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There are existing healthcare disparities in pediatric surgery today. Identity and racial incongruity between patients and providers contribute to systemic healthcare inequities and negatively impacts health outcomes of minoritized populations. Understanding the current demographics of the American Pediatric Surgical Association and therefore the cognitive diversity represented will help inform how best to strategically build the organization to optimize disparity solutions and improve patient care.1558 APSA members were sent an anonymous electronic survey. Comparative data was collected from the US Census Bureau and the Association of American Medical Colleges. Results were analyzed using standard statistical tests.Of 423 respondents (response rate 27%), the race and ethnicity composition were 68% non Hispanic White, 12% Asian American and Pacific Islander, 6% Hispanic, 5% multiracial, and 4% Black/African American. Respondents were 35% women, 63% men, and 1% transgender, androgyne, or uncertain. Distribution of sexual identity was 97% heterosexual and 3% LGBTQIA. Religious identity was 50% Christian, 22% Agnostic/Atheist, 11% Jewish, 3% Hindu, and 2% Muslim. 32% of respondents were first-generation Americans. Twenty-four different primary languages were spoken, and 46% of respondents were conversational in a second language. These findings differ in meaningful ways from the overall American population and from the population of matriculants in American medical schools.There are substantial differences in the racial, gender, and sexual identity composition of APSA members compared with the overall population in the United States. To achieve excellence in patient care and innovate solutions to existing disparities, representation, particularly in leadership is essential.Survey; original research.Level IV.

Firearm injuries (GSW) in the pediatric population is a public health crisis. Little is known about the outcomes of damage control laparotomy (DCL) following abdominal GSW. This study aims to evaluate outcomes from abdominal GSWs in the pediatric population.The trauma registry from an urban Level 1 trauma was queried for pediatric (0-18 y) GSW was queried from September 2013 to June 2020. Demographics, clinical variables, outcomes, readmissions, and recidivism were analyzed.Abdominal GSW were identified in 83 patients (17% of all GSW). The median age was 16 [15-17], 84% were male and 86% Black. Violent intent accounted for 90% of GSW. The injury severity score was 16 [9-26] and 80% went directly from the resuscitation bay to the operating room. Laparotomy was required in 87% of patients, and surgery was not required in any patient initially managed nonoperatively. The most common complications were intraabdominal infection (20%), other infections (13%), and small bowel obstruction (8%). DCL with temporary abdominal closure was performed in 16% of laparotomies and was associated with a longer length of stay, more infections, but similar rates of readmission and mortality. Overall mortality was 13%, with all but one patient expiring in the resuscitation bay or the operating room. All patients who underwent DCL survived to discharge.Abdominal firearm injuries have high morbidity and mortality in the pediatric population. Damage control operations for abdominal GSWs are a valuable surgical option with similar outcomes to primary abdominal closure after initial injury survival.

Pyloromyotomy for hypertrophic pyloric stenosis (HPS) is one of the most common non-elective operations performed in the neonatal period. This project aims to explore outcomes of pyloromyotomy and compare differences between laparoscopic versus open pyloromyotomies in newborns diagnosed with HPS.The Nationwide Readmissions Database (NRD) from 2010 to 2014 was queried to identify patients diagnosed with HPS that underwent repair.In total, 30,915 children (18% female) underwent pyloromyotomy for HPS. Median length of stay for index admission was 2 days. A total of 212 (0.7%) patients required a redo pyloromyotomy. 127 (60%) were performed during index admission. Readmission rate at 30 days was 3% and 5% at one year, and 22% presented to a different hospital. The most common indications for readmission were feeding intolerance (24%), dehydration (10%), and malnutrition (10%). Patients from low-income households were more likely to present with malnutrition and weight loss (9% vs 4%, p0.001) and had higher readmission rates (8% vs 4%, p0.001). Laparoscopic pyloromyotomies accounted for 10% (n = 2951) of cases. Those undergoing laparoscopy were less likely to have electrolyte disturbances (41% vs 54%, p0.001) or weight loss (2% vs 11%, p0.001) on admission. The rate of open conversion was 1%. Intraoperative perforation was not more common in laparoscopic than open cases. Open pyloromyotomies had higher 30-day readmission rates and more surgical site infections.Complications from pyloromyotomies are rare. Although infrequent, the incidence of incomplete pyloromyotomy is higher than previously reported and more common with open approaches. Newborns from low-income households are more likely to present with advanced symptoms and have disproportionately higher rates of readmission.Level III TYPE OF STUDY: Treatment Study, retrospective.

Bicycle accidents are potentially preventable, and helmets can mitigate the severity of injuries. The purpose of the study it to investigate geo-demographic areas to establish prevention policies and targeted programs.From October 2013 to March 2020 all bicycle injuries at a Level 1 trauma center were collected for ages ≤18 years. Demographics, injuries, and outcomes were analyzed. Incidents were aggregated to zip codes and the Local Indicators of Spatial Association (LISA) statistic was used to test for spatial clustering of injury rates per 10,000 children.Over the 8-year time period, 77 cases were identified with an average age of 13±4 years, 83% male and 48% non-Hispanic white. The majority of patients (98%) were not wearing a helmet. Loss of consciousness was reported in 44% and 21% sustained a traumatic brain injury. Twenty-eight percent required ICU care and 36% required operative interventions. There was only 1 mortality in the cohort (1%).Injuries were more common in lower household income zip codes (Figure 1). Six zip codes encompassing several interstate exits and the connected heavy-traffic roadways comprise a statistically significant cluster of pediatric bicycle accidents (Figure 1).Low-income neighborhoods and those near major roadways held the highest risk for pediatric bicycle accidents. Use of helmets was extremely low in the patient population, with high rates of traumatic brain injury. With this information, targeted programs to address high-risk intersections, helmet access, and safety education can be implemented locally.

Bias and discrimination remain pervasive in the medical field and increase the risk of burnout, mental health disorders, and medical errors. The experiences of APSA members with bias and discrimination are unknown, therefore the APSA committee on Diversity, Equity and Inclusion conducted a survey to characterize the prevalence of bias and discrimination.1558 APSA members were sent an anonymous survey, of which 423 (27%) responded. Respondents were asked about their demographics, knowledge of implicit bias, and experience of bias and discrimination within their primary workplace, APSA, and APSA committees. Data were analyzed using Fisher's Exact test, Kruskal-Wallis test, and multivariable logistic regression as appropriate with significance defined as p0.05.Discrimination was reported across all levels of practice, academic appointments, race, ethnicity, and gender identities. On multivariable analysis, surgical trainees (OR 3.6) as well as Asian American and Pacific Islander (OR 4.8), Black (OR 5.2), Hispanic (OR 8.2) and women (OR 8.7) surgeons were more likely to experience bias and discrimination in the workplace. Community practice surgeons were more likely to experience discrimination within APSA committees (OR 3.6). Members identifying as Asian (OR 0.4), or women (OR 0.6) were less likely to express comfort reporting instances of bias and discrimination.Workplace discrimination exists across all training levels, academic appointments, and racial and gender identities. Trainees and racial- and gender-minority surgeons report disproportionately high prevalence of bias and discrimination. Improving reporting mechanisms and implicit bias training are possible initiatives in addressing these findings.

Endobiliary stents placed for benign and malignant indications can spontaneously dislocate from the biliary system and migrate to the distal gastrointestinal tract. Stent migration can result in gastrointestinal perforation, with the most common locations in the sigmoid and distal colon, and may require surgical intervention. We describe the case of a 60-year-old female presenting with an ascending colonic perforation secondary to a dislodged plastic biliary stent placed for palliation of her gallbladder carcinoma. The patient was managed with a combined laparoendoscopic approach by a multidisciplinary team—gastroenterology performed an endoscopic stent retrieval and colorectal surgery identified the location of the perforation laparoscopically and performed colonic serosal repairs. The patient had an uneventful postoperative course and was discharged on postoperative day 4. This case demonstrates a novel minimally invasive laparoendoscopic approach at a high-volume academic center for the treatment of ascending colonic perforation secondary to biliary stent migration.

Background Kentucky has one of the highest rectal cancer incidences in the United States. High poverty rates have led to poor insurance coverage and inadequate access to care. The treatment of locally advanced rectal cancer utilizes a multimodal regimen requiring regular access to expert care. The rate of receipt of neoadjuvant therapy in Kentucky is unknown. Objective This study aimed to evaluate the rate and factors associated with the receipt of neoadjuvant therapy for localized advanced rectal cancer in Kentucky and the effect on overall survival. Design This is a retrospective database review. Settings This study was conducted by utilizing the Kentucky Cancer Registry at an academic center. Patients All patients diagnosed with stage II/III rectal adenocarcinoma from 2005 to 2015 in the Commonwealth of Kentucky were included. Main outcome measures The primary outcomes measured were the factors associated with nonreceipt of neoadjuvant therapy and overall survival. Results Of 1896 patients, only 46.8% received neoadjuvant therapy. Factors associated with not receiving neoadjuvant therapy included older age, female sex, low education level, high poverty level, and treatment at nonacademic centers. Survival analysis demonstrated significantly improved survival in patients receiving neoadjuvant therapy compared with other treatment regimens. Limitations This study was limited by the retrospective nature of the review and by unmeasured confounders. Conclusions Our study was the first to evaluate the factors behind the low rates of neoadjuvant therapy for locally advanced rectal cancer in Kentucky. Neoadjuvant therapy in this population is beneficial for survival; efforts should be made in policy and education with focus on older patients, female patients, and treatment at nonacademic centers. Centralization of rectal cancer care improves outcomes, but we must be aware of the effect it may have on disparate populations with poor access. See Video Abstract at http://links.lww.com/DCR/B596. Terapia neoadyuvante en el manejo del cncer de recto en estadio ii / iii un estudio retrospectivo en una poblacin dispar y el efecto en la supervivencia ANTECEDENTES:El estado de Kentucky tiene una de las mayores incidencias de cancer de recto en los EE. UU. Debido a una alta tasa de pobreza, el porcentaje de la poblacion que cuenta con seguro de salud, es muy limitado, y por lo tanto el acceso a una atencion de alto nivel es muy bajo. El tratamiento del cancer de recto localmente avanzado, es multidisciplinario, lo que exige acceso y disponibilidad a un grupo experto. Se desconoce la tasa de pacientes que reciben terapia neoadyuvante en Kentucky.OBJETIVO:Establecer la tasa y los factores asociados con el uso de terapia neoadyuvante en el tratamiento del cancer de recto localmente avanzado en Kentucky, y su efecto en la supervivencia global.DISENO:Revision retrospectiva de una base de datos.ESCENARIO:Este estudio se llevo a cabo utilizando el Registro de Cancer de Kentucky en un centro academico.PACIENTES:Se incluyen todos los pacientes diagnosticados con adenocarcinoma de recto, de la Mancomunidad (Commonwealth) de Kentucky, en estadio II / III entre 2005 y 2015.PRINCIPALES MEDIDAS DE RESULTADO:Establecer los factores asociados con el hecho de no recibir terapia neoadyuvante; y establecer la supervivencia global.RESULTADOS:De 1896 pacientes evaluados, solo el 46,8% recibio terapia neoadyuvante. Los factores asociados, para no haber recibido terapia neoadyuvante fueron: la edad avanzada, sexo femenino, bajo nivel educativo, alto nivel de pobreza y tratamiento en centros no academicos. El analisis de la supervivencia mostro una supervivencia significativamente mejor en los pacientes que recibieron terapia neoadyuvante en comparacion con otros esquemas de tratamiento.LIMITACIONES:Revision retrospectiva, factores de confusion no medidos.CONCLUSIONES:Nuestro estudio ha sido el primero en evaluar los factores determinantes de las bajas tasas de terapia neoadyuvante para el tratamiento del cancer de recto localmente avanzado en Kentucky. La terapia neoadyuvante mejora y favorece la supervivencia en esta poblacion, por lo tanto se deben hacer esfuerzos en las politicas de salud, asi como en educacion, enfocados a los pacientes mayores, pacientes femeninas y tratamiento en centros no academicos. El centralizar la atencion del cancer de recto, mejora los resultados, pero debemos ser conscientes del efecto que puede tener en poblaciones desiguales economicamente, con acceso deficiente a la posibilidad de recibir atencion de alto nivel. Consulte Video Resumen en http://links.lww.com/DCR/B596.

Malrotation with midgut volvulus is a surgical emergency commonly encountered in pediatric surgical practice. Outcomes are excellent with timely diagnosis and treatment, but the development of bowel ischemia is associated with many negative consequences.The Nationwide Readmissions Database was used to identify patients 0-18 years (excluding newborns) with malrotation and midgut volvulus from 2010 to 2014. Demographics, procedures, and outcomes were compared by income group (highest quartile vs. lowest quartile) using standard statistical tests. Results were weighted for national estimates.Emergency surgery for midgut volvulus was performed in 572 patients. The majority (86%) underwent Ladd's procedure, while 14% required bowel resection and/or ostomy. Patients in the lowest income quartile were more likely to require bowel resection (18% vs. 8%, p = 0.03) or ostomy (9% vs. 2%, p = 0.015) compared to those in the highest income quartile. Low-income patients were more likely to experience prolonged hospital stay (8 [5-13] days vs. 6 [4-8] days, p0.001) and experience complications including infections (19% vs. 5%, p = 0.002), endotracheal intubation (18% vs. 4%, p0.001), and blood transfusions (13% vs. 3%, p = 0.003).Income disparity represents a major factor in surgical outcomes in children with midgut volvulus. A broad spectrum of clinical outcomes following surgery for midgut volvulus exists. Patients from lower-income communities are at significantly higher risk for numerous complications, negative outcomes, and higher resource utilization. These findings support additional investigations of practices to mitigate risk for low-income patients.Level III: Retrospective comparative study.

Mesenteric bypass grafts can be constructed either antegrade or retrograde. There is debate regarding which is the optimal approach. We have modified the technique for retrograde mesenteric revascularization using a direct open retrograde revascularization (DORR) technique. This report is a retrospective single-institution study that describes the DORR technique and compares it with antegrade mesenteric bypass.The medical records of patients undergoing open mesenteric bypass between January 2001 and December 2017 for mesenteric ischemia were reviewed. Patients who underwent mesenteric thromboembolectomy, retrograde stenting, or bypass for aneurysmal disease were excluded. Patient demographics, operative details, and follow-up data were recorded. Antegrade bypasses were constructed using a polyester, collagen-coated, knitted, (Maquet, Getinge Group)- bifurcated graft. The supraceliac aorta was exposed, and the Dacron graft limbs were tunneled to the celiac and/or superior mesenteric artery (SMA). The DORR was constructed by anastomosing a vein graft to an iliac artery. The vein was tunneled through the base of the small bowel mesentery to create a direct course to the SMA. When revascularization to both the SMA and celiac vessels was indicated, the vein was anastomosed to the SMA in a side-to-side fashion with the distal vein tunneled through the mesocolon and anastomosed in a end-to-side fashion to the hepatic artery. Statistical analysis was done using Student's t-test, Mann-Whitney U test, Fisher's exact test, and log-rank test with a P ≤ 0.05 considered significant.Forty-one patients underwent open mesenteric bypass: 16 antegrade and 25 retrograde. Patient age, gender, and body mass index were similar. Indication for operation was acute ischemia in a greater portion of patients undergoing retrograde bypass (P = 0.025). For antegrade bypasses, Dacron was used in 15 and saphenous vein in 1. The DORR bypass originated from an iliac artery (21), limb of an aortofemoral graft (2), or infrarenal aorta (2). All DORR were constructed using veins (19 femoral veins and 6 greater saphenous veins). In DORR configurations, the bypass was created to only the SMA in 23 cases (92%). By comparison, in antegrade bypasses, the bypass was constructed to both the SMA and celiac arteries in all but 1 case (P 0.00001). Median operative time was significantly shorter for DORR compared with antegrade bypass (282 vs. 375 min; P 0.05). Blood loss, need for second-look laparotomy, morbidity, mortality, length of stay, and discharge disposition were similar between groups. There was a shift in favor of the DORR technique in the second half of the study (4 of 15 [27%] DORR from 2001 to 2009 vs. 21 of 26 [81%] DORR from 2010 to 2017). In survivors, 57% of the antegrade cohort and 74% of the DORR cohort had documented follow-up (average, 47.5 ± 59.9 and 28.8 ± 31.3 months, respectively). No difference was noted in survival between groups. All grafts in both cohorts were patented at follow-up.Direct tunneling of the graft under the mesentery with the DORR technique avoids concern for kinking and has shorter operative time despite the need for vein harvest. No differences were noted in long-term survival between patient groups. The use of a venous conduit makes DORR adaptable for both chronic and acute mesenteric ischemia. These factors have resulted in the DORR technique to be our preferred method for open mesenteric revascularization.

This study aims to analyze the relative risks for total thyroidectomies by comparing complication rates for total versus partial thyroidectomy in the pediatric population.We queried the Kids' Inpatient Database (KID) 1997-2012 for all cases of total (n = 3253) or partial (n = 2380) thyroidectomy. We then designed a propensity score matching model and compared total versus partial thyroidectomy based on surgical complications and outcomes.In our cohort, the median age was 16 years and 79% were females. Those treated at a specialty pediatric hospital or pediatric unit in a general hospital comprised 73% of all patients. The most common indications for surgery were malignancy (46%) and goiter (42%). The most common complications were hypocalcemia and nerve injury with an unweighted incidence of 9% (n = 174) and 3% (n = 57) respectively. When compared to partial thyroidectomy, total thyroidectomy was associated with increased rates of postoperative complications. Additionally, the median length of stay was significantly higher for total thyroidectomy patients.This is the largest analysis to date comparing outcomes for total versus partial thyroidectomy in the pediatric population. Surgeons should consider the increased rates of hypocalcemia and nerve injury complications when selecting total compared to partial thyroidectomy in children.

Down syndrome (DS) is the most common abnormality associated with Hirschsprung disease (HD). It has been suggested patients with HD and DS have worse outcomes, however the literature is controversial.The Kids' Inpatient Database (KID) from 2003 to 2012 was used to identify newborns with HD. Demographics, hospital characteristics, and outcomes were compared among patients with and without DS using standard statistical tests.There were 481 patients identified with HD, of which 45 (9%) had DS. Patients with DS were older at the time of first rectal biopsy (6 [3-11] days vs. 4 [3-6] days, p = 0.012). There were no differences in operative versus non-operative management in patients with and without DS (p = 0.706). Hospital length of stay was longer in the DS cohort (22 [13-33] days vs. 15 [10-24] days, p = 0.019), and patients with DS were more likely to have a concomitant diagnosis of wound infection (12% vs. 3%, p = 0.002) and necrotizing enterocolitis (14% vs. 5%, p = 0.018). The mortality rate for patients with DS was four times higher than those without DS (5% vs.0.8%, p = 0.018).In this nationwide cohort of patients with Hirschsprung disease, those with Down syndrome experienced delays in diagnosis and worse outcomes.Level III.Treatment study, retrospective comparative study.

Pediatric patients with Crohn's disease often require colectomies. The laparoscopic approach is considered safe, but there is little national data on outcomes and readmissions in this population.The Nationwide Readmissions Database was queried from 2010 to 2014 for patients ≤ 18 years who underwent colectomy for Crohn's disease during index admission. Patients were stratified by operative approach: laparoscopic versus open. Outcomes were compared with standard statistical methods.There were 2833 patients (47% female) who underwent a colectomy via laparoscopic (58%) vs. open (42%) approach. Index admissions were elective 55% of the time. Most operations were right hemicolectomy (86%), followed by total colectomy (8%). Of the study population, 489 (17%) were diverted with an ostomy. Readmission rates at 30 days and 1 year were 9% and 18%, respectively. The most common diagnoses at readmission were intra-abdominal infection (16%), small bowel obstruction (16%), and surgical site infection (9%). Laparoscopy was more commonly performed during elective admissions (63% vs. 44%), for patient with private insurance (72% vs. 39%), and for patients in the highest income quartile (66% vs. 48% in the lowest income quartile), all p0.001. Length of stay was longer on index admission for open colectomy (8[5-12] days vs. 6[4-11] days, p0.001), while cost was similar ($17,754[$12,375-$30,625] vs. $17,017[$11,219-$27,336], p = 0.104). There were no differences in readmission rate, intraabdominal infection or small bowel obstruction.In pediatric patients, laparoscopic colectomy for Crohn's disease is safe and is associated with shorter hospitalization and equivalent hospital costs compared to the open procedure. Socioeconomic disparities in laparoscopic utilization exist and warrant future investigation.Level III.

This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes.The 2010-2014 Nationwide Readmissions Database was used to identify patients18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates.There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs.7%, p = 0.017) settings.In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.