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The impact of thoracoscopic surgery on outcomes in children with congenital lung malformations (CLM) remains controversial. The purpose of this study was to determine the effect of operative approach on perioperative outcomes in infants undergoing lobectomy for an asymptomatic CLM.After IRB approval, a retrospective cohort study was conducted on 506 children with a CLM resected at one of eleven children's hospitals over a seven-year period. Infants undergoing elective lobectomy were identified, and covariates were balanced based on operative approach using propensity scores with full matching. Outcomes were analyzed based on intention to treat with weighted conditional regression.One hundred seventy-five infants met inclusion criteria. There were 67 (38.3%) open, 89 (50.9%) thoracoscopic, and 19 (10.9%) thoracoscopic-converted-to-open lobectomies. Thoracoscopic lobectomy was associated with significantly longer operative times (26 min, 95% CI 6-47 min, p = 0.012) but used less epidural anesthesia (OR 0.02, 95% CI 0.004-0.11, p0.001) when compared to open lobectomy. There were no significant differences in intraoperative blood loss, postoperative complications, chest tube duration, or length of stay.Thoracoscopy has become the most common operative approach for elective lobectomy in infants with asymptomatic CLMs. The non-inferiority of thoracoscopic lobectomy in postoperative outcomes supports its continued use as an alternative to open lobectomy.Treatment study, Level III.

Background The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. Materials and methods A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. Results Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. Conclusions Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

OBJECTIVE To assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes. SUMMARY BACKGROUND DATA Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery have not been well defined. METHODS A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at eleven children's hospitals from 2009-2016. Statistical analyses were performed using non-parametric bivariate or multivariable logistic regression. RESULTS Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection (p < 0.001). An initial CVR ≤ 1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR < 0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth. CONCLUSION In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning.

Introduction The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection. Methods After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative. Results Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1–12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6–11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%). Conclusion This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients. Level of evidence Level II.

Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. Type of study Prospective pilot study Level of evidence Level III.

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children’s hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a “successful” treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Purpose The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). Methods We performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. Results Among 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). Conclusion Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM. Type of Study Prospective Cohort Study. Level of Evidence II.

OBJECTIVE The purpose of this study was to determine if implementation of a Pediatric Emergency Care Applied Research Network (PECARN)-based Closed Head Injury Assessment Tool could safely decrease computed tomography (CT) use for pediatric head injury evaluation at a nonpediatric community emergency department (ED). METHODS A quality improvement project was initiated at a nonpediatric community ED to implement an institution-specific, PECARN-based Pediatric Closed Head Injury Assessment Tool. Baseline head CT use at the participating ED was determined for children with closed head injury through retrospective chart review from March 2014 through November 2015. Head injury patients were identified using International Classification of Disease (ICD)-9 codes for head injury, unspecified (959.01) and concussion with and without loss of consciousness (850-850.9) until October 2015, after which ICD-9 was no longer used. To identify eligible patients after October 2015, lists of all pediatric patients evaluated at the participating ED were reviewed, and patients were included in the analysis if they had a physician-assigned discharge diagnosis of head injury or concussion. Exclusion criteria were age ≥ 18 years, penetrating head trauma, history of brain tumor, ventriculoperitoneal shunt, bleeding disorder, or presentation > 24 hours postinjury. Medical history, injury mechanism, symptoms, head CT use, and disposition were recorded. Implementation of the Pediatric Closed Head Injury Assessment Tool was achieved through provider education sessions beginning in December 2015 and ending in August 2016. Head CT use was monitored for 12 months postimplementation, from September 2016 through August 2017. Patients were classified into low, intermediate, or high risk for clinically important traumatic brain injury (ciTBI) by chart review. ED length of stay (LOS), disposition, and ED returns within 72 hours were recorded. Categorical variables were compared using chi-square test or Fisher's exact test, and continuous variables, using Kruskal-Wallis test. RESULTS A total of 252 children with closed head injury were evaluated preimplementation (March 2014 through November 2015), 132 children were evaluated during implementation (December 2015 through August 2016), and 172 children were evaluated postimplementation (September 2016 through August 2017). Overall CT use decreased from 37.7% (95% confidence interval [CI] = 31.7-43.7) preimplementation to 16.9% (95% CI = 11.3-22.5) postimplementation (p

This study investigates differences in 1-year outcomes by clinical and socioeconomic factors among US children with uncomplicated appendicitis who were treated with antibiotics vs surgery.

BACKGROUND: Pediatric lung lesions are a group of mostly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. Our objective was to evaluate the characteristics of children undergoing resection of a primary lung lesion and to identify preoperative risk factors for malignancy. METHODS: A retrospective cohort study was conducted by using an operative database of 521 primary lung lesions managed at 11 children’s hospitals in the United States. Multivariable logistic regression was used to examine the relationship between preoperative characteristics and risk of malignancy, including pleuropulmonary blastoma (PPB). RESULTS: None of the 344 prenatally diagnosed lesions had malignant pathology (P < .0001). Among 177 children without a history of prenatal detection, 15 (8.7%) were classified as having a malignant tumor (type 1 PPB, n = 11; other PPB, n = 3; adenocarcinoma, n = 1) at a median age of 20.7 months (interquartile range, 7.9–58.1). Malignancy was associated with the DICER1 mutation in 8 (57%) PPB cases. No malignant lesion had a systemic feeding vessel (P = .0427). The sensitivity of preoperative chest computed tomography (CT) for detecting malignant pathology was 33.3% (95% confidence interval [CI]: 15.2–58.3). Multivariable logistic regression revealed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology (odds ratios of 42.15 [95% CI, 7.43–340.3; P < .0001] and 42.03 [95% CI, 3.51–995.6; P = .0041], respectively). CONCLUSIONS: In pediatric lung masses initially diagnosed after birth, the risk of PPB approached 10%. These results strongly caution against routine nonoperative management in this patient population. DICER1 testing may be helpful given the poor sensitivity of CT for identifying malignant pathology.

Background Antibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown. Methods/design A 3-year stepped wedge cluster randomized trial will be conducted at nine US Children’s Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members’ assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented. Discussion This study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation. Trial registration NCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440.

This study aims to examine contemporary practice patterns and compare short-term outcomes for vesicoureteral reflux procedures (ureteral reimplant/endoscopic injection) using National Surgical Quality Improvement Program-Pediatric data.Procedure-specific variables for antireflux surgery were developed to capture data not typically collected in National Surgical Quality Improvement Program-Pediatric (eg vesicoureteral reflux grade, urine cultures, 31-60-day followup). Descriptive statistics were performed, and logistic regression assessed associations between patient/procedural factors and outcomes (urinary tract infection, readmissions, unplanned procedures).In total, 2,842 patients (median age 4 years; 76% female; 68% open reimplant, 6% minimally invasive reimplant, 25% endoscopic injection) had procedure-specific variables collected from July 2016 through June 2018. Among 88 hospitals, a median of 24.5 procedures/study period were performed (range 1-148); 95% performed ≥1 open reimplant, 30% ≥1 minimally invasive reimplant, and 70% ≥1 endoscopic injection, with variability by hospital. Two-thirds of patients had urine cultures sent preoperatively, and 76% were discharged on antibiotics. Outcomes at 30 days included emergency department visits (10%), readmissions (4%), urinary tract infections (3%), and unplanned procedures (2%). Over half of patients (55%) had optional 31-60-day followup, with additional outcomes (particularly urinary tract infections) noted. Patients undergoing reimplant were younger, had higher reflux grades, and more postoperative occurrences than patients undergoing endoscopic injections.Contemporary data indicate that open reimplant is still the most common antireflux procedure, but procedure distribution varies by hospital. Emergency department visits are common, but unplanned procedures are rare, particularly for endoscopic injection. These data provide basis for comparing short-term complications and developing standardized perioperative pathways for antireflux surgery.

This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF).Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively.One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029).Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes.Level II.Treatment Study.

Importance Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery. Objective To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. Design, Setting, and Participants Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children’s hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. Interventions Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). Main Outcomes and Measures The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. Results Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor’s degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%;P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, −4.3 days (99% CI, −6.17 to −2.43;P Conclusion and Relevance Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met. Trial Registration ClinicalTrials.gov Identifier:NCT02271932

Background:Overuse of antibiotics has caused secondary poor outcomes and has led to a current rate of antibiotic resistant infections that constitutes a public health crisis. In pediatric surgical specialties, children continue to receive unnecessary antibiotics.Objective:To understand the factors that contribute to pediatric surgeons’ decisions regarding the use of perioperative antibiotic prophylaxis.Methods:Focus groups included pediatric proceduralists/surgeons from the following specialties: interventional cardiology, otolaryngology, orthopedic surgery, cardiothoracic surgery, and general surgery.Results:A total of 23 surgeons with a median of 9 years of experience (range, 0.5–29 years) participated in the focus groups that lasted 30–90 minutes each. Five themes emerged influencing beliefs about antibiotic prescribing practices: (1) reliance on previous experience and early education, (2) balancing antibiotic use with risk of infection, (3) uncertainty about the state of the scientific evidence, (4) understanding importance of communication and team collaboration, and (5) a prevalence of hospital-level concerns.Conclusions:Surgeons describe a complex set of factors that impact their antibiotic prescribing in pediatric surgical cases. They reported initial, but not ongoing, training and a use of individual weight of risk and benefit as a major dictator of prescribing practices. Antimicrobial stewardship programs should work with surgeons to develop acceptable implementation strategies to optimize antibiotic prescribing.

The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis.There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis.Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates.Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)].Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

This study evaluates screening practices and the incidence of associated anomalies in infants with anorectal malformations (ARM).We performed a multi-institutional retrospective cohort study of children born between 2007 and 2011 who underwent surgery for ARM at 10 children's hospitals. ARM type was classified based on the location of the distal rectum, and all screening studies were reviewed.Among 506 patients, the most common ARM subtypes were perineal fistula (40.7%), no fistula (11.5%), and vestibular fistula (10.1%). At least 1 screening test was performed in 96.6% of patients, and 11.3% of patients underwent all. The proportion of patients with ≥1 abnormal finding on any screening test varied by type of ARM (p0.001). Screening rates varied from 15.2% for limb anomalies to 89.7% for renal anomalies. The most commonly identified anomalies by screening category were: spinal: tethered cord (20.6%); vertebral: sacral dysplasia/hemisacrum (17.8%); cardiac: patent foramen ovale (58.0%); renal: hydronephrosis (22.7%); limb: absent radius (7.9%).Screening practices and the incidence of associated anomalies varied by type of ARM. The rate of identifying at least one associated anomaly was high across all ARM subtypes. Screening for associated anomalies should be considered standard of care for all ARM patients.Multi-institutional retrospective cohort study.III.

Background Risk-adjustment is a key feature of the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-Ped). Risk-adjusted model variables require meticulous collection and periodic assessment. This study presents a method for eliminating superfluous variables using the congenital malformation (CM) predictor variable as an example. Methods This retrospective cohort study used NSQIP-Ped data from January 1st to December 31st, 2019 from 141 hospitals to compare six risk-adjusted mortality and morbidity outcome models with and without CM as a predictor. Model performance was compared using C-index and Hosmer-Lemeshow (HL) statistics. Hospital-level performance was assessed by comparing changes in outlier statuses, adjusted quartile ranks, and overall hospital performance statuses between models with and without CM inclusion. Lastly, Pearson correlation analysis was performed on log-transformed ORs between models. Results Model performance was similar with removal of CM as a predictor. The difference between C-index statistics was minimal (≤ 0.002). Graphical representations of model HL-statistics with and without CM showed considerable overlap and only one model attained significance, indicating minimally decreased performance (P = 0.058 with CM; P = 0.044 without CM). Regarding hospital-level performance, minimal changes in the number and list of hospitals assigned to each outlier status, adjusted quartile rank, and overall hospital performance status were observed when CM was removed. Strong correlation between log-transformed ORs was observed (r ≥ 0.993). Conclusions Removal of CM from NSQIP-Ped has minimal effect on risk-adjusted outcome modelling. Similar efforts may help balance optimal data collection burdens without sacrificing highly valued risk-adjustment in the future. Level of evidence Level II prognosis study.

Background Multicenter clinical research studies in pediatric surgery have been largely limited to relatively small case-series and retrospective reviews because of the rarity of many of the diseases we treat and difficulty coordinating and executing multi-institutional studies. Creation of a collaborative research network can provide the needed patient population and infrastructure to perform high quality multi-institutional studies. Methods In 2013, eleven academic pediatric surgery centers within the United States formed a research consortium to develop and conduct multicenter clinical research projects to advance the practice of pediatric surgery. Results We present our process for creating, developing, and maintaining this consortium including initial regional geographic limitation, charter development with by-laws and procedures for adopting studies, and research infrastructure including a central website for study monitoring and central reliance institutional review board process. Conclusion Our model could be reproduced or adapted by other institutions to develop or strengthen other research collaboratives. Level of evidence Type of study: retrospective, IV.

Background: Pediatric cystic lung lesions represent a rare group of predominantly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. We aimed to examine the clinical presentation, pathology data, and diagnostic evaluation of children undergoing resection of a cystic lung lesion diagnosed after birth. Methods: A multisite observational cohort study was conducted of children undergoing resection of a postnatally diagnosed primary cystic lung lesion between Jan 1, 2009 and Dec 31, 2015 at one of 11 United States children’s hospitals (Midwest Pediatric Surgery Consortium). Clinical presentation, perioperative findings, and pathologic diagnosis were reviewed and analyzed using non-parametric bivariate and multivariable logistic regression models. Findings: Of 521 children with resected lung lesions, 177 (34·0%) underwent resection for a lesion that was not diagnosed prenatally. Operations was performed with low morbidity at median ages of 4.4 months [interquartile range (IQR), 0·9-28·7], 10·9 months (IQR, 7·6-151·2), and 42·3 months (IQR, 11·1-86·2) for respiratory symptoms (n=89, 50·6%), asymptomatic disease (n=35, 19·9%), and pneumonia history (n=54, 30.7%), respectively. The most common pathologic diagnosis was congenital pulmonary airway malformation (n=59, 34·3%). Fifteen (8·5%) were classified as malignant tumors [type 1 pleuropulmonary blastoma (PPB), n=11; other PPB, n=3; adenocarcinoma, n=1) at a median resection age of 20.7 months (IQR, 7·9-58·1). The sensitivity of preoperative chest CT for detecting malignant pathology was 33.3% (95% CI: 15·2-58·3). Multivariable logistic regression showed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology [odds ratios, 42·15 (95% CI: 7·43-340·3, p

The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium.After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015).Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0).Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion.Level III.

Background/purpose Hirschsprung disease (HD) is diagnosed by rectal biopsy, with suction rectal biopsy (SRB), the preferred technique in neonates. Reported SRB adequacy has varied overall with concern for decreased diagnostic yield in older children. The study aim was to assess SRB adequacy by age in children with the current device used at our institution. Methods Following IRB approval, a retrospective cohort of children (1 to 18years) evaluated by SRB for HD was identified through billing records. Data regarding demographics, procedure, results, and complications were collected and analyzed using SPSS. Results 56 children (median age 3.9years) underwent SRB with an 80.4% overall success rate. Patients older than 5years had 90.5% adequacy rate compared to 74.3% in those younger. Univariate analysis revealed weak association of inadequate specimens with younger age and males, and no association with insurance, race/ethnicity, weight–height or BMI percentile, sedation type, or procedure location. SRB under general anesthesia (GA) had 100% adequacy ( n =6). Patients with inadequate initial biopsy achieved diagnosis by SRB with increased sedation ( n =5) or full thickness biopsy under GA ( n =5). Conclusion With adequacy of 80.4% overall and 90.5% for patients greater than 5years, SRB is effective in evaluating the older child for HD.

OBJECTIVE To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P = < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P = < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.

Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF.A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up.In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p 0.29).RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach.Level III.

Infantile hemangioma (IH) is one of the most common vascular anomalies of early childhood and is usually recognized in the first few weeks to months of life as a solitary cutaneous lesion. This report documents our experience with a GLUT-1 positive IH presenting as the pathologic lead point in a colocolic intussusception in a 10-week-old infant who had no skin lesions. Literature suggests approximately 2% of all children presenting with an intussusception require surgical intervention; however, an IH as the pathologic lead point is unique.

Objective This goal of this review was to examine the clinical evidence in support of commonly utilized measures intended to reduce complications following elective colorectal surgery. Data source Literature searches were performed to identify relevant studies from Medline, PubMed, and Cochrane databases. Study selection The American Pediatric Surgery Association Outcomes and Clinical Trials Committee selected eight questions to address this topic systematically in the context of three management areas: 1) appropriate utilization of systemic antibiotics for colorectal procedures, 2) reduction of stool burden through mechanical bowel preparation, and 3) intraluminal gut decontamination through use of enteral nonabsorbable antibiotics. Primary outcomes of interest included the occurrence of infectious and mechanical complications related to stool burden and intraluminal bacterial concentration (incisional surgical site infection, anastomotic leakage, and intraabdominal abscess). Results The evidence in support of each management category was systematically reviewed, graded, and summarized in the context of the review's primary outcomes. Practice recommendations were made as deemed appropriate by the committee. Conclusions Clinical evidence in support of interventions to reduce infectious complications following colorectal surgery is derived almost exclusively from the adult literature. High-quality evidence to guide clinical practice in children is sorely needed, as the available data may have only limited relevance to pediatric colorectal diseases.

Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF.The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers.292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p0.3). Hospital volume was not associated with postoperative complication rates (p0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7.Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds.Treatment study.III.

The United States' healthcare system is facing unprecedented pressures: the healthcare cost curve is not sustainable while the bar of standards and expectations for the quality of care continues to rise. Systems committed to the surgical treatment of children will likely require changes and reorganization. Regardless of these mounting pressures, hospitals must remain focused on providing the best possible care to each child at every encounter. Available clinical expertise and hospital resources should be optimized to match the complexity of the treated condition. Although precise criteria are lacking, there is a growing consensus that the optimal combination of clinical experience and hospital resources must be defined, and efforts toward this goal have been supported by the Regents of the American College of Surgeons, the members of the American Pediatric Surgical Association, and the Society for Pediatric Anesthesia (SPA) Board of Directors. The topic of optimizing outcomes and the discussion of the concepts involved have unfortunately become divisive. Our goals, therefore, are 1) to provide a review of the literature that can provide context for the discussion of regionalization, volume, and optimal resources and promote mutual understanding of these important terms, 2) to review the evidence that has been published to date in pediatric surgery associated with regionalization, volume, and resource, 3) to focus on a specific resource (anesthesia), and the association that this may have with outcomes, and 4) to provide a framework for future research and policy efforts.

BACKGROUND The American College of Surgeons National Surgical Quality Improvement Program-Pediatric was initiated in 2008 to drive quality improvement in children’s surgery. Low mortality and morbidity in previous analyses limited differentiation of hospital performance. METHODS: Participating institutions included children’s units within general hospitals and free-standing children’s hospitals. Cases selected by Current Procedural Terminology codes encompassed procedures within pediatric general, otolaryngologic, orthopedic, urologic, plastic, neurologic, thoracic, and gynecologic surgery. Trained personnel abstracted demographic, surgical profile, preoperative, intraoperative, and postoperative variables. Incorporating procedure-specific risk, hierarchical models for 30-day mortality and morbidities were developed with significant predictors identified by stepwise logistic regression. Reliability was estimated to assess the balance of information versus error within models. RESULTS: In 2011, 46 281 patients from 43 hospitals were accrued; 1467 codes were aggregated into 226 groupings. Overall mortality was 0.3%, composite morbidity 5.8%, and surgical site infection (SSI) 1.8%. Hierarchical models revealed outlier hospitals with above or below expected performance for composite morbidity in the entire cohort, pediatric abdominal subgroup, and spine subgroup; SSI in the entire cohort and pediatric abdominal subgroup; and urinary tract infection in the entire cohort. Based on reliability estimates, mortality discriminates performance poorly due to very low event rate; however, reliable model construction for composite morbidity and SSI that differentiate institutions is feasible. CONCLUSIONS: The National Surgical Quality Improvement Program-Pediatric expansion has yielded risk-adjusted models to differentiate hospital performance in composite and specific morbidities. However, mortality has low utility as a children’s surgery performance indicator. Programmatic improvements have resulted in actionable data.

Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly lacking contemporary data detailing patient demographics, medical/surgical management and outcomes. Substantial variation in the care of infants with EA/TEF may affect both short- and long-term outcomes. The purpose of this study was to characterize the demographics, management strategies and outcomes in a contemporary multi-institutional cohort of infants diagnosed with EA/TEF to identify potential areas for standardization of care.A multi-institutional retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals between 2009 and 2014 was performed. Over the 5year period, 396 cases were identified in the 11 centers (7±5 per center per year). All infants with a diagnosis of EA/TEF made within 30days of life who had surgical repair of their defect defined as esophageal reconstruction with or without ligation of TEF within the first six months of life were included. Demographic, operative, and outcome data were collected and analyzed to detect associations between variables.Prenatal suspicion or diagnosis of EA/TEF was present in 53 (13%). The most common anatomy was proximal EA with distal TEF (n=335; 85%) followed by pure EA (n=27; 7%). Clinically significant congenital heart disease (CHD) was present in 137 (35%). Mortality was 7.5% and significantly associated with CHD (p0.0001). Postoperative morbidity occurred in 62% of the population, including 165 (42%) cases with anastomotic stricture requiring intervention, anastomotic leak in 89 (23%), vocal cord paresis/paralysis in 26 (7%), recurrent fistula in 19 (5%), and anastomotic dehiscence in 9 (2%). Substantial variation in practice across our institutions existed: bronchoscopy prior to repair was performed in 64% of cases (range: 0%-100%); proximal pouch contrast study in 21% (0%-69%); use of interposing material between the esophageal and tracheal suture lines in 38% (0%-69%); perioperative antibiotics ≥24h in 69% (36%-97%); and transanastomotic tubes in 73% (21%-100%).Contemporary treatment of EA/TEF is characterized by substantial variation in perioperative management and considerable postoperative morbidity and mortality. Future studies are planned to establish best practices and clinical care guidelines for infants with EA/TEF.Type of study: Treatment study. Level IV.

Background There is an increased desire among patients and families to be involved in the surgical decision-making process. A surgeon's ability to provide patients and families with patient-specific estimates of postoperative complications is critical for shared decision making and informed consent. Surgeons can also use patient-specific risk estimates to decide whether or not to operate and what options to offer patients. Our objective was to develop and evaluate a publicly available risk estimation tool that would cover many common pediatric surgical procedures across all specialties. Study Design American College of Surgeons NSQIP Pediatric standardized data from 67 hospitals were used to develop a risk estimation tool. Surgeons enter 18 preoperative variables (demographics, comorbidities, procedure) that are used in a logistic regression model to predict 9 postoperative outcomes. A surgeon adjustment score is also incorporated to adjust for any additional risk not accounted for in the 18 risk factors. Results A pediatric surgical risk calculator was developed based on 181,353 cases covering 382 CPT codes across all specialties. It had excellent discrimination for mortality (c-statistic = 0.98), morbidity (c-statistic = 0.81), and 7 additional complications (c-statistic > 0.77). The Hosmer-Lemeshow statistic and graphic representations also showed excellent calibration. Conclusions The ACS NSQIP Pediatric Surgical Risk Calculator was developed using standardized and audited multi-institutional data from the ACS NSQIP Pediatric, and it provides empirically derived, patient-specific postoperative risks. It can be used as a tool in the shared decision-making process by providing clinicians, families, and patients with useful information for many of the most common operations performed on pediatric patients in the US.

Aberrant right subclavian artery (ARSA), the most common aortic arch abnormality, occurs in approximately 0.5 to 1.8% of the general population, with prevalence of up to 25% in those with esophageal atresia. Although ARSA is often asymptomatic, a fistulous tract into esophagus may develop with prolonged nasogastric tube placement or endotracheal intubation and lead to potentially fatal hematemesis. We present a first case of ARSA-esophageal fistula in a 20-year-old woman with VATER association in the absence of an esophageal anomaly and review 28 cases of ARSA-esophageal fistula reported in the literature to date. Requiring nasogastric and endotracheal tube placement for approximately 4 months, the patient had a prolonged hospital course and died after sudden hematemesis. An autopsy demonstrated an ARSA-esophageal fistula and no other source of upper gastrointestinal bleeding. In patients with esophageal atresia requiring prolonged placement of an endotracheal or nasogastric tube, a screening imaging study and corrective surgery may be indicated. Although the mortality rate is still high, timely recognition and repair of ARSA-esophageal fistula appear to be improving. Given the potentially prolonged latency for its development with occasional presence of heralding symptoms, increased awareness may facilitate surgical intervention to prevent a catastrophic exsanguination.

The aim of this study is to review the current evidence on the diagnosis and management of empyema. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee compiled 8 questions to address. A comprehensive review was performed on each topic. Topics included the distinction between parapneumonic effusion and empyema, the optimal imaging modality in evaluating pleural space disease, when and how pleural fluid should be managed, the first treatment option and optimal timing in the management of empyema, the optimal chemical debridement agent for empyema, therapeutic options if chemical debridement fails, therapy for parenchymal abscess or necrotizing pneumonia and duration of antibiotic therapy after an intervention. The evidence was graded for each topic to provide grade of recommendation where appropriate.

Our goal is to identify the impact of time to surgical intervention on the outcomes of infants with gastroschisis.After institutional review board approval, we performed a retrospective review of the medical records of all infants admitted to our institution from 2001 to 2010. Transport, bowel stabilization, and closure times were defined as the time from birth to admission, admission to the first-documented operative intervention, and first operative intervention to abdominal closure, respectively. Outcomes included age at full enteral feeds, total parental nutrition days, ventilator days, and hospital length of stay. Multivariate analysis was used to identify independent predictors of the outcomes.One hundred eighteen infants with gastroschisis were included in our study. Transport and bowel stabilization times were not predictive of any outcome. However, the time to abdominal wall closure and postnatal gastrointestinal complications were independently predictive of age at full enteral feeds, total parenteral nutrition days, and hospital length of stay.Time to surgical evaluation/bowel stabilization was not predictive of any clinically relevant outcomes in infants with gastroschisis. These data demonstrate that potential benefits from prenatal regionalization of infants with gastroschisis are not supported by decreased time to operative intervention.

IMPORTANCE: The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals. OBJECTIVE: To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis. DESIGN: This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children’s hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014. MAIN OUTCOMES AND MEASURES: Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals. RESULTS: A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P

Purpose Recurrent gastroesophageal reflux is a common complication after fundoplication and is often treated with revision fundoplication. We report our experience with laparoscopic redo fundoplication. Methods The medical records of all patients in whom laparoscopic revision fundoplication was attempted over a 7 1/2-year period were reviewed. Results Redo laparoscopic fundoplication was attempted in 72 pediatric patients. Ten patients had undergone initial open fundoplication, and 9 additional patients had prior abdominal surgery. Fifty-one percent of patients were neurologically impaired. Laparoscopic fundoplication was completed in 89% of first-time redo operations and 68% of second revisions with average operative times of 2.2 ± 1.0 and 2.6 ± 0.9 hours, respectively. Herniation of the fundoplication through the hiatus was common (75%) and the fundoplication was intact in 49%. Conversions to laparotomy were because of difficulties with dissection or visualization. No patients required intraoperative transfusion. No patients required reoperation in the perioperative period. There were no perioperative deaths. Twenty-six percent of the 72 patients went on to a third operation for gastroesophageal reflux, and 4 of these had a fourth. Conclusion Revision laparoscopic fundoplication is a technically challenging operation but can usually be completed and is characterized by a low rate of complications.

Appendicitis epiploicae is an inflammatory condition often confused with acute vermiform appendicitis and rarely diagnosed preoperatively. It is extremely rare in the pediatric population. We report a case of a 9-year-old boy with abdominal pain who was found to have appendicitis epiploicae, which was diagnosed and treated with laparoscopy. Laparoscopy is a valuable tool for both diagnosis and treatment of this uncommon entity.

OBJECTIVE: Accurate, timely diagnosis of pediatric appendicitis minimizes unnecessary operations and treatment delays. Preoperative abdominal-pelvic computed tomography (CT) scan is sensitive and specific for appendicitis; however, concerns regarding radiation exposure in children obligate scrutiny of CT use. Here, we characterize recent preoperative imaging use and accuracy among pediatric appendectomy subjects. METHODS: We retrospectively reviewed children who underwent operations for presumed appendicitis at a single tertiary-care children’s hospital and examined preoperative CT and ultrasound use with subject characteristics. Preoperative imaging accuracy was compared with postoperative and histologic diagnosis as the reference standard. RESULTS: Most children (395/423, 93.4%) who underwent an operation for appendicitis during 2009–2010 had preoperative imaging. Final diagnoses included normal appendix (7.3%) and perforated appendicitis (23.6%). In multivariable analysis, initial evaluation at a community hospital versus the children’s hospital was associated with 4.4-fold higher odds of obtaining a preoperative CT scan (P = .002), whereas preoperative ultrasound was less likely (odds ratio 0.20; P = .003). Ultrasound and CT sensitivities for appendicitis were diminished for studies performed at community hospitals compared with the children’s hospital. Girls were 4.5-fold more likely to undergo both ultrasound and CT scans and were associated with lower ultrasound sensitivity for appendicitis. CONCLUSIONS: Widespread preoperative imaging did not eliminate unnecessary pediatric appendectomies. Controlling for factors potentially associated with referral bias, a CT scan was more likely to be performed in children initially evaluated at community hospitals compared with the children’s hospital. Broadly-applicable strategies to systematically maximize diagnostic accuracy for childhood appendicitis, while minimizing ionizing radiation exposure, are urgently needed.

Objective The optimal treatment of necrotizing enterocolitis (NEC) is a common challenge for pediatric surgeons. Although many studies have evaluated prevention and medical therapy for NEC, few guidelines for surgical care exist. The aim of this systematic review is to review and evaluate the currently available evidence for the surgical care of patients with NEC. Methods Data were compiled from a search of PubMed, OVID, the Cochrane Library database, and Web of Science from January 1985 until December 2011. Publications were screened, and their references were hand-searched to identify additional studies. Clinicaltrials.gov was also searched to identify ongoing or unpublished trials. The American Pediatric Surgical Association Outcomes and Clinical Trials Committee proposed six questions deemed pertinent to the surgical treatment of NEC. Recent Cochrane Reviews examined three of these topics; a literature review was performed to address the additional three specific questions. Results The Cochrane Reviews support the use of prophylactic probiotics in preterm infants less than 2500 grams to reduce the incidence of NEC, as well as the use of human breast milk rather than formula when possible. There is no clear evidence to support delayed initiation or slow advancement of feeds. For surgical treatment of NEC with perforation, there is no clear support of peritoneal drainage versus laparotomy. Similarly, there is a lack of evidence comparing enterostomy versus primary anastomosis after resection at laparotomy. There are little data to determine the length of treatment with antibiotics to prevent recurrence of NEC. Conclusion Based on available evidence, probiotics are advised to decrease the incidence of NEC, and human milk should be used when possible. The other reviewed questions are clinically relevant, but there is a lack of evidence-based data to support definitive recommendations. These areas of NEC treatment would benefit from future investigation.

Purpose of review Evaluation of the child with acute abdominal pain is challenging because of the wide range of potential diagnoses. Presenting symptoms, clinical examination, and laboratory findings can guide selection of diagnostic imaging. Recent findings Intussusception and intestinal malrotation are potentially serious causes of intestinal obstruction, which are best evaluated by ultrasound and upper gastrointestinal series, respectively. Ultrasound has diagnostic importance in the evaluation of multiple diseases, including appendicitis, by potentially decreasing the need for inpatient observation, cholecystitis and complications of gall stones such as pancreatitis, and ovarian diseases. Pelvic inflammatory disease should be considered in evaluation of a teenage girl with lower abdominal pain. Less common causes of acute abdominal pain include ingested foreign bodies, infected congenital anomalies, and perforated peptic ulcer disease. Summary Presenting symptoms and physical examination findings can narrow the number of potential diagnoses in pediatric acute abdominal pain and thereby guide diagnostic imaging selection. Abdominal/pelvic ultrasound, rather than computed tomography scan, is the preferred modality for initial evaluation of many potential causes of pediatric abdominal pain.

Objectives: Congenital diaphragmatic hernia (CDH) remains a significant cause of neonatal morbidity and mortality. Summary of Background Data: Previous studies have suggested that hospital volume is an independent predictor of in-hospital mortality. We sought to validate this effect using a large national database incorporating 37 free-standing children's hospitals in the United States. Methods: Infants who underwent repair of CDH from 2000 to 2008 at Pediatric Health Information Systems-member hospitals were evaluated. Hospitals were categorized by tertiles into low-volume (≤6 cases/yr), medium-volume (6―10 cases/yr), and high-volume (>10 cases/yr). Using generalized linear mixed models with random effects, we computed the risk-adjusted odds ratio of mortality by yearly hospital volume of CDH repair, after adjustment for salient patient and hospital characteristics. Results: There were 2203 infants who underwent repair with an overall survival of 82%. Average yearly hospital volume of CDH repair varied from 1.4 to 17.5 cases per year. Smaller birthweight (adjusted odds ratio [aOR]: 0.56 per kg, P < 0.001), year of birth (P < 0.001), chromosomal abnormalities (aOR: 3.83, P < 0.01), longer time to repair (aOR: 1.12 per week, P < 0.05), the thoracic approach for repair (P < 0.02), and requirement for extracorporeal membrane oxygenation (aOR: 10.31, P < 0.0001), or inhaled nitric oxide (aOR: 5.25, P < 0.0001) were each independently associated with mortality. Compared with low-volume hospitals, medium-volume (aOR: 0.56, P < 0.05) and high-volume (aOR: 0.44, P < 0.01) hospitals had a significantly lower mortality. The rate of extracorporeal membrane oxygenation use at each facility was not independently associated with mortality. Conclusions: This large study suggests that hospitals which perform high volumes of CDH repair achieve lower in-hospital mortality. These data support the paradigm of regionalized centers of excellence for the management of infants with this morbid condition.

Background There has been increasing interest and concern raised in the surgical literature regarding changes in the culture of surgical training and practice, and the impact these changes may have on surgeon stress and the appeal of a career in surgery. We surveyed pediatric surgeons and their partners to collect information on career satisfaction and work-family balance. Methods The American Pediatric Surgical Association Task Force on Family Issues developed separate survey instruments for both pediatric surgeons and their partners that requested demographic data and information regarding the impact of surgical training and practice on the surgeon's opportunity to be involved with his/her family. Results We found that 96% of pediatric surgeons were satisfied with their career choice. Of concern was the lack of balance, with little time available for family, noted by both pediatric surgeons and their partners. Conclusion The issues of work-family balance and its impact on surgeon stress and burnout should be addressed in both pediatric surgery training and practice. The American Pediatric Surgical Association is positioned to play a leading role in this effort.

This study was conducted to determine the effect of age at diagnosis and length of ganglionated bowel resected on postoperative Hirschsprung-associated enterocolitis (HAEC).Children who underwent endorectal pull-through (ERPT) between January 1993 and December 2004 were retrospectively reviewed. t Test, analysis of variance, Kaplan-Meier, and Cox's proportional hazards analyses were performed.Fifty-two children with Hirschsprung disease (median age, 25 days; range, 2 days-16 years) were included. Nineteen (37%) had admissions for HAEC. Proportional hazards regression showed that HAEC admissions decreased by 30% with each doubling of age at diagnosis (P = .03) and increased 9-fold when postoperative stricture was present (P.01), after controlling for type of ERPT, trisomy 21, transition zone level, and preoperative enterocolitis. Thirty-six children, with age at initial operation less than 6 months, were grouped based on length of ganglionated bowel excised (A [5 cm] and B [5 cm]). No significant difference in the number of HAEC admissions during initial 2 years post-ERPT was seen between groups A (n = 18) and B (n = 18). The study had a power of 0.8 to detect a difference of 1 admission over 2 years.Children diagnosed with Hirschsprung disease at younger ages are at a greater risk for postoperative enterocolitis. Excising a longer margin of ganglionated bowel (5 cm) does not seem to be beneficial in decreasing HAEC admissions.