William G. Lee, MD - Best of the Best in Pediatric Surgery 2024

All right. And now we move on to our last presentation of the last heat of the day. It's another presentation from AAP by Doctor William G. Lee, uh, titled Sex-based Disparities in the Management of Pediatric goadal Torsion. So let's see it. Good morning. Thank you to the selection committee for the opportunity to present our work. I have no disclosures. Gonadal torsion commonly affects the adolescent population where timely surgical intervention is critical in preserving long-term fertility. In an effort to standardize expedited care for testicular torsion, in GA 2015, the US News and World Report implemented a national quality metric encouraging children's hospitals to expedite patients with suspected testicular torgy to the OR in under 4 hours. This led to the introduction of expedited clinical pathways for testicular torsion and subsequently increased testicular salvage rates. However, despite the benefits observed in testicular torsion, national quality metrics for the expedited management of ovarian torsion are lacking. In addition, since the implementation of the National Quality Metric artistic torsion, no prior studies have evaluated the trends of time to operative intervention for children with ovarian torsion. Thus, the objective of this study was to evaluate trends in time to OR both before and after national quality metric implementation for both male and female children with suspected gonallop portion. We hypothesized that post-quality metric implementation, the top to OR would decrease in male children but remain unchanged for female children. To study this, we performed a civil center retrospective cohort study of children who presented with suspected enamel torsion and underwent surgery during this time period. The primary outcome was defined as time for patient presentation to the medical center to patient entrance into the OR. Our secondary outcome was defined as skenatal detortion without orchiectomy or oophorectomy. As the quality metro artistic retorsion was implemented in June of 2015, we evaluated trends in animal median time to OR by performing an interrupted time series analysis using G 2015 as an intervention time one. In addition, by varied analysis of the ovarian torsion coord was also performed to evaluate the potential impact of a known enlarged ovary greater than 5 centimeters of time of hospital intake on the primary and secondary albums of interest. We excluded patients who underwent surgery for any indication other than suspected grenadal torsion. Over the 9-year study period, 216 patients were included in the testicular torsion cohort, and 1920 patients were included in the ovarian torsion cohort. In the testicular torsion cohort, median age was 13 years, with the majority of patients presenting with testicular pain and or scrotal swelling. Post-quality metric implementation, we observed an increase in patients reporting symptoms of nausea and emesis and a decrease in scrotal swelling, but there was otherwise no difference in patient demographic with clinical characteristics pre versus post-quality metric. In the ovarian torsion cohort, the median age was also 13 years, and the majority of patients presented with abdominal pain, nausea, and nemesis, and there was also no difference in patient characteristics pre versus post-quality metric. For the testicular torsion cohort, overall median time to OR was factored at 47 minutes. After implementation of the National Quality metric for testicular torsion in June of 2015, an interrupted time series analysis revealed a significant decrease in median year to year time to OR by 27.8 minutes per year. In addition, the variation in time to OR demonstrated by the interquartile range also decreased pulse quality metric. For the ovarian torsion cohort. Overall median time to OR was 462 minutes, and following quality metric implementation particular torsion, there was no significant change in time to OR. In addition, the variation in time to OR remained unchanged. Over the nine year study period, we also evaluated the rates of gonadal salvage in comparing patients who underwent gonadal salvage to those that did not. For testicular torsion, patients who avoid the orchiectomy have a significantly shorter median time to OR. However, for ovarian torsion, we did not observe a significant difference in pampda or between patients who underwent oophorectomy and those that did not. Lastly, by varied analysis of the ovarian torsion cohort was also performed to compare patients with the M and pre-hospital enlarged ovary to those without. Patients with a known enlarged ovary were found to experience a shorter medium time to OR, but this ultimately did not affect rates of ovarian salvage. In summary, following implementation of a national quality metric to expedite surgical care and testicular torsion, we observed a significant decrease in time to OR for patients with suspected testicular torsion. However, patients with suspected ovarian torsion did not experience similar expedited surgical care. We also found that a shorter time to OR was associated with the female patients with a known enlarged ovary, which consisted of 52% of our female cohort. However, there was no significant association between time to OR and ovarian salvage which may be confounded by an overall trend toward ovary sparing surgery during this time period at our institution. In conclusion, this study highlights the benefit of a national quality metric in expediting surgical care in gonado torging, as well as the sex-based disparity in the urgent surgical treatment of female children presented with suspect to gonadotorgine. As we work towards a national polling metric for ovarian torsion, prospective longitudinal studies on patients with ovarian torsion are needed to further elucidate the effect of symptom duration and expedite surgical care on long-term metrics of fertility, such as successful pregnancy and line birth rates. However, we feel that we can do better for our patients with ovarian torsion by implementing QI initiatives which may expedite the referral, evaluation, imaging, and surgical care pathways, especially in patients with a known history of an enlarged ovary. I'd like to thank my mentor and Project PR Deson Marie and Kelly Kuan for her guidance with this project. Thank you very much. I'll be happy to take any questions. Awesome. I actually have a, uh, couple of quick questions. Number one, in this study were the, um, surgeons, uh, who did the testicles, urologists and the surgeons who did the ovary, pediatric general surgeons, or were they the same cohort of surgeons? Yeah, thanks so much for that clarifying question. Um, yes, you're absolutely correct. The ones who did the testicular torsions were pediatric urologists, and then pediatric surgeons, um, did the ovarian torsion. Different surgeons, different, um, cri criteria of how they do things in their, uh, in their literature. The second question is, um, would you, in general, is testicular torsion more easily diagnosed than ovarian torsion? Yeah, that's, that's one of the main discrepancies that's described in the literature between ovarian torsion and testicular torsion. Um, it's difficult to compare them apples to apples because they are very different, um, as far as their diagnostic and evaluation and management. Um, uh, males, they often present earlier, um, due to the external site of the gonad, uh, their image and expedited to the OR quickly. Um, or more rapidly compared to ovarian torsion as well. That's well described in the literature. Um, and ovarian torsion is when we see these consults, you know, the symptoms are often non-specific. Abdominal pain, nausea, and emesis were the most common in the study. And the internal location of the ovary also has diagnostic overlap with alternative intraabdominal pathologies that are more common, such as appendicitis. Um, And then the process of imaging and the sensitivity of imaging is also different as well. Um, you know, the sensitivity for, uh, ovarian torsion for absent flow is anywhere from 40 to 73%. And then for a negative or I'm sorry, a positive read, um, meaning concerning for ovarian torsion or cannot exclude the sensitivity is only 51%. Um, and so compared. But two directly is, is, I don't think appropriate. But I think that what we've been learning from this study is that implementing quality metrics to help um improve uh care overall has worked for testicular torsion and something we can learn from to improve the care of our female patients. We just have to make sure the, the problem with ovarian torsion is we have to find that balance because we looked at a couple of the, the, the negative laparoscopy rate is very high, uh, because you can't rule it out. So we go in and we look all the time and we have a very, very high negative rate across the country. So we have to figure out how to, how to do better for the, for the ovaries without overindexing on the uh aggressive surgery side either. So it's, it's a great study. It's very provocative and it, it points out a lot of uh ways we could do better. So thanks for presenting that. Yeah, thank you very much for the opportunity.