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IntroductionData examining rates of postoperative complications among SARS-CoV-2 positive children are limited. The purpose of this study was to evaluate the impact of symptomatic and asymptomatic SARS-CoV-2 positive status on postoperative respiratory outcomes for children.MethodsThis retrospective cohort study included SARS-CoV-2 positive pediatric patients across 20 hospitals who underwent general anesthesia from March to October 2020. The primary outcome was frequency of postoperative respiratory complications, including: high-flow nasal cannula/non invasive ventilation, reintubation, pneumonia, Extracorporeal Membrane Oxygenation (ECMO), and 30-day respiratory-related readmissions or emergency department (ED) visits. Univariate analyses were used to evaluate associations between patient and procedure characteristics and stratified analyses by symptoms were performed examining incidence of complications.ResultsOf 266 SARS-CoV-2 positive patients, 163 (61.7%) were male, and the median age was 10 years (interquartile range 4-14). The majority of procedures were emergent or urgent (n=214, 80.5%). The most common procedures were appendectomies (n=78, 29.3%) and fracture repairs (n=40,15.0%). 13 patients (4.9%) had preoperative symptoms including cough or dyspnea. 26 patients (9.8%) had postoperative respiratory complications, including 15 requiring high-flow oxygen, 8 with pneumonia, 4 requiring non invasive ventilation, 3 respiratory ED visits, and 2 respiratory readmissions. Respiratory complications were more common among symptomatic patients than asymptomatic patients (30.8% vs. 8.7%, p=0.01). Higher ASA class and comorbidities were also associated with postoperative respiratory complications.ConclusionsPostoperative respiratory complications are less common in asymptomatic versus symptomatic SARS-COV-2 positive children. Relaxation of COVID-19-related restrictions for time-sensitive, non urgent procedures in selected asymptomatic patients may be reasonably considered. Additionally, further research is needed to evaluate the costs and benefits of routine testing for asymptomatic patients.Level of evidenceIii, Respiratory complications.

The purpose of this study was to analyze the clinical characteristics and outcomes of low birthweight (LBW) infants with congenital diaphragmatic hernia (CDH) compared to normal birthweight (NBW) infants with CDH. We hypothesized that LBW was associated with increased mortality, decreased extracorporeal life support (ECLS) utilization, and increased pulmonary morbidity in CDH patients. Patients in the CDH Study Group from 2007 to 2018 were included. LBW was defined as p = .03). LBW infants had longer durations of mechanical ventilation and were more likely to require supplemental oxygen at 30 days and at the time of discharge. LBW is a risk factor for mortality and pulmonary morbidity in CDH. Prolonged oxygen requirement and increased length of stay are important considerations when managing this population.

OBJECTIVES Fetal surgery for repair of open neural tube defect (ONTD) typically results in decreased need for a ventriculoperitoneal shunt (VPS). Our objectives were to determine the trend in ventricle size (VS) during pregnancy and whether VS and change in VS, as assessed by ultrasound, were predictive of the need for VPS in pregnancy with ONTD. METHODS This was a retrospective analysis of prospectively collected data of consecutive pregnancies with ONTD, evaluated in a single center from January 2012 to May 2018. Two groups were identified: the first consisted of pregnancies that underwent in-utero repair (IUR) and the second those that had postnatal repair (PNR). Penalized B splines were used to determine the trend in VS, across 2-week gestational-age (GA) epochs, between 24 and 36 weeks of gestation. VS at each GA epoch and the change in VS between each GA epoch were compared between the IUR and PNR groups. To determine whether VS at any GA was predictive of VPS, receiver-operating-characteristics (ROC) curves were used and the optimal cut-off at each GA epoch was identified. Univariate analysis and multiple logistic regression were used for further analysis. RESULTS ONTD was diagnosed in 110 fetuses, of whom 69 underwent IUR and 41 had PNR. Fetuses in the IUR group were more likely to have Chiari II malformation (100.0% vs 82.9%; P

Background The relative influences of baseline risk factors for pediatric nonaccidental burns have not been well described. We evaluated baseline characteristics of pediatric nonaccidental burn patients and their primary caretakers. Methods A single-center retrospective cohort study was conducted of pediatric (age, Highlights • Non-Hispanic black children had higher rates of Child Protective Services referral. • Non-Hispanic black children had higher rates of nonaccidental burn diagnosis. • Caretaker history with Child Protective Services correlated with nonaccidental burns. • Patient non-Hispanic black race/ethnicity was associated with nonaccidental burn.

Background Errors and preventable harm to patients remain regrettably common and expensive in healthcare. Improvement requires transforming the culture of the healthcare industry to put a greater emphasis on safety. Safety culture involves holding collective attitudes, values, and behaviors that prioritize safety. The Safer Culture framework, previously established through a narrative review of literature in multiple industries, provides a consensus on what impacts safety culture, how it manifests in behavior, and how it influences safety-related outcomes. Methods Through a theoretical review, we validate, refine, and provide nuance to this framework for the development of safety culture in healthcare contexts. To accomplish this, we conceptually map existing dimensions pulled through the literature onto our Safer Culture framework. Results A total of 360 articles were reviewed. We present specific elements for each dimension in our framework and apply the dimension to healthcare contexts. Conclusion We provide an evidence-based and comprehensive framework that can be used by patient safety leaders and researchers to guide the evaluation of safety culture and develop interventions to foster patient safety culture and improve patient safety outcomes.

BACKGROUND: Pediatric trauma patients sustaining blunt abdominal trauma (BAT) with intra-abdominal injury (IAI) are frequently admitted to the intensive care unit (ICU). This study was performed to identify predictors for ICU admission following BAT. METHODS: Prospective study of children (< 16 years) who presented to 14 Level-One Pediatric Trauma Centers following BAT over a 1-year period. Patients were categorized as ICU or non-ICU patients. Data collected included vitals, physical exam findings, laboratory results, imaging, and traumatic injuries. A multivariable hierarchical logistic regression model was used to identify predictors of ICU admission. Predictive ability of the model was assessed via tenfold cross-validated area under the receiver operating characteristic curves (cvAUC). RESULTS: Included were 2,182 children with 21% (n = 463) admitted to the ICU. On univariate analysis, ICU patients were associated with abnormal age-adjusted shock index, increased injury severity scores (ISS), lower Glasgow coma scores (GCS), traumatic brain injury (TBI), and severe solid organ injury (SOI). With multivariable logistic regression, factors associated with ICU admission were severe trauma (ISS > 15), anemia (hematocrit < 30), severe TBI (GCS < 8), cervical spine injury, skull fracture, and severe solid organ injury. The cvAUC for the multivariable model was 0.91 (95% CI 0.88–0.92). CONCLUSION: Severe solid organ injury and traumatic brain injury, in association with multisystem trauma, appear to drive ICU admission in pediatric patients with BAT. These results may inform the design of a trauma bay prediction rule to assist in optimizing ICU resource utilization after BAT. STUDY DESIGN: Prognosis study. LEVEL OF EVIDENCE: 1.

Fetal therapies undertaken to improve fetal outcome or to optimize transition to neonate life often entail some level of maternal, fetal or neonatal risk. A fetal therapy center needs access to resources to carry out such therapies and to manage maternal, fetal or neonatal complications that might arise, either related to the therapy per se or as part of the underlying fetal or maternal condition. Accordingly, a fetal therapy center requires a dedicated operational infrastructure and necessary resources to allow for appropriate oversight, monitoring of clinical performance, and to facilitate multidisciplinary collaboration between the relevant specialties. Three care levels for fetal therapy centers are proposed in order to match the anticipated care complexity with appropriate resources to achieve an optimal outcome at an institutional and regional level. A level 1 fetal therapy center should be capable of offering fetal interventions that may be associated with obstetric risks of preterm birth or membrane rupture, but which would be very unlikely to require maternal medical subspecialty or intensive care, with neonatal risks not exceeding those of moderate prematurity. A level 2 center should have the incremental capacity to provide maternal intensive care and to manage extreme neonatal prematurity. A level 3 therapy center should offer the full range of fetal interventions (including open fetal surgery), and could manage any of the associated maternal complications and comorbidities, as well as have access to neonatal and pediatric surgical intervention including indicated surgery for neonates with congenital anomalies.

Background It is hypothesized that cesarean delivery may reduce mortality among infants with spina bifida (e.g., by reducing trauma to the open lesion); however, few studies have assessed this relationship. Methods We used the Texas Birth Defects Registry to identify neonates with spina bifida born between 1999 and 2014. The mode of delivery (main exposure) was abstracted from each subject's birth certificate. The vital status (main outcome) was determined based on the presence or absence of a death certificate. When a death certificate was present, survival time was calculated by subtracting the date of birth from the date of death. We then conducted multivariable Cox proportional hazards regression to estimate the adjusted hazard ratio between cesarean delivery and death prior to 29 days. We adjusted for maternal race/ethnicity, maternal education, gestational age/birthweight, and breech presentation. This analysis was repeated for death prior to 365 days. Results We analyzed 1,983 nonsyndromic, liveborn neonates with spina bifida, and 68% of these neonates were delivered by cesarean. After adjusting for potential confounders, the adjusted hazard ratio [aHR] for death prior to 29 days was 0.77 (95% confidence interval [CI] 0.49, 1.21) and the aHR for death prior to 365 days was 0.93 (95% CI 0.63, 1.38) comparing infants delivered by cesarean to those delivered vaginally. Conclusions Despite a lack of strong prior epidemiologic evidence, cesarean rates for neonates with spina bifida were high. Further investigations of the relationship between mode of delivery and infant outcomes, including mortality, complications, and long-term prognosis, are warranted.

Maternal and pediatric delivery outcomes may vary in patients who underwent open fetal myelomeningocele repair and elected to deliver at the fetal center where their fetal intervention was performed versus at the referring physician&rsquo, s hospital. A prospective cohort study of 88 patients were evaluated following in utero open fetal myelomeningocele repair at a single fetal center between the years 2011&ndash, 2019. Exclusion criteria included patients that delivered within two weeks of the procedure (n = 6), or if a patient was lost to follow-up (n = 1). Of 82 patients meeting inclusion criteria, 36 (44%) patients were delivered at the fetal center that performed fetal intervention, and 46 (56%) were delivered locally. Comparative statistics found that with the exception of parity, baseline characteristics and pre-operative variables did not differ between the groups. No differences in oligohydramnios incidence, preterm rupture of membranes, gestational age at delivery or delivery indications were found. Patients who delivered with a referring physician were more likely to be multiparous (p = 0.015). With the exception of a longer neonatal intensive care unit (NICU) stay in the fetal center group (median 30.0 vs. 11.0 days, p = 0.004), there were no differences in neonatal outcomes, including wound dehiscence, cerebrospinal fluid leakage, patch management, ventricular diversion, or prematurity complications. Therefore, we conclude that it is safe to allow patients to travel home for obstetric and neonatal management after open fetal myelomeningocele repair.

Background Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. Objective The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. Study Design An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. Results From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3–37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). Conclusion The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.

Objective This study reviews theoretical models of organizational safety culture to uncover key factors in safety culture development. Background Research supports the important role of safety culture in organizations, but theoretical progress has been stunted by a disjointed literature base. It is currently unclear how different elements of an organizational system function to influence safety culture, limiting the practical utility of important research findings. Method We reviewed existing models of safety culture and categorized model dimensions by the proposed function they serve in safety culture development. We advance a framework grounded in theory on organizational culture, social identity, and social learning to facilitate convergence toward a unified approach to studying and supporting safety culture. Results Safety culture is a relatively stable social construct, gradually shaped over time by multilevel influences. We identify seven enabling factors that create conditions allowing employees to adopt safety culture values, assumptions, and norms; and four behaviors used to enact them. The consequences of these enacting behaviors provide feedback that may reinforce or revise held values, assumptions, and norms. Conclusion This framework synthesizes information across fragmented conceptualizations to clearly depict the dynamic nature of safety culture and specific drivers of its development. We suggest that safety culture development may depend on employee learning from behavioral outcomes, conducive enabling factors, and consistency over time. Application This framework guides efforts to understand and develop safety culture in practice and lends researchers a foundation for advancing theory on the complex, dynamic processes involved in safety culture development.

BACKGROUND: Mode of delivery is hypothesized to influence clinical outcomes among neonates with gastroschisis. Results from previous studies of neonatal mortality have been mixed; however, most studies have been small, clinical cohorts and have not adjusted for potential confounders. OBJECTIVES: To evaluate whether cesarean delivery is associated with mortality among neonates with gastroschisis. METHODS: We studied liveborn, nonsyndromic neonates with gastroschisis delivered during 1999–2014 using data from the Texas Birth Defect Registry. Using multivariable Cox proportional hazards regression, we separately assessed the relationship between cesarean and death during two different time periods, prior to 29 days (

Introduction: Despite recognizing the occurrence of variances, we noted a low rate of reporting with the established computer variance program. Therefore, we developed and introduced a simple, handwritten variance reporting system. The goal of this study was to compare our pediatric perioperative handwritten variance cards to our established computerized variance reporting system. Methods: We developed a handwritten variance card program through a stakeholder-driven quality-improvement initiative. We collected variances from handwritten cards in 4 perioperative locations and also from the established computerized variance system. We analyzed the variances and categorized them into 6 safety domains and 5 variance categories. Results: Over 6 consecutive years, 3,434 variances were reported (687 computerized and 2,747 handwritten). For safety domains, the computerized system was more likely to capture adverse events and near-misses (8.7% vs. 1.1%, P < 0.001; 23.5% vs. 8.6%, P < 0.001, respectively) while the handwritten system was more likely to identify the safety process and other non-safety issues (20.1% vs. 38.3%, P < 0.001). Both systems addressed policy/process issues most often, with 37.9% of the handwritten cards and 66.6% of the computerized variance reports. Of the handwritten cards with a patient identifier (n = 1,407), only 5.1% (n = 72) also had a computerized variance filed about the same event. Thus, staff reported >1,300 additional variances that were not identified with the computerized variance system alone. Conclusion: The handwritten, stakeholder-driven variance reporting system was essential to identify local and system issues that would not have been identified by the computerized variance reporting system alone.

Background Applying Artificial Intelligence techniques to healthcare data are gaining momentum. Early identification of patients at risk of surgical site infections is a major clinical goal. Our objective for this study was to determine whether deep learning AI techniques could identify patients at risk of intra-abdominal abscess development post-appendectomy using clinical data for pediatric patients undergoing appendectomy. Methods A dataset of 1,574 patients classified by surgeons as negative (1,328) or positive (246) for Intra-Abdominal Abscess Post-Appendectomy for Appendicitis were selected from a database containing 6,127 patients less than 19 years-old who had appendectomy at our institution between 2009–2018. Demographic, clinical, and surgical information were extracted. 34 Independent variables were identified to be useful for the study. Using Random Forest methodology 12 variables with the highest influence on the outcome were selected for the final dataset. Data imputation (MICE algorithm) was used to replace missing data points. Two “Reproducible” Artificial Neural Networks with different architectures were developed to predict the risk of developing Intra-Abdominal Abscess Post- Appendectomy: Model (1) 12 Inputs, 3 hidden layers with 12 Neurons each, and 1 Output. Model (2) 12 Inputs, 2 hidden layers with 18 Neurons each, and 1 Output. Results For the 1,574 patients (80%-20% used as training and test sets), Model (1) achieved Accuracy of 89.84%, Sensitivity of ~ 70%, and Specificity of 93.61% on the test set while Model (2) achieved Accuracy of 84.13%, Sensitivity of 81.63%, and Specificity of 84.6%. The difference between the models is that in Model (2) we over sampled the minority class (using SMOTE algorithm) to balance both classes which helped the model to learn both classes without bias and improved sensitivity over Model (1). Conclusion Deep learning algorithms applied to enough clinical variables can identify patients with high probability for the risk of developing intra-abdominal abscess post-appendectomy. While further test sets are necessary to validate the models, Artificial Neural Networks can be an important addition to current post-surgical care guidelines to personalize and optimize care to reduce infections following appendectomy. Disclosures All authors: No reported disclosures.

The devastating effect of traumatic brain injury is exacerbated by an acute secondary neuroinflammatory response, clinically manifest as elevated intracranial pressure due to cerebral edema. The treatment effect of cell-based therapies in the acute post-traumatic brain injury period has not been clinically studied although preclinical data demonstrate that bone marrow-derived mononuclear cell infusion down-regulates the inflammatory response. Our study evaluates whether pediatric traumatic brain injury patients receiving IV autologous bone marrow-derived mononuclear cells within 48 hours of injury experienced a reduction in therapeutic intensity directed toward managing elevated intracranial pressure relative to matched controls.The study was a retrospective cohort design comparing pediatric patients in a phase I clinical trial treated with IV autologous bone marrow-derived mononuclear cells (n = 10) to a control group of age- and severity-matched children (n = 19).The study setting was at Children's Memorial Hermann Hospital, an American College of Surgeons Level 1 Pediatric Trauma Center and teaching hospital for the University of Texas Health Science Center at Houston from 2000 to 2008.Study patients were 5-14 years with postresuscitation Glasgow Coma Scale scores of 5-8.The treatment group received 6 million autologous bone marrow-derived mononuclear cells/kg body weight IV within 48 hours of injury. The control group was treated in an identical fashion, per standard of care, guided by our traumatic brain injury management protocol, derived from American Association of Neurological Surgeons guidelines.The primary measure was the Pediatric Intensity Level of Therapy scale used to quantify treatment of elevated intracranial pressure. Secondary measures included the Pediatric Logistic Organ Dysfunction score and days of intracranial pressure monitoring as a surrogate for length of neurointensive care. A repeated-measure mixed model with marginal linear predictions identified a significant reduction in the Pediatric Intensity Level of Therapy score beginning at 24 hours posttreatment through week 1 (p0.05). This divergence was also reflected in the Pediatric Logistic Organ Dysfunction score following the first week. The duration of intracranial pressure monitoring was 8.2 ± 1.3 days in the treated group and 15.6 ± 3.5 days (p = 0.03) in the time-matched control group.IV autologous bone marrow-derived mononuclear cell therapy is associated with lower treatment intensity required to manage intracranial pressure, associated severity of organ injury, and duration of neurointensive care following severe traumatic brain injury. This may corroborate preclinical data that autologous bone marrow-derived mononuclear cell therapy attenuates the effects of inflammation in the early post-traumatic brain injury period.

Importance Inhaled nitric oxide (iNO) is an expensive, commonly used therapy among patients with congenital diaphragmatic hernia (CDH); however, data to support its ongoing use in this patient population are lacking. Objective To describe the spectrum of iNO use among patients with CDH and its association with pulmonary hypertension (pHTN) and mortality. Design, Setting, and Participants A review was conducted of prospectively collected patient data in the Congenital Diaphragmatic Hernia Study Group registry between January 1, 2007, and December 31, 2014, from 70 participating centers in 13 countries. A total of 3367 newborn infants diagnosed with CDH and entered into the registry were reviewed. On the basis of echocardiogram data, pHTN was defined as right ventricular systolic pressure greater than or equal to two-thirds of the systemic systolic pressure. Propensity score and regression analyses were performed. Intervention Use of iNO. Main Outcomes and Measures Variability in iNO use and its association with pHTN and mortality. These outcomes were formulated prior to data evaluation. Results Sixty-eight (97.1%) centers used iNO. Of 3367 patients with CDH (1366 [40.6%] females; median estimated gestational age, 38 weeks; range, 23-42 weeks), a total of 2047 (60.8%) received iNO; the mean percentage of those receiving iNO per center was 62.3% (range, 0%-100%). Median iNO dose and duration were 20 (range, 0.1-80) ppm and 8 (range, 0-100) days. Of the 2174 infants with pHTN, 1613 infants (74.2%) received iNO. Of the 943 infants without pHTN, 343 infants (36.4%) were treated with iNO. Based on propensity score analysis incorporating 10 clinically relevant variables, iNO use was significantly associated with increased mortality (average treatment effect on the treated: 0.15; 95% CI, 0.10-0.20). Conclusions and Relevance Inhaled nitric oxide use is common but highly variable among centers, and 36% of patients without pHTN received iNO therapy. Based on data from 70 centers, iNO use in patients with CDH may be associated with increased mortality. Future efforts should be directed toward data-driven standardization of iNO use to ensure cost-effective practices.

Ewing sarcoma (ES) is the second most common bone tumor in children, and survival of those with metastatic ES has not improved. Previous studies have shown a survival benefit to whole lung irradiation in patients with pulmonary metastases and may be given either before, after, or instead of surgical pulmonary metastasectomy (PM). The contribution of surgery compared with irradiation in ES has not previously been studied.A retrospective review of patients younger than 21 years (median age, 16 years) treated at a single institution (1990-2006) was performed. Kaplan-Meier survival curves were compared using log-rank test and a multivariate Cox proportional hazards model. P ≤ .05 was regarded as significant.Eighty patients with ES were identified. Of these, 31 (39%) had pulmonary metastases. Nine patients had incomplete details of their full treatment regimen, but the following groups could be defined from the remainder: resection alone (n = 5), radiation alone (n = 3), radiation and resection (n = 3), or chemotherapy alone (n = 11). There were 24 deaths overall, with a median overall survival (OS) of 2.7 (95% confidence interval [CI], 1.7-5.2) years. Patients who had PM had the best OS (80%), whereas those who underwent radiation to the lung without PM compared with chemotherapy only for pulmonary metastasis both had similar OS of 0% at 5 years (P = .002). Patients who had radiation followed by PM for lung metastasis had a 5-year OS of 65%. Patients with PM had a longer OS compared with those without lung resection (P.0001).These data suggest a possible benefit for ES patients who undergo surgical resection of lung metastases.

Introduction: Surgeons play a crucial role in preventing harm and contributing to the safety culture of their institutions. External safety data programs are designed to review adverse events and provide performance benchmarks to ameliorate future adverse events. The extent to which pediatric surgeons are aware of these programs, utilize data from these programs, and believe that they improve patient safety, is unknown. Methods: A cross-sectional survey of the American Pediatric Surgical Association membership was conducted to evaluate participation in and attitudes toward national safety benchmark programs (eg, National Surgical Quality Improvement Program). Surgeons’ perceptions of these activities, including barriers to participation and utilization of safety data, were measured. We performed standard frequency analyses and tests of associations between surgeon characteristics and the likelihood of utilizing safety data. Results: The response rate was 38% (353/928). Seventy-two percentage of respondents reported institutional participation in external safety benchmark programs. Of those, only 68% utilized data to improve or monitor patient safety. Surgeon-reported barriers to this process included lack of knowledge, time, and institutional resources. Conclusions: Many pediatric surgeons are aware of institutional participation in external safety data programs, but only a portion are involved in the utilization of these data. We have identified several barriers to participation and data utilization. These findings can help direct educational efforts to optimize our ability to learn from adverse event benchmarking and improve pediatric surgical care.

Supplemental Digital Content is available in the text., Introduction: Surgical safety checklists (SSCs) aim to create a safe operating room environment for surgical patients. Provider attitudes toward checklists affect their ability to prevent harm. Pediatric surgeons’ perceptions surrounding SSCs, and their role in improving patient safety, are unknown. Methods: American Pediatric Surgical Association members conducted an online survey to evaluate the use of and attitudes toward SSCs. The survey measured surgeons’ perceptions of checklists, including the components that make them effective and barriers to participation. To better evaluate the available data on SSCs, the authors performed a systematic literature review on the use of SSCs with a focus on pediatric studies. Results: Of the 353 survey respondents, 93.6% use SSCs and 62.6% would want one used in their own child’s operation, but only 54.7% felt that checklists improve patient safety. Reasons for checklist skepticism included the length of the checklist process, a distraction from thoughtful patient care, and lack of data supporting use. Literature review shows that checklists improve communication, promote teamwork, and identify errors, but do not necessarily decrease morbidity. Staff perception is a major barrier to implementation. Conclusions: Almost all pediatric surgeons participate in SSCs at their institutions, but many question their benefit. Better pediatric surgeon engagement in checklist use is needed to change the safety culture, improve operating room communication, and prevent harm.

Congenital diaphragmatic hernia (CDH) remains a significant cause of death in newborns. With advances in neonatal critical care and ventilation strategies, survival in the term infant now exceeds 80% in some centers. Although prematurity is a significant risk factor for morbidity and mortality in most neonatal diseases, its associated risk with infants with CDH has been described poorly. We sought to determine the impact of prematurity on survival using data from the Congenital Diaphragmatic Hernia Registry (CDHR).Prospectively collected data from live-born infants with CDH were analyzed from the CDHR from January 1995 to July 2009. Preterm infants were defined as37 weeks estimated gestational age at birth. Univariate and multivariate logistic regression analysis were performed.During the study period, 5,069 infants with CDH were entered in the registry. Of the 5,022 infants with gestational age data, there were 3,895 term infants (77.6%) and 1,127 preterm infants (22.4%). Overall survival was 68.7%. A higher percentage of term infants were treated with extracorporeal membrane oxygenation (ECMO) (33% term vs 25.6% preterm). Preterm infants had a greater percentage of chromosomal abnormalities (4% term vs 8.1% preterm) and major cardiac anomalies (6.1% term vs 11.8% preterm). Also, a significantly higher percentage of term infants had repair of the hernia (86.3% term vs 69.4% preterm). Survival for infants that underwent repair was high in both groups (84.6% term vs 77.2% preterm). Survival decreased with decreasing gestational age (73.1% term vs 53.5% preterm). The odds ratio (OR) for death among preterm infants adjusted for patch repair, ECMO, chromosomal abnormalities, and major cardiac anomalies was OR 1.68 (95% confidence interval [CI], 1.34-2.11).Although outcomes for preterm infants are clearly worse than in the term infant, more than 50% of preterm infants still survived. Preterm infants with CDH remain a high-risk group. Although ECMO may be of limited value in the extremely premature infant with CDH, most preterm infants that live to undergo repair will survive. Prematurity should not be an independent factor in the treatment strategies of infants with CDH.

Pancreatic pseudocysts are problematic sequelae of pancreatitis or pancreatic trauma causing persistent abdominal pain, nausea, and gastric outlet obstruction. Due to the low volume of disease in children, there is scant information in the literature on the operative management of pseudocysts with minimally invasive techniques. We conducted a multi-institutional review to illustrate several technical variations utilized in achieving laparoscopic cystgastrostomy in the pediatric population.A retrospective review was conducted of all patients who underwent laparoscopic cystgastrostomy in five institutions. Patient data, operative techniques, and postoperative course were analyzed.There were 13 patients with a mean age of 10.4 years and mean weight of 52.1 kg. The etiologies of pancreatitis included: trauma (4), gallstones (3), chemotherapy (2), hereditary (1), and idiopathic (3). Preoperative radiographic measurements of the maximal cyst diameter averaged 11.7 cm. Cystgastrostomy was approached by using transgastric exposure in 5 cases and intragastric ports in 8 cases. An average of four ports were used to complete these operations. Mean operative time was 113 minutes. There were no conversions in this series. Cystgastrostomy was performed by using an endoscopic stapler (average 3.8 loads) in 6 cases, sutures in 6 cases, and 1 was formed solely with the Harmonic Scalpel (Johnson and Johnson). Gastrotomy sites were closed by using a stapler in 4 cases and suture techniques in 9. Mean time to initial and goal feeds was 3 and 4 days, respectively. Postoperative imaging revealed persistent pseudocyst in 1 patient, who was treated with a distal pancreatectomy. Therefore, 92% required no further operative intervention and remained asymptomatic upon recovery from their pancreatitis.A laparoscopic approach to pancreatic cystgastrostomy for chronic pseudocyst proved to be safe and effective in this five-institution survey. Techniques varied, but 92% had complete resolution with minimal morbidity and rapid recovery. Laparoscopic cystgastrostomy should be considered as an appropriate first-line treatment for chronic pseudocysts in children.

Emesis after pyloromyotomy for pyloric stenosis is a common clinical phenomenon and the limiting factor in time to goal feeds. The amount of emesis that can be expected after myotomy is unknown. No data have been published that equip caregivers with the ability to understand which patients are more likely to have emesis and take longer to advance to goal feeds after pyloromyotomy. Therefore, we performed analysis of prospective data obtained from a randomized trial to determine if outcome can be predicted from preoperative or intraoperative variables.The dataset was prospectively collected from a randomized trial comparing open to laparoscopic pyloromyotomy in 200 patients. All patients had serum electrolytes and sonographic pyloric measurement recorded upon presentation. The postoperative feeding schedule and criteria for stopping feeds was controlled by a standard computer entry order set. In this study, we used Pearson's correlation to evaluate the influence of patient variables, presenting electrolytes, and intraoperative variables against 2 outcome variables (postoperative emesis and time to goal feeds). Significance is defined as a Por= .01.In patient demographics, only weight on admission held a significant correlation to the number of episodes of postoperative emesis, which was an inverse correlation. Of the electrolytes on admission, chloride, potassium, and anion gap correlated significantly with number of emesis and time to goal feeds. There was an inverse correlation for potassium and chloride, whereas it was direct with anion gap. Significance was not detected in the correlation to outcomes for operative or sonographic variables.The degree of hypochloremic, hypokalemic, metabolic alkalosis on presentation strongly correlates to the number of episodes of postoperative emesis and time to goal feeds in patients undergoing pyloromyotomy for pyloric stenosis. Furthermore, the corresponding duration of dehydration and failure to thrive appears to correlate with outcomes as there was a significant inverse correlation with weight on admission to the number of episodes of postoperative emesis and time to goal feeds.

The treatment options for complicated appendicitis in children continue to evolve. Optimal management of complicated appendicitis relies on an accurate preoperative diagnosis. We examined the accuracy of our preoperative diagnosis including computed tomography (CT) and the influence on the management of children with perforated and nonperforated appendicitis.Following IRB approval, a 6-year review of all patients that underwent an appendectomy for suspected appendicitis was performed. Treatments included immediate operations and initial nonoperative management (antibiotic therapy +/- percutaneous drainage of abscess). Appendicitis was confirmed by histological examination.One thousand seventy-eight patients underwent appendectomy for suspected appendicitis. Preoperative CT scans were performed in 697 (64.7%) patients: 615 (88.2%) positive for appendicitis; 42 (6.0%) negative; and 40 (5.7%) equivocal. One hundred seventy-three (28.1%) positive CT scans further suggested perforation. Initial nonoperative management was initiated in 39 (22.5%) cases of suspected perforated appendicitis with abscess. The positive-predictive value (PPV) for suspected acute appendicitis based on history and physical examination alone was 90.8%. The PPV for positive CT scan for acute appendicitis was 96.4% with a PPV of 91.9% for positive CT scan for perforated appendicitis.The correct preoperative diagnosis of appendicitis appears statistically more accurate with CT scan compared to history and physical examination alone (PPV 96.4% versus 90.8%, P = 0.045). For those with clinically suspicious complicated appendicitis, CT evaluation may direct therapy toward initial nonoperative management. The efficacy of this regimen warrants further investigation.

The safety and efficacy of thoracoscopy for thoracic lesions and conditions in children is evolving. Our experience with thoracoscopy has expanded in recent years. Therefore, we reviewed our most recent 7-year experience to examine the current applications for thoracoscopy in children.A retrospective review of all patients undergoing a thoracoscopic operation at Children's Mercy Hospital (Kansas City, MO) between January 1, 2000, and June 18, 2007, was performed. Data points reviewed included patient demographics, type of operation, final diagnosis, complications, and recovery.During the study period, 230 children underwent 231 thoracoscopic procedures. The mean age was 9.6 +/- 6.1 years with a mean weight of 36.6 +/- 24.1 kg. Fifty percent of the patients were male. The thoracoscopic approach was used for decortication and debridement for empyema in 79 patients, wedge resection for lung lesions in 37, exposure for correction of scoliosis in 26, excision or biopsy of an extrapulmonary mass in 26, operation for spontaneous pneumothorax in 25, lung biopsy for a diffuse parenchymal process in 15, lobectomy in 9, repair of esophageal atresia with a tracheoesophageal fistula (EA-TEF) in 8, clearance of the pleural space for hemothorax or effusion in 3, diagnosis for trauma in 1, and repair of bronchopleural fistula in 1. Conversion was required in 3 patients, all of whom were undergoing a lobectomy. Two of these were right upper lobectomies and the other was a left lower lobectomy with severe infection and inflammation. The mean time of chest tube drainage (excluding scoliosis and EA-TEF patients) was 2.9 +/- 2.0 days. There were no major intraoperative thoracoscopic complications. A correct diagnosis was rendered in all patients undergoing a biopsy. One patient required a second thoracoscopic biopsy to better define a mediastinal mass. Two patients developed postoperative atelectasis after scoliosis procedures. One patient had a small persistent pneumothorax after a bleb resection for a spontaneous pneumothorax. This subsequently resolved.In pediatric patients with thoracic pathology, thoracoscopy is highly effective for attaining the goal of the operation, with a low rate of conversion and complications.

Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive malignant neoplasm of unknown origin, and is comprised of small round cells with a characteristic desmoplastic stroma. DSRCT typically expresses epithelial, mesenchymal and neural markers simultaneously. We describe a case of DSRCT with an atypical immunohistochemical profile and rhabdoid-like tumor cells on electron microscopy. In the present case, the neoplastic cells were positive only for vimentin, desmin (cytoplasmic membranous pattern) and CD56, and negative for smooth muscle actin, synaptophysin, CD117, CD45, myogenin, CAM5.2, pancytokeratin, WT1, EMA, CD99, neurofilament, CD34 and p53. Ki67 showed a low proliferative activity. Electron microscopy showed focal rhabdoid differentiation. However, INI-1 (SNF-5/BAF47) demonstrated preservation of nuclear positivity in the neoplastic cells. Cytogenetic studies showed translocation t(11;22)(p13;q12) confirming an EWSR1-WT1 translocation characteristic for DSRCT, and t(1;15)(q11;p11.2) of unknown significance. This case is a diagnostic challenge because of atypical immunohistochemical profile and cytogenetic study is crucial in rendering the correct diagnosis.

During repair for duodenal atresia, it has been emphasized that inspection of the small bowel to identify a second atresia is required. The laparoscopic approach for repair of duodenal atresia has been criticized for its limitation to perform this step. Given that duodenal atresia and jejunoileal atresias do not share common embryologic origins, we question the validity of this concern. Therefore, we conducted a multicenter retrospective review of duodenal atresia patients to quantify the incidence of jejunoileal atresia in this population.After institutional review board approval (IRB #07-12-187X), a retrospective review was conducted on all patients who have undergone duodenal atresia repair at seven institutions over the past 7-12 years. Demographics and the presence or absence of a jejunoileal atresia were recorded.Four hundred eight patients with duodenal atresia were identified. The mean gestaational age was 36.3 ± 2.9 weeks, and the mean weight was 2.5 ± 0.8 kg. Mean age at operation was 19 days (range, 1-1314). There was a 28% incidence of trisomy 21. Two patients (0.5%) were identified as having a second intestinal atresia, and both were type IIIb. One patient was diagnosed at the time of duodenal atresia repair; the other was a delayed diagnosis. Both patients did well after repair.In this, the largest series of duodenal atresia patients compiled to date, the rate of a concomitant jejunoileal atresia is less than 1%. This low incidence is not high enough to mandate extensive inspection of the entire bowel in these patients, and a second atresia should not be a concern during laparoscopic repair of duodenal atresia.

Background: The significance of meconium plug syndrome is dependent on the underlying diagnosis. The incidence of pathologic finding, particularly Hirschsprung's disease, contributing to the presence of these plugs, has been debated. However, there are little recent data in the literature. Therefore, we reviewed our experience with meconium plugs as a cause of abdominal distension to evaluate the associated conditions and incidence of Hirschsprung's disease. Methods: We reviewed the records of newborns with meconium plugs found in the distal colon on contrast enema from 1994 to 2007. Demographics, radiologic findings, histologic findings, operative findings, and clinical courses were reviewed. Results: During the study period, 77 patients were identified. Mean gestational age was 37.4 weeks and birth weight, 2977 g. Hirschsprung's disease was found in 10 patients (13%). One had ultrashort segment disease and another had total colonic aganglionosis. Maternal diabetes was identified in 6 patients. No patients were diagnosed with cystic fibrosis, meconium ileus, malrotation, or intestinal atresia. Conclusion: Meconium plugs found on contrast enema are associated with a 13% incidence of Hirschsprung's disease in our experience. Although all patients with plugs and persistent abnormal stooling patterns should prompt a rectal biopsy and genetic probe, the incidence of Hirschsprung's and cystic fibrosis may not be as high as previously reported.

Ganglioneuroma (GN) is the uncommon, benign representative of the peripheral neuroblastic tumours (PNTs), which arise from primitive sympathetic ganglion cells. PNTs comprise one of the most common groups of neoplastic diseases in infants and children, but its occurrence in the pancreas is rare. We report a 4-year-old girl with GN of the pancreas requiring pancreaticoduodenectomy as a definitive therapy and with a great outcome, and we review the published literature.