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Children with severe constipation and a neurodiverse disorder (Autism and/or developmental delay) represent a challenging bowel management group. Treatment outcomes with laxative or enema therapy remain limited and are often complicated by patient/caregiver compliance. We hypothesized that children with neurodiverse disorders and severe constipation would benefit from a bowel management program (BMP) that includes early use of antegrade enemas.Children requiring BMP in the Pediatric Colorectal and Pelvic Learning Consortium (PCPLC) registry with diagnosis of constipation and/or constipation with pseudo-incontinence were reviewed. Those with Hirschsprung disease and/or Anorectal Malformation were excluded. BMP needs in patients with a neurodiverse diagnosis were compared to those without to evaluate differences in BMP's.372 patients requiring a BMP were identified. 95 patients (58 autism spectrum, 54 developmental delay) were neurodiverse, and 277 patients were not. Neurodiverse patients had a higher prevalence of enema therapy 62.1% (59/95) vs. 54.9% (152/273) and use of antegrade enema therapy 33.7% (32/95) vs. 21.2% (58/273), p = 0.126. Neurodiverse patients were older 37.9% (36/95)12 years vs. 23.1% (63/273), p = 0.001 and 47.6% (10/21) were changed from laxative to enema therapy over time. 80% (8/10) of those changed from laxatives to enemas used antegrade therapy. 67.3% (35/52) of neurodiverse patients followed over time were on enema therapy at the most recent visit with 80% (28/35) requiring antegrade therapy.A large portion of patients with a neurodiverse disorder who fail laxative therapy use antegrade enemas to achieve effective bowel management. Early consideration of an antegrade conduit may simplify treatment in this group of children.III.

Background Pediatric inflammatory bowel disease (IBD) carries significant morbidity and requires extensive medical and often surgical intervention. The aim of this study was to evaluate the impact of a dedicated Multidisciplinary clinic on the outcomes of children with IBD. Methods A retrospective review of a prospective database, established to track quality and outcomes of children undergoing an abdominal operation for IBD, was performed. Children who were managed before (09/2017–03/2019) and after (04/2019–06/2020) establishment of the multidisciplinary clinic were examined. The clinic instituted several care process protocols including early recovery (ERAS) and garnered additional resources for patients (wound ostomy, nutrition, social work, etc.) Primary outcomes were unanticipated return to the operating room, length of stay, ER visits within 30 days of surgery and hospital readmissions within 30 days of surgery. Results We identified 41 children who underwent a total of 80 major abdominal operations; 46.3% of procedures occurred before and 53.7% occurred after instituting our clinic. There were no notable changes in disease distribution (e.g., ulcerative colitis vs. Crohn's), disease severity, medication exposure, or case urgency (elective vs. emergent). ER visits within 30 days of surgery decreased (4 (9.3%) vs. 10 (27%), p = 0.04) as did readmissions within 30 days of surgery (1 (2.3%) vs. 9 (24.3%), p = 0.005). Conclusions Implementation of a dedicated multidisciplinary clinic for IBD and its attendant focus on protocols and appropriate use of adjunctive resources was associated with decreased emergency department visits and hospital readmissions in the post-operative setting. Level of evidence : III

Background An appendicostomy (ACE) is a surgical option for antegrade enemas in children with severe constipation and/or fecal incontinence who have failed medical management. In 2019, we initiated an expedited post-operative protocol and sought to examine our short-term outcomes compared with our historical cohort. Methods A retrospective review was performed of all children undergoing ACE between 2017 and 2020. Children were excluded if they underwent an associated procedure (e.g. colon resection). Patients were divided into two cohorts: historical cohort (2017–2018, Group A) and the expedited protocol (2019 to present, Group B). The primary outcome was length of stay. Results 30 patients met inclusion (Group A = 16, Group B = 14). The most common indications for ACE were constipation (50%) and constipation or fecal incontinence associated with anorectal malformation (43%). Group B experienced a decreased length of stay (1 vs 3 days, P = 0.001) without differences in 30-day surgical site infection (7.1% vs 18.8%, p = 0.61) or unplanned visit (15.4% vs 18.8%, p = 1.0). Group B had a higher prevalence of MiniACE® button placed through the appendix vs. Malone (42.8% vs 12.5%, p = 0.10). Conclusions Our expedited post-op protocol decreased length of stay without other significant adverse clinical sequelae. Level of evidence Retrospective Comparative Study, Level III.

Children with ulcerative colitis (UC) may undergo a staged approach for restorative proctocolectomy and ileal pouch anal anastomosis (IPAA). Previous studies in adults suggest a decreased morbidity with delayed pouch creation, but pediatric studies are limited. We compared outcomes for delayed versus early pouch construction in children.Patients with UC undergoing IPAA were selected from the National Surgical Quality Improvement Program Pediatric database from 2012 to 2018. Patients were categorized as early (2-stage) or delayed (3-stage) pouch construction based on Current Procedural Terminology codes. Our primary outcome was any adverse event. We used a multivariable logistic regression model to assess the relationship between timing of pouch creation and adverse events.We identified 371 children who underwent IPAA: 157 (42.3%) had early pouch creation and 214 (57.6%) had a delayed pouch. Those with an early pouch creation were more likely to have exposure to immunosuppressants (11% vs. 5%, p = 0.017) and steroids (30% vs. 10%, p 0.001) at the time of surgery. After controlling for patient characteristics, there were no significant differences in adverse events between the two groups.Children undergoing early pouch creation have increased exposure to steroids and immune suppressants; nevertheless, no differences in adverse events were identified.II.

Introduction Enhanced recovery protocols include multimodal perioperative pain control and frequently include use of NSAIDs. There is conflicting evidence that ketorolac use in inflammatory bowel disease (IBD) may precipitate disease flares and postoperative complications. The outcomes of children who receive ketorolac in this setting are not well known. We sought to evaluate ketorolac utilization in children following colectomy for ulcerative colitis. Methods All patients undergoing colectomy for ulcerative colitis between 2007 and 2017 at a tertiary children's hospital were reviewed. We collected patient age, duration of symptoms, operative details, medication utilization, length of stay, and postoperative complications. We performed a cohort comparison of these variables across patients who did vs. did not receive postoperative ketorolac. Results Sixty children were identified with median age at diagnosis of 12.6 years (IQR: 9.9–14.5). At colectomy, patients had a median PUCAI score of 60 (45–70), ESR 34 mm/h (15–50), hemoglobin 10.9 g/dL (9.3–12.9), and albumin 3.1 g/dL (2.4–3.8). Postoperatively, 45% (n = 27) received ketorolac. Patients in both cohorts had a similar length of stay, duration of opioid exposure, total morphine equivalents utilized, readmission rate, and unexpected return to the operating room. There were no documented cases of postoperative bleeding, acute kidney injury, or disease related flares among children receiving ketorolac. Conclusions Administration of ketorolac after colectomy in IBD was not associated with an increase in any postoperative complications, though the study was underpowered to detect these differences. However, ketorolac administration did not lead to a decreased utilization of opioid analgesia. Further prospective research is necessary to understand whether ketorolac in this population is safe and offers benefit. Type of study Retrospective study. Level of evidence III

Pulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodules in pediatric patients.A retrospective review was performed on patients 21 years of age undergoing localization of pulmonary nodules at 15 institutions. Localization and resection success, time in interventional radiology (IR), operating room (OR) and total anesthesia time, complications, and technical problems were compared between techniques.225 patients were included with an average of 1.3 lesions (range 1-5). Median nodule size and depth were 4 mm (range 0-30) and 5.4 mm (0-61), respectively. The most common localization techniques were: wire + methylene blue dye (MBD) (28%), MBD only (25%), wire only (14%), technetium-99 only (11%), coil + MBD (7%) and coil only (5%). Localization technique was associated with institution (p 0.01); technique and institution were significantly associated with mean IR, OR, and anesthesia time (all p 0.05). Comparing techniques, there was no difference in successful IR localization (range 92-100%, p = 0.75), successful resection (94-100%, p = 0.98), IR technical problems (p = 0.22), or operative complications (p = 0.16).Many IR localization techniques for small pulmonary nodules in children can be successful, but there is wide variability in application by institution and in procedure time.Retrospective review, Level 3.

Structured abstract Purpose Experience with autologous blood patch (ABP) pleurodesis for persistent air leak in the pediatric population is limited. The purpose of this series was to describe the experience with ABP at a single tertiary children's hospital. Methods A retrospective study was performed of all thoracic procedures done by the pediatric surgery service over three years. Results Ten patients underwent a total of 17 ABPs. The median age of patients was 12 years (IQR 6–16). The most common underlying reasons for a thoracic procedure included: blebectomy for spontaneous pneumothorax (2), need for lung biopsy (2), resection of known malignant tumor (2), and empyema (2). The median number of days of persistent air leak before first ABP was 7.5 days (IQR 7–10). A second ABP was performed in 6 cases with a third procedure performed in one case. None of the patients developed respiratory compromise during ABP and no infectious complications were identified following ABP. Conclusions Our cohort demonstrates that ABP for persistent air leak following thoracic surgery is effective with minimal morbidity in children. We believe ABP can be used early and in patients with a broad range of underlying lung pathology.

Purpose We sought to examine the short-term outcomes following single-stage repair of rectoperineal and rectovestibular fistulae in infants and identify risk factors for wound complication. Methods Patients with a rectoperineal or rectovestibular fistula treated with a single-stage repair beyond the neonatal period (>30days of age) at a pediatric colorectal center (2011–2016) were reviewed. Results 36 patients with a rectoperineal and 7 patients with a rectovestibular fistula were repaired using the Posterior Sagittal Anorectoplasty (PSARP) approach. Median follow-up was 31months. The median age and weight at the time of repair were 166days and 6.5kg. Four patients (11%) suffered a wound complication (3 rectoperineal, 1 rectovestibular). Two required a diverting colostomy to allow wound healing. Two patients suffered skin separation managed with local wound care. All 4 patients experienced satisfactory wound healing without anoplasty stricture. Two different patients developed a stricture of the neo-anus. Age and weight at time of repair, gender, and presence of a genitourinary anomaly were not associated with wound complications. Conclusion Delayed single-stage repair of rectoperineal and rectovestibular fistulae can be performed safely in infants beyond the newborn period. With attentive treatment, satisfactory healing can be anticipated if a wound complication is encountered. Level of Evidence Retrospective Comparative Study, Level III.

Introduction Recreation on longboards is gaining in popularity. The purpose of this study is to detail the injury patterns, treatment and management of children with longboarding injuries seen at a level 1 pediatric trauma center. Methods A retrospective review using our trauma registry from 2006 to 2016 of pediatric patients who sustained injuries while riding a longboard. Results Of 12,920 injured children, 64 (0.5%) were treated for injuries that occurred while riding a longboard. Median age was 14.5 years (IQR 13.6, 15.4) and 84% were male. Fifty-one (80%) suffered a traumatic brain injury (TBI) including 32 intracranial hemorrhages (ICH), 17 concussions, and 31 skull fractures. Seven (11%) were wearing helmets. Three patients required neurosurgical intervention. Extremity fractures were the most common reason for surgery. Ninety-six percent of patients were admitted to the hospital with a median length of stay of 1 day (IQR 1, 3). All children survived to discharge. Compared with skateboard injuries during the same period, TBI, ICH, concussion, and skull fractures were all greater. Conclusions TBI ranging from concussion to ICH requiring craniotomy is common in children injured while riding a longboard, and greater than rates after skateboarding injuries. Extremity fracture was the most common reason for operative intervention. Level of evidence III.

Total colonic aganglionosis is a rare phenotype of Hirschsprung disease (HD). While the diagnosis is generally established within the neonatal period there are reports of delayed presentation. In this case, we describe a 9-month old girl with no previous medical or surgical history who presented with a small bowel obstruction. A contrast enema performed as part of the work up demonstrated right sided colonic diverticula with no other anatomical abnormalities. Surgical intervention was required to manage the obstruction and colonic biopsies were consistent with HD. This case highlights the association of the unusual finding of colonic diverticula with total colonic HD in infants.

Purpose Awareness of equestrian related injury remains limited. Studies evaluating children after equestrian injury report under-utilization of safety equipment and rates of operative intervention as high as 33%. Methods We hypothesized that helmets are underutilized during equestrian activity and lack of use is associated with increased traumatic brain injury. We queried the trauma database of a level one pediatric trauma center for all cases of equestrian and rodeo related injury from 2005 to 2015. Analysis was conducted using SAS 9.4. Results Of 312 children identified, 142 were assessed for use of a helmet. Only 28 children (19.7%) had documented use of a helmet. Most injuries occurred while riding a horse (83%) or bull (13%) with traumatic brain injury being the most common injury (51%). Helmet use was associated with decreased ISS (7.1 vs. 11.3, p p =0.03), and ICU admission (10.7% vs. 29%, p =0.05). Multivariable analysis reveals lack of helmet use to be an independent predictor of TBI (OR 2.5, 95% CI 1.1–6.3). Conclusion Helmets are underutilized by children during equestrian related activity. Increased awareness of TBI and education encouraging helmet use may decrease morbidity associated with equestrian activities. Level of Evidence Retrospective comparative study, Level III.

Perianal perforating disease (PF) has been reported in approximately 15% of children with Crohn's disease (CD). It is unknown whether children who present with PF at the time of diagnosis have a different course than those that develop PF while on therapy.From a prospective, single institution observational registry of children diagnosed with CD, we identified children with perianal perforating CD, defined as perianal abscesses and/or fistulae. Patients who presented with perianal perforating CD (PF-CD0) were compared to those who developed perianal perforating CD (PF-CD1) after initial diagnosis.Thirty-eight of 215 (18%) children with CD had PF-CD during a median follow up of 4.5 years. Patients with PF-CD0 (n=26) tended to be more likely male (81% vs. 50%, p=0.07) and younger (9.3 yrs vs. 12.5 yrs, p=0.02). PF-CD1 (n=12) patients were more likely to require diverting ileostomy (42% vs. 8%, p=0.02) and colectomy (33% vs. 4%, p=0.03). Multivariable analysis predicted increased rate of diverting ileostomy in the PF-CD1 group (p=0.007, OR 19.1, 95% CI 1.6-234.8).Pediatric CD patients who develop PF while on therapy for CD have a more severe phenotype and are more likely to require diverting ileostomy or colectomy compared to those who present with PF-CD.

Our aim was to compare outcomes of children undergoing laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LC+CBDE) to those undergoing laparoscopic cholecystectomy with adjunctive endoscopic retrograde cholangiopancreatography (LC+ERCP).We performed a two-center retrospective chart review of all children (18 years) undergoing LC+CBDE or LC+ERCP between January 2000 and July 2011. Wilcoxon test was performed on continuous variables and logistic regression modeling on categorical data. A P value0.05 was considered significant. Outcomes with a P value0.2 were selected for multivariable analysis.Forty-two patients were identified. Twenty-four (57%) underwent LC+ERCP, and eighteen (43%) underwent LC+CBDE. Demographic and clinical factors were well matched between groups. Total operative time was similar between groups (157 min vs. 152 min, P = .26). LC+CBDE patients had zero major complications and five minor complications (retained stone: 3, pancreatitis: 1, late recurrence: 1). LC+ERCP patients experienced two major complications (duodenal perforation: 1, bleeding requiring transfusion: 1), and four minor complications (pancreatitis: 2, retained stone: 2, P = .57). Median length of stay was significantly longer (15.7 days vs. 6.6 days, P = .02), and median hospital cost was significantly higher ($18,132 vs. $12,735, P.01) in the LC+ERCP group. Multivariable analysis revealed that cost was significantly lower in patients undergoing LC+CBDE (P = .05, OR= 0.71; 95% CI: 0.51-0.97).LC+CBDE at the time of cholecystectomy is associated with decreased length of stay, decreased cost, and has similar or improved morbidity compared to LC+ERCP.

Malrotation with midgut volvulus requires prompt recognition and urgent treatment. We describe a 5-year-old boy who presented with malrotation and midgut volvulus in whom the diagnosis was made by computed tomography. We describe the diagnostic images and operative findings in the patient. This case highlights the importance of recognizing the inversion in orientation of the superior mesenteric vessels and “whirlpool” sign in making the diagnosis of midgut volvulus when few other clues may be present.