Search

Pancreatic ductal adenocarcinoma (PDAC) tumor growth is enhanced by tumor-associated macrophages (TAMs), yet the mechanisms by which tumor cells and TAMs communicate are not fully understood. Here we show that exosomes secreted by PDAC cell lines differed in their surface proteins, lipid composition, and efficiency of fusing with THP-1-derived macrophages in vitro. Exosomes from AsPC-1, an ascites-derived human PDAC cell line, were enriched in ICAM-1, which mediated their docking to macrophages through interactions with surface-exposed CD11c on macrophages. AsPC-1 exosomes also contained much higher levels of arachidonic acid (AA), and they fused at a higher rate with THP-1-derived macrophages than did exosomes from other PDAC cell lines or from an immortalized normal pancreatic ductal epithelial cell line (HPDE) H6c7. Phospholipase A2 enzymatic cleavage of arachidonic acid from AsPC-1 exosomes reduced fusion efficiency. PGE2 secretion was elevated in macrophages treated with AsPC-1 exosomes but not in macrophages treated with exosomes from other cell lines, suggesting a functional role for the AsPC-1 exosome-delivered arachidonic acid in macrophages. Non-polarized (M0) macrophages treated with AsPC-1 exosomes had increased levels of surface markers indicative of polarization to an immunosuppressive M2-like phenotype (CD14hi CD163hi CD206hi). Furthermore, macrophages treated with AsPC-1 exosomes had significantly increased secretion of pro-tumoral, bioactive molecules including VEGF, MCP-1, IL-6, IL-1β, MMP-9, and TNFα. Together, these results demonstrate that compared to exosomes from other primary tumor-derived PDAC cell lines, AsPC-1 exosomes alter THP-1-derived macrophage phenotype and function. AsPC-1 exosomes mediate communication between tumor cells and TAMs that contributes to tumor progression.

Background: The increased use of remote monitoring and telemedicine support may help alleviate the need for some of the postoperative inpatient hospital care and reduce health care costs, but little is known about current postoperative hospital resource use patterns. We aim to describe hospital resources use patterns in pediatric patients postappendectomy for complicated appendicitis and to evaluate the potential of earlier discharge with remote monitoring., Methods: This was a retrospective cohort study using the Pediatric Health Information System database for patients who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Health care use/costs (antibiotics, intravenous fluids [proxy for diet], analgesics, laboratory studies, and imaging tests) were determined using administrative billing data. Potentially avoidable days were defined as nondischarge days without codes for intravenous opioid pain medication or intravenous fluids. Descriptive statistics and logistic regression were used., Results: In total, 24,165 patients were included: 8,300 patients (34.3%) had at least 1 potentially avoidable hospitalization day, totaling 13,970 days or 14.2% of all hospitalization days. Median hospitalization cost was $19,434 [$15,658-$25,157], with accommodation and operating room being the greatest contributors. Public insurance and minority races and ethnicities were associated with greater odds of potentially avoidable days. More than 80% of hospitalized patients had intravenous antibiotics through 10 days postoperatively. More than 20% received opioids daily., Conclusions: More than one third of the patients who underwent laparoscopic appendectomy for complicated appendicitis could have had at least 1 potentially avoidable hospitalization day. Remote monitoring and telemedicine support should be explored and could help with earlier discharge and lower costs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Introduction: The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit., Methods: This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts., Results: Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18., Conclusions: We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity., Methods: This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes., Results: A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55)., Conclusions: Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Recent studies are discordant regarding postoperative use of piperacillin/tazobactam (PT) versus ceftriaxone/metronidazole (CM) for pediatric complicated appendicitis. Some argue that the broader spectrum PT decreases intraabdominal abscess formation; however, antibiotic stewardship, and once-a-day dosing favor CM. We aim to compare outcomes of postoperative antibiotic utilization using a large administrative database., Methods: We queried the Pediatric Health Information System for patients 2-18 years old who underwent laparoscopic appendectomy for complicated appendicitis between 2016 and 2021. Patients were grouped into PT, CM, or other using the first postoperative day antibiotics. Adverse events and antibiotic use trends were evaluated., Results: We included 29,015 children from 45 hospitals. CM was used in 51.9% and 31.3% received PT. Wide variation was seen among hospitals with PT use decreasing over the years. Overall rate of abscess was 9.2%. On multivariable regression, PT was associated with higher risk for abscess formation (RR 1.35, 99% CI 1.04-1.75) and readmission (RR 1.38, 99% CI 1.13-1.68) compared to the CM group. However, following adjustment for hospitals with high CM prevalence, these associations were no longer significant., Conclusion: Postoperative use of PT for complicated appendicitis is associated with higher rates of readmissions and intraabdominal abscess when compared to CM. However, this effect is mitigated when adjusting for common practice patterns., Level of Evidence: Level III., Study Type: Retrospective Comparative Study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Fluorescence-guided surgery (FGS) with indocyanine green (ICG) is a rapidly diffusing surgical innovation, but its utilization in pediatrics remains unknown. We present a cross-sectional descriptive analysis of trends from a national database., Methods: The Pediatric Health Information System (PHIS) database was queried for patient encounters between January 2016 and July 2021 with an associated ICG administration within 3 days prior to surgery. All procedure codes from each encounter were reviewed by two surgeons to determine the most likely associated FGS procedure and assign an operative category., Results: 1270 encounters were identified from 38 participating hospitals. The mean patient age (SD) was 8.3 (6.4) years, 54.5% were male, 63.8% were white, and 30.1% were Hispanic. The most common categories for ICG use were neurosurgery (21.3%), biliary (18.3%), perfusion (14.8%), urology (12.5%), gastrointestinal (10.8%), ophthalmology (8.8%), and thoracic (5.6%). Utilization over time increased for some categories (thoracic, visceral perfusion, and neurological procedures) or remained stable for other categories. Overall ICG utilization has increased in 2020 (n = 314) compared to 2016 (N = 83). The number of centers utilizing ICG has also increased from 14 hospitals in 2016 to 29 hospitals in 2020 though adoption remains unevenly distributed, with 5 high-utilization hospitals accounting for 56.8% of all ICG FGS cases., Conclusion: ICG is being used across a wide variety of pediatric surgical disciplines. Trends over time show increasingly frequent adoption across the country, with a few high-volume centers driving the innovation. Fluorescence-guided surgery is commercially available and is becoming more commonplace for pediatric surgeons. Dedicated efforts will now be needed to assess outcomes using this promising technology., Level of Evidence: Level IV., Study Type: Retrospective study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database., Methods: We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation., Results: In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis., Conclusion: SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method., Level of Evidence: Level III., Study Type: Retrospective Comparative Study., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Digital phenotyping refers to near-real-time data collection from personal digital devices, particularly smartphones, to better quantify the human phenotype. Methodology using smartphones is often considered the gold standard by many for passive data collection within the field of digital phenotyping, which limits its applications mainly to adults or adolescents who use smartphones. However, other technologies, such as wearable devices, have evolved considerably in recent years to provide similar or better quality passive physiologic data of clinical relevance, thus expanding the potential of digital phenotyping applications to other patient populations. In this perspective, we argue for the continued expansion of digital phenotyping to include other potential gold standards in addition to smartphones and provide examples of currently excluded technologies and populations who may uniquely benefit from this technology., (©Christopher De Boer, Hassan Ghomrawi, Suhail Zeineddin, Samuel Linton, Soyang Kwon, Fizan Abdullah. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 14.03.2023.)

Purpose: Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation., Methods: A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups., Results: During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups., Conclusions: Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique., (Copyright © 2022. Published by Elsevier Inc.)

Background: Current reports of adolescent bariatric surgery underutilization for treating severe obesity do not comprehensively assess the extent of existing disparities. We sought to describe national trends in adolescent bariatric surgery over a 9-year period and investigate previously described ethnoracial-, insurance-, income-, and geographic-based disparities. Methods: A cross-sectional analysis of adolescents aged 10-19 years who underwent bariatric surgery from 2009 to 2017 was conducted using Healthcare Cost and Utilization Kids' Inpatient Database and National Inpatient Sample Databases. Annual rates and types of bariatric surgery were assessed using trend analysis and stratified by patient, hospital, and regional characteristics. Results: The rate of bariatric surgeries per 1,000,000 adolescents with severe obesity increased over time (227 cases in 2009 to 331cases in 2017). Roux-en-Y gastric bypass and gastric band significantly decreased ( p  < 0.001), while sleeve gastrectomy became the most commonly performed bariatric surgery ( p  < 0.001). Surgeries were increasingly performed in urban teaching hospitals (77.9%) and most commonly in the Northeast (34.4%) and South (40.9%). The proportion of black patients (12.1%-15.8%) undergoing bariatric surgery increased, although was not significant and remained below that of white patients ( p  = 0.06). The proportion of publicly insured patients undergoing bariatric surgery significantly increased (17.0% to 30.7%, p  < 0.001), although no changes were observed based on median household income. Conclusions: Over the study period, utilization of adolescent bariatric surgery has increased. Yet, vulnerable populations, who have the highest rates of severe obesity, continue to undergo bariatric surgery at disproportionately lower rates. Further efforts to address disparities and barriers to care are urgently needed to care for these children.

Purpose: There is wide practice variation in the use of laparoscopic fundoplication (LF) versus gastrojejunostomy (GJ) tube insertion for children who do not tolerate gastric feeds. Using weight gain as an objective proxy of adequate nutrition, we sought to evaluate the difference in weight gain between LF and GJ., Methods: A retrospective, cohort study was conducted of patients ≤ 2 years who underwent LF or GJ between 2014 and 2019 at a single institution. Patient characteristics, change in weight 1-year post-procedure and frequency of unplanned healthcare utilization encounters were collected and examined., Results: A total of 125 patients (50.4%LF, 49.6%GJ) were identified. Adjusted modeling demonstrated that on average, there was an additional 0.85-unit increase in weight-for-age Z scores in the LF compared to the GJ cohort (p = 0.01). The GJ cohort had significantly more unplanned healthcare utilization encounters (4.2, SD 3.4) compared to LF (3.0, SD 3.1) (p = 0.03). Furthermore, the GJ cohort underwent an average of 3.3 planned GJ exchanges within 1-year post-procedure., Conclusion: In the first year post-operatively, LF is associated with increased weight gain and fewer unplanned and overall healthcare encounters compared to GJ. Long-term outcomes including weight gain and quality-of-life measures should be studied to develop standardized guidelines for this common clinical scenario., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Importance: Presenting with complicated appendicitis, which is associated with higher rates of complications and readmissions compared with simple appendicitis, may indicate delayed access to care. Although both patient-level and neighborhood-level social determinants of health are associated with access to care, little is known about the association between neighborhood factors and access to acute pediatric surgical care., Objective: To examine the association between neighborhood factors and the odds of presenting with complicated appendicitis and unplanned postdischarge health care use., Design, Setting, and Participants: A retrospective cohort study of patients aged 18 years or younger diagnosed with appendicitis was conducted. Discharge data from October 1, 2015, to September 30, 2018, were obtained from the Pediatric Health Information System Database and linked to the Child Opportunity Index (COI) 2.0 Database. Data analysis was conducted from January 1 through July 1, 2021., Exposures: The COI, a composite score of zip code neighborhood opportunity level information, divided into quintiles ranging from very low to very high opportunity., Main Outcomes and Measures: Based on COI level, the main outcome was the odds of presenting with complicated appendicitis, which was defined using the Agency for Healthcare Research and Quality-specified International Statistical Classification of Diseases, 10th Edition, Clinical Modification codes. The secondary outcome was the odds of unplanned postdischarge health care use (emergency department visits and/or readmissions) for patients with simple and with complicated appendicitis., Results: A total of 67 489 patients (mean [SD] age, 10.5 [3.9] years) had appendicitis, with 31 223 cases (46.3%) being complicated. A total of 1699 patients (2.5%) were Asian, 24 234 (35.9%) were Hispanic, 4447 (6.6%) were non-Hispanic Black, and 29 234 (43.3%) were non-Hispanic White; 40 549 patients (60.1%) were male; and 32 343 (47.9%) were publicly insured. Patients living in very low-COI neighborhoods had 28% higher odds of presenting with complicated appendicitis (odds ratio, 1.28; 95% CI, 1.20-1.35) compared with those in very high-COI neighborhoods. There was no significant association between COI level and unplanned postdischarge health care use (very high COI, 20.8%; very low COI, 19.1%)., Conclusions and Relevance: In this cohort study, children from lower-COI neighborhoods had increased odds of presenting with complicated appendicitis compared with those from higher-COI neighborhoods, even after controlling for patient-level social determinants of health factors. These findings may inform policies and programs that seek to improve access to pediatric surgical care.

Purpose: 1.7 billion children lack access to surgical care, particularly in low- and middle-income countries (LMIC). The pediatric surgical workforce density (PSWD), an indicator of surgical access, correlates with survival of complex pediatric surgical problems. To determine if PSWD also correlates with population-level health outcomes for children, we compared PSWD with pediatric-specific mortality rates and determined the PSWD associated with improved survival., Methods: Using medical licensing registries, pediatric surgeons practicing in 26 countries between 2015 and 2019 were identified. Countries' PSWD was calculated as the ratio of pediatric surgeons per 100,000 children. The correlation between neonatal, infant and under 5 mortality rates and PSWD was assessed using Spearman's correlations and piecewise linear regression models., Results: Four LIC, eight L-MIC, ten UMIC and four HIC countries, containing 420 million children, were analyzed. The median PSWD by income group was 0.03 (LIC), 0.12 (L-MIC), 1.34 (UMIC) and 2.13 (HIC). PSWD strongly correlated with neonatal (0.78, p < 0.001), infant (0.82, p < 0.001) and under 5 (0.83, p < 0.001) mortality rates. Survival improved with increasing PSWD to a threshold of 0.37., Conclusion: PSWD correlates with pediatric population mortality rates, with significant improvements in survival with PSWD > 0.37. Currently, PSWD in LMICs is inadequate to meet UN Sustainable Development Goal 3.2 for child mortality., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Despite more than two million pediatric operations performed in the United States annually, normal postoperative recovery remains difficult to define. Wearable sensors that assess physical activity and vital signs in real time represent a tool to assess postoperative recovery. This study examined the use of a wearable, the FitBit Inspire HR, to describe recovery in children after appendectomy and to determine the sensitivity of wearable data to distinguish disease severity., Materials and Methods: Children 3-18 y old undergoing appendectomy in a tertiary children's hospital were invited to participate. Participants wore the FitBit Inpire HR after surgery for 21 d. t-tests compared daily step counts, and piecewise linear regression models were fit to examine recovery trajectories for patients with simple and complicated appendicitis., Results: Thirty-two patients were enrolled, and 26 met eligibility criteria. Nine (35%) children had complicated appendicitis, and 14 (54%) were female; the mean age was 9.1 y (standard deviation: 2.9). Four hundred nineteen postoperative days were captured (range: 8-22 d; median: 16 d). Step counts increased after surgery; however, piecewise models showed that patients with simple appendicitis had a more rapid increase (P < 0.01) and reached a plateau (approximately 8000 steps/d) on postoperative day 9, whereas patients with complicated appendicitis did not reach a plateau and had lower step counts during the entire 21-postoperative day period (P < 0.01)., Conclusions: Recovery in children after surgery can be characterized using wearables, which can also distinguish recovery trajectories based on disease severity. Establishing such "normative" recovery patterns may lead to earlier detection of complications., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Autologous fat grafting is a dynamic modality used in plastic surgery as an adjunct to improve functional and aesthetic form. However, current practices in fat grafting for soft-tissue augmentation are plagued by tremendous variability in long-term graft retention, resulting in suboptimal outcomes and repetitive procedures. This systematic review identifies and critically appraises the evidence for various enrichment strategies that can be used to augment and improve the viability of fat grafts., Methods: A comprehensive literature search of the Medline and PubMed databases was conducted for animal and human studies published through October of 2017 with multiple search terms related to adipose graft enrichment agents encompassing growth factors, platelet-rich plasma, adipose-derived and bone marrow stem cells, gene therapy, tissue engineering, and other strategies. Data on level of evidence, techniques, complications, and outcomes were collected., Results: A total of 1382 articles were identified, of which 147 met inclusion criteria. The majority of enrichment strategies demonstrated positive benefit for fat graft survival, particularly with growth factors and adipose-derived stem cell enrichment. Platelet-rich plasma and adipose-derived stem cells had the strongest evidence to support efficacy in human studies and may demonstrate a dose-dependent effect., Conclusions: Improved understanding of enrichment strategies contributing to fat graft survival can help to optimize safety and outcomes. Controlled clinical studies are lacking, and future studies should examine factors influencing graft survival through controlled clinical trials in order to establish safety and to obtain consistent outcomes.