Utility of continuous pulse CO-oximetry for hemoglobin monitoring in pediatric patients with solid organ injuries at level 1 trauma centers: A pilot study.

INTRODUCTION: Hemorrhage is a major cause of preventable death in injured children. Monitoring after admission often requires multiple blood draws, which have been shown to be stressful in pediatric patients. The Rainbow-7 device is a continuous pulse CO-oximeter that measures multiple wavelengths of light, permitting continuous estimation of the total hemoglobin (Hb) level. The purpose of this study was to evaluate the utility of the noninvasive Hb measurement for monitoring pediatric trauma patients admitted with solid organ injury. METHODS: This is a prospective, dual-center, observational trial for patients younger than age 18 years admitted to a Level I pediatric trauma center. Following admission, blood was routinely measured as per current solid organ injury protocols. Noninvasive Hb monitoring was initiated after admission. Time-synced data for Hb levels were compared with that taken using blood draws. Data were evaluated using bivariate correlation, linear regression, and Bland-Altman analysis. RESULTS: Over a 1-year period, 39 patients were enrolled. The mean ± SD age was 11 ± 3.8 years. Forty-six percent (n = 18) of patients were male. The mean ± SD Injury Severity Score was 19 ± 13. The average change in Hb levels between laboratory measurements was -0.34 ± 0.95 g/dL, and the average change in noninvasive Hb was -0.12 ± 1.0 g/dL per measurement. Noninvasive Hb values were significantly correlated with laboratory measurements ( p < 0.001). Trends in laboratory Hb measurements were highly correlated with changes in noninvasive levels ( p < 0.001). Bland-Altman analysis demonstrated similar deviation from the mean throughout the range of Hb values, but the differences between measurements were increased by anemia, African American race, and elevated shock index, pediatric age-adjusted score and Injury Severity Score. CONCLUSION: Noninvasive Hb values demonstrated correlation with measured Hb concentration as isolated measurements and trends, although results were affected by skin pigmentation, shock, and injury severity. Given the rapid availability of results and the lack of requirement of venipuncture, noninvasive Hb monitoring may be a valuable adjunct for pediatric solid organ injury protocols. Further study is required to determine its role in management. LEVEL OF EVIDENCE: Dianostic Test or Criteria; Level III.

Delayed Surgical Management of an Unusual Classic Bladder Exstrophy Variant.

Anterior abdominal wall defects are rare anomalies that can affect multiple organ systems including gastrointestinal, genitourinary, musculoskeletal, and the neurospinal axis. The highly varied, complex anatomy in this patient population creates a challenging reconstruction scenario that merits careful surgical planning. We present an unusual female variant with an anorectal malformation as well as musculoskeletal and genital abnormalities consistent with classic bladder exstrophy in which the urinary bladder, sphincter, and urethra were largely uninvolved.

Multimodality treatment of pediatric Ewing sarcoma: A single-center 10-year analysis of outcomes.

BACKGROUND: Ewing sarcoma, a malignancy originating from the bone or soft tissues most commonly diagnosed in adolescents, requires multimodality therapy. Although both surgical resection and radiation therapy are effective local control modalities, there are limited data comparing outcomes in patients treated with surgery versus radiation. We sought to determine whether there were differences in 5-year local failure-free survival, event-free survival, and overall survival based on the modality used for local control. METHODS: Patients treated for Ewing sarcoma at a single tertiary pediatric hospital between 2010 and 2020 were included for retrospective analysis. Patient and tumor demographics, treatment information, and patient response to therapies were collected from the medical record. Outcome measures were local failure-free survival, event-free survival, and overall survival at 5 years from diagnosis. RESULTS: Sixty-one patients met inclusion criteria. All patients received chemotherapy, and 68.9% of patients presented with localized disease. Of these, 23.8% were treated with radiation alone; the remaining 76.2% underwent resection ± radiation. A total of 52.4% of patients with localized disease achieved R0 resection. Only 3 patients experienced local progression; there was no difference between treatment groups. There was no significant association between local control modality and event-free survival or overall survival in patients with localized disease, regardless of margin status. CONCLUSION: There was no significant difference in 5-year local failure-free survival, event-free survival, or overall survival in Ewing sarcoma patients treated with radiation versus surgery ± radiation, regardless of whether or not R0 resection was achieved. Future directions include a multi-institutional study to allow for further subgroup analysis and increased sample size.

Pediatric Abdominal Malignancies and Intravascular Extension: Contemporary Single-Center Experience.

INTRODUCTION: Inferior vena cava (IVC) thrombus is an uncommon and challenging complication of abdominal malignancies in the pediatric population, which significantly influences the treatment options and clinical outcomes in this population. METHODS: In this review, we present the presentation, treatments, interventions, and outcomes with this clinically and technically challenging oncological finding from a free-standing children's hospital from 2006 to 2017. RESULTS: Fourteen patients with IVC thrombus were identified as having an associated abdominal malignancy. The abdominal malignancies consisted of eight Wilms tumors (63% stage III and 37% stage IV), and one spindle cell sarcoma, neuroblastoma (stage III), kidney clear cell sarcoma (stage III), sclerosing epithelioid fibrosarcoma, hepatoblastoma-epithelial (stage IV), and hepatic embryonal sarcoma (stage IV). 50% of patients were male, 71% White, 29% Black, 7% Hispanic; mean age at diagnosis was 4.09 (SD 2.43) years. CT imaging identified IVC tumor thrombus for 79% of patients, US abdomen complete recorded 14%, and MRI lumbar 7%. 3Out of 14 patients, 13 patients were taken to the operating room with 12 patients undergoing concurrent tumor resection and IVC thrombectomy. Of the remaining patients, one had IVC thrombectomy via femoral cutdown by interventional radiology, and one was noted to have resolution of IVC thrombus with neoadjuvant chemotherapy. Of patients who underwent resection, one required IVC ligation, and one patient required IVC interposition vein graft reconstruction using a right IJ conduit. 60% of patients undergoing thrombectomy received neoadjuvant chemotherapy. Mean time from the diagnosis of IVC tumor thrombus to surgical thrombectomy was 46 (SD 44) days. No operative mortalities were reported. There were five major complications (hemothorax, pulmonary embolisms, seroma, and sepsis) and two minor complications (pneumonia and UTI). With exclusion of patient who underwent IVC ligation, no patients developed signs of IVC compression or recurrent thrombosis after thrombectomy. CONCLUSIONS: IVC tumor thrombus can significantly alter the clinical treatment, surgical options, and outcomes of malignant abdominal tumors. Treatment of IVC tumor thrombus included adjuvant chemotherapy, segmental IVC resection with or without reconstruction, thrombectomy with intimal stripping, or resection of the thrombus with part of the IVC wall. Evidence for standard treatment practices for IVC tumor thrombus in the setting of abdominal malignancy is lacking due to the rarity of this finding and the varied clinical presentations.

Surgical Repair of Orofacial Clefts in North Kivu Province of Eastern Democratic Republic of Congo (DRC).

BACKGROUND: There is a high prevalence of orofacial clefts in low- and middle-income countries with significant unmet need, despite having 50% of the population younger than 18 years in countries such as the Democratic Republic of Congo (DRC). The purpose of this article is to report on the experience of general surgeons with orofacial clefts at a single institution. METHODS: This is a retrospective study of patients treated for cleft lip/palate in the province of North Kivu, DRC between 2008 and 2017. RESULTS: A total of 1112 procedures (122/year) were performed. All procedures were performed by general surgeons following training by an international nongovernmental aid organization. A total of 59.2% of patients were male and the median age was 3.4 years (interquartile range: 0.7-13 years). Average distance from surgical center to patient location was 242.6 km (range: 2-1375 km) with outreach performed for distances >200 kms. A majority (82.1%) of patients received general anesthesia (GA) with significant differences in use of GA, age, weight, and length of stay by major orofacial cleft category. Of the 1112 patients, 86.1% were reported to have cleft lip alone, 10.5% had cleft lip and palate, and 3.4% cleft palate alone. Despite this, only 5.3% of patients underwent surgical repair of cleft palate. CONCLUSIONS: Multiple factors including malnutrition, risk of bleeding, procedural complexity, and cosmetic results may contribute to the distribution of procedures performed where most cleft palates are not treated. Based on previously published estimates, unmet needs and social burden of cleft lip and palate are high in the DRC.

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo.

BACKGROUND: Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging. METHODS: This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care. RESULTS: Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment. CONCLUSIONS: Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.

Gastrostomy tube placement in neonates undergoing tracheostomy: an opportunity to coordinate care?

OBJECTIVES: To describe variations in timing of gastrostomy tube (GT) placement for neonates undergoing tracheostomy. METHODS: Database study of neonates undergoing tracheostomy and GT placement using the Pediatric Health Information System (2012-2015). The primary outcome was timing of GT relative to tracheostomy. Logistic regression evaluated associations of patient- and hospital-level characteristics with GT timing. RESULTS: Of 1156 patients undergoing GT and tracheostomy placement, 42.4% had concurrent GT placement, 23.3% GT placement prior to tracheostomy, and 34.3% GT placement after tracheostomy. The proportion of patients undergoing concurrent placement ranged from 0 to 80% among 47 hospitals. Neonates born at 31-35 weeks, having cardiovascular comorbidities, history of diaphragmatic hernia repair, or gastroesophageal reflux disorder were more likely to receive GT placement prior to tracheostomy. CONCLUSION: Significant variability exists in the timing of neonatal tracheostomy and GT placement. Opportunities may exist to optimize coordination of care for neonates and reduce anesthetic exposure and hospital resource utilization.

Provider education decreases opioid prescribing after pediatric umbilical hernia repair.

PURPOSE: To improve opioid stewardship for umbilical hernia repair in children. METHODS: An educational intervention was conducted at 9 centers with 79 surgeons. The intervention highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics, and encouraged limiting doses/strength if opioids were prescribed. Three to six months of pre-intervention and 3 months of post-intervention prescribing practices for umbilical hernia repair were compared. RESULTS: A total of 343 patients were identified in the pre-intervention cohort and 346 in the post-intervention cohort. The percent of patients receiving opioids at discharge decreased from 75.8% pre-intervention to 44.6% (p < 0.001) post-intervention. After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post- versus the pre-intervention period was 0.27 (95% CI = 0.18-0.39, p < 0.001). Among patients receiving opioids, the number of doses prescribed decreased after the intervention (adjusted mean 14.3 to 10.4, p < 0.001). However, the morphine equivalents/kg/dose did not significantly decrease (adjusted mean 0.14 to 0.13, p = 0.20). There were no differences in returns to emergency departments or hospital readmissions between the pre- and post-intervention cohorts. CONCLUSIONS: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention. TYPE OF STUDY: Retrospective cohort study. LEVEL OF EVIDENCE: Level II.

Association of perioperative red blood cell transfusion with postoperative venous thromboembolism in pediatric patients: A propensity score matched analysis.

OBJECTIVE: To examine the association between perioperative red blood cell (RBC) transfusion and postoperative venous thromboembolism (VTE) in pediatric surgical patients. METHODS: Retrospective cohort study using the National Surgical Quality Improvement Project Pediatric, a validated registry of 118 United States children's hospitals. Patients under 19 years of age undergoing a surgical procedure between 2012 and 2017 were included, with the main exposure being RBC transfusion in the perioperative period (48 hours prior to operation to 72 hours after operation). The primary 30-day outcome of interest was a postoperative VTE requiring therapy. Risk-adjusted odds ratios (aOR) were calculated using multiple logistic regression. Subgroup analyses were performed across multiple surgical specialties. Sensitivity analyses were performed after (a) imputation for missing variables and (b) propensity score matching. RESULTS: During the study years, 482 867 pediatric patients (56.7% male; median age, 6 years [interquartile range, 1-12 years]) underwent an operation. Of these, 30 879 (6.4%) received at least one perioperative RBC transfusion. Postoperative VTE requiring therapy occurred in 618 patients (0.13%). After adjustment for multiple risk factors, perioperative RBC transfusion was associated with an increased risk of VTE (aOR 2.4; 95% CI, 1.9-3.0). The increased VTE risk persisted after imputation of missing demographic and clinical data as well as after 1:1 propensity score matching (29 811 matched pairs, aOR 2.2; 95% CI, 1.7-2.8). CONCLUSIONS: Perioperative RBC transfusion is associated with an increased, albeit still very low, risk of postoperative VTE in pediatric patients. Patients receiving blood in the perioperative period may benefit from additional monitoring or VTE prophylaxis.

Porcine bladder extracellular matrix in paediatric pilonidal wound care: healing and patient experience evaluation.

OBJECTIVE: Pilonidal disease (PD) with inflammation and abscess formation occurs frequently in adolescents. The management of pilonidal disease, time to wound healing, and patient satisfaction, however remains variable despite advances in wound care methods. Porcine bladder extracellular matrix (PBEM) facilitates site-specific tissue deposition/re-growth for the management of a variety of wounds. The aim was to describe the use and outcomes of PBEM in PD at a single centre. METHOD: A retrospective chart review of adolescent patients who underwent treatment of pilonidal disease with PBEM between 2012 and 2016 at a single institution, was undertaken. Patient demographics and clinical characteristics were collected and compared with historical controls and literature regarding traditional wound therapies. RESULTS: We reviewed 52 pilonidal disease wounds on 41 patients. Of these 36 were treated with PBEM. The average age was 16 years old at the time of operation with 39% male. Furthermore, 85% were being treated for recurrent pilonidal disease. Follow-up was available by chart review for 89% of patients with documented complete wound healing in 78% of patients treated with PBEM at an average of two months. Subjective reports included majority positive experience with PBEM dressing, minimal pain and overall high levels of patient satisfaction. There were three patients in which pilonidal disease recurred within two years of initial treatment and underwent repeat treatment with PBEM. There was one patient who transitioned to wet-to-dry saline dressings because of difficulty keeping the PBEM dressing intact. CONCLUSION: Advances in wound care technology include materials such as PBEM to promote site-specific tissue deposition. Follow-up phone calls and a prospective study to compare alternative wound care with porcine PBEM in the management of pilonidal disease is underway to better quantify time to wound healing and patient satisfaction.

Variation in postoperative narcotic prescribing after pediatric appendectomy.

BACKGROUND: Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics. METHODS: Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control. RESULTS: Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention. CONCLUSION: Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain. LEVEL OF EVIDENCE: III.

Variability in perioperative evaluation and resource utilization in pediatric patients with suspected biliary dyskinesia: A multi-institutional retrospective cohort study.

INTRODUCTION: Biliary dyskinesia (BD) is a common indication for pediatric cholecystectomy. While diagnosis is primarily based on diminished gallbladder ejection fraction (GB-EF), work-up and management in pediatrics is controversial. METHODS: We conducted a multi-institutional retrospective review of children undergoing cholecystectomy for BD to compare perioperative work-up and outcomes. RESULTS: Six hundred seventy-eight patients across 16 institutions were included. There was no significant difference in gender, age, or BMI between institutions. Most patients were white (86.3%), non-Hispanic (79.9%), and had private insurance (55.2%). Gallbladder ejection fraction (EF) was reported in 84.5% of patients, and 44.8% had an EF <15%. 30.7% of patients were initially seen by pediatric surgeons, 31.3% by pediatric gastroenterologists, and 23.4% by the emergency department with significant variability between institutions (p < 0.001). Symptoms persisted in 35.3% of patients post-operatively with a median follow-up of 21 days (IQR 13, 34). On multivariate analysis, only non-white race and the presence of psychiatric comorbidities were associated with increased risk of post-operative symptoms. CONCLUSION: There is significant variability in evaluation and follow-up both before and after cholecystectomy for BD. Prospective research with standardized data collection and follow-up is needed to develop and validate optimal care pathways for pediatric patients with suspected BD. STUDY TYPE: Case Series, Retrospective Review. LEVEL OF EVIDENCE: Level IV.

Trends in hospital length of stay and 30-day morbidity in pediatric patients undergoing laparoscopic ileocecal resection, 2012-2016.

PURPOSE: To examine postoperative length of stay (LOS), hospital readmission, and 30-day complications in pediatric patients undergoing laparoscopic ileocecal resection in a contemporary cohort. METHODS: Retrospective review of the American College of Surgeons National Surgery Quality Improvement Project, Pediatric (NSQIP-P) 2012-2016 participant user files for patients <19 years old who underwent laparoscopic ileocecal resection. Mean postoperative LOS, hospital readmission and both wound-specific and composite complications were calculated and compared by year of operation. RESULTS: 348 patients were identified (range, 46-96 per year); 55.2-69.8% of these were admitted the day of operation, with a nonsignificant increase in frequency over the study period. Postoperative LOS ranged from 5.4 ±â€¯2.9 days to 7.3 ±â€¯9.1 days (p = 0.24). In subset analysis of only those patients admitted on the day of operation, postoperative LOS remained relatively long, ranging from 5.0 ±â€¯3.0 days to 5.7 ±â€¯4.0 days (p = 0.89). 30-day hospital readmission proportions rose insignificantly, from 6.9% in 2012 to 15.5% in 2016 (p = 0.41). Wound complication rates (including superficial, deep, and deep organ space infections, as well as wound dehiscence) ranged from 0.0% to 8.6%, but did not vary in a statistically significant manner. Nonwound complication rates were vanishingly small. CONCLUSIONS: Postoperative LOS in pediatric patients undergoing laparoscopic ileocecal resection in a select group of patients cared for in hospitals participating in NSQIP-P has not decreased in the past 5 years despite emerging evidence of the safety and relevance of enhanced recovery after surgery programs. Opportunities for shortening LOS without compromising patient safety may still exist. LEVEL-OF-EVIDENCE: III Retrospective comparative study.

Down Syndrome and Postoperative Complications in Children Undergoing Intestinal Operations.

OBJECTIVE: This paper intends to evaluate the association between Down Syndrome (DS) and postoperative medical and surgical complications and inpatient postoperative mortality in pediatric patients undergoing intestinal operations. METHODS: The 2012 Kids' Inpatient Database was queried to compare short-term postoperative medical and surgical complications and in-patient mortality among patients with DS undergoing intestinal operations to a cohort without DS using inverse probability weighting. Subset analysis was performed for patients undergoing intestinal operations exclusive of gastrostomy placement. Adverse treatment effects were calculated for the outcomes of interest. RESULTS: Of 17,026 pediatric patients undergoing intestinal operations, 444 had DS. In unadjusted analysis, medical complications (urinary tract infection, deep venous thrombosis, sepsis, pneumonia) occurred in 7.9% of patients with DS, compared to 14.1% of those without (p < 0.001). Surgical complications (wound disruption, hemorrhage, superficial or deep wound infection) occurred in 3.5% of patients with DS, compared to 4.6% of those without (p = 0.34), and in-patient mortality occurred in 0.3% of patients with DS, compared to 2.7% of those without (p = 0.009). Adverse treatment effects (ATE) calculated after inverse probability weighting demonstrated no difference for medical or surgical complications but a significantly decreased mortality with DS. CONCLUSIONS: Contrary to common perception and data extrapolated from the adult literature, pediatric patients with DS have neither higher medical nor surgical complication rates after intestinal operations. Similar to patients undergoing congenital heart surgery, pediatric patients with DS have a lower postoperative inpatient mortality after these general operations compared to those without DS. Mechanisms influencing risks in DS patient remain unknown. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Quantitative Analysis of Surgical Residency Reform: Using Case-Logs to Evaluate Resident Experience.

BACKGROUND: Curricular changes at a mid-sized surgical training program were developed to rebalance clinical rotations, optimize education over service, decrease the size of service teams, and integrate apprenticeship-type experiences. This study quantifies the operative experience before and after implementation as part of a mixed-methods program evaluation. STUDY DESIGN: Retrospective review of case-log data and data from the Accreditation Council for Graduate Medical Education (ACGME) and the American College of Surgeons National Surgical Quality Improvement Program: quality in-training initiative to evaluate case volume pre- and postintervention. RESULTS: 11,365 cases, excluding "first-assistant" and "endoscopic" cases, were logged for an average of 291 and 263 cases/resident pre- and postintervention, respectively. Average case volume increased significantly for postgraduate year (PGY) 3 residents and decreased significantly for PGY 4 residents between the two time periods. Variability was observed among residents at the same PGY level both pre- and postintervention, with coefficients of variation of 6.0% to 34.1% in 2014 to 2015 and 11.2% to 66.8% in 2015 to 2016. Inter-resident variability persisted when comparing a specific procedure between ACGME case-log and quality in-training initiative data sets. CONCLUSION: The data suggest that inter-resident variability in case load is not an artifact of case logging behavior alone, but may reflect personal preferences and choices in case selection that are not impacted by curriculum change. Logging behavior and accuracy of case-logs may contribute to variability. The shift in case load from PGY 4 to PGY 3 after curriculum implementation requires validation by ongoing analysis of ACGME case-log data.

Direct hyperbilirubinemia in newborns with gastroschisis.

BACKGROUND: Patients with gastroschisis and prolonged total (or partial) parenteral nutrition (PN) commonly develop direct hyperbilirubinemia (DH). OBJECTIVE: To quantify the prevalence and severity of DH in newborns with gastroschisis and characterize the diagnostic work-up for DH in this patient population. DESIGN/METHODS: Retrospective chart review of patients born with gastroschisis between 2005 and 2015 for the first 6 months of life. RESULTS: 29 patients were identified with gastroschisis. Mean gestational age and birthweight were 36.4 (± 1.8) weeks and 2.5 (± 0.6) kg. 41% were treated with primary reduction versus staged closure. Peak total and direct bilirubin (DB) levels were 10.17 ± 6.21 mg/dL and 5.58 ± 3.94 mg/dL, respectively. 23 patients (79.3%) were diagnosed with DH and 78.2% underwent additional work-up for hyperbilirubinemia consisting of imaging and laboratory studies, none of which revealed a cause for DH other than the presumed PN-associated cholestasis. In all patients, DB began to decline within 1-10 days of initiation of enteral feeds. CONCLUSION(S): DH is common in patients with gastroschisis and is unlikely to be associated with pathology aside from PN. Additional work-up may lead to unnecessary resource utilization. LEVELS OF EVIDENCE: Case series with no comparison group, Level IV.

Minimally invasive surgical exposure among US and Canadian pediatric surgery trainees, 2004-2016.

BACKGROUND: Minimally invasive pediatric surgery has increased in breadth and complexity over the past several decades, with little data on minimally invasive surgery (MIS) training in US and Canadian pediatric surgery fellowship programs. METHODS: We performed a time series analysis of Accreditation Council for Graduate Medical Education pediatric surgery fellow case logs from 2003 to 2016. Proportions of cases performed in an MIS fashion as well as per-fellow MIS case averages were recorded over time. RESULTS: There was a 30.9% increase in average number of MIS cases per fellow over the study time period. Twenty-three recorded procedures included MIS and open options (17 abdominal, three thoracic, and three genitourinary). The proportion of cases performed using a minimally invasive approach increased by an average of 29.0%, 14.6%, and 47.0% for each of these categories, respectively. Significant variability was observed in specific cases such as laparoscopic and open inguinal hernias, ranging from 0 to 85 and nine to 152 per trainee, respectively, in the final year of data collection. When examining pyloromyotomy, a high-volume procedure with a known increase in the MIS approach, the proportion of cases performed MIS increased by 83.3%. The minimum and maximum number of cases per fellow recorded ranged from 0 to 114 during the eight years in which MIS pyloromyotomy was recorded. CONCLUSIONS: MIS case exposure among graduating US and Canadian pediatric survey fellows increased substantially during the study period. More granular data, however, are needed to better define the current operative experience and criteria for determination of competency in advanced MIS.

Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure.

OBJECTIVES: Evaluate trends in method of access (percutaneous cannulation vs open cannulation) for pediatric extracorporeal membrane oxygenation and determine the effects of cannulation method on morbidity and mortality. DESIGN: Retrospective cohort study. SETTING AND SUBJECTS: The Extracorporeal Life Support Organization's registry was queried for pediatric patients on extracorporeal membrane oxygenation for respiratory failure from 2007 to 2015. INVERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 3,501 patients identified, 77.2% underwent open cannulation, with the frequency of open cannulation decreasing over the study period from approximately 80% to 70% (p < 0.001). Percutaneous cannulation patients were more commonly male (24.2% vs 21.5%; p = 0.01), older (average 7.6 vs 4.5 yr; p < 0.001), and heavier (average 33.0 vs 20.2 kg; p < 0.001). Subset analysis of patients on venovenous extracorporeal membrane oxygenation revealed higher rates of mechanical complications due to blood clots (28.9% vs 22.6%; p = 0.003) or cannula problems (18.9% vs 12.7%; p < 0.001), cannula site bleeding (25.3% vs 20.2%; p = 0.01) and increased rates of cannula site repair in the open cannulation cohort. Limb related complications were not significantly different on subset analysis for venovenous extracorporeal membrane oxygenation patients stratified by access site. Logistic regression analysis revealed that method of access was not associated with a difference in mortality. CONCLUSIONS: The proportion of pediatric patients undergoing percutaneous extracorporeal membrane oxygenation cannulation is increasing. Mechanical and physiologic complications occur with both methods of cannulation, but percutaneous cannulation appears safe in this cohort. Further analysis is needed to evaluate long-term outcomes with this technique.

Controversies in extracorporeal membrane oxygenation (ECMO) utilization and congenital diaphragmatic hernia (CDH) repair using a Delphi approach: from the American Pediatric Surgical Association Critical Care Committee (APSA-CCC).

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