Clinical relevance of inflammation on rectal biopsy for Hirschsprung disease: An outcomes analysis.

OBJECTIVES: Inflammation on diagnostic rectal biopsy for children with suspected Hirschsprung disease (HSCR) is reported on pathology, and its significance is unknown. We describe the management and outcomes of a cohort with inflammation on rectal biopsy compared to those without. Specifically, to address the hypothesis that inflammation on diagnostic biopsy is associated with increased complication rates irrespective of intervention type and timing. METHODS: A single institution retrospective review of children with HSCR who underwent biopsy and endorectal pull-through (ERPT) from 2010 to 2020 was performed. The primary outcome was overall complications at 30-days following ERPT. Secondary outcomes included timing and type of operative intervention as well as postoperative enterocolitis diagnosed within 6-months of ERPT. RESULTS: Forty-nine children were identified; inflammation was present on diagnostic biopsy for 17 children. Those with inflammation were more likely to have clinical evidence of enterocolitis at the time of biopsy (p = 0.001) and were more likely to undergo leveling colostomy before ERPT (p = 0.01). Children with inflammation had a higher anastomotic leak rate (p = 0.04). Subgroup analysis of patients with inflammation undergoing primary ERPT versus leveling colostomy demonstrated no significant difference in outcomes following definitive ERPT. CONCLUSIONS: Our study suggests inflammation on diagnostic rectal biopsy for HSCR is associated with increased anastomotic leak rates. While additional prospective studies are indicated, attention to methods of mitigating inflammation and confirming its resolution before definitive pull-through may be of benefit for improving clinical outcomes in patients found with inflammation on diagnostic rectal biopsy.

Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study.

OBJECTIVE: The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus. BACKGROUND: The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported. METHODS: Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed. RESULTS: Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival. CONCLUSIONS: Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.

Relationship between the COVID-19 pandemic and structural inequalities within the pediatric trauma population.

BACKGROUND: The COVID-19 pandemic disrupted social, political, and economic life across the world, shining a light on the vulnerability of many communities. The objective of this study was to assess injury patterns before and after implementation of stay-at-home orders (SHOs) between White children and children of color and across varying levels of vulnerability based upon children's home residence. METHODS: A multi-institutional retrospective study was conducted evaluating patients < 18 years with traumatic injuries. A "Control" cohort from an averaged March-September 2016-2019 time period was compared to patients injured after SHO initiation-September 2020 ("COVID" cohort). Interactions between race/ethnicity or social vulnerability index (SVI), a marker of neighborhood vulnerability and socioeconomic status, and the COVID-19 timeframe with regard to the outcomes of interest were assessed using likelihood ratio Chi-square tests. Differences in injury intent, type, and mechanism were then stratified and explored by race/ethnicity and SVI separately. RESULTS: A total of 47,385 patients met study inclusion. Significant interactions existed between race/ethnicity and the COVID-19 SHO period for intent (p < 0.001) and mechanism of injury (p < 0.001). There was also significant interaction between SVI and the COVID-19 SHO period for mechanism of injury (p = 0.01). Children of color experienced a significant increase in intentional (COVID 16.4% vs. Control 13.7%, p = 0.03) and firearm (COVID 9.0% vs. Control 5.2%, p < 0.001) injuries, but no change was seen among White children. Children from the most vulnerable neighborhoods suffered an increase in firearm injuries (COVID 11.1% vs. Control 6.1%, p = 0.001) with children from the least vulnerable neighborhoods having no change. All-terrain vehicle (ATV) and bicycle crashes increased for children of color (COVID 2.0% vs. Control 1.1%, p = 0.04 for ATV; COVID 6.7% vs. Control 4.8%, p = 0.02 for bicycle) and White children (COVID 9.6% vs. Control 6.2%, p < 0.001 for ATV; COVID 8.8% vs. Control 5.8%, p < 0.001 for bicycle). CONCLUSIONS: In contrast to White children and children from neighborhoods of lower vulnerability, children of color and children living in higher vulnerability neighborhoods experienced an increase in intentional and firearm-related injuries during the COVID-19 pandemic. Understanding inequities in trauma burden during times of stress is critical to directing resources and targeting intervention strategies.

Paediatric surgeons' current knowledge and practices of obtaining assent from adolescents for elective reconstructive procedures.

PURPOSE: Adolescents develop their decision-making ability as they transition from childhood to adulthood. Participation in their medical care should be encouraged through obtaining assent, as recommended by the American Academy of Pediatrics (AAP). In this research, we aim to define the current knowledge of AAP recommendations and surgeon practices regarding assent for elective reconstructive procedures. METHODS: An anonymous electronic survey was distributed to North American paediatric surgeons and fellows through the American Pediatric Surgical Association (n=1353). RESULTS: In total, 220 surgeons and trainees responded (16.3%). Fifty per cent of the surgeons who are familiar with the concept of assent had received formal training; 12% of the respondents had not heard of assent before the survey. Forty-seven per cent were aware of the 2016 AAP policy statement regarding assent in paediatric patients. Eighty-nine per cent always include adolescents as part of the consent discussion. Seventy-seven per cent solicit an expression of willingness to accept the proposed care from the patient. The majority (74%) of the surgeons perceived patient cooperation/understanding as the biggest barrier to obtaining assent. Over half of the respondents would consider proceeding with elective surgery despite the adolescent patient's refusal. Reasons cited for proceeding with elective surgery include surgeons' perception of medical necessity, perceptions of disease urgency, and lack of patient maturity. CONCLUSION: Paediatric surgeons largely acknowledge the importance of assent, but variably practice the principles of obtaining assent from adolescent patients undergoing elective reconstructive procedures. Fewer surgeons are explicitly aware of formal policy statements or received formal training. Additional surgeon education and institutional policies are warranted to maximise inclusion of adolescents in their medical care.

Implementation Science Fundamentals: Pediatric Surgery Enhanced Recovery After Surgery Protocol for Pectus Repair.

INTRODUCTION: Surgical repair of pectus excavatum and carinatum in children has historically been associated with severe postoperative pain and prolonged hospitalization. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary, multimodal approach designed to fast-track surgical care. However, obstacles to implementation have led to very few within pediatric surgery. The aim of this study is to outline the process of development and implementation of an ERAS protocol for pectus surgical repair using fundamental principles of implementation science. METHODS: A multidisciplinary team of providers worked collaboratively to develop an ERAS protocol for surgical repair of pectus excavatum and carinatum and methods for identifying eligible patients. The surgical champion collaborated with all end users to review and revise the ERAS protocol, assessing all foreseeable barriers and facilitators prior to implementation. RESULTS: Our entire pediatric surgery team, nurses at every stage (clinic/preoperative/recovery/floor), physical therapy, and information technology contributed to the creation and implementation of an ERAS protocol with seven phases of care. The finalized version was implemented by end users focusing on four main areas: pain control, ambulation, diet, and education. Barriers and facilitators were continually addressed with an iterative process to improve the success of implementation. CONCLUSIONS: This is one of the first studies in children which details the step-by-step process of developing and implementing an ERAS protocol for pectus excavatum and carinatum. The process of development and implementation of an ERAS protocol as outlined in this manuscript can serve as a model for future ERAS protocols in pediatric surgery.

Contrast Challenge Algorithms for Adhesive Small Bowel Obstructions Are Safe in Children: A Multi-Institutional Study.

OBJECTIVE: The purpose of this study was to evaluate the safety of a water-soluble contrast challenge as part of a nonoperative management algorithm in children with an adhesive small bowel obstruction (ASBO). BACKGROUND: Predicting which children will successfully resolve their ASBO with non-operative management at the time of admission remains difficult. Additionally, the safety of a water-soluble contrast challenge for children with ASBO has not been established in the literature. METHODS: A retrospective review was performed of patients who underwent non-operative management for an ASBO and received a contrast challenge across 5 children's hospitals between 2012 and 2020. Safety was assessed by comparing the complication rate associated with a contrast challenge against a pre-specified maximum acceptable level of 5%. Sensitivity, specificity, negative (NPV) and positive (PPV) predictive values of a contrast challenge to identify successful nonoperative management were calculated. RESULTS: Of 82 children who received a contrast challenge, 65% were successfully managed nonoperatively. The most common surgical indications were failure of the contrast challenge or failure to progress after initially passing the contrast challenge. There were no complications related to contrast administration (0%; 95% confidence interval: 0-3.6%, P = 0.03). The contrast challenge was highly reliable in determining which patients would require surgery and which could be successfully managed non-operatively (sensitivity 100%, specificity 86%, NPV 100%, PPV 93%). CONCLUSION: A contrast challenge is safe in children with ASBO and has a high predictive value to assist in clinical decision-making.

A multi-disciplinary, comprehensive approach to management of children with heterotaxy.

Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.

Current Management of Adhesive Small Bowel Obstructions in Children.

Adhesive small bowel obstructions are a common cause of morbidity in children who underwent prior abdominal surgery. The concept of partial versus complete bowel obstruction is outdated and lacks precision to be clinically useful. Identifying patients with indications for immediate operative intervention is critical and must be recognized to limit morbidity. Clinical protocols and contrast challenge algorithms have attempted to identify patients that will resolve their bowel obstruction nonoperatively; there has been slow uptake in the pediatric patient population versus adults until recently. Incorporating predictive models and standardized contrast challenge protocols will help reduce interpractitioner variability and improve clinical outcomes.

Ultrasound-Guided Gastrostomy Tube Placement: An Evaluation of Postoperative Complications in the Pediatric Population.

Background: Using ultrasound guidance has been demonstrated as a feasible alternative method for gastrostomy tube placement in the pediatric population. The aim of this study is to evaluate short- and long-term postoperative complications after ultrasound-guided gastrostomy tube placement (USGTP) and to compare them with complications after laparoscopic gastrostomy tube placement (LGTP). Methods: A retrospective chart review evaluated patients who underwent USGTP (n = 41) and LGTP (n = 120) at the same institution. Comparisons were made between the two groups in the context of demographics as well as 30-day and 6-month postoperative complications. A phone survey (n = 26) further identified USGTP complications potentially not captured in the electronic medical records. Results: There were no significant differences in age, gender, and indication for procedure between the two groups. Chart review revealed that USGTP and LGTP had statistically comparable rates of emergency department (ED) visits for postoperative complications. Among USGTP patients, 8% had a recorded ED visit within 30 days of the operation and 13% presented to the ED within 6 months, compared with 6% and 11%, respectively, in the LGTP group (P = .65, P = .69). The USGTP phone survey reported total complications over an average postoperative follow-up time of 34.6 months (range 8-87) and revealed a total ED visit rate of 35%, which is comparable with rates reported in the literature for minimally invasive feeding tube placement. Conclusion: USGTP is a safe and feasible alternative option for gastrostomy tube placement in the pediatric population and it has postoperative complication rates that are comparable with LGTP.

Inflammatory myofibroblastic tumor: A multi-institutional study from the Pediatric Surgical Oncology Research Collaborative.

Inflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm of intermediate malignancy. We describe the largest cohort of IMT patients to date, aiming to further characterize this rare, poorly understood tumor. This is a multi-institutional review of IMT patients ≤39 years, from 2000 to 2018, at 18 hospitals in the Pediatric Surgical Oncology Research Collaborative. One hundred and eighty-two patients were identified with median age of 11 years. Thirty-three percent of tumors were thoracic in origin. Presenting signs/symptoms included pain (29%), respiratory symptoms (25%) and constitutional symptoms (20%). Median tumor size was 3.9 cm. Anaplastic lymphoma kinase (ALK) overexpression was identified in 53% of patients. Seven percent of patients had distant disease at diagnosis. Ninety-one percent of patients underwent resection: 14% received neoadjuvant treatment and 22% adjuvant treatment. Twelve percent of patients received an ALK inhibitor. Sixty-six percent of surgical patients had complete resection, with 20% positive microscopic margins and 14% gross residual disease. Approximately 40% had en bloc resection of involved organs. Median follow-up time was 36 months. Overall 5-year survival was 95% and 5-year event-free survival was 80%. Predictors of recurrence included respiratory symptoms, tumor size and distant disease. Gross or microscopic margins were not associated with recurrence, suggesting that aggressive attempts at resection may not be warranted.

Recognition and management of traumatic fetal injuries.

Trauma during pregnancy is the leading non-obstetric cause of morbidity and mortality, and accounts for five per 1000 fetal deaths. Direct fetal injury due to trauma during pregnancy is rare, and limited information is available about how to optimize fetal outcomes after injury. Early recognition and appropriate management of direct fetal trauma may improve outcomes for the fetus. There are currently no available guidelines to direct management of the injured fetus. We provide a detailed literature review of the management and outcomes of direct fetal injury following blunt and penetrating injury during pregnancy, and describe a suggested initial approach to the injured pregnant patient with a focus on evaluation for fetal injury. We identified 45 reported cases of blunt trauma resulting in direct fetal injury, with 21 surviving past the neonatal period, and 33 of penetrating trauma resulting in direct fetal injury, with 24 surviving past the neonatal period. Prenatal imaging identified fetal injury in 19 cases of blunt trauma and was used to identify bullet location relative to the fetus in 6 cases. These reports were used to develop management algorithms for the injured fetus.

Laparoscopic adrenal-sparing approach for children with bilateral pheochromocytoma in Von Hippel-Lindau disease.

INTRODUCTION: Von Hippel-Lindau disease (VHL) is a rare cause of hereditary bilateral Pheochromocytomas (PHEO). Traditionally, treatment has been total adrenalectomy due to a lifetime risk of developing new tumors. Limited data exists on the surgical management of bilateral PHEO in children with VHL. We reviewed our experience with laparoscopic partial adrenalectomy for bilateral PHEO. METHODS: A retrospective review was performed of patients undergoing adrenalectomy for PHEO in children with VHL from 2004 to 2019. RESULTS: Eight children with VHL diagnosed with bilateral PHEO underwent 16 adrenalectomies (10 synchronous, 5 metachronous, 1 for recurrence). Median age at diagnosis was 13 [range 8-17] years with a median tumor size of 2.3 [range 0.5-7.7] cm. Of 16 adrenalectomies, all were performed laparoscopically, 14 were partial adrenalectomies; 2 patients required a contralateral total adrenalectomy due to size and diffuse multinodularity. There were no postoperative complications. No patients required corticosteroid replacement at the end of the study period. Two patients had new ipsilateral tumors identified after a median follow up of 5 [range 4-6] years with one undergoing repeat partial adrenalectomy. There were no mortalities in the study period. CONCLUSION: Partial adrenalectomy for bilateral PHEO in patients with VHL is safe and does not compromise outcomes. When technically feasible, laparoscopic partial adrenalectomy should be considered as a primary surgical approach for children with VHL. LEVEL OF EVIDENCE: Level IV - Case series with no comparison group.

Variability in the management of adhesive small bowel obstruction in children.

BACKGROUND: This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO). METHODS: A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO. RESULTS: Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001). CONCLUSIONS: Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation. LEVEL OF EVIDENCE: III.

From the Cecum to the Sigmoid: Twisted Colon in the Pediatric Population.

Colonic volvulus (CV) is the third leading cause of colonic obstruction in adults. In infants and children, this is exceedingly rare, with only sporadic cases reported so far. We present two cases of CV to highlight the differences in etiology, presentation, diagnosis, and treatment of this condition. The first patient is a 12-year-old boy with no previous surgeries who presented with four days of abdominal pain. Imaging showed a sigmoid volvulus that was decompressed endoscopically, and he was discharged. He had a contrast enema showing an abnormal rectosigmoid ratio. At the time of the rectal biopsy four weeks later, he was found to have a recurrence, at which point definitive operative treatment was pursued. The second patient is a 17-year-old boy who presented with five days of abdominal pain and CT findings concerning for ischemic volvulus. This prompted emergent operative intervention, where a cecal volvulus was discovered as the result of a congenital band. The band was divided without complication.  Pediatric CV is a rare condition that might be severe in some cases. High suspicion, prompt diagnosis, and treatment are essential to prevent early and long-term morbidity.

Single-stage restorative proctocolectomy for ulcerative colitis in pediatric patients: a safe alternative.

BACKGROUND: Surgical management for refractory ulcerative colitis (UC) has been restorative proctocolectomy (RP) with ileal-pouch-anal-anastomosis (IPAA) done as one to three stages, with safety and effectiveness of a single-stage operation unclear. METHODS: Pediatric UC patients from 2004 to 2019 who underwent RP/IPAA in the initial operation were retrospectively reviewed. 1-stage operations were matched 1:2 to 2-stage operations using age, duration of disease, and disease severity. RESULTS: Ninety-nine patients (33 1-stage, 66 2-stage) were identified. The median total operative time was shorter in the 1-stage group (6 h:00 min vs. 7 h:47 min, p = 0.004). Total length of stay was shorter in the 1-stage group (9 vs. 17 days, p = 0.001). Rates of readmission were higher in 2-stage group (30 vs. 9%, p = 0.02). There was no difference in pouch leak rates (p = 1.00). Stricture rates were higher in the 2-stage group (50 vs. 16%, p = 0.005). Functional outcomes including pouchitis (p = 0.13), daily bowel movements (p = 0.37), and incontinence (p = 0.77) were all similar. CONCLUSIONS: Restorative proctocolectomy with IPAA in children with UC can be performed as a 1- or 2-stage operation with equivalent short-term, long-term, and functional outcomes in similar risk population. Our findings suggest 1-stage RP/IPAA operations without ileostomy are a safe alternative for patients considered for a 2-stage operation.

Central line placement at ECMO decannulation: A missed opportunity.

INTRODUCTION: ECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation. METHODS: A single-institution retrospective study of patients undergoing open neck decannulation from 2015 to 2019. Patients were divided into two groups:  ≤ 28-days and > 28-days. RESULTS: Of 65 patients, 31% had a CVL placed at decannulation. Sepsis and pneumonia were the most common indications for ECMO in the older-group compared to CDH in neonates. The most common indications for CVL were hemodialysis (45%), monitoring (25%), and access (25%). 89% of neonates had an access line placed, whereas 73% of the older group received hemodialysis catheters. Median CRRT requirement was 20 days. 85% of lines were functional at time of removal or death. None were removed for infection. 40% of the patients not receiving a CVL at decannulation required one within 30 days. CONCLUSION: 69% of patients did not have a CVL placed at decannulation, however 40% required a CVL within 30 days. Most lines placed at decannulation remained functional and none were removed for infection. Decannulation removes the circuit as a route for vascular access, but it also presents an opportunity to safely place an essential CVL.

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

INTRODUCTION: Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes. METHODS: This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation. RESULTS: N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed. CONCLUSION: Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.

From Ancient Texts to Digital Imagery: A Brief History on the Evolution of Anatomic Illustrations.

In a time when social isolation heavily relies on the use of digital representation, photography, and e-books, it is easy to take for granted the impact imagery has on our society and the pedagogical purposes of illustration, particularly in the teaching of surgery. Illustrations after all are the basis of all anatomical atlases and are quintessential tools that allow for an expedient and thorough understanding of concepts underlying the fabric of the human body. Yet, surgery has not always been taught with an atlas. Illustrations, much like surgery, have seen an incredible transformative process spanning across the ages to achieve their status in modern medicine. Through this brief review, we will not only glean an understanding of the evolution of anatomical illustrations but also the social context in which surgery has also evolved throughout history.

Efficacy of Early Pleurectomy for Severe Congenital Chylothorax.

BACKGROUND: Severe congenital chylothorax (SCC) may result in respiratory failure, malnutrition, immunodeficiency, and sepsis. Although typically managed with bowel rest, parenteral nutrition, and octreotide, persistent chylothoraces require surgical management. At our institution, a pleurectomy, unilateral or bilateral, in combination with mechanical pleurodesis and thoracic duct ligation is performed for SCC, and we describe our approach and outcomes. MATERIALS AND METHODS: We reviewed over 15-year period neonatal patients with SCC managed surgically with pleurectomy after medical therapy was unsuccessful. Patients were divided into two groups: those who underwent pleurectomy within 28 d of diagnosis (early group) and those who underwent pleurectomy after 28 d (late group). Resolution of chylothorax was defined by the absence of clinical symptoms as well as absent or minimal pleural effusion on chest X-ray. RESULTS: Of 40 patients diagnosed with SCC over the study period, 15 underwent pleurectomy, eight early [mean time to operation = 20 (IQR 17, 23) d] and 7 late [59 (42, 75) d, P = 0.001]. Overall survival was 67% (10 of 15). Seven of 8 (88%) neonates who underwent early pleurectomy survived versus 3 of 7 (43%) who underwent late pleurectomy (P = 0.07). Length of stay was lower in the early group than the late group [73 (57, 79) versus 102 (109, 213) d, P = 0.05]. All patients who survived to discharge had resolution of their chylothorax. CONCLUSIONS: Pleurectomy with mechanical pleurodesis and thoracic duct ligation is effective in the management of severe congenital chylothorax. When performed earlier, pleurectomy for severe congenital chylothorax may be associated with improved survival and shorter hospital length of stay.