Use of VA ECMO and percutaneous palliation of ductal dependent coarctation in a neonate with trisomy 21 and COVID-19 pneumonia

We present a case of a neonate with trisomy 21, ductal-dependent aortic coarctation, and severe respiratory failure secondary to coronavirus disease 2019 (COVID-19) pneumonia. The neonate was managed with venoarterial extracorporeal membrane oxygenation (VA ECMO), palliative stenting of the coarctation, and a vascular plug occlusion of a large patent ductus arteriosus. The patient was successfully weaned off extracorporeal membrane oxygenation (ECMO). The patient is currently awaiting a definitive surgical repair in the near future.     

Natural language processing and entrustable professional activity text feedback in surgery: A machine learning model of resident autonomy

BackgroundEntrustable Professional Activities (EPAs) contain narrative ‘entrustment roadmaps’ designed to describe specific behaviors associated with different entrustment levels. However, these roadmaps were created using expert committee consensus, with little data available for guidance. Analysis of actual EPA assessment narrative comments using natural language processing may enhance our understanding of resident entrustment in actual practice.MethodsAll text comments associated with EPA microassessments at a single institution were combined. EPA—entrustment level pairs (e.g. Gallbladder Disease—Level 1) were identified as documents. Latent Dirichlet Allocation (LDA), a common machine learning algorithm, was used to identify latent topics in the documents associated with a single EPA. These topics were then reviewed for interpretability by human raters.ResultsOver 18 months, 1015 faculty EPA microassessments were collected from 64 faculty for 80 residents. LDA analysis identified topics that mapped 1:1 to EPA entrustment levels (Gammas >0.99). These LDA topics appeared to trend coherently with entrustment levels (words demonstrating high entrustment were consistently found in high entrustment topics, word demonstrating low entrustment were found in low entrustment topics).ConclusionsLDA is capable of identifying topics relevant to progressive surgical entrustment and autonomy in EPA comments. These topics provide insight into key behaviors that drive different level of resident autonomy and may allow for data-driven revision of EPA entrustment maps.     

A single institution experience with Laparoscopic Hernia repair in 791 children

IntroductionThere are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.MethodsA retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.Results791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41).In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.ConclusionsThe use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.     

Posterior Ankle Decompression With Os Trigonum or Stieda Process Resection in Dancers: Case Series Report and Review of the Literature

This case series reports the outcome of posterior ankle decompression and os trigonum or Stieda process resection utilizing an open posterolateral approach in 54 professional, pre-professional, and dedicated recreational dancers. All procedures were performed by a single surgeon at the same facility between 2008 and 2018. The surgical technique is described in detail. Data related to results of the surgery were gathered via follow-up questionnaire and verified by referencing the patients’ medical records. Outcomes were self-assessed in terms of categories ranging from excellent through moderate to poor. Eighty-nine percent of the dancers (N = 48 of 54) chose excellent or good, 11% (N = 6) chose moderate, and none selected poor. These results were compared with those achieved in 17 previous studies reporting the use of both open (posterolateral and posteromedial) and arthroscopic/endoscopic techniques in dancers. This comparison found similarly favorable reported outcomes, but also great variation in methodology for determining patient reported outcomes (PROs). While the preferred surgical technique for posterior ankle decompression remains controversial, the open posterolateral approach utilized in this series resulted in high expectation of return to dance with minimal complications. The need for a dancer-specific PRO tool is discussed.     

Sentinel Node Biopsy Should Not be Routine in Older Patients with ER-Positive HER2-Negative Breast Cancer Who Are Willing and Able to Take Hormone Therapy

Annals of Surgical Oncology - The SSO Choosing Wisely campaign recommended selective sentinel lymph node biopsy (SLNB) in clinically node-negative women aged ≥ 70 years with ER+ breast...     

Biliary disease and cholecystectomy after initiation of elexacaftor/ivacaftor/tezacaftor in adults with cystic fibrosis

Individuals with cystic fibrosis (CF) have an increased risk for gallbladder abnormalities and biliary tract disease, but the reported incidence of these manifestations of CF varies widely in the literature. With the approval of elexacaftor/tezacaftor/ivacaftor (ELX/TEZ/IVA), increasing numbers of CF patients have been initiated on highly effective cystic fibrosis transmembrane regulator (CFTR) modulator therapy. While elevations in hepatic panel are known potential side effects of CFTR modulators, there have been no published cases of biliary disease or acute cholecystitis attributed to these medications. In this case series, we describe seven patients at two adult CF centers with biliary colic shortly after initiation with ELX/TEZ/IVA, six of whom required cholecystectomy.