common procedure. Most surgeons (95%) use chemical prophylaxis to prevent VTE, but almost 60% preferred low-molecular-weight heparin compared with 13% in 1998. More than 60% of bariatric surgeons discharged their patients with chemical prophylaxis compared with 12% in 1998. Inferior vena cava filters for prophylaxis are considered by 55% compared with only 7% in 1998. The incidence of reported deep vein thrombosis was significantly lower in 2007 (2.635 versus .93), as was the incidence of pulmonary embolism (.95% versus .75%). Almost 50% of surgeons still reported ≥1 fatality because of VTE complications.ConclusionChemical prophylaxis for VTE with some type of heparin is the standard of care for patients undergoing bariatric surgery. Low-molecular-weight heparin is now used by two thirds of the respondents to this survey. Most surgeons who responded to the survey discharged their patients home with heparin, and many consider the use of inferior vena cava filters for VTE prophylaxis. Our findings support the American Society for Metabolic Bariatric Surgery position statement regarding VTE prophylaxis in this patient population. Research is necessary to establish the role of inferior vena cava filters, discharging patients with chemoprophylaxis and to determine the adequate dosage and duration of prophylaxis.     

Pediatric laparoscopic appendectomy: a population-based study of trends,associations, and outcomes

PurposeWe performed a population-based study to analyze the trends, associations, and outcomes of laparoscopic appendectomy (LA) in the Canadian universal health care setting.MethodsChildren younger than 18 years coded for urgent appendectomy in the discharge abstract database of the Canadian Institute of Health Information during 2004–2010 were analyzed. The Cochran–Armitage test, logistic regression, and quintile regression were used to perform the necessary analyses.Results41,405 children were studied. LA incidence steadily increased from 28.8% to 66.4%, p < .0001. Conversion rates significantly decreased, while LA for perforated appendicitis significantly increased. LA occurred significantly less in younger patients [OR 0.24 (< 5 years), OR 0.45 (6–11 years)], males [OR 0.79], and operations by a general surgeon [OR 0.33]. Rural domicile, socioeconomic status, and hospital type had no effect. LA decreased hospital stay for simple appendicitis by one day beginning in 2006, and by variable durations for perforated appendicitis throughout the study period.ConclusionsThe incidence of LA in Canada has more than doubled. Older children, females, and patients treated by pediatric surgeons are more likely to receive LA, while domicile, socioeconomic status, and hospital type have no effect. LA reduced hospital stay for both simple and perforated appendicitis.     

Temporal trends in ileoanal pouch surgery for paediatric onset ulcerative colitis in England from 1997 to 2015 using hospital episode statistics

IntroductionIleal pouch-anal anastomosis (IPAA) following colectomy for ulcerative colitis (UC) achieves restoration of intestinal continuity with potential return of continence. It is undertaken relatively infrequently in children. We aimed to investigate the national frequency of IPAA in paediatric UC and report outcomes useful for surgeon/centre benchmarking.MethodsHospital Episode Statistics data were obtained for all admissions in England (1997–2015) in children (< 18 years) who underwent IPAA for UC using OPCS-4 procedural codes. Surgeon specialty, readmission, and reoperation rates were identified. Data are median (interquartile range).ResultsUC was diagnosed in 7604 children in whom 346 (4.6%) underwent IPAA at age 15 [13], [14], [15], [16], [17] years. Laparoscopy was used in 55 (15.9%) cases and in the most recent 10 years more commonly by specialist paediatric surgeons (SPS) than general surgeons (GS) (34.3%vs14.7%, p = 0.001). National frequency of IPAA ranged from 12 to 34 annually. Where specialty was available, 95/342 (57%) cases were undertaken by GS and 147/342 (43%) cases by SPS. The proportion of cases undertaken by SPS increased significantly compared to GS over the study period, p = 0.0003. Post-operative length of stay was 8 [6], [7], [8], [9], [10], [11] days. During the index admission, unplanned return to theatre was required in 25/346 (7.2%). Following discharge 58 (16.8%) were readmitted within 30 days. Overall return to theatre rate within 30 days of pouch surgery was 11.0% (38/346).ConclusionIPAA for UC within childhood is undertaken infrequently in England, with a shift towards SPS undertaking surgery. These data can be used by surgeons to benchmark outcomes.Level of EvidenceIV.     

剪切波弹性成像对食管静脉曲张的诊断价值

目的探讨剪切波弹性成像技术(SWE)对食管静脉曲张(EV)严重程度和破裂出血的诊断价值。方法对临床确诊的103例肝硬化患者行超声、内镜及实验室检查,分析性别、年龄、体质量指数(BMI)、肝功能Child-Pugh分级、肝硬度(LS)、LS×脾长径与血小板(PLT)比值指数(LSPS)、血小板与天冬氨酸氨基转移酶比值指数(APRI)、脾硬度(SS)对有无EV、低危和高危EV、有无EV破裂出血的预测价值,并进行相关性分析。结果有EV与无EV肝硬化患者之间,Child-Pugh分级、LSPS、APRI、LS、SS差异均有统计学意义(P均0.05),LS、SS是诊断EV的独立影响因素。LSPS、APRI、LS、SS诊断EV的AUC为0.84、0.79、0.83和0.89。低危和高危EV患者Child-Pugh分级、LS、SS差异有统计学意义(P均0.05);有无EV破裂出血患者SS差异有统计学意义(P0.01),SS为预测高危EV及有无EV破裂出血的独立影响因素。有无EV与Child-Pugh分级相关性较弱(r=0.35,P0.05),与LSPS、APRI、LS相关性中等(r=0.52、0.45、0.51,P均0.05),与SS相关性较强(r=0.61,P0.05)。结论 SWE对肝硬化患者EV严重程度和破裂出血有较高价值,可作为预测EV分级和破裂出血的无创检查技术。SS对EV的诊断价值高于LS。