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Introduction The disruption score is a new bibliometric tool that has recently been utilized to identify studies that are innovative and shift paradigms. We sought to identify and characterize the top 100 most disruptive publications in pediatric surgery. Methods The 100 most disruptive and cited publications in 17 pediatric surgery journals were identified from a validated dataset and linked with the iCite NIH tool. The top 100 most disruptive publications were reviewed to determine study design, clinical focus, and perceived contribution. Results The publications included in the top 100 list were more disruptive than 99.5% of the entire PubMed universe. Journal of Pediatric Surgery (n = 45) had the most articles included. There was a weak correlation between citation count and disruption score (r = 0.27). Retrospective cohort studies (38%), contributions in clinical outcomes (39%), technical/technological innovations (31%), clinical focus in trauma (18%), and disorders of the gastrointestinal tract (18%) were the most represented. The disruption score identified a unique subset of literature that has created new paradigms with long lasting influence and may be further applied as another tool to measure scientific impact. This wide array of literature highlights both technical and technological innovations as well as key moments in the history of pediatric surgery. Level of evidence V

The use of the laparoscopic approach to perform antireflux procedures has increased dramatically since its introduction in 1991. To date, no prospective randomized studies comparing open surgery to the minimal invasive approach in children have been reported. Many retrospective reviews and case series have demonstrated that laparoscopic antireflux procedures are safe and effective once the learning curve is achieved. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize the available evidence to identify the risks and benefits of laparoscopic antireflux procedures.

Pediatric empyema can be managed with a variety of modalities, and the evidence for an ideal management strategy is limited. Early or simple effusions can be treated with antibiotics alone or with drainage when respiratory distress occurs. Once fibrinopurulent empyema has developed, therapy may involve either chest tube placement with instillation of fibrinolytics or video-assisted thoracoscopic surgery with pleural decortication. In late or fibrotic empyema, an assumption persists that the fibrotic peel must be managed by decortication that can be done either thoracoscopically or through a minithoracotomy incision. This position paper is coauthored by the New Technology Committee of the American Pediatric Surgery Association. The goal is to discuss the ongoing controversies and summarize, in an evidence-based manner, the various treatment options and to suggest a reasonable therapeutic algorithm for the care of children with empyema.

Introduction Several studies have examined predictors of publication of research presented in scientific meetings in different disciplines. A tendency toward publishing studies with positive results has been described as "publication bias." Our objective was to determine the proportion of the studies that were published, time to publication, and factors that could predict publication in pediatric surgery. Methods The abstract books of the Canadian Association of Pediatric Surgeons and the American Pediatric Surgery Association meetings for 2001 to 2002 were reviewed. Data were gathered regarding the methodology and characteristics of each study. Case reports and editorials were excluded. A Medline search was then conducted to determine the publication status. Analysis using univariate and multivariate techniques was undertaken, comparing the difference between published and unpublished studies. Results Two hundred seven abstracts were reviewed. Of the 183 abstracts included, 118 (64.5%) were published. Most studies were published 1 year after presentation (93.2%). Presentation in the American Pediatric Surgery Association meeting and research originating from North America and reporting statistically significant results were significantly associated with subsequent publication on univariate analysis. The presence of statistically significant results was the only factor associated with successful publication on multivariate analysis (odds ratio, 3.3; confidence interval, 1.5-7.7). Conclusion The strong association between successful publication and the presence of statistically significant results point to the strong possibility of publication bias affecting decisions made about publishing research in the pediatric surgery.

A test strip has been developed for the detection of increased amounts of VMA and metanephrine in the urine. The strip is both inexpensive (less than 15 cents per strip) and simple to use, and is based on the color change of the LaBrosse spot test. It has an acceptable false positive incidence (1:400). It is suggested that such an approach would be useful in decreasing the mortality and morbidity associated with neuroblastoma in childhood, if such a strip were to be employed on a mass screening basis until the child is 7 yr of age. The test strip can also be currently used on a routine basis for follow-up examination in children with previously diagnosed neuroblastoma, and as a screening test for hypertensive patients with a potential for pheochromocytoma, regardless of age.

Purpose Rectal prolapse is a relatively common condition in infants and young children with a multifactorial etiology. Despite its prevalence, there remains clinical equipoise with respect to secondary treatment in pediatric surgery literature. We conducted a systematic review to evaluate methods of secondary treatment currently used to treat rectal prolapse in children. Methods We searched Pubmed, Medline, and Scopus with the terms “rectal prolapse” and “children” for papers published from 1990 to April 2017. Papers satisfying strict criteria were analyzed for patient demographics, intervention, efficacy, and complications. Procedures were grouped by like type. Pooled success rates were calculated. Results Twenty-seven studies documenting 907 patients were included. Injection sclerotherapy had an overall initial success rate of 79.5%. Ethyl alcohol seemed the best sclerosing agent due to a high first-injection success rate, low complication rate, and ready accessibility. Several perineal repairs were found, with operative success rates ranging from 60.8%–100%. Laparoscopic rectopexy with mesh was the most commonly reported transabdominal procedure and had an overall success rate of 96.1%. Postoperative complications from all procedures were comparable. Conclusion Though many secondary treatment options have been reported for rectal prolapse, sclerotherapy and laparoscopic rectopexy predominate in contemporary literature and appear to have high success and low complication rates. Level of Evidence IV.

BACKGROUND: The optimal age for endorectal pull-through (ERPT) surgery in infants with short-segment Hirschsprung disease varies, with a trend toward earlier surgery. However, it is unclear if the timing of surgery impacts functional outcomes. We undertook the present study to determine the optimal timing of ERPT in infants with short-segment Hirschsprung disease. METHODS: The NCBI PubMed database was searched for English-language manuscripts published between 2000–2019 analyzing functional outcomes for patient following the initial Soave ERPT for short-segment Hirschsprung disease. Raw data from these studies was obtained from the corresponding author for each manuscript. We combined data from these papers with our own institutional data and performed a meta-analysis. RESULTS: A total of 780 infants were included in our meta-analysis. Constipation occurred in 1.0–31.7%, soiling 1.3–26.0%, anastomotic stricture 0.0–14.6%, and anastomotic leak 0.0–3.4%. Regarding age at ERPT, younger infants at the time of initial corrective surgery had higher rates of soiling, stricture, and leak. On sub-group analysis, patients

Medical errors were largely concealed prior to the landmark report "To Err Is Human". The purpose of this systematic scoping review was to determine the extent pediatric surgery defines and studies errors, and to explore themes among papers focused on errors in pediatric surgery.The methodological framework used to conduct this scoping study has been outlined by Arksey and O'Malley. In January 2020, PubMed, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched. Oxford Level of Evidence was assigned to each study; only studies rated Level 3 or higher were included.Of 3,064 initial studies, 12 were included in the final analysis: 4 cohort studies, and 8 outcome/audit studies. This data represented 5,442,000 aggregate patients and 8,893 errors. There were 6 different error definitions and 5 study methods. Common themes amongst the studies included a systems-focused approach, an increase in errors seen with increased complexity, and studies exploring the relationship between error and adverse events.This study revealed multiple error definitions, multiple error study methods, and common themes described in the pediatric surgical literature. Opportunities exist to improve the safety of surgical care of children by reducing errors. Original Scientific Research Type of Study: Systematic Scoping Review Level of Evidence Rating: 1.

Background/Purpose Oesophageal Atresia (OA) is associated with co-existent anomalies. There is a controversy of literature pertaining to the risk (s) of intestinal malrotation. In order to guide management we critically evaluate the incidence of IM anomalies in OA newborns. Design MEDLINE and EMBASE databases were searched using keywords "(O)Esophageal Atresia and Malrotation/Associated Abnormalities/Associated Anomalies". Full texts of articles were screened if manuscripts exclusively reported patients with OA malrotation and/or associated anomalies. Larger case series (> 10patients) were included if abstract (s) showed that associated anomalies were systematically assessed. Full eligibility criteria required at least one case of malrotation in an OA index case. Data were collected on article type, number of patients and method (s) of diagnosis. Results 632 abstracts were screened of which 158 papers were analysed based on inclusion criteria-30 manuscripts documented the incidence (%) of malrotation. Incidence rate (s) were 0.5-13%. Malrotation was observed to have a higher incidence (10-44%) in OA babies with other gastrointestinal anomalies (VACTERL). Conclusion Newborns with OA appear to be at a higher risk (%) of having intestinal malrotation anomalies than healthy babies. Prospective studies are required to accurately quantify and define the ' true incidence ' of this association. Given the potential lethal consequences of midgut volvulus screening may be justified in OA babies. Consensus guidelines (DELPHI) exploring surgeons attitudes with regards management of ' asymptomatic malrotation ' disorders in OA newborns may further guide best practice.

Background Cloacal exstrophy (CE) is the most severe end of the Exstrophy-Epispadias Complex malformations spectrum. Improvements in postnatal management and well-established operative techniques have resulted in survival rates approaching 100%. This systematic review aims to define the prevalence of long-term active medical problems affecting CE patients after the first decade of life. Methods PubMed/Medline, Embase, Scopus, and ISI Web of Knowledge databases were used for the literature search. Original articles related to medical, surgical, and psychosocial long-term problems in CE patients >10 years of age were included in the study. Quality assessment of the articles was performed through the Newcastle-Ottawa Scale. Prevalence estimates and 95% CI were assessed for each outcome. Results Twelve studies were included. The most common long-term active problems identified were: urinary incontinence with a prevalence ranging from 9.1% to 85%; sexual function issues related to vaginal anomalies with a prevalence ranging from 8.3% to 71.3%, and uterine anomalies, with a prevalence from 14.3% to 71%; gender identity issues in 46, XY patients raised female had a prevalence from 11.1% to 66.7%. There is no documented history of paternity. Impairment of ambulatory capacity was recorded in 13.8% of patients. Only one paper studied psychological well-being, reporting significantly higher levels of depression among gender reassigned patients. Conclusions Teenagers and adults born with CE have well defined long-term problems compared to the general population. Recognition and expert management are crucial to improve care and quality of life during and after the transition into adulthood.

Background/Purpose The aim of this study was to develop a method of management of large omphalocele, with easily available inexpensive materials. The efficacy of using the plastic of urine collection bag and paper stapler, in creating the “silo” for the management of 3 newborns with such defects, were assessed. Methods All operations were done within 36 hours of birth. A silo was created with the plastic of a sterile urine collection bag, which was stapled with a paper stapler at its free margin. The omphalocele was gradually reduced every 24 to 48 hours, using the stapler, until the contents were reduced, when the abdominal wall was repaired. Results The mean time taken to close the abdominal defect was 34 days. All patients could be breast-fed from 48 hours after the first stage is done. Rooming in was done by day 7. None of the babies required assisted ventilation. Conclusion This method is simple and cost-effective, using minimally expensive, easily available materials.

Objective: Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery. Methods: A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted. Results: 257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615). Conclusion: Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration. Type of Study: Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III

Introduction The American Pediatric Surgical Association (APSA) travel fellowship was established in 2013 to allow pediatric surgeons from low- and middle-income countries to attend the APSA annual meeting. Travel fellows also participated in various clinical and didactic learning experiences during their stay in North America. Methods Previous travel fellows completed a survey regarding their motivations for participation in the program, its impact on their practice in their home countries, and suggestions for improvement of the fellowship. Results Eleven surgeons participated in the travel fellowship and attended the annual APSA meetings in 2013–2018. The response rate for survey completion was 100%. Fellows originated from 9 countries and 3 continents and most fellows worked in government practice (n = 8, 73%). Nine fellows (82%) spent > 3 weeks participating in additional learning activities such as courses and clinical observerships. The most common reasons for participation were networking (n = 11, 100%), learning different ways of providing care (n = 10, 90.9%), new procedural techniques (n = 9, 81.8%), exposure to a different medical culture (n = 10, 90.9%), and engaging in research (n = 8, 72.7%). Most of the fellows participated in a structured course: colorectal (n = 6, 55%), laparoscopy (n = 2, 18%), oncology (n = 2, 18%), leadership skills (n = 1, 9%), and safety and quality initiatives (n = 1, 9%). Many fellows participated in focused clinical mentorships: general pediatric surgery (n = 9, 82%), oncology (n = 5, 45%), colorectal (n = 3, 27%), neonatal care (n = 2, 18%) and laparoscopy (n = 2, 18%). Upon return to their countries, fellows reported that they were able to improve a system within their hospital (n = 7, 63%), expand their research efforts (n = 6, 54%), or implement a quality improvement initiative (n = 6, 54%). Conclusions The APSA travel fellowship is a valuable resource for pediatric surgeons in low- and middle-income countries. After completion of these travel fellowships, the majority of these fellows have implemented important changes in their hospital’s health systems, including research and quality initiatives, to improve pediatric surgical care in their home countries. Level of evidence This is not a clinical study. Therefore, the table that lists levels of evidence for “treatment study”, “prognosis study”, “study of diagnostic test” and “cost effectiveness study” does not apply to this paper.

The surgical morbidity and mortality (MM) conferences at a regional children's hospital achieved the goals of case by case peer review and education for trainees but provided limited data for trending and analysis. In 2019, an institution-wide effort was initiated to create an electronic case review system with the goals of improving event capture and real-time practice performance feedback. Surgical MM was migrated to this structured case review format to provide a platform for surgical performance improvement.An online secure database was created with a 3-step classification system based on Clavien-Dindo severity score, peer review, and causality fishbone analysis. The data entered were available in an interactive dashboard. Retrospective tabulation of the 2018 MM data was performed using the archived paper system used prior to 2019.For the calendar year of 2019, the division of pediatric surgery captured and categorized 193 complications in the case review system. The capture rate was 50 per 1000 surgical procedures. For a similar time frame in 2018, the capture rate was 35 per 1000 surgical procedures. The dashboard provided run charts of the incidence and types of complications by procedure and by surgeon. Similar trend data were not available in 2018. The dashboard output has made possible the creation of (non- risk adjusted) individual surgeon performance reports. The output has been used to direct process improvement projects and educational content.Creation of an online database with interactive dashboard has allowed surgical MM to evolve into a systematic case review that greatly facilitates quality improvement efforts. This system increased the event capture rate and provided novel practice performance feedback, resulting in process improvement projects and educational objectives predicated on the trending data. These electronic reporting tools are now available to all surgical divisions and represent a transformative approach to surgical case review.Retrospective Historical control; Quality improvement.Level III.

Pediatric patients with complex colorectal and genitourinary conditions often require coordinated multidisciplinary care; however, this coordinated care can be hard to structure and deliver. The purpose of this paper is to review the development and implementation of a multidisciplinary colorectal and pelvic health program, one year after the program's initiation.This is an observational retrospective 1-year study (10/1/2017 to 9/30/2018). In fiscal year (FY) 2018, a multidisciplinary colorectal and pelvic health program was initiated. The program development incorporated bimonthly team meetings, educational conferences, and initiation of three clinics: a complex colorectal and genitourinary reconstruction clinic, a bowel management clinic, and a colonic motility clinic. Conditions treated included complex anorectal and cloacal malformations, Hirschsprung disease, and idiopathic constipation. The fiscal year was selected to provide comparative administrative data after program implementation.During the study period, 121 patients underwent comprehensive collaborative evaluation of which 58 (47%) were new to the institution compared to 12 (19%) new patients in the previous year (p 0.001). In FY 2018, there were 130 procedures performed and 512 collaborative visits with an average of 47 visits per month. This was a 3.4-fold increase in visits compared to FY2017 (171 visits). Of the new patients, 60% (35/58), traveled a median of 181 miles, representing 33 statewide counties, and 4 states compared to a median of 93 miles in the previous fiscal year (p = 0.004).The development of a colorectal and pelvic health program is feasible and requires a collaborative approach, necessitating multiple service lines within an institution. Program creation and implementation can result in rapid institutional clinical growth by filling a local and regional need through coordinated multidisciplinary care.IV.

Background/Purpose Endoscopic dilatation of caustic esophageal stricture is the mainstay of therapy. The need for esophageal replacement has decreased over the past decades owing to advancement in techniques of dilatation. In this study, we aimed to assess our results of four-quadrant corticosteroid injection of impassable caustic esophageal strictures followed by a trial endoscopic dilatation. Methods During the period from June 2003 to May 2017, in 340 patients in whom a trial of endoscopic dilatation after corrosive ingestion failed, corticosteroid was injected in 4 quadrants at the site of the stricture in the same setting. After 2 weeks, another trial of endoscopic dilatation was done. Results Out of the 340 patients with failed first trial of endoscopic dilatation followed by four-quadrant corticosteroid injection, the second trial of endoscopic dilatation, after 2 weeks, was possible in 255 patients (75%). In the remaining 85 patients (25%), the endoscope could not pass and they were candidate for esophageal replacement. Conclusions Four-quadrant corticosteroid injection of impassable caustic esophageal stricture followed by endoscopic dilatation is a minor procedure which decreased the need of a major procedure to replace the injured esophagus. Type of the study Clinical research paper. Level of evidence Level III.

Introduction Budd–Chiari syndrome (BCS) is a rare condition affecting children. It is characterized by occlusion of venous outflow from liver at the level of hepatic veins (HV) or inferior vena cava (IVC). The management of BCS in children revolves around forming new collaterals for venous outflow or by elimination of blockage in the venous outflow tracts. These can be achieved by balloon venoplasty (BV), transjugular intrahepatic portosystemic shunting (TIPSS) or open shunt surgeries. Aim The aim of this study is to evaluate the management of BCS in children with balloon venoplasty as primary modality of treatment. Materials and methods This is a retrospective study which includes children diagnosed with BCS managed by balloon venoplasty by a single surgeon at a single institute. Once confirmed, the child was posted for balloon venoplasty and liver biopsy. When venoplasty was successful, child was subsequently heparinized and dose titrated. Routine follow up was mandated and dose adjustments were continued during follow up. In case of unsuccessful venoplasty, depending on the liver biopsy report, shunt procedure or liver transplantation is offered to patients. An algorithm was then designed for management of BCS in children. Results A total of 35 children who underwent evaluation of symptoms associated with Budd–Chiari syndrome were included in the study. Of all the children, 14 are alive and symptom free, 9 are deceased and 12 lost to follow up. Hepatic vein was the most common site of obstruction (85%), followed by both IVC and HV (15%). Overall, in 35 children, 26 had a successful balloon venoplasty, in 3 venoplasty was not done (2 spontaneous resolution and 1 died awaiting), in 6 it was unsuccessful (3 technical failures: 1 underwent TIPSS and 2 lost to follow up, 3 clinical failures: portocaval shunt for failed venoplasty). Conclusion Budd–Chiari syndrome is a rare condition affecting children. Balloon venoplasty as a primary modality of treatment for BCS is a promising option for management in children. Early and aggressive use of radiological intervention can help achieve recanalization in children. Type of study Clinical research paper. Level of evidence Level IV.

Purpose Antimicrobial resistance is a major concern that we are facing nowadays. This is due to antibiotic misuse and bacteria developing resistance to the commonly used antibiotics. This may lead to increased mortality and consumption of country resources. Implementation of an antimicrobial stewardship program [ASP] can limit the use of unnecessary antibiotics and subsequently decrease the infection rates with better patient outcome. We aimed to control antibiotic misuse, reduce infection rate, decrease drug costs, and reduce length of hospital stay in the ICU. Methods We conducted a prospective study on the surgical neonatal ICU [SNICU] over a period of 6 months divided into pre-implementation phase, followed by an ASP phase, in which we applied the antibiotic guidelines approved by the ASP committee. Data were collected in the two phases and analyzed for demographics, compliance with guidelines, prescribed antibiotics, lab investigations, surgical site infection [SSI], length of stay and patient outcome. Results Compliance to the guidelines was encountered in 86% and SSI rate decreased to 20%. Days of Therapy (DOT) per 1000 patient days showed a significant decrease in Ampicillin Sulbactam by 296 (p = 0.024), Imipenem by 220.34 (p = 0.024) and Vancomycin by 287.34 (p = 0.048). Drug cost showed a 1185.97 EGP decrease in the ASP period compared to the pre-implementation period (p = 0.714). Average LOS decreased in the ASP period by a mean difference of 2.5 (p = 0.027). Conclusion ASP implementation can control antibiotic misuse, decrease the medical care expenses and improve patient outcome. Type of study Clinical research paper. Level of evidence Level one.

Pediatric surgery remains the most competitive general surgery subspecialty. The authors suspected significant inflation in academic metrics since the last published paper. This study aimed to identify factors associated with applicant success in the match.After IRB approval, all applications to a single accredited pediatric surgery fellowship program were reviewed for match years 2014-2018. Matched and unmatched applicants were compared in an unadjusted and adjusted analysis.This training program received 414 of 425 total applications (97%). Match results were available for 388 (94%). Matched applicants were more likely to train in programs with pediatric surgery fellowships (64% vs. 28%) and to have dedicated research time (55% vs. 21%; all p 0.01). Matched applicants had more total publications (median: 12 vs. 7, p 0.01) and higher ABSITE scores (median: 64th vs. 59th percentile, p 0.01). Training in multiple programs negatively impacted the chance to match (p 0.01). The median number of publications per applicant increased over the study time period from 7 to 11 (p 0.01).The likelihood of matching into a pediatric surgery fellowship was related to the type of residency attended, dedicated research time, ABSITE scores, and number of publications. Overall, the total number of publications reported by all applicants increased.Retrospective Comparative Study.Level III.

Purpose With the wide application of immunologic reconstitution treatment, such as hematopoietic stem-cell transplantation (HSCT), most patients of inflammatory bowel disease (IBD) with immunodeficiency owing to monogenic abnormalities need surgical intervention during the course of treatment, which is quite different from traditional IBD surgery. The aim of this study was to generalize the surgical strategies as a part of comprehensive therapy for these rare diseases. Methods A retrospective study was conducted based on the clinical data of children with immunodeficiency-derived IBD who underwent surgical treatment in Children's Hospital of Fudan University between January 2015 and December 2017. Results A total of 18 patients with monogenic abnormalities were enrolled. The major surgical indications included 11 cases of acute or chronic intestinal obstructions, 4 refractory intestinal infections, and 3 pneumoperitoneum, while 12 cases had perforations noted during intraoperative exploration. All of the patients underwent varieties of enterostomies to divert the affected or obstructed intestine during the primary surgery. Wound infections or dehiscence occurred in 7 patients, and 2 patients underwent reoperations for adhesive intestinal obstruction and prolapse. Postoperatively, 15 patients survived, 13 of which achieved immune reconstitution through subsequent HSCT or immunoglobulin supplementation. In the second-stage surgery, a posterior sagittal approach rectal resection was performed in 5 patients with complex anorectal complications. Twelve patients had undergone stoma closure procedures. Conclusion Surgical intervention should be performed earlier because the perforations are usually insidious in monogenic IBD. Preventative enterostomies are suggested in preparation for HSCT among patients with severe anorectal complications. Wound infections are the most common complication after the primary operation. Posterior sagittal rectal resection is a good option for patients with complex anorectal complications. Type of study Clinical research paper. Level of evidence Level IV.

This paper intends to evaluate the association between Down Syndrome (DS) and postoperative medical and surgical complications and inpatient postoperative mortality in pediatric patients undergoing intestinal operations.The 2012 Kids' Inpatient Database was queried to compare short-term postoperative medical and surgical complications and in-patient mortality among patients with DS undergoing intestinal operations to a cohort without DS using inverse probability weighting. Subset analysis was performed for patients undergoing intestinal operations exclusive of gastrostomy placement. Adverse treatment effects were calculated for the outcomes of interest.Of 17,026 pediatric patients undergoing intestinal operations, 444 had DS. In unadjusted analysis, medical complications (urinary tract infection, deep venous thrombosis, sepsis, pneumonia) occurred in 7.9% of patients with DS, compared to 14.1% of those without (p 0.001). Surgical complications (wound disruption, hemorrhage, superficial or deep wound infection) occurred in 3.5% of patients with DS, compared to 4.6% of those without (p = 0.34), and in-patient mortality occurred in 0.3% of patients with DS, compared to 2.7% of those without (p = 0.009). Adverse treatment effects (ATE) calculated after inverse probability weighting demonstrated no difference for medical or surgical complications but a significantly decreased mortality with DS.Contrary to common perception and data extrapolated from the adult literature, pediatric patients with DS have neither higher medical nor surgical complication rates after intestinal operations. Similar to patients undergoing congenital heart surgery, pediatric patients with DS have a lower postoperative inpatient mortality after these general operations compared to those without DS. Mechanisms influencing risks in DS patient remain unknown.Level III, retrospective comparative study.

Background Congenital paraesophageal hernia (CPEH) is a rare diaphragmatic anomaly for which repair has primarily been described by laparotomy, although, more recent case series describe laparoscopic repair. In reports with over five patients, the predominant approach has been with laparotomy. The purpose of our study was to review our recent institutional experience and results with exclusively laparoscopic repair of CPEH in infants and children. Methods An IRB approved retrospective review of all patients with CPEH who underwent laparoscopic treatment at a tertiary children's hospital from 2010 to 2017 was performed. We included only those patients from our own institution with primary CPEH, or CPEH with prior repair (s) at other centers, with recurrence presenting for operation. Data including demographics, diagnostic studies, operative details, complications, outcomes, and follow up were analyzed. Age at diagnosis was 1 day to 25 years of age (mean 2.5 years). Results A total 28 patients underwent 30 operations to treat CPEH. All operations were completed laparoscopically with no conversions to open. There were 6 Type II, 16 Type III, and 6 Type IV CPEH patients. Seventeen patients were less than one year of age (61%). Weight at time of repair was 10.3 kg (1.2–44 kg). Twelve patients were less than 5 kg (43%), eight patients (28.5%) were less than 10 kg, and 8 were more than 10 kg (28.5%). Operative time averaged 125 min (range 61–247 min). Three patients underwent initial CPEH repair (s) (open: 2 and laparoscopic: 1) at other institutions before laparoscopic revision was performed at our hospital (11%). Crural repair was performed in all patients, fundoplication in 26 (93%) and concomitant gastrostomy was performed in 14 patients (50%). Complications included two patients with recurrent hiatal hernias, which were redone laparoscopically (2/28 or 7% recurrence) and 1 capnothorax requiring pigtail drainage postoperatively. There were no deaths, no requirement for esophageal dilations, or esophageal lengthening. One patient required laparoscopic gastrostomy six weeks post initial repair for failure to thrive. Follow-up ranged from 4 months to 8 years (average 36 months). Conclusion Congenital paraesophageal hernia in infants and children is uncommon. Based on our experience, the laparoscopic approach to repair is feasible, even for neonates, with excellent results, acceptably low recurrence rate, and may even be considered for revisional operations. Study type Clinical research paper. Level of evidence Type IV.

Gender and diversity in the workforce are hot topics in both the public and professional spheres. Medicine has not been immune to these discussions, with many recent publications highlighting the lack of equal representation of women and minorities within medicine and surgery. This paper will review the history and current state of gender and minority representation in the Canadian Association of Pediatric Surgeons (CAPS) as presented at the 50th Annual Meeting of CAPS in September 2018 in Toronto, Ontario, Canada.

Background Sclerotherapy is a commonly utilized treatment for rectal prolapse in children. This study systematically evaluates the effectiveness and complications of various sclerosing agents in treating pediatric rectal prolapse. Methods After protocol registration (CRD-42018088980), multiple databases were searched. Studies describing injection sclerotherapy for treatment of pediatric rectal prolapse were included, with screening and data abstraction duplicated. The methodological quality of included papers was assessed using the Methodological Index for Non-Randomized Studies (MINORS) score. Results Nineteen studies were identified, published between 1970 and 2017. Most studies were single institution case series, with median “N” 57 +/−88.9 and mean MINORS score of 0.51 +/−0.17 (perfect score = 1). 1510 patients with a mean age of 4.5 years were accounted for: 36.2% female, most without comorbidities. Mean follow up length was 30 months. The most common sclerosing agent described was ethanol (45%), followed by phenol (33%). The mean number of treatments per patient was 1.1 +/−0.34. The overall success rate after a single sclerotherapy treatment was 76.9%+/−8.8%. The overall complication rate was 14.4%+/−2%. Conclusions Injection sclerotherapy appears effective and low-risk in the treatment of pediatric rectal prolapse and should be considered before more invasive surgical options. The available evidence is of relatively poor quality, and prospective comparative investigations are warranted. Level of evidence 3 (meta-analysis of level 3 studies).

Background Large fetal head and neck (HN) masses can be life-threatening at birth and postnatally owing to airway obstruction. The two most frequent congenital masses that may obstruct the airway are lymphatic malformation (LM) and teratoma. The aim of this paper was to evaluate the results of our experience in the management of giant congenital HN masses and to conduct a literature review. Methods The study involved a consecutive series of 13 newborns (7 females) affected by giant HN masses. Prenatal diagnosis was achieved by means of ultrasound (US) and fetal magnetic resonance imaging (MRI). Delivery was performed by means of EXIT procedure in case of radiological evidence of airway obstruction. In the postnatal period all feasible therapeutic options (surgery, sclerotherapy, medical therapy) were discussed and adopted by a multidisciplinary team. Twelve patients underwent surgery and one received Rapamycin for one month, with consequent surgical resection owing to increasing size of the mass. Results The histopathological diagnosis was LM in 11 cases and teratoma in 2 cases. Airway obstruction was solved in 11 cases; 2 LM patients required a tracheotomy because of persistent airway obstruction. Major complications were flap necrosis (one patient) and facial nerve palsy (2 cases). Recurrence occurred in 5 patients. Conclusions The management of congenital HN masses is always challenging and necessarily requires an interdisciplinary approach. Current therapeutic options include surgery, sclerotherapy, medical therapy or a combination of them. When they are large enough to obstruct the airway, a patient-centered approach should guide timing and modality of treatment. Level of evidence IV

Europe has changed remarkably over the past decades and so have concepts and outcomes of esophageal atresia repair. In this article, both the efforts to create a united Europe and the achievements in dealing with esophageal atresia from the 1950s on are outlined. Furthermore, this paper deals with the future of pediatric surgery and is focused on two aspects: the "Fourth Industrial Revolution" which builds on the digital revolution, artificial intelligence and robotics, and its potential impact on pediatric surgery and the life of patients. I suggest that pediatric surgeons should participate and lead in the development of machine learning, data control, assuring appropriate use of machines, control misuse, and in particular ensure appropriate maintenance of ethical standards. Changes in health care structures within Europe, in particular the effect of centralization, will affect the concept of treatment for patients with rare diseases.

Delayed primary repair is still the method of choice in the management of long-gap oesophageal atresia in many centres, but the timing of anastomoses varies. Some assume the infant's bodyweight to be an important factor, whereas others prefer age. We therefore aimed to clarify whether age or bodyweight determined oesophageal length in a rodent model.We explanted the oesophagi of 20 Sprague-Dawley rats, aged 15 to 444 days (n = two per time point), measured bodyweight, oesophageal length, weight, and linear breaking strength to measure tissue resilience. Univariate and multivariate regression analyses were conducted to determine the influence of age and bodyweight on oesophageal length and linear breaking strength.All parameters were highly correlated (R 0.8), except for age and linear breaking strength (R = 0.65). Both age and bodyweight were univariate significant predictors of oesophageal length, weight, and linear breaking strength (p 0.0001). Multivariate analyses showed bodyweight to be a significant predictor of oesophageal length (p 0.0001), whereas age was not (p = 0.18) [adjusted ROnly weight determines oesophageal length and tissue resilience in rodents, whereas age is irrelevant. If a similar relationship exists in humans, it may facilitate choosing the optimum time point for delayed primary anastomosis.IV - Experimental Paper.

This is a review of the 65th British Association of Paediatric Surgeons (BAPS) held jointly with the British Association of Endoscopic Surgeons (BAPES) during July 2018 in Liverpool, UK. The congress issue contains manuscripts prepared from papers and posters presented during the open sessions and transcripts based on invited lectures. LEVEL OF EVIDENCE: V.

Objective The aim of this study was to determine if meconium-stained amniotic fluid (MSAF) was associated with neonatal outcomes in gastroschisis. Study design A retrospective chart review of gastroschisis patients from 2000 to 2014 at a single, tertiary institution was performed. Statistical analysis was performed with Fisher exact test, Welch's t-test, logistic regression and/or linear regression with significance at p Results Sixty-four of 135 (47.4%) gastroschisis patients had MSAF. On univariate analysis, patients with MSAF were more likely to require staged closure (30 (46.9%) vs. 18(25.4%), p = 0.012), had more ventilator days (8.9 ± 11.1 vs. 5.3 ± 6.3, p = 0.021) and longer times to commence enteral feeds (24.9 ± 21.7 vs. 18.5 ± 14.5, p = 0.045). However, multi-variate regression analysis controlling for the type of closure, showed that delayed closure, but not MSAF, was associated with worse outcomes. Conclusions In gastroschisis patients, MSAF is associated with delayed closure but is not associated with outcomes independent of closure type. This association may be because of the matting of the bowel or increased intestinal damage. The MSAF status will aid in setting expectations for parents during their initial NICU stay and further investigation is warranted. Type of study: Clinical Research Paper Level of evidence: III

Background The GAS study is an international RCT to evaluate neurodevelopmental outcome comparing general plus regional anesthesia versus regional anesthesia alone in 722 neonates and infants who had inguinal hernia repair up to 60 weeks of postmenstrual age. This paper comprises a secondary descriptive analysis of hernias, aspects of surgery and outcomes. Methods The incidence of unilateral and bilateral hernias, side preponderance, predictive factors for bilateral hernias and surgical approaches were collated. Follow-up outcome data were examined at 2 years. Results Of 711 eligible patients, there were 679 with hernia data showing that 321 hernias were right-sided, 190 left and 168 bilateral. Male to female ratio was 5:1. Of those with unilateral hernias, 25.8% underwent contralateral exploration and in these cases a patent processus vaginalis was found in 68.9%. Bilateral hernias were more common in younger and female patients. At 2 years there was a recurrence rate of 0.99% and in 2.7% of patients a hernia was evident on the contralateral side (metachrony), and this was unrelated to the anesthesia technique. Conclusions Bilateral hernias are associated with lower gestational age at birth and female gender. There was a low incidence of complications and the anesthesia technique did not affect surgical outcome. Level of evidence Level 1 evidence from prospective treatment study.

The prevalence and type of life-threatening complications related to the minimally invasive repair of pectus excavatum (MIRPE) and bar removal are unknown and underreported. The purpose of this communication is to make surgeons aware of the risk of these life threatening complications as well as the modifications which have been developed to prevent them. Methods Data related to life-threatening complications of Pectus Excavatum (PE) patients was obtained from four sources: 1. A survey of Chest Wall International Group (CWIG) surgeons who specialize in repairing congenital chest wall malformations, 2. Papers and case reports presented at CWIG meetings, 3. Review of medico-legal cases from the USA and 4. A systematic review of the literature related to major complications post MIRPE. Results From 1998 to 2016, we identified 27 published cases and 32 unreported life-threatening complications including: cardiac perforation, hemothorax, major vessel injury, lung injury, liver injury, gastrointestinal problems, and diaphragm injury. There were seven cases of major complications with bar removal (reported and non-reported) with two lethal outcomes. Mortality data with bar placement surgery: Four published death cases and seven unpublished death cases. The overall incidence of minor & major complications post MIRPE has been reported in the literature to be 2–20%. The true incidence of life-threatening complications and mortality is not known as we do not know the overall number of procedures performed worldwide. However, based on data extrapolated from survey information, the pectus bar manufacturer in the USA, literature reports, and data presented at CWIG meetings as to the number of cases performed we estimated that approximately fifty thousand cases have been performed and that the incidence of life-threatening complications is less than 0.1% with many occurring during the learning curve. Analysis of the cases identified in our survey revealed that previous chest surgery, pectus severity and inexperience were noted to be significant risk factors for mortality. Conclusions Published reports support the safety and efficacy of MIRPE; however major adverse outcomes are underreported. Although major complications with MIRPE and pectus bar removal surgery are very rare, awareness of the risk and mortality of life-threatening complications is essential to ensure optimal safety. Factors such as operative technique, patient age, pectus severity and asymmetry, previous chest surgery, and the surgeon's experience play a role in the overall incidence of such events. These preventable events can be avoided with proper training, mentoring, and the use of sternal elevation techniques. Type of study Treatment Study. Level of evidence Level IV.

Background Measurements in chest wall deformities are typically conducted using a thorax caliper or a CT scan of the chest wall. This paper focuses on the possible correlation between these two methods to validate the reliability of the thorax caliper, minimize radiation exposure, and limit the usage of expensive imaging techniques. Methods We evaluated 95 consecutive patients (77 pectus excavatum (PE), 17 pectus carinatum (PC), 1 mixed deformity) who received surgical correction of the anterior chest wall. The results of the external chest wall measurements and the CT-based measurements were statistically compared. Results A significant correlation between the two measurements was observed in PE and PC at the highest point of the deformation. The strongest correlation was noted in PE. We also noted a correlation between the transverse diameter of the external measurement and the inner thoracic diameter of the CT scan but not for the sagittal diameters in the upper parts of the sternum. Conclusions Thorax caliper measurements are suitable for determining the sagittal thoracic diameter at the maximum level of the deformity and the transverse diameter with an accuracy comparable to that of CT measurements. Since these values key, the thorax caliper is reliable for monitoring and documenting chest wall malformations. Level of evidence Study of diagnostic test. Testing previously developed diagnostic criteria in a consecutive series of patients and a universally "gold" standard—Level I.

The following is the conference proceeding of the Second Ein Debate from the 48th Annual Meeting of the Canadian Association of Paediatric Surgeons held in Vancouver, BC, from September 22 to 24, 2016. The three main topics for debate, as prepared by the members of the CAPS Ethics Committee, are: 1. Regionalization of care: pros and cons, 2. Innovation in clinical care: ethical considerations, and 3. Surgeon well-being: caring for the caregiver. The authors of this paper, as participants in the debate, were assigned their positions at random. Therefore, the opinions they express within this summary might not reflect their own viewpoints. In the first discussion, arguments for and against the regionalization of pediatric surgical care are discussed, primarily in the context of a case of BA. In the pro argument, the evidence and lessons learned from different European countries are explored as well as different models to provide the best BA care outside of large teaching centers. In the counterargument, the author explains how regionalization of care could be detrimental for the patient, the family, the regional center, and for the health care system in general. In the debate on surgical innovation the authors define surgical innovation. They review the pertinent ethical principles, explore a model for its implementation, and the role of the institution at which the innovation is proposed. In the third section, surgeon well-being is examined, and recent literature on surgeon resiliency and burnout both at the attending and resident level is reviewed.

Purpose To determine whether treatment of lichen sclerosus et atrophicus (LS), with topical steroids reduces the rate of circumcision. Methods Two independent reviewers performed a literature search of studies reporting treatment of LS with topical steroids using EMBASE and MEDLINE database(s). Inclusion criteria: boys aged 0–18 years, clinical diagnosis of LS, treatment with topical steroids. Literature reviews, studies of phimosis without LS and adult patients were excluded. Data analysed for each paper included age, duration of treatment, length of follow up and outcome, notably circumcision or no surgery. Results The original search identified 26 titles. Application of exclusion criteria left 6 articles for inclusion in the study. Eighty nine patients with LS were treated with topical corticosteroids. Circumcision was avoided in 31/89 (35%; range 0–100%). Median patient age was 6.5 years (1 month–15 years). Median duration of treatment was 2 months (1–23 months); median follow-up 4 months (6 weeks–5 years). Conclusions Treatment of LS with topical steroids reportedly avoided circumcision in 35% of boys. Duration of medical therapy and patient follow up in analysed studies were, however, short. A prospective randomised trial would provide a definitive answer. Type of Study Systematic review. Level of Evidence III.

Background/aim How testes descend through the inguinal canal is well described, but how the ovaries appear inside an inguinal hernia remains controversial. We reviewed the literature to determine whether ovarian ‘descent' has been described. Methods The English literature from 1950 to 2014 was reviewed via PubMed, Medline and Web of Science to identify papers describing an ovary in the hernia sac: reports were examined to find whether the ovary prolapsed or ‘descended', and the anatomy of its supporting ligaments, cranial suspensory ligament (CSL) and round ligament (female gubernaculum, RL). Results In forty reports of >7140 inguinal herniotomies and/or imaging studies in females the hernia contains an ovary in 15–20%, often with the ipsilateral fallopian tube. The RL and ovary were aligned along the same path as testicular descent only rarely in Mullerian anomalies with an isolated uterine horn preceding the ovary into the sac. The ligament usually found inside the hernia sac was the CSL, not the RL. Discussion The high frequency of incarcerated ovary, along with the close proximity of the CSL to the internal ring in females is consistent with a sliding hernia pulling the CSL (and ovary) into the hernia sac, not ovarian ‘descent' by traction on the RL.

This is a review of the 63rd British Association of Paediatric Surgeons (BAPS) annual conference which was held in July 2016 in Amsterdam in the Netherlands. This congress issue contains papers presented during the open sessions and transcripts based on invited lectures.

Background Human milk fortifier (HMF) is used in neonatal units throughout North America to facilitate growth of preterm infants. Little data is available on the gastrointestinal side effects and potential adverse events. The purpose of this paper was to present a series of infants presenting with bowel obstruction associated with HMF. Methods Cases of HMF obstruction were collected between January 2010 and December 2012. Charts were reviewed and relevant data was collected. Results During the study period, 7 premature infants presented with bowel obstruction secondary to intestinal concretions of HMF. All babies were premature with gestational ages from 25 to 27weeks. Birth weight was less than 1000 grams in all patients. Patients presented with feeding intolerance, bilious aspirates, abdominal distension, and obstipation. Four of the patients presented with acute deterioration and required urgent surgical intervention. Conclusions HMF is an important source of nutritional support in infants, which is felt to be safe. We present a series of infants where its use has resulted in significant complications. HMF should be used with caution in infants, especially those with a history of necrotizing enterocolitis. Further research should examine the calcium, protein, and fatty acid concentration tolerable in the gastrointestinal tract of infants.

Purpose The purpose of the paper was to study the potential risk and management of adult biliary atresia (BA) patients. Materials and Methods Clinical courses and biochemical data were retrospectively analyzed in 52 BA patients who were operated in our department and are now older than 15 years, with special emphasis on 47 patients who survived beyond the age of 20 years. Results Of these 47 patients, 45 (95.7%) are employed, receiving higher education, and/or married. Thirty-three patients showed favorable liver function at the age of 20 years with their native liver. Thereafter, 6 (18.2%) developed liver dysfunction after working hard or pregnancy. In these 6 patients, cholinesterase levels were significantly lower at the age of 20 years than those in the 27 stable patients (239.5 ± 42.6 vs 285.8 ± 47.5, P = .0216), whereas no significant difference was found in alanine aminotransferase, aspartate aminotransferase, or total protein levels at the age of 20 years or in any biochemical parameters at the age of 15 years. Of the 14 transplanted patients, 5 who underwent transplantation after the age of 20 years had relatively uneventful courses until the age of 20 years; however, their biochemical data already showed significant deterioration at puberty. Conclusion Social activities and pregnancy should be managed individually according to the risk assessment for potential hepatic failure even in stable adult BA patients. A falling cholinesterase level after the age of 20 years may predict the risk for the late hepatic dysfunction.

Necrotizing fascitis (NF) is a severe infection of the subcutaneous tissue and fascia affecting children and adults. Conventional management includes resuscitation, aggressive debridement of necrotic tissue, and sometimes, additional measures such as hyperbaric oxygen and immunoglobulin therapy. This paper reports conservative management of 18 patients with NF with minimal morbidity and mortality.Patients with NF admitted to our department between January 2000 and February 2004 were included in the study (N = 18). In all cases, the presentation was rapidly progressing cellulitis progressing to cutaneous gangrene between 6 and 18 hours. The patients were managed by aggressive fluid resuscitation, analgesia, broad-spectrum antibiotics, and dressing with liberal quantities of povidone iodine ointment. After separation of the gangrenous skin margins from the surrounding healthy tissue between 24 and 72 hours, dead skin and fascia were removed with forceps on the ward, the wound washed with liberal quantities of water, and the ointment dressing reapplied. This procedure was repeated until all the dead tissue had been removed. Once the wound was granulating, dressings were changed at increasing intervals until healing took place by secondary intention.The patients were aged between 5 days and 11 years. In all, NF began as a small boil progressing to a rapidly spreading cellulitis. None of the patients was operated during the acute stage of the infection. Blackening of the skin and separation of the edges occurred within 8-72 hours, the dead tissue was allowed to separate from the granulating base and could be removed at the bedside with minimal blood loss. Blood transfusion was required only in 2 patients where hemoglobin was9 gm/dL. Of the 18 patients, 6 grew group A streptococci and staphylococci in a polymicrobial wound culture, whereas the other 12 had polymicrobial flora without streptococci. The clinical course and outcomes were similar in both types of wounds. There was 1 death in the study group, and 1 patient required skin grafting. All other survivors had healing by secondary intention without disability. The period for complete epithelization varied between 3 and 8 weeks. Patients were discharged home when 70% of the wound had healed. There was extensive scarring in 3 children with NF involving the back. The other children had minimal or no scarring. None of the patients had any restriction in the movement of limbs or joints. These findings were compared with 16 retrospective patients of NF treated before January 2000 by the conventional approach of aggressive early debridement, the results of the conservative approach were superior with shorter hospital stay, lower number of blood transfusions, earlier appearance of granulation tissue, and shorter duration of complete healing.We conclude that the conservative management of NF offers advantages in morbidity without compromising the outcome. In our hospital setup, conservative treatment was less expensive and easily carried out. We would therefore advocate conservative management for the treatment of this condition.

Formal training in pediatric surgery is highly competitive. The limited number of accredited positions has historically favored applicants with basic science experience, numerous publications, national presentations, and exposure to well-known pediatric surgeons. This review analyzes characteristics of successful applicants and cost associated with the Match.A survey was e-mailed to 45 applicants after the 2003 Match. Geographic provenance, demographics, qualifications, costs, and valued program characteristics were assessed. Statistics were formulated by chi2 and Student's t test.Thirty-six applicants (80%) responded. Successful characteristics for matched vs unmatched included number of publications, 11.2 vs 5.7 (P.01); first-author designation, 6.4 vs 3.1 (P = .02); basic science papers, 5.7 vs 1.7 (P.01); national presentations, 5.8 vs 2.4 (P = .02); and presentations at pediatric surgical meetings, 2.0 vs 0.6 (P = .04). Ninety percent of matched applicants took time off to perform basic science research (P.01). Average candidate expense was $6974, which represented 14% of pretax salary. Forty-one percent of applicants noted that cost limited the number of interviews taken. Fifty percent preferred a regional interview process to limit expense. Candidates ranked case diversity, volume, and mentor's advice as the most valued program characteristics. Successful applicants matched at their fifth rank on average. Eighty-six percent of unsuccessful applicants will reapply.Results of this study are important to those interested in the future of pediatric surgery. Successful applicants were shown to have several national presentations and multiple scientific publications, especially in basic sciences. Applicant costs are high, totaling more than $236,000 for survey respondents.

The 62nd British Association of Paediatric Surgeons (BAPS) Annual Conference was held July 22–24, 2015, in Cardiff, Wales. This congress issue contains papers presented during the open sessions and transcripts based on invited lectures.

Background/Purpose: More than 97% of the clinical research in pediatric surgery consists of retrospective data. Although these studies have significant limitations, they fundamentally shape clinical practice within the field. In this report, the authors describe the development and potential applications of a standardized quality assessment scale designed for retrospective studies in pediatric surgery. Methods: The authors developed a comprehensive quality assessment instrument incorporating 30 items within 3 subscales. These subscales were designed to assess 3 integral components of study design: clinical relevance, reporting methodology, and the strength of conclusions. Global quality ratings (poor, fair, or good) were derived by combining scores from each subscale. To examine inter-rater reliability, 10 retrospective studies from the pediatric surgery literature were assessed with the instrument by 6 independent reviewers. Results: Inter-rater reliability was excellent as assessed by the level of agreement for all items within the instrument (84.6% concordance, n=1,573 total item-choices) and for individual subscales (range, 73.3% to 85.8%, n=60 to 1,258). The extent of agreement among reviewers was 82% for classifying reports into qualitative categories by global quality scores (n = 60). The ranking of papers by individual reviewers was highly predictive of overall ranking by mean quality scores (n = 60 rank pairs, r=0.83; P Conclusions: The authors have developed a standardized and reliable quality assessment scale for the analysis of retrospective data in pediatric surgery. Potential applications include: (1) providing the practicing surgeon with a knowledge base to critically evaluate published retrospective data; (2) providing a standardized methodology for the systematic review of existing retrospective data; and (3) developing standardized reporting guidelines for use in peer-reviewed journals. J Pediatr Surg 38:390-396. Copyright 2003, Elsevier Science (USA). All rights reserved.

Background/Purpose: Scar formation after scald injury in children is managed commonly by application of pressure garment. The duration of the treatment depends on clinical assessment. The objective of the study was to evaluate the efficacy of the pressure garment therapy and to correlate the clinical assessment scar thickness with ultrasound measurement. Methods: Prospective study of children with hypertrophic scars receiving pressure garment therapy was carried out between 1993 and 1998. The scars were mapped with paper cutting. Representative scar sites were scored clinically according to Vancouver General Hospital Burn Assessment Scale (pigmentation, vascularity, pliability, height, pain, itchiness). Blind to the clinical results, 2 radiologists measured the scar thickness of the same sites with ultrasonography (5 to 10 MHz transducer, General Electric LOGIQ 500). The correlation between the clinical scores and ultrasound measurement of scar thickness were analysed using analysis of variance (ANOVA). Results: The median age of 58 children with scald injury (M:F = 36:22) was 2.8 years (0.5 to 15.8 years). The mean percentage of scald was 8.8% (24% had scald area >10%). In addition, there were 5 children with burn from naked flame and 9 children with keloid secondary to surgical incisions. With pressure garment therapy, the scar thickness reached a plateau 1½ years after the injury and began to decline gradually thereafter. The clinical estimation of scar thickness correlated well with the ultrasound measurement (ANOVA, P =.003, Adjusted R square=0.99). The accuracy rate of clinical thickness estimation was 67%. Overestimation and underestimation accounted for 15% and 18%, respectively. There also was good correlation between total clinical score and the ultrasound measurement (ANOVA, P Conclusions: In children with scald injury, the pressure garment needs to be continued for a minimum of 1 year. Ultrasound measurement correlates well with overall score of the Vancouver General Hospital Burn Assessment Scale but not individual components of the scoring system except wound height. J Pediatr Surg 36:466-469. Copyright © 2001 by W.B. Saunders Company.

Purpose: The purpose of this paper is to review the effect of intralesional corticosteroid therapy in the treatment of 155 head and neck hemangiomas. Methods: In the past 10 years, we have treated 155 proliferating head and neck hemangiomas with intralesional corticosteroid injections. Three to 6 injections of triamcinolone acetonide (10 mg/mL) in monthly intervals were given. Using slides and chart review, the results were assessed 1 month after completion of the treatment. Results: Eighty-five percent of the lesions showed greater than 50% reduction in volume. Varied treatment response was noted in different classes of hemangioma. Eighty percent of the superficial, 75% of the deep, and 60% of the combined hemangiomas show more than 50% reduction in volume. Further growth was not found after treatment. The postinjection complication rate was 6.4% in this series. There were 2 patients with cushingoid appearance, 5 with cutaneous atrophy, and 3 suffered from anaphylactic shock. We found that lesions showing less than 50% reduction in volume were located mostly in the perioral area. Conclusions: Intralesional corticosteroid injections are safe and effective in arresting hemangioma proliferation. Superficial hemangiomas yield the best results. J Pediatr Surg 35:420-423. Copyright © 2000 by W.B. Saunders Company.

Background/Purpose: Purpura fulminans (PF) is a serious, often life-threatening disease. As more children are surviving their disease, surgeons are presented with increasing numbers of multiple and complicated wounds as sequelae of PF. The purpose of this paper is to review the management of nine cases of PF, and present the reconstruction method in treating bilateral exposed elbow and knee joints. Methods: All cases of pediatric patients with PF and treated by the division of plastic and reconstructive surgery between 1986 and 1998 were reviewed. Results: Seven children (78%) had meningococcal PF, and one (11%) had PF after Haemophilus influenza septicemia. PF developed in one (11%) but with no growth in either blood or cerebrospinal fluid cultures. Five children (56%) required amputation procedures. Two children (22%) required knee disarticulation. Two patients (22%) had free myocutaneous flap transfers for bone coverage. One (11%) had PF involving the face. Conclusions: Meningococcal PF is a rare, often life-threatening disease generally of childhood. More children are surviving their diseases but with devastating sequelae. Successful reconstructive treatment outcome of these children requires a multidisciplinary team approach involving multiple specialties. The goal is to preserve function, maintain maximal length, and salvage limbs when possible. Flexibility and innovation are necessary in treating these multiple and complicated wounds.

Oroparyngeal tumors in neonates protruding from the mouth are extremely rare. They have the potential to cause respiratory distress, or even death of the child during the perinatal period owing to airway obstruction and may need a multidisciplinary team approach at the time of birth. Congenital epulis and epignathus are the 2 rare lesions usually presenting like this and clinical manifestations depend on their position and size. They have an excellent prognosis, if treated properly. This paper will discuss our experience with these 2 lesions and review the literature.

This is a summary of the joint 61st British Association of Paediatric Surgeons (BAPS) and 23rd International Pediatric Endosurgery Group (IPEG) Congress held in Edinburgh, Scotland, on July 23rd–25th, 2014. This was the first time that these independent organisations had held a joint congress with delegates able to pick and choose between two separate academic programmes and a shared social programme. Contents include invited lectures, in-depth reviews, and submitted papers.

Background/Purpose: A significant number of children (50%) with gastroesophageal reflux (GER) have delayed gastric emptying (DGE). Although controversial, many pediatric surgeons use a gastric outlet procedure in conjunction with fundoplication for gastroesophageal reflux in these patients. This paper describes the technique and clinical outcome of 61 patients undergoing a laparoscopic gastric antroplasty at the time of the laparoscopic fundoplication. Methods: The charts of 61 patients who underwent laparoscopic gastric antroplasty in conjunction with laparoscopic fundoplication between May 26, 1992 and October 17, 1996 were reviewed retrospectively. All patients had a documented DGE confirmed by a liquid isotope meal being retained in the stomach. After completion of the fundoplication, a laparoscopic antroplasty was performed by incising a 2 to 3.5-cm linear incision in the pylorus and distal gastric antrum. The seromuscular wall was divided to the level of the mucosa allowing the mucosa to bulge through the defect. The wound was closed transversely using interrupted 2-0 silk sutures. Results: Four of the 61 patients underwent conversion to open antroplasty for technical reasons. The remaining 57 patients recovered uneventfully from the laparoscopic antroplasty with clinical resolution of both GER and DGE. Two of 57 patients had intermittent episodes of retching and were unable to tolerate large bolus feedings because of dumping. They were treated by dividing the feedings into two smaller portions. These symptoms cleared within 6 months. The remaining 55 patients have tolerated feedings well. Evaluation of the gastric emptying was performed randomly in selected patients with documented improvement of the emptying after antroplasty. An evisceration of omentum through the umbilical incision developed in one patient on the third postoperative day. Conclusions: Patients with delayed gastric emptying who need fundoplication can be treated with laparoscopic gastric antroplasty in conjunction with laparascopic fundoplication. Laparoscopic antroplasty appears to be clinically efficacious in improving delayed gastric emptying.

Purpose: The purpose of this paper is to describe the ultrasonographic findings of the patent processus vaginalis (PPV) in neonates. Methods: The patency of the processus vaginalis was examined by ultrasonography in 117 neonates. The ultrasonographic findings, with increment and decrement of the intraabdominal pressure, were categorized into 6 types as follows: type I, the intraabdominal organ is observed; type II, cystic PPV; type III, the PPV is widened with abdominal pressure increment, the length is ≥20 mm; type IV, the PPV contains moving fluid without PPV widening; type V, the PPV is widened with abdominal pressure increment, the length is less than 20 mm; type VI, others. The authors we regarded types I to IV as PPV with inguinal hernia. Results: Twenty-two of 40 neonates with a birth weight under 2,500 g had PPV, including 8 with type I. Twenty of 37 premature neonates 22 to 37 gestational weeks had PPV, including 8 with type I. Eighty-one percent (13 of 16) of PPV in low-birth-weight neonates and 91% (10 of 11) in premature neonates closed spontaneously. The median ages at the time of spontaneous regression of PPV were 242 days in low birth weight neonates and 262 days in premature neonates. Conclusions: Most premature or low-birth-weight neonates with PPV regress spontaneously. The inguinal hernia in neonates (especially in premature or low-birth-weight neonates) should be observed until at least 9 months of age without attempting hernia repair.

This paper explores whether there is a correlation between kidney and lung growths in an experimental model of congenital diaphragmatic hernia (CDH) induced by intragastric administration of Nitrofen (115 mg/kg) in olive oil on time-dated pregnant Wistar rats at the 9th day of gestation. For comparison we used pregnant rats treated with olive oil alone. Twenty-nine normal fetuses from 3 control rats and 24 left CDH fetuses from 6 Nitrofen rats were studied. Fetal (3.6 +/- 0.8 v 4.9 +/- 0.4 g, P.001) and total lung (2% +/- 0.5% v 2.6% +/- 0.3% of body weight, P.001) weights were significantly decreased in animals with CDH. Kidneys were also smaller in CDH animals although not significantly (0.7% +/- 0.1% v 0.8% +/- 0.1% of body weight, P = .05) and were also histologically immature. Regression of kidney weight on body weight for both groups yielded regression lines that were identical at analysis of covariance and all data points from the CDH group were within the control group 95% confidence limits. After converting raw data into lung/body and kidney/body weight ratios, no inverse correlation suggesting a feedback mechanism of growth regulation between both organs could be found. Since nitrofen acts through modifications of the thyroid hormone status in both dam and fetus, altered maturation of several organs should be expected although some of them, like the lung, are the leading targets. The present CDH rodent model is probably different from the human malformation in spite of the striking anatomic similarities between them.(ABSTRACT TRUNCATED AT 250 WORDS)