Peer Support to Promote Surgeon Well-being: The APSA Program Experience.

BACKGROUND: Peer support programs have evolved to train physicians to provide outreach and emotional first aid to their colleagues when they experience the inevitable challenge of a serious adverse event, whether or not it is related to a medical error. Most pediatric surgeons have experienced the trauma of a medical error, yet, in a survey of APSA membership, almost half said that no one reached out to them, and few were satisfied with their institution's response to the error. Thus, the APSA Wellness Committee developed an APSA-based peer support program to meet this need. METHODS: Peer supporters were nominated by fellow APSA members, and the group was vetted to ensure diversity in demographics, practice setting, and seniority. Formal virtual training was conducted before the program went live in 2020. Trained supporters were surveyed 6 months after the program launched to evaluate their experiences with providing peer support. RESULTS: 15 referrals were made in the first year, 60 % of which were self-initiated. Most referrals were for distress related to adverse events or toxic work environments (33 % each). While only about 25 % of trained supporters had provided formal support through the APSA program, more than 80 % reported using the skills to support colleagues and trainees within their own institutions. CONCLUSION: Our experience in the first year of the APSA peer support program demonstrates the feasibility of building and maintaining a national program to provide emotional first aid by a professional society to expand the safety net for surgeons who are suffering.

Prognostic factors in resolution of nonalcoholic fatty liver disease post bariatric surgery in adolescents.

BACKGROUND: The long-term effect of bariatric surgery on adolescent non-alcoholic fatty liver disease is not clear. OBJECTIVES: To evaluate longitudinal change in serum alanine aminotransferase (ALT) levels and to determine the factors independently associated with this change over 2 years after bariatric surgery in adolescents with severe obesity. SETTING: An observational prospective cohort from the Teen-LABS Consortium. METHODS: We examined the relationship of longitudinal change in serum ALT (% change and normalization) to change in body mass index (BMI), homeostasis model assessment of insulin resistance (HOMA-IR), triglycerides (TG), high- (HDL) and low-density lipoprotein cholesterol, A1C and fasting glucose, accounting for age, sex, race-ethnicity, blood pressure, and baseline BMI in 219 adolescents during the first 2 years post-surgery. RESULTS: Mean BMI declined from a baseline of 52.6 to 37.2 kg/m2 at 2 years (P < .01). Alanine aminotransferase decreased significantly from baseline (36.5 [95% CI: 31.4, 41.7]) to 6 months (30.5 [95% CI: 25.4, 35.6]), and remained stable at 12 and 24 months, all P < .01 versus baseline. After adjustment, improvement in BMI, fasting glucose, HOMA-IR, triglycerides, TG/HDL ratio, and HDL were independently associated with reduced ALT at 6 months. These remained significantly associated with a decline in ALT after adjusting for BMI change. The %participants with elevated ALT decreased from 71% at baseline to 42% and 36% at 1 and 2 years post-surgery. CONCLUSIONS: Bariatric surgery resulted in significant and sustained improvement in ALT levels over 2 years. Although associated with weight loss, this decline was also associated with improved metabolic indices, independent of weight loss.

Growing Up After Adolescent Bariatric Surgery.

This study investigates the effects of adolescent bariatric surgery among young adults approximately 10 years post-surgery. Participants were recruited from a hospital-based bariatric registry. We used an exploratory, qualitatively-driven mixed methods design. Findings were integrated with medical chart data and the SF-36, Body QoL, and the Transition Readiness Assessment Questionnaire. Of the 22 participants who completed surveys (14 females and 8 males), 20 participants also completed a phone interview. Median participant age was 25 years (range = 19-30). Median weight-loss was 23% (6.0%‒58%). Four themes emerged: taking control, weight loss challenges, body image adjustment, and growing up. Participants reported physical benefits of surgery yet were challenged by eating habits, body image, and interpersonal relationships. Participants were indifferent to preventative healthcare, despite the potential for vitamin deficiencies and the return of weight-related comorbidities. Clinicians can facilitate the transition to young adulthood by providing continued mental support, education, and medical monitoring.

Ultrasound for the diagnosis of malrotation and volvulus in children and adolescents: a systematic review and meta-analysis.

CONTEXT: Despite the advantages of ultrasound (US), upper gastrointestinal contrast series (UGI) remains the first-line diagnostic modality in the diagnosis of midgut malrotation and volvulus in children. OBJECTIVE: Evaluate the diagnostic accuracy of US in the diagnosis of malrotation with or without volvulus in children and adolescents aged 0-21 years, compared with the reference standard (diagnosis by surgery, UGI, CT, MRI, and clinical follow-up individually or as a composite). DATA SOURCES: We searched the electronic databases Ovid-MEDLINE, Embase, Scopus, CINAHL, and the Cochrane library in October 2019 and updated on 18 August 2020. STUDY SELECTION: Studies evaluating the diagnostic performance of US for diagnosis of midgut malrotation with or without volvulus in children (0-21 years). DATA EXTRACTION AND SYNTHESIS: The data were extracted independently by two authors and a bivariate model was used for synthesis. RESULTS: Meta-analysis of 17 cohort or cross-sectional studies and 2257 participants estimated a summary sensitivity of 94% (95% CI 89% to 97%) and summary specificity of 100% (95% CI 97% to 100%) (moderate certainty evidence) for the use of US for the diagnosis of malrotation with or without midgut volvulus compared with the reference standard. Subgroup analysis and meta-regression revealed better diagnostic accuracy in malrotation not complicated by volvulus, in the neonatal population and enteric fluid administration before US. CONCLUSIONS: Moderate certainty evidence suggests excellent diagnostic accuracy and coupled with the advantages, a strong case exists for the use of abdominal US as the first-line diagnostic test for suspected midgut malrotation with or without volvulus in children and adolescents.

A cross-sectional analysis of compassion fatigue, burnout, and compassion satisfaction in pediatric surgeons in the U.S.

BACKGROUND/PURPOSE: To determine the prevalence of compassion fatigue (CF), burnout (BO), and compassion satisfaction (CS) and identify potential predictors of these phenomena in pediatric surgeons. METHODS: The Compassion Fatigue and Satisfaction Self-Test and a survey of personal/professional characteristics were distributed electronically to American Pediatric Surgical Association members. Linear regression models for CF, BO, and CS as a function of potential risk factors were constructed. RESULTS: The analyzeable study response rate was 25.7%. The prevalence of CF, BO, and CS was 22%, 24% and 22, respectively, which were similar to prevalences previously identified in pediatric subspecialists. Higher CF scores were significantly associated with: higher BO scores; solo practice; compensation; ≥5 operating days/week; current distress about a 'clinical situation'; mental health-care for work-related distress; and history of childhood surgery. Lower CF scores were significantly associated with 'talking with a life partner' about work-related distress. Higher BO scores were significantly associated with: higher CF scores; current distress about 'coworkers'; and 'keeping lawsuits confidential'. Lower BO scores were significantly associated with higher CS scores. CONCLUSIONS: CF, BO, and CS are distinct but highly related entities. Pediatric surgeons experience these phenomena at similar rates to other pediatric subspecialists. Establishing local channels for physician peer support may be particularly impactful.

Supporting recovery after adverse events: An essential component of surgeon well-being.

BACKGROUND: Failure to recover after a medical error is a major contributor to burnout. The degree to which pediatric surgeons experience errors and the barriers and facilitators to successful recovery are largely unknown. METHODS: We conducted a survey of American Pediatric Surgical Association (APSA) members to measure frequency of personal experience with medical errors resulting in significant patient harm, describe coping mechanisms, and explore surgeon satisfaction with institutional support in the wake of an error. RESULTS: We found that 80% of respondents have personally experienced a medical error resulting in significant patient harm or death, and that only about one-quarter were satisfied with the support provided by their institution. Only 11% of surgeons would prefer not to be contacted after an adverse event, and most would want to be contacted by their partners. Barriers to providing and receiving support included lack of knowledge, "shame and blame" culture, and lack of trust in the institution as an ally. CONCLUSIONS: Pediatric surgeons routinely experience intense and stressful clinical scenarios and face challenging paths to recovery after adverse events. Institutions and national societies can play a critical role in creating infrastructure to help surgeons recover, in order to prevent burnout and promote well-being.

Drivers of distress and well-being amongst pediatric surgeons.

INTRODUCTION: Although pediatric surgeons have lower rates of burnout compared to other surgical subspecialists, they still struggle with work-home conflict, depersonalization, and emotional exhaustion. Prior surveys have measured career satisfaction and burnout, but none have identified factors that contribute to physician well-being or provided potential solutions. METHODS: Members of the American Pediatric Surgical Association were surveyed regarding sources of distress and institutional practices intended to promote well-being. Responses were analyzed using content analysis. RESULTS: There was a 31.5% response rate to the survey. The most frequently cited sources of distress were administrative issues (45.2%), work/life balance (42.3%), personal issues (18.8%), and relationships with coworkers (17.9%). In open-ended questions, other sources of distress included poor leadership, loss of autonomy, lack of support and mentorship, and patient complications. Successful wellness strategies included relief from clinical burden, substantive wellness programming, surgeon inclusion in administrative decision making, support after adverse events, appropriate compensation and benefits, and opportunities for career development in research, teaching, and clinical care. CONCLUSION: Pediatric surgeons are affected by multiple sources of distress. Interventions that ameliorate stress in pediatric surgeons were identified and should be considered by local institutions and national organizations to promote well-being. LEVEL OF EVIDENCE: n/a.

Does academic authorship reflect gender bias in pediatric surgery? An analysis of the Journal of Pediatric Surgery, 2007-2017.

BACKGROUND: Gender representation in academic publications has been considered a surrogate for gender equity in medicine, although this concept has not been evaluated in pediatric surgery. METHODS: First and last author genders for Journal of Pediatric Surgery articles from United States and/or Canadian institutions (2007, 2012, 2017) were identified. These data were compared to gender proportions for applicants to and matriculants in pediatric surgery fellowships as well as among American Pediatric Surgical Association (APSA) members. RESULTS: Authorship gender was identified for 632/640 primary articles (98.8%). From 2007 to 2017, the proportion of women as first authors increased from 33.0% to 53.9% (p < 0.001) and as last authors from 16.2% to 26.4% (p = 0.01). The proportion of women fellowship applicants rose from 35.9% to 57.6% (p < 0.001); among those who successfully matched the rise was nonlinear (20.5%-34.0%, p = 0.16). APSA junior and senior women membership proportions rose during the study period [from 28.1% to 43.4% (p = 0.06 for linear trend) and 17.9% to 24.4% (p = 0.005 for linear trend), respectively]. CONCLUSIONS: Over the past decade, the overall proportion of women authors in a leading academic pediatric surgery journal has increased significantly, although representation among last authors remains disproportionately low. The numbers of women applicants to pediatric surgery fellowship increased but there was not a concordant rise in the number of women accepted into training positions. TYPE OF STUDY: Bibliometric analysis. LEVEL OF EVIDENCE: n/a.

Weight Loss and Health Status 5 Years After Adjustable Gastric Banding in Adolescents.

OBJECTIVE: This prospective cohort analysis describes changes in weight, cardiometabolic health, and weight-related quality of life (WRQOL) following adolescent LAGB. METHODS: Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) collected demographic, anthropometric, micronutrient, cardiometabolic risk, and WRQOL data for 242 adolescents. Data through 5 years were analyzed for 14 participants who underwent LAGB with 2 patients lost to follow-up. RESULTS: Participants (mean age 18.2 ± 0.4 years) were mostly female (86%) and white (71%) with a median body mass index (BMI) of 48.7 kg/m2 (45.5-54.1). Preoperatively, 100%(13/13), 62%(8/13), 57%(8/14), and 7%(1/14) had elevated high sensitivity C-reactive protein (hs-CRP), dyslipidemia, elevated blood pressure (EBP), and type 2 diabetes (T2D), respectively. At 5 years, mean BMI decreased by 3.3% (51.0 vs. 49.3 kg/m2, p = 0.6), 43%(6/14) had BMI values exceeding baseline and 21% (3/14) underwent band removal. Postoperative prevalence of hs-CRP, dyslipidemia, EBP, and T2D was 45% (4/11), 36% (5/11), 33% (4/12), and 0% (0/11), respectively. CONCLUSION: Adolescents undergoing LAGB experienced modest initial weight loss and improvements in cardiovascular risk factors with later weight regain and frequent need for band removal. Despite the small sample size, this prospective study highlights long-term outcomes with high rates of participant retention over time. CLINICAL TRIAL REGISTRATION: NCT00465829.

An assessment of provider satisfaction with the use of a standardized visual aid for informed consent for appendectomy in children.

PURPOSE: We previously validated a visual aid for the use in the consent process for an appendectomy showing improved parental satisfaction and understanding. In this study, we evaluated provider satisfaction and perceived value of using the visual aid. METHODS: An IRB approved survey was developed assessing provider experience with use of the visual aid. This was distributed and analyzed via Research Electronic Data Capture (RedCap) Database. RESULTS: We administered 58 surveys (45% response rate). Participants included faculty (n = 2), fellows (n = 1), residents (n = 6), and physician assistants (n = 17). The visual aid was used >10 times by 50% of providers. The most common reason for not using the visual aid was not remembering it was available. Nearly half (40%) did not feel the visual aid added any time. 9/20 (45%) felt it added a small amount of time. Slightly over half of providers (52%) felt using the visual aid significantly increased family ability to give informed consent and made the consenting process easier for both providers and families. CONCLUSION: Using a visual aid in consenting families for appendectomy does not add significant time and subjectively improves the process for providers and increases provider perception of parental understanding. LEVEL OF EVIDENCE: Cost effectiveness, Level IV.

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties.

BACKGROUND: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty. METHODS: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model. RESULTS: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ±â€¯3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only. CONCLUSIONS: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care. STUDY AND LEVEL OF EVIDENCE: Cost-effectiveness study, Level II.

Nutritional Risks in Adolescents After Bariatric Surgery.

BACKGROUND & AIMS: Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these. METHODS: Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B1, B12; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies. RESULTS: The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m2 at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B12 significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B1, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy. CONCLUSIONS: In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B12 after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction.

PURPOSE: Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR. METHODS: Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression. RESULTS: Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001). CONCLUSION: For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults.

BACKGROUND: Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear. METHODS: We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts. RESULTS: There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004). CONCLUSIONS: Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).

High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia.

BACKGROUND: High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires. METHODS: Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison. RESULTS: Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ±â€¯3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ±â€¯2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ±â€¯10 mmHg, 14 ±â€¯6 mmHg, and 18 ±â€¯9, respectively. ESS (2.3/12), ASQ (39/100 ±â€¯16), PGSQ (symptom: 0.6/4 ±â€¯0.4, school: 0.4/4 ±â€¯0.4), and overall PedsQL (82/100 ±â€¯15) were similar to those of healthy historical controls. CONCLUSION: Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients. STUDY AND LEVEL OF EVIDENCE: Retrospective, II.

Bowel preparation for colostomy reversal in children.

PURPOSE: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children. METHODS: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR]. RESULTS: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts. CONCLUSION: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure. LEVEL OF EVIDENCE: III. STUDY TYPE: Treatment study.

Surgical interventions and anesthesia in the 1st year of life for lower urinary tract obstruction.

BACKGROUND: Patients with a prenatal diagnosis of lower urinary tract obstruction (LUTO) may undergo prenatal interventions, such as vesicoamniotic shunt (VAS) placement, as a temporary solution for relieving urinary tract obstruction. A recent FDA communication has raised awareness of the potential neurocognitive adverse effects of anesthesia in children. We hypothesized as to whether a prenatal LUTO staging system was predictive of the number of anesthesia events for prenatally diagnosed LUTO patients. METHODS: We retrospectively reviewed the prenatal and postnatal clinical records for patients with prenatally diagnosed LUTO from 2012 to 2015. Patients were stratified by prenatal VAS status and by LUTO disease severity according to Ruano et al. (Ultrasound Obstet Gynecol. 2016). RESULTS: 31 patients were identified with a prenatal LUTO diagnosis, and postnatal records were available for 21 patients (seven patients in each stage). When combining prenatal and postnatal anesthesia, there was a significant difference in the number of anesthesia encounters by stage (1.6, 3.7, and 6.7 for Stage I, II, and III respectively, p = .034). Upon univariate analysis, higher gestational age (GA) at birth was associated with a decreased number of anesthesia events in the first year (p = .031). CONCLUSIONS: The majority of infants with prenatally diagnosed LUTO will undergo postnatal procedures with general anesthesia exposure in the first year of life. Patients with higher prenatal LUTO severity experienced a higher number of both prenatal and postnatal anesthesia encounters. In addition, higher GA at birth was associated with fewer anesthesia encounters in the first year. LEVEL OF EVIDENCE: This is a prognostic study with Level IV evidence.

Considerations for total thyroidectomy in an adolescent with PTEN mutation.

Individuals with PTEN Hamartoma Tumor Syndrome (PHTS) are at greatly increased risk for developing well-differentiated thyroid cancer. Specific circumstances in which total thyroidectomies should be considered have not been defined. A 14-year-old macrocephalic female with history of developmental delay and lipoma over her left flank presented with neck swelling and was found have multinodular goiter and auto-immune thyroiditis. Asymptomatic tracheal narrowing was also detected on her initial diagnostic imaging. Later on, she developed positional dyspnea during sleep. Genetic testing revealed a heterozygous pathogenic variant in the PTEN gene (c.463T>A). A total thyroidectomy was performed. In addition to addressing the symptomology in our case, a total thyroidectomy also fortuitously eliminated the thyroid cancer risk. This case spurred us on further to identify specific clinical scenarios where total thyroidectomy may be considered as a true prophylactic measure to manage thyroid cancer risk in PHTS patients.