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Background: The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. Methods: The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. Results: Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B–D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. Conclusions: There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease. [ABSTRACT FROM AUTHOR]

Isolated fallopian tube torsion is a rare cause of acute abdominal pain in adolescent females. It is known to be a surgical emergency as it may lead to ischemia of the fallopian tube which can result in necrosis, infertility or infection. Presenting symptoms and radiographic findings are vague making diagnosis difficult, often requiring direct visualization in the operating room to make the definitive diagnosis. There has been an increase in this diagnosis at our institution in the previous year prompting compilation of cases and a literature review. [ABSTRACT FROM AUTHOR]

Cardiothoracic surgical services have been provided at 7 military treatment facilities over the past decade. Accurate case volume data for adult cardiac and general thoracic surgical service lines in the Military Health System is unknown. We queried the Military Health System Data Repository for adult cardiac and general thoracic cases performed at military treatment facilities in the Military Health System and surrounding purchased care markets for fiscal years 2007 to 2017. Cases were filtered and classified into major cardiac and major general thoracic categories. Five military treatment facility markets had sufficient cardiac case data to perform cost analysis. Institutional major cardiac case volume was low across the Military Health System with less than 100 cardiopulmonary bypass cases per year (range, 17-151 cases per year) performed most years at each military treatment facility. Similarly, general thoracic surgical case volume was universally low, with less than 30 anatomic lung resections (range, 0-26) and fewer than 5 esophageal resections (range, 0-4) performed at each military treatment facility annually. Cost analysis revealed that provision of cardiac surgical services is significantly more expensive at most military treatment facilities compared with their surrounding purchased care markets. Adult cardiac and general thoracic surgical volume within the Military Health System is low across all institutions and inadequate to provide clinical readiness for active-duty surgeons. Recapture of major cases from the purchased care market is unlikely and would not significantly increase military treatment facility or individual surgeon case volume. [ABSTRACT FROM AUTHOR]

Canada is the second largest country in the world, with most of the population located in the southern-most portion of its geography. We sought to define the relative distribution of pediatric surgeons to potential pediatric patients using data from the Canadian census. The 2011 Canadian Census and a convenience sample of current Canadian pediatric surgeons were used to calculate straight-line distances between pediatric surgeon postal code centroids and census dissemination block centroids. Currently, there are 74 practicing pediatric surgeons in Canada; 493,345 populated census blocks were identified, and 7,752,075 children were enumerated. The median (IQR) kilometers to the closest pediatric surgeon was 27.99 (11.35, 85.47) kilometers, and 22.7% of Canadian children lived more than 100 km from care. Nearly 13% of children lived greater than 200 km from the nearest pediatric surgeon. More than 1.7 million Canadian children, nearly one quarter of all Canadian children, live greater than 100 km from the closest pediatric surgeon. This identifies a disparate group of patients who do not have an equal access-to-care as compared to others in the country. Level IV. [ABSTRACT FROM AUTHOR]

Purpose: Review current practices and expert opinions on contraindications to extracorporeal membrane oxygenation (ECMO) in congenital diaphragmatic hernia (CDH) and contraindications to repair of CDH following initiation of ECMO.Methods: Modified Delphi method was employed to achieve consensus among members of the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).Results: Overall response rate was 81% including current and former members of the APSA-CCC. An average of 5-15 CDH repairs were reported annually per institution; 26-50% of patients required ECMO. 100% of respondents would not offer ECMO to a patient with a complex or unrepairable cardiac defects or lethal chromosomal abnormality; 94.1% would not in the setting of severe intracranial hemorrhage (ICH). 76.5% and 72.2% of respondents would not offer CDH repair to patients on ECMO with grade III-IV ICH or new diagnosis of lethal genetic or metabolic abnormalities, respectively. There was significant variability in whether or not to repair CDH if unable to wean from ECMO at 4-5 weeks.Conclusions: Significant variability in practice pattern and opinions exist regarding contraindications to ECMO and when to offer repair of CDH for patients on ECMO. Ongoing work to evaluate outcomes is needed to standardize management and minimize potentially futile interventions.Level Of Evidence: V (expert opinion). [ABSTRACT FROM AUTHOR]

The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to derive recommendations from the medical literature regarding the management of pilonidal disease. The PubMed, Cochrane, Embase, Web of Science, and Scopus databases from 1965 through June 2017 were queried for any papers addressing operative or non-operative management of pilonidal disease. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived for three questions based on the best available evidence, and a clinical practice guideline was constructed. A total of 193 articles were fully analyzed. Some non-operative and minimally invasive techniques have outcomes at least equivalent to operative management. Minimal surgical procedures (Gips procedure, sinusectomy) may be more appropriate as first-line treatment than radical excision due to faster recovery and patient preference, with acceptable recurrence rates. Excision with midline closure should be avoided. For recurrent or persistent disease, any type of flap repair is acceptable and preferred by patients over healing by secondary intention. There is a lack of literature dedicated to the pediatric patient. There is a definitive trend towards less invasive procedures for the treatment of pilonidal disease, with equivalent or better outcomes compared with classic excision. Midline closure should no longer be the standard surgical approach. Systematic review of level 1 – 4 studies. Level 1 – 4 (mainly level 3 – 4). [ABSTRACT FROM AUTHOR]

The American Pediatric Surgical Association (APSA) guidelines for the treatment of isolated solid organ injury (SOI) in children were published in 2000 and have been widely adopted. The aim of this systematic review by the APSA Outcomes and Evidence Based Practice Committee was to evaluate the published evidence regarding treatment of solid organ injuries in children. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Four principal questions were examined based upon the previously published consensus APSA guidelines regarding length of stay (LOS), activity level, interventional radiologic procedures, and follow-up imaging. A literature search was performed including multiple databases from 1996 to 2016. LOS for children with isolated solid organ injuries should be based upon clinical findings and may not be related to grade of injury. Total LOS may be less than recommended by the previously published APSA guidelines. Restricting activity to grade of injury plus two weeks is safe but shorter periods of activity restriction have not been adequately studied. Prophylactic embolization of SOI in stable patients with image-confirmed arterial extravasation is not indicated and should be reserved for patients with evidence of ongoing bleeding. Routine follow-up imaging for asymptomatic, uncomplicated, low-grade injured children with abdominal blunt trauma is not warranted. Limited data are available to support the need for follow-up imaging for high grade injuries. Based upon review of the recent literature, we recommend an update to the current APSA guidelines that includes: hospital length of stay based on physiology, shorter activity restrictions may be safe, minimizing post-injury imaging for lower injury grades and embolization only in patients with evidence of ongoing hemorrhage. Systematic Review. Levels 2–4. [ABSTRACT FROM AUTHOR]

Children who have undergone splenectomy may develop impaired immunologic function and heightened risk of overwhelming postsplenectomy infection. We sought to define the long-term rate of and risk factors for postsplenectomy sepsis. We leveraged the Military Health System Data Repository, a nationally representative claims database including > 3 million children registered as dependents of members of the United States Armed Services (2005–2014). Inclusion criterion was splenectomy at age 18 years or prior. The primary outcome was hospitalization for sepsis. Among 195 children who underwent splenectomy, 7% (n = 13) were hospitalized with sepsis, with an incidence of 1.8 (95% CI = 1.0-3.1) events per 100 person-years. The median time to sepsis was 224 days (IQR = 109–606) and 38% (5/13) of events occurred within the first postsplenectomy year. The postsplenectomy mortality rate was 1% (n = 3). After adjusting for underlying diagnosis, older age at splenectomy (HR = 0.90 per year, 95% CI = 0.81–0.99) was associated with decreased hazard of sepsis. In a contemporary national cohort, the prevalence of postsplenectomy sepsis was 7% (1.8 events per 100 person-years). Although most presented during the first year after splenectomy, many (62%) sepsis events occurred later, suggesting that postsplenectomy immunologic dysfunction persists beyond one year. The immunologic consequences of asplenia must continue to be acknowledged, as postsplenectomy sepsis remains a serious concern. Prognosis study. Level III. [ABSTRACT FROM AUTHOR]

Geographic proximity to pediatric surgical care has not been evaluated using the Decennial Census nor have racial, ethnic, gender, or urbanization variations been reported. This study's aim is to describe proximity of children living in the continental U.S. to a pediatric surgeon with respect to these variations. The 2010 American Pediatric Surgical Association member file and the 2010 Decennial Census were used to calculate straight-line distances between pediatric surgeons' zip code centroids and census block centroids. In 2010, 716 practicing pediatric surgeons were identified, 6,182,882 populated Census blocks were identified, and 73,690,271 children were enumerated. Of white non-Hispanic children, 30.1% lived greater than 40 miles from care. Of Native American children, 40.5% lived more than 60 miles from care. Among children 0–5 years of age, the median (IQR) miles to closest pediatric surgeon was 14.2 (6.2, 39.6), and 3,010,698 of these children lived more than 60 miles from care. More than 10 million children lived greater than 60 miles from a pediatric surgeon in 2010. Racial, ethnic, age, and urbanization variations in proximity to pediatric surgeons were present. This method is feasible to describe distance-to-care with the upcoming 2020 Decennial Census and may benefit future allocation of pediatric surgeons. IV [ABSTRACT FROM AUTHOR]

Abstract Background Treatment of the neonate with long gap esophageal atresia (LGEA) is one of the most challenging scenarios facing pediatric surgeons today. Contributing to this challenge is the variability in case definition, multiple approaches to management, and heterogeneity of the reported outcomes. This necessitates a clear summary of existing evidence and delineation of treatment controversies. Methods The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted four consensus-based questions regarding LGEA. These questions concerned the definition and determination of LGEA, the optimal method of surgical management, expected long-term outcomes, and novel therapeutic techniques. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to identify, review and report salient articles. Results More than 3000 publications were reviewed, with 178 influencing final recommendations. In total, 18 recommendations are provided, primarily based on level 4–5 evidence. These recommendations provide detailed descriptions of the definition of LGEA, treatment techniques, outcomes and future directions of research. Conclusions Evidence supporting best practices for LGEA is currently low quality. This review provides best recommendations based on a critical evaluation of the available literature. Based on the lack of strong evidence, prospective and comparative research is clearly needed. Type of study Treatment study, prognosis study and study of diagnostic test. Level of evidence Level II–V. [ABSTRACT FROM AUTHOR]

Abstract Background The treatment of ovarian masses in pediatric patients should balance appropriate surgical management with the preservation of future reproductive capability. Preoperative estimation of malignant potential is essential to planning an optimal surgical strategy. Methods The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee drafted three consensus-based questions regarding the evaluation and treatment of ovarian masses in pediatric patients. A search of PubMed, the Cochrane Library, and Web of Science was performed and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to identify articles for review. Results Preoperative tumor markers, ultrasound malignancy indices, and the presence or absence of the ovarian crescent sign on imaging can help estimate malignant potential prior to surgical resection. Frozen section also plays a role in operative strategy. Surgical staging is useful for directing chemotherapy and for prognostication. Both unilateral oophorectomy and cystectomy have been used successfully for germ cell and borderline ovarian tumors, although cystectomy may be associated with higher rates of local recurrence. Conclusions Malignant potential of ovarian masses can be estimated preoperatively, and fertility-sparing techniques may be appropriate depending on the type of tumor. This review provides recommendations based on a critical evaluation of recent literature. Type of study Systematic review of level 1–4 studies. Level of evidence Level 1–4 (mainly 3–4). [ABSTRACT FROM AUTHOR]

Abstract Purpose We aimed to describe the incidence, timing, and predictors of recurrence following inguinal hernia repair (IHR) in children. Methods We used the TRICARE claims database, a national cohort of > 3 million child dependents of members of the U.S. Armed Forces. We abstracted data on children < 12y who underwent IHR (2005–2014). Our primary outcome was recurrence (ICD9-CM diagnosis codes). We calculated incidence rates for the population and stratified by age, time from repair to recurrence, and multivariable logistic regression to determine predictors. Results Nine thousand nine hundred ninety-three children met inclusion criteria. Age at time of IHR was ≤ 1y in 37%, 2-3y in 23%, 4–5y in 16%, and 5–12y in 24%. Median follow-up time was 3.5y (IQR:1.6–6.1). 137 patients recurred (1.4%), with an incidence of 3.46 per 1000 person-years. Over half occurred in children 0-1y at repair (60%). The majority occurred within a year following repair (median 209 days [IQR:79–486]). Children 0-1y had 2.53 times greater odds of recurrence (compared to > 5y). Children with multiple comorbidities had 5.45 times greater odds compared to those with no comorbidities. Conclusions The incidence of recurrence following IHR is 3.46 per 1000 person-years. The majority occurred within a year of repair. Children ≤ 1y and those with multiple comorbidities were at increased risk. Level of Evidence Prognosis Study, Level II. [ABSTRACT FROM AUTHOR]

Objective Ovarian torsion in pediatric patients is a rare event and is primarily managed by pediatric general surgeons. Torsion can be treated with detorsion of the ovary or oopherectomy. Oopherectomy is the most common procedure performed by pediatric general surgeons for ovarian torsion. The purpose of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee was to examine evidence from the medical literature and provide recommendations regarding the optimal treatment of ovarian torsion. Methods Using PRISMA guidelines, six questions were addressed by searching Medline, Cochrane, Embase Central and National clearing house databases using relevant search terms. Risks of ovarian detorsion including thromboembolism and malignancy, indications for oophoropexy, benefits of detorsion including recovery of function and subsequent fertility, and recommended surveillance after detorsion were evaluated. Consensus recommendations were derived for each question based on the best available evidence. Results Ninety-six studies were included. Risks of ovarian detorsion such as thromboembolism and malignancy were reviewed, demonstrating minimal evidence for unknowingly leaving a malignancy behind in the salvaged ovary and no evidence in the literature of thromboembolic events after detorsion of a torsed ovary. There is no clear evidence supporting the benefit of oophoropexy after a single episode of ovarian torsion. The gross appearance of the ovary does not correlate with long-term ovarian viability or function. Pregnancies have occurred in patients after detorsion of an ovary both spontaneously and with harvested oocytes from previously torsed ovaries. The consensus recommendation for imaging surveillance following ovarian detorsion is an ultrasound at 3 months postprocedure but sooner if there is a concern for malignancy. Conclusion There appears to be overwhelming evidence supporting ovarian detorsion rather than oopherectomy for the management of ovarian torsion in pediatric patients. Ovarian salvage is safe and is the preferred treatment for ovarian torsion. Most salvaged ovaries will maintain viability after detorsion. Type of study Systematic review of level 3–4 studies. Level of evidence 3–4 [ABSTRACT FROM AUTHOR]