Robotic technology is being utilized in multiple hepatobiliary procedures, including hepatic resections. The benefits of minimally invasive surgical approaches have been well documented; however, there is some concern that robotic liver surgery may be prohibitively costly and therefore should be limited on this basis. A single-institution, retrospective cohort study was performed of robotic and open liver resections performed for benign and malignant pathologies. Clinical and cost outcomes were analyzed using adjusted generalized linear regression models. Clinical and cost data for 71 robotic (RH) and 88 open (OH) hepatectomies were analyzed. Operative time was significantly longer in the RH group (303 vs. 253 min; p = 0.004). Length of stay was more than 2 days shorter in the RH group (4.2 vs. 6.5 days; p < 0.001). RH perioperative costs were higher ($6026 vs. $5479; p = 0.047); however, postoperative costs were significantly lower, resulting in lower total hospital direct costs compared with OH controls ($14,754 vs. $18,998; p = 0.001). Robotic assistance is safe and effective while performing major and minor liver resections. Despite increased perioperative costs, overall RH direct costs are not greater than OH, the current standard of care.

Introduction Safety concerns about the use of radiation-based imaging such as computed tomography (CT) in children have resulted in national recommendations to use ultrasound (US) for diagnosis of appendicitis when possible. We evaluated trends in CT and US use in a statewide sample and the accuracy of these modalities. Methods Patients ≤18 years old undergoing appendectomy in Washington State from 2008 to 2013 were evaluated for preoperative US/CT use as well as imaging/pathology concordance using data from the Surgical Care and Outcomes Assessment Program. Results Among 3353 children, 98.3% underwent preoperative imaging. There was a significant increase in the use of US first over the study period (p<.001). The use of CT at any time during the evaluation decreased. Despite this, in 2013 over 40% of children still underwent CT imaging. Concordance between US imaging and pathology varied between 40–75% at hospitals performing ≥10 appendectomies in 2013. Over one third (34.9%) of CT scans performed in evaluation of children with appendicitis were performed after an indeterminate US. Discussion While use of US as the first imaging modality to diagnose pediatric appendicitis has increased over the past five years, over 40% of children still undergo a CT scan during their preoperative evaluation. Causality for this persistence of CT use is unclear, but could include variability in ultrasound accuracy, lack of training, and lack of awareness of the risks of radiation-based imaging. Developing a campaign to focus on continued reduction in CT and increased use of high-quality ultrasound should be pursued.

Children and adolescents with renal cell carcinoma present with more advanced disease than those 21 to 30 years old. In patients younger than 21 years mortality was associated with the nonchromophobe histological subtype, stage 4 disease, government insurance and not undergoing surgery as first-line therapy.

Background There are safety concerns about the use of radiation-based imaging (computed tomography [CT]) to diagnose appendicitis in children. Factors associated with CT use remain to be determined. Methods For patients ≤18 years old undergoing appendectomy, we evaluated diagnostic imaging performed, patient characteristics, hospital type, and imaging/pathology concordance (2008–2012) using data from Washington State’s Surgical Care and Outcomes Assessment Program. Results Among 2538 children, 99.7% underwent pre-operative imaging. 52.7% had a CT scan as their first study. After adjustment, age >10 years (OR 2.9 (95% CI 2.2–4.0), Hispanic ethnicity (OR 1.7, 95% CI 1.5–1.9), and being obese (OR 1.7, 95% CI 1.4–2.1) were associated with CT use first. Evaluation at a non-children’s hospital was associated with higher odds of CT use (OR 7.9, 95% CI 7.5–8.4). Ultrasound concordance with pathology was higher for males (72.3 vs. 66.4%, p = .03), in perforated appendicitis (75.9 vs. 67.5%, p = .009), and at children’s hospitals compared to general adult hospitals (77.3 vs. 62.2%, p < .001). CT use has decreased yearly statewide. Conclusions Over 50% of children with appendicitis had radiation-based imaging. Understanding factors associated with CT use should allow for more specific QI interventions to reduce radiation exposure. Site of care remains a significant factor in radiation exposure for children.

Pediatric patients with NPC were more commonly black and presented more frequently with stage IV disease. Pediatric patients had a decreased mortality risk relative to adults, even after adjusting for covariables. Asian race was not associated with increased mortality in pediatric patients with NPC. Racial differences are not associated with an increased risk for mortality among pediatric patients.

Although total operative volume rebounded after implementation of DHR, diversity of operative experienced narrowed. The combined increase in alimentary and abdominal cases is nearly 13%, over a half-year's worth of operating in 5-year training programs. Bedrock general surgery cases-trauma, vascular, pediatrics, and breast-decreased. Laparoscopic operations have steadily increased. If the competence of current graduates has, in fact, diminished. Our analysis suggests that operative volume is not the problem. Rather, changing disease processes, subspecialization, reductions in resident autonomy, and technical innovation challenge how today's general surgeons are trained.

Although pediatric patients with head and neck melanoma present with similar tumor depth and more frequent nodal metastases than do adult patients, younger patients have higher overall survival.

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