Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial.

OBJECTIVE: The aim of this study was to determine which initial surgical treatment results in the lowest rate of death or neurodevelopmental impairment (NDI) in premature infants with necrotizing enterocolitis (NEC) or isolated intestinal perforation (IP). SUMMARY BACKGROUND DATA: The impact of initial laparotomy versus peritoneal drainage for NEC or IP on the rate of death or NDI in extremely low birth weight infants is unknown. METHODS: We conducted the largest feasible randomized trial in 20 US centers, comparing initial laparotomy versus peritoneal drainage. The primary outcome was a composite of death or NDI at 18 to 22 months corrected age, analyzed using prespecified frequentist and Bayesian approaches. RESULTS: Of 992 eligible infants, 310 were randomized and 96% had primary outcome assessed. Death or NDI occurred in 69% of infants in the laparotomy group versus 70% with drainage [adjusted relative risk (aRR) 1.0; 95% confidence interval (CI): 0.87-1.14]. A preplanned analysis identified an interaction between preoperative diagnosis and treatment group (P = 0.03). With a preoperative diagnosis of NEC, death or NDI occurred in 69% after laparotomy versus 85% with drainage (aRR 0.81; 95% CI: 0.64-1.04). The Bayesian posterior probability that laparotomy was beneficial (risk difference <0) for a preoperative diagnosis of NEC was 97%. For preoperative diagnosis of IP, death or NDI occurred in 69% after laparotomy versus 63% with drainage (aRR, 1.11; 95% CI: 0.95-1.31); Bayesian probability of benefit with laparotomy = 18%. CONCLUSIONS: There was no overall difference in death or NDI rates at 18 to 22 months corrected age between initial laparotomy versus drainage. However, the preoperative diagnosis of NEC or IP modified the impact of initial treatment.

Stress and the Gut-Brain Axis: Implications for Cancer, Inflammation and Sepsis.

BACKGROUND: The gut-brain axis has been discussed, directly or indirectly, for centuries, with the ideas of the gut affecting anything from moods to overall physiology being discussed across the centuries. With a recent explosion in research that looks to the microbiota as a mechanistic link between the gut and the brain, one sees that the gut-brain axis has various means of communication, such as through the vagus nerve and the enteric nervous system and can use the metabolites in the gut to communicate to the brain. METHODS: The purpose of this review is to view the gut-brain axis through the lens of stress and how stress, from the prenatal period all the way through adulthood can impact the physiology of a human being. Studies have shown multiple mechanisms of measurable change with disruption in the microbiota that lead to behavioral changes. There are also effects of gut inflammation on the brain and the corresponding systemic response observed. CONCLUSION: The overall literature is encouraging that the more understanding of the gut-brain axis, the greater ability to wield that understanding for therapeutic benefits.

Effectiveness of a central line associated blood stream infection protocol in a pediatric population.

BACKGROUND: Central line associated bloodstream infections are a common cause of bacteremia and sepsis in pediatric patients with intestinal failure, secondary to long-term CVC use. METHODS: An IRB approved retrospective chart review was conducted on TPN-dependent patients with IF who had an identified CLABSI and presented to Children's of Alabama's emergency department (ED) and were admitted to the hospital. RESULTS: Forty-four patients were included in the study, 28 in the first 18-month period and 26 in the second, with 10 in both populations. After implementation, mean time from ED presentation to antibiotic ordered and ED admission to antibiotic administered were lower. Mean time between antibiotic administration and admission to the floor was greater, and number of infectious disease consultations was greater. Floor-ICU transfers were lower, readmissions within 30 days was similar, and mean length of stay was similar. CONCLUSION: A collaborative, multidiscipline-supported protocol for the care of patients with IF presenting to the ED enhances efficiency of antibiotic ordering/administration, as well as reduces the number of unplanned floor-ICU transfers.

Reassessing career pathways of surgical leaders: An examination of surgical leaders' early accomplishments.

BACKGROUND: The American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and Society of Black Academic Surgeons (SBAS) partnered to gain insight into whether inequities found in surgical society presidents may be present earlier. METHODS: ACS, ASA, AWS, and SBAS presidents' CVs were assessed for demographics and scholastic achievements at the time of first faculty appointment. Regression analyses controlling for age were performed to determine relative differences across societies. RESULTS: 66 of the 68 presidents' CVs were received and assessed (97% response rate). 50% of AWS future presidents were hired as Instructors rather than Assistant professors, compared to 29.4% of SBAS, 25% of ASA and 29.4% of ACS. The future ACS, ASA, and SBAS presidents had more total publications than the AWS presidents, but similar numbers of 1st and Sr. author publications. CONCLUSION: Gender inequities in academic surgeon hiring practices and perceived scholastic success may be present at first hire.

A Novel Use of Artificial Intelligence to Examine Diversity and Hospital Performance.

BACKGROUND: The US population is becoming more racially and ethnically diverse. Research suggests that cultural diversity within organizations can increase team potency and performance, yet this theory has not been explored in the field of surgery. Furthermore, when surveyed, patients express a desire for their care provider to mirror their own race and ethnicity. In the present study, we hypothesize that there is a positive correlation between a high ranking by the US News and World Report for gastroenterology and gastrointestinal (GI) surgery and greater racial, ethnic, and gender diversity among the physicians and surgeons. METHODS: We used the 2019 US News and World Report rankings for best hospitals by specialty to categorize gastroenterology and GI surgery departments into 2 groups: 1-50 and 51-100. Hospital websites of these top 100 were viewed to determine if racial diversity and inclusion were highlighted in the hospitals' core values or mission statements. To determine the rates of diversity within departments, Betaface (Betaface.com) facial analysis software was used to analyze photos taken from the hospitals' websites. This software was able to determine the race, ethnicity, and gender of the care providers. We examined the racial and ethnic makeup of the populations served by these hospitals to see if the gastroenterologists and surgeons adequately represented the state population. We then ran the independent samples t-test to determine if there was a difference in rankings of more diverse departments. RESULTS: Hospitals with gastroenterology and GI surgery departments in the top 50 were more likely to mention diversity on their websites compared with hospitals that ranked from 51-100 (76% versus 56%; P = 0.035). The top 50 hospitals had a statistically significant higher percentage of underrepresented minority GI physicians and surgeons (7.01% versus 4.04%; P < 0.001). In the 31 states where these hospitals were located, there were more African Americans (13% versus 3%; P < 0.001) and Hispanics (12% versus 2%; P < 0.001), while there were fewer Asians (4% versus 21%; P < 0.001) in the population compared with the faculty. CONCLUSIONS: We used artificial intelligence software to determine the degree of racial and ethnic diversity in gastroenterology and GI surgery departments across the county. Higher ranking hospitals had a greater degree of diversity of their faculty and were more likely to emphasize diversity in their mission statements. Hospitals stress the importance of having a culturally diverse staff, yet their care providers may not adequately reflect the populations they serve. Further work is needed to prospectively track diversity rates over time and correlate these changes with measurable outcomes.

Trending diversity: Reviewing four-decades of graduating fellows and the current leadership in pediatric surgery.

PURPOSE: Diversity in the physician workforce remains a priority in healthcare as it has been shown to improve outcomes. Decisions for choosing specific fields in medicine are partly influenced by mentors, which tend to be the same sex or ethnicity. Females are starting to outnumber males in medical school and minorities are targeted for recruitment. We hypothesized that diversity in pediatric surgery has increased over time. METHODS: The recently published A Genealogy of North American Pediatric Surgery was utilized to identify graduating pediatric surgery fellows from 1981 to 2018. Organization websites were used to identify past and current leaders. A web-based analysis, including online facial recognition software, was performed. A year-to-year and decade-to-decade demographic comparison was completed. RESULTS: 1217 pediatric surgery fellows graduated between 1981 and 2018. When comparing graduates from the first and last decades, an increase from 16.9% to 39.5% for female graduates was observed (p = 0.046). A significant increase in nonwhite graduates was seen for all races (p < 0.05). Representation in leadership was White and male dominant. CONCLUSION: There was a significant increase in diversity in pediatric surgery fellowship graduates. There were increasing trends in female graduates and all nonwhite racial groups. Focusing on enhancing the pipeline and mentoring underrepresented minorities will continue to enhance this trend for the field of pediatric surgery. LEVEL OF EVIDENCE: III; Retrospective Review.

New directions in necrotizing enterocolitis with early-stage investigators.

The 2019 Necrotizing Enterocolitis (NEC) Symposium expanded upon the NEC Society's goals of bringing stakeholders together to discuss cutting-edge science, potential therapeutics and preventative measures, as well as the patient-family perspectives of NEC. The Symposium facilitated discussions and shared knowledge with the overarching goal of creating "A World Without NEC." To accomplish this goal, new research to advance the state of the science is necessary. Over the last decade, several established investigators have significantly improved our understanding of the pathophysiology of NEC and they have paved the way for the next generation of clinician-scientists funded to perform NEC research. This article will serve to highlight the contributions of these young clinician-scientists that seek to elucidate how immune, microbial and nervous system dysregulation contributes to the pathophysiology of NEC.

Benchmarking Accomplishments of Leaders in American Surgery and Justification for Enhancing Diversity and Inclusion.

OBJECTIVE: To comprehensively assess the level of achievement and demographics of national surgical society presidents. BACKGROUND: Data on the accomplishments needed to rise to positions of national surgical leadership is scarce and merit alone does not always yield such opportunities. Recognizing the shortcomings of sex and ethnic diversity within academic surgical leadership, the American College of Surgeon (ACS), American Surgical Association (ASA), Association of Women Surgeons (AWS), and the Society of Black Academic Surgeons (SBAS) partnered to address these challenges by performing a comprehensive assessment of their presidents over the last 16 years. METHODS: ACS, ASA, AWS, and SBAS presidents' CVs, at the time of their presidential term, were assessed for demographics and scholastic achievements. Regression analyses controlling for age were performed to determine relative differences across societies. RESULTS: A total of 62 of the 64 presidents' CVs were received and assessed (97% response rate). There was a large discrepancy in the average age in years of ACS (70) and ASA (66) presidents compared to the AWS (51) and SBAS (53) presidents. For the ACS and ASA cohort, 87% were male and 83% were White, collectively. After controlling for age (52), the AWS and SBAS presidents' scholastic achievements were comparable to the ACS (and ASA) cohort in 9 and 12 of the 15 accessed metrics, respectively. CONCLUSION: The ACS and ASA presidents' CVs displayed unsurpassed scholastic achievement, and although not equivalent, both the AWS and the SBAS presidents had comparable attainment. These findings further substantiate that women and ethnic minority surgeons are deserving of additional national leadership consideration as organized medicine pursues a more diverse and reflective physician workforce.

The Society of Black Academic Surgeons CV benchmarking initiative: Early career trends of academic surgical leaders.

BACKGROUND: Surgeons from under-represented backgrounds are less likely to receive academic tenure and obtain leadership positions. Our objective was to query the curriculum vitaes (CVs) of SBAS leadership to develop a benchmarking tool to promote and guide careers in academic surgery. METHODS: CVs from academic leaders were reviewed for academic productivity at early career stages-the first 5-and 10-years. Variables queried: peer-reviewed publications, grant funding, surgical societal involvement, invited lectureships and visiting professorships. RESULTS: Of 20 CVs, 41 leadership positions including 13 SBAS Presidents were identified. At 5- and 10-years, respectively, the academic productivity increased: 20.6 and 52.3 publications; 4.7 and 9.7 grants; 18 and 42.6 lectures/professorships. CONCLUSION: The CV benchmarking tool may be a useful framework for aspiring academic surgeons to track their progress relative to successful SBAS members. Creative strategies like these, paired with faculty mentorship and sponsorship are necessary to improve the ethnic diversity in academic surgery.

Development of venous thrombi in a pediatric population of intestinal failure.

BACKGROUND/PURPOSE: Although pediatric intestinal failure (IF) is now a survivable diagnosis, children are still at risk for complications. Loss of venous access persists as a leading indication for intestinal transplantation. The goal of this study was to identify risk factors for loss of venous access in a pediatric intestinal failure population on long-term PN. METHODS: We identified all patients who were PN dependent. RESULTS: Patients that developed venous thrombosis had significantly more lines placed in the first 2 years of life compared to those who did not develop thrombosis. Multivariate regression analysis revealed that diagnosis (NEC and gastroschisis) and parental education were significant predictors of venous thrombosis. CONCLUSION: By identifying potential risk factors for thrombus development, interventions can be developed to improve the overall outcome in pediatric IF patients. TYPE OF STUDY: Diagnostic LEVEL OF EVIDENCE: III.

Survey on Robot-Assisted Surgical Techniques Utilization in US Pediatric Surgery Fellowships.

INTRODUCTION: Robotic technology has transformed both practice and education in many adult surgical specialties; no standardized training guidelines in pediatric surgery currently exist. The purpose of our study was to assess the prevalence of robotic procedures and extent of robotic surgery education in US pediatric surgery fellowships. MATERIALS AND METHODS: A deidentified survey measured utilization of the robot, perception on the utility of the robot, and its incorporation in training among the program directors of Accreditation Council for Graduate Medical Education (ACGME) pediatric surgery fellowships in the United States. RESULTS: Forty-one of the 47 fellowship programs (87%) responded to the survey. While 67% of respondents indicated the presence of a robot in their facility, only 26% reported its utilizing in their surgical practice. Among programs not utilizing the robot, most common reasons provided were lack of clear supportive evidence, increased intraoperative time, and incompatibility of instrument size to pediatric patients. While 58% of program directors believe that there is a future role for robotic surgery in children, only 18% indicated that robotic training should play a part in pediatric surgery education. Consequently, while over 66% of survey respondents received training in robot-assisted surgical technique, only 29% of fellows receive robot-assisted training during their fellowship. CONCLUSIONS: A majority of fellowships have access to a robot, but few utilize the technology in their current practice or as part of training. Further investigation is required into both the technology's potential benefits in the pediatric population and its role in pediatric surgery training.

Altered T-Cell Balance in Lymphoid Organs of a Mouse Model of Colorectal Cancer.

The adenomatous polyposis coli (APC) gene is a known tumor suppressor gene, and mice with mutations in Apc (ApcMin/+) spontaneously form multiple intestinal neoplasms. In this model of human colorectal cancer (CRC), it has been reported that CD4+ T-cell-derived interleukin 17 (IL-17) promotes intestinal tumor development, but it is not known if the Apc mutation actually directly alters T-cell function and subsequently tumor immunosurveillance. To investigate the ApcMin/+ mutation on T-cell function, flow cytometric, histochemical, and immunofluorescent studies on both wild-type (Apc+/+) and ApcMin/+ mice were performed. We identified decreased levels of interferon gamma (IFN-γ+)IL-17+ double-positive CD4+ cells in the mesenteric lymph nodes and Peyer's patches of ApcMin/+ mice. In addition, altered levels of CD8+ cells, and changes in CD8+ production of IFN-γ and granzyme B were observed. These T-cell alterations did modify tumor immunosurveillance, as the adoptive transfer of splenocytes from ApcMin/+ animals into a chemically induced CRC model resulted in the inability to prevent epithelial dysplasia. These results suggest an altered T-cell balance in ApcMin/+ mice may disrupt intestinal homeostasis, consequently limiting intestinal tumor immunosurveillance.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience.

BACKGROUND: Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use. PATIENTS AND METHODS: This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration. RESULTS: Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1). CONCLUSIONS: Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

Single-incision pediatric endosurgery (SIPES) splenectomy: what dictates the need for additional ports?

BACKGROUND: As proficiency with single-incision pediatric endosurgery (SIPES) increases, more challenging operations are being performed. While the ultimate goal is safe surgery, it may be beneficial to know what anatomical and technical factors contribute to the need for additional ports. This aspect of SIPES splenectomy has yet to be evaluated. The study objective was to identify these factors, potentially allowing surgeons to gauge appropriateness for single incision and to tailor techniques for optimal results. METHODS: This was an institutional review board-approved retrospective analysis of prospectively collected data (FWA00005960). SIPES splenectomies performed at a tertiary children's hospital since March of 2009 were included. Demographic and technical factors pertaining to each operation were available in our SIPES database. Fischer's exact and Wilcoxon rank sum tests were used to analyze categorical and continuous variables, respectively. RESULTS: Thirty-seven patients 18 years of age and younger underwent attempted SIPES splenectomy. Two operations were converted directly to open and were excluded from analysis. Of the remaining 35 operations, 15 (42.9 %) were completed with additional ports. Gender, age, body mass index, splenic weight, indication for operation and the presence of accessory spleens did not contribute to the need for added ports. The only factor to reach statistical significance was the number of channels present in the SIPES access device (p = 0.002). CONCLUSIONS: Completion of SIPES splenectomy was associated with the decision to utilize an access device with four channels. Anatomic variables did not appear to affect the ability to complete SIPES splenectomy.