Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -a Survey on Opinion and Experience Among IPEG Members.

PURPOSE: Laparoscopic resection of choledochal cyst (CC) has become a popular approach. As the discussion about optimal treatment and technical strategies continues, we aimed to investigate perspectives of IPEG members. METHODS: An online survey was conducted in 2023 on behalf of the IPEG Research Committee. IPEG members were asked to complete an anonymous questionnaire that included 36 items on the management of CC. RESULT: 148 members responded to the survey (North America:49/Asia:44/Europe:23/South America:21/Others:11) and 116 completed all questions. Most surgeons (92.5%) operate on less than 5 cases annually. Diagnostic tools of choice were Magnetic Resonance Imaging (MRI, 95.9%) and ultrasonography (US, 74.5%). Regarding fusiform-type CC, operative indications were cyst size greater than 10 mm (68.9%), typical symptoms (78.5%), or anomalous pancreatico-biliary junction (63.8%). In unilateral intrahepatic biliary cysts (type IVa) cases, 81.3% of respondents do not perform a simultaneous liver resection with the initial cyst resection. While 22.0% resect the CC at diagnosis, even if asymptomatic, a larger group of surgeons (41%; 49/118) wait until the infant reaches six months. Intraoperative cholangiography and choledochoscopy are performed routinely by 38.9% and 13.7%, respectively. The majority (52.5%) ligates the common bile duct stump just below the CC. Laparoscopic reconstructions are performed by retrocolic hepatico-jejunostomy (48.3%) or hepatico-duodenostomy (45.8%) at similar rates, but when done open, 71.2% of respondents prefer retrocolic hepatico-jejunostomy. For the laparoscopic anastomosis, interrupted sutures with intracorporeal knot tying were most often utilized (48.3%). CONCLUSION: Inidividual pediatric surgeons treat a small number of patients with CC each year. Laparosopic and open reconstruction techniques vary, likely due to technical challenges. LEVEL OF EVIDENCE: III.

Clinical Consensus Statement on the Use of Indocyanine Green Fluorescence-guided Surgery in Pediatric Patients.

BACKGROUND AND AIMS: Indocyanine Green Fluorescence (ICG-F)- guided surgery is becoming an increasingly helpful tool in pediatric surgical care. This consensus statement investigates the utility of ICG-F in various pediatric surgical applications, primarily focusing on its evidence base, safety, indications, use across different surgical specialties and dosing strategies. The aim is to establish an international consensus for ICG-F use in pediatric surgery. METHODS: An international panel of 15 pediatric surgeons from 9 countries was assembled. The structured process consisted of a rapid scoping review, iterative discussion sessions, mixed-methods studies with key stakeholders, and voting rounds on individual statements to create draft consensus statements. RESULTS: 100 articles were identified during the review and summarized by application. Based on this condensed evidence, consensus statements were generated after 3 iterative rounds of anonymous voting. Key areas of agreement were quality of evidence, the safety of ICG, pediatric surgical indications, utilization per surgical specialty, and dosing of ICG. CONCLUSION: This consensus statement aims to guide healthcare professionals in managing ICG-F use in pediatric surgical cases based on the best available evidence, key stakeholder consultation, and expert opinions. Despite ICG-F's promising potential, the need for higher-quality evidence, prospective trials, and safety studies is underscored. The consensus also provides a framework for pediatric surgeons to utilize ICG-F effectively. LEVEL OF EVIDENCE: III.

Integrating Artificial Intelligence Into the Visualization and Modeling of Three-Dimensional Anatomy in Pediatric Surgical Patients.

BACKGROUND: Pediatric surgeons often treat patients with complex anatomical considerations due to congenital anomalies or distortion of normal structures by solid organ tumors. There are multiple applications for three-dimensional visualization of these structures based on cross-sectional imaging. Recently, advances in artificial intelligence (AI) applications and graphics hardware have made rapid 3D modelling of individual structures within the body accessible to surgeons without sophisticated and expensive hardware. In this report, we provide an overview of these applications and their uses in preoperative planning for pediatric surgeons. METHODS: Deidentified DICOM files containing cross-sectional imaging of preoperative pediatric surgery patients were loaded from an institutional PACS database onto a secure PC with dedicated graphics and AI hardware (NVIDIA Geforce RTX 4070 laptop GPU). Visualization was obtained using an open-source imaging platform (3D Slicer). AI extensions to the platform were utilized to delineate the anatomy of interest. RESULTS: Segmentations of skeletal and visceral structures within a scan were obtained using the TotalSegmentator extension with an average processing time under 5 min. Additional AI modules were utilized for providing detailed mapping of the airways (AirwaySegmentation), lungs (Chest Imaging Platform), liver (SlicerLiver), or vasculature (SlicerVMTK). Other extensions were used for delineation of tumors within the hepatic parenchyma (MONAI Auto3DSeg) and hepatic vessels (RVesselX). CONCLUSION: AI algorithms for image interpretation and processors dedicated to AI functions have significantly decreased the technical and financial requirements for obtaining detailed three-dimensional images of patient anatomy. Models obtained using AI algorithms have potential applications in preoperative planning, surgical simulation, patient education, and training. LEVEL OF EVIDENCE: V, Case Series, Description of Technique.

An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation.

Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

A Pilot Study for Biliary Atresia Diagnosis: Fluorescent Imaging of Indocyanine Green in Stool.

BACKGROUND: Biliary atresia is the most common cause of obstructive jaundice in infants and conventional cholangiography is the current diagnostic gold standard. Fluorescent cholangiography with indocyanine green can enhance biliary tree visualization during surgery because it is exclusively excreted into the bile ducts and eventually into the intestine. Therefore, we hypothesized that indocyanine green presence in stool could confirm bile duct patency in infants. METHODS: A prospective single center cohort study was performed on infants (age ≤ 12 months) with and without jaundice after obtaining IRB approval. Indocyanine green was administered intravenously (0.1 mg/kg). Soiled diapers collected post-injection were imaged for fluorescence. RESULTS: After indocyanine green administration, fluorescence was detected in soiled diapers for control patients (n = 4, x = 14 h22 m post-injection) and jaundiced patients without biliary atresia (n = 11, x = 13 h28 m post-injection). For biliary atresia patients (n = 7), post-injection soiled diapers before and after Kasai portoenterostomy were collected. Fluorescence was not detected in stool from 6 of 7 biliary atresia patients. As a test, indocyanine green detection in stool was 97% accurate for assessing biliary patency. CONCLUSION: Fluorescent Imaging for Indocyanine Green (FIInd Green) in stool is a fast and accurate approach to assess biliary patency non-invasively in infants. LEVEL OF EVIDENCE: Level III.

Prevalence and outcomes of high versus low ratio plasma to red blood cell resuscitation in a multi-institutional cohort of severely injured children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level III.

The sensitivity of limited-sequence magnetic resonance imaging in identifying pediatric cervical spine injury: A Western Pediatric Surgery Research Consortium multicenter retrospective cohort study.

INTRODUCTION: Clinical clearance of a child's cervical spine after trauma is often challenging because of impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the criterion standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence magnetic resonance imaging (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared with criterion standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. METHODS: We conducted a 10-center, 5-year retrospective cohort study (2017-2021) of all children (0-18 years) with a cervical spine MRI after blunt trauma. Magnetic resonance imaging images were rereviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. RESULTS: We identified 2,663 children younger than 18 years who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (younger than 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. CONCLUSION: Limited-sequence magnetic resonance imaging is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic examination. LEVEL OF EVIDENCE: Diagnostic Test/Criteria; Level III.

Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study.

OBJECTIVE: Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children. BACKGROUND: Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited. METHODS: We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery. RESULTS: We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration. CONCLUSIONS: The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

Development of a Prediction Model for Surgery or Early Mortality at the Time of Initial Assessment for Necrotizing Enterocolitis.

OBJECTIVE: No available scale, at the time of initial evaluation for necrotizing enterocolitis (NEC), accurately predicts, that is, with an area under the curve (AUC) ≥0.9, which preterm infants will undergo surgery for NEC stage III or die within a week. STUDY DESIGN: This is a retrospective cohort study (n = 261) of preterm infants with <33 weeks' gestation or <1,500 g birth weight with either suspected or with definite NEC born at Parkland Hospital between 2009 and 2021. A prediction model using the new HASOFA score (Hyperglycemia, Hyperkalemia, use of inotropes for Hypotension during the prior week, Acidemia, Neonatal Sequential Organ Failure Assessment [nSOFA] score) was compared with a similar model using the nSOFA score. RESULTS: Among 261 infants, 112 infants had NEC stage I, 68 with NEC stage II, and 81 with NEC stage III based on modified Bell's classification. The primary outcome, surgery for NEC stage III or death within a week, occurred in 81 infants (surgery in 66 infants and death in 38 infants). All infants with pneumoperitoneum or abdominal compartment syndrome either died or had surgery. The HASOFA and the nSOFA scores were evaluated in 254 and 253 infants, respectively, at the time of the initial workup for NEC. Both models were internally validated. The HASOFA model was a better predictor of surgery for NEC stage III or death within a week than the nSOFA model, with greater AUC 0.909 versus 0.825, respectively, p < 0.001. Combining HASOFA at initial assessment with concurrent or later presence of abdominal wall erythema or portal gas improved the prediction surgery for NEC stage III or death with AUC 0.942 or 0.956, respectively. CONCLUSION: Using this new internally validated prediction model, surgery for NEC stage III or death within a week can be accurately predicted at the time of initial assessment for NEC. KEY POINTS: · No available scale, at initial evaluation, accurately predicts which preterm infants will undergo surgery for NEC stage III or die within a week.. · In this retrospective cohort study of 261 preterm infants with either suspected or definite NEC we developed a new prediction model (HASOFA score).. · The HASOFA-model had high discrimination (AUC: 0.909) and excellent calibration and was internally validated..

Creation of Three-dimensional Anatomic Models in Pediatric Surgical Patients Using Cross-sectional Imaging: A Demonstration of Low-cost Methods and Applications.

BACKGROUND: Pediatric surgery patients often present with complex congenital anomalies or other conditions requiring deep understanding of their intricate anatomy. Commercial applications and services exist for the conversion of cross-sectional imaging data into three-dimensional (3D) models for education and preoperative planning. However, the associated costs and lack of familiarity may discourage their use in centers with limited resources. The purpose of this report is to present a low-cost, reproducible method for generating 3D images to visualize patient anatomy. METHODS: De-identified DICOM files were obtained from the hospital PACS system in preparation for assorted pediatric surgical procedures. Using open-source visualization software, variations in anatomic structures were examined using volume rendering and segmentation techniques. Images were further refined using available editing tools or artificial intelligence-assisted software extensions. RESULTS: Using the described techniques we were able to obtain excellent visualization of desired structures and associated anatomic variations. Once structures were selected and modeled in 3D (segmentation), they could be exported as one of several 3D object file formats. These could then be retained for 3D printing, visualization in virtual reality, or as an anatomic reference during the perioperative period. Models may also be imported into commercial gaming engines for rendering under optimal lighting conditions and with enhanced detail. CONCLUSION: Pediatric surgeons are frequently tasked with the treatment of patients with complex and rare anomalies. Visualization and preoperative planning can be assisted by advanced imaging software at minimal to no cost, thereby facilitating enhanced understanding of these conditions in resource-limited environments. LEVEL OF EVIDENCE: V, Case Series, Description of Technique.

Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study.

BACKGROUND: The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm. METHODS: A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset. RESULTS: A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935. CONCLUSION: This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.

The Sinister Surgeon: Advanced Pediatric Minimally Invasive Surgery for Left-Handed Surgeons.

Purpose: Left-handed (LH) surgeons face unique challenges in their training and practice. Contrary to the historical and unjust perception of technical inferiority, LH surgeons can thrive under appropriate mentorship and support. Here, we describe modifications to pediatric minimally invasive surgeries to benefit the LH surgeon. Methods: The surgical approaches to common and complex pediatric surgical operations were modified to facilitate training of an LH pediatric surgical fellow. Results: Preoperative preparation, including communication with the operating room team, patient positioning, and provision of appropriate equipment, allowed the procedures to be accomplished in a safe and efficient manner. Conclusions: Modifying complex minimally invasive surgery to allow for use of the dominant hand is feasible and safe.

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Utilization of robotics in pediatric surgical oncology.

Despite increasing implementation of robotic surgery and minimally invasive techniques within adult surgical oncology and pediatric general surgery, the utilization of robotic-assisted resections for pediatric tumors has been met with controversy. The robotic platform affords numerous advantages over conventional surgical techniques. However, limited data and guidelines regarding patient selection, indications for the robotic approach, and long-term oncologic outcomes have delayed the widespread adoption of robotic-assisted resection of pediatric tumors. This paper reviews the benefits, limitations, and existing guidelines and data regarding the utilization of robotics in pediatric surgical oncology.

Pediatric robotic surgery: An overview.

Pediatric robotic surgery offers children a minimally invasive approach with numerous advantages over open or thoracoscopic and laparoscopic surgery. However, despite its widespread adoption for adult patients, the utilization of robotic surgery within pediatrics has been relatively slower to progress. This paper provides an overview of pediatric robotic surgery and discusses benefits, limitations, and strategies for successful implementation of robotics within pediatric surgical practice.

Robotic repair of pediatric hernias: Current techniques and practices.

The use of minimally invasive surgical techniques has gained popularity in pediatric surgery due to decreased length of stay, improved post-operative pain and smaller incisions. Laparoscopic assisted robotic surgical procedures are becoming more common in adults as they carry all of the benefits of traditional MIS but also allow for improved dexterity, visualization and surgeon ergonomics. In adults, hernia repairs are one of the most commonly performed robotic cases but adaption to pediatric repairs has been slower. Case reports and small case series have described a number of various types of pediatric hernia repairs including congenital diaphragmatic hernias, paraesophageal hernias and inguinal hernias. These cases have demonstrated that robotic repair of pediatric hernias is safe and feasible with minimal documented post-operative complications or recurrence. Future directions should focus on larger patient volume in order to assess outcomes between traditional laparoscopic and robotic approaches.

Improving Billing and Collections in a High-Volume Pediatric Surgery Practice: Denials-Based Approach.

BACKGROUND: Despite minimal coding and billing training, surgeons are frequently tasked with both in clinical practice. This often results in denials for reimbursement based on incorrect or insufficient documentation, and reduced collections for work performed. We sought to evaluate how to correct these deficits while improving reimbursement for the most frequently rejected procedures at a high-volume academic center. STUDY DESIGN: Hospital billing data were analyzed for a 4-year period (2018 to 2021) to determine the CPT code denials with the largest overall cost. The denials were then stratified according to payor, reason for denial, and preventability. Assigned ICD-10 codes were categorized based on specificity as related to the procedure. The distribution of denials according to ICD-10 specificity was evaluated using the chi-square test. RESULTS: A total of 8,833 denials representing $11,009,108 in billing were noted during the study period. The CPT code 44970 (laparoscopic appendectomy) was the code associated with the largest financial impact, representing 12.8% of the total denied amount ($1.41M). Of the 823 denials for CPT 44970, 93.3% were associated with nonspecific ICD-10 codes, whereas only 42.0% had been associated with procedure-specific ICD-10 codes. Of the patients with nonspecific codes, 80.7% of denials were due to criteria that could be remedied with supplemental information or timely filing, representing $1,059,968 in collections. CONCLUSIONS: This is the first study to systematically evaluate a pathway for using denial data to improve collections for work performed at a high-volume academic pediatric surgery practice. Using this methodology, targets for improvement in coding and/or documentation can be identified to improve the financial performance of a surgical department. This study also provides evidence that association with nonspecific diagnostic codes is correlated with initial denial of payment by insurance companies.

Standardized perioperative care reduces colorectal surgical site infection in children: A Western Pediatric Surgery Research Consortium multicenter analysis.

PURPOSE: Surgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery. METHODS: We conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or "colon bundle", we divided patients into low (1-4 elements) or high (5-8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days. RESULTS: Three hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI. CONCLUSION: Standardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity. TYPE OF STUDY: Clinical Research Paper LEVEL OF EVIDENCE: Level II.

Impact of Cryoablation on Pectus Excavatum Repair in Pediatric Patients.

BACKGROUND: Minimally invasive repair of pectus excavatum (MIRPE) involves placement of a transthoracic, retrosternal support bar under thoracoscopic guidance. Despite its minimally invasive technical approach, postoperative pain is a significant morbidity that often results in increased length of stay. Multi-modal pain control strategies have been used in the past with limited success. Recently, the use of intraoperative intercostal nerve cryoablation (CA) has been added. In the present study, we aim to evaluate the effects of CA on postoperative pain control, opioid requirements, and perioperative outcomes. STUDY DESIGN: A single-center, retrospective chart review of all patients (less than 18 years old) who underwent MIRPE from 2009 to 2020 was performed. CA was started in June 2018. Data collection included demographics, preoperative characteristics, intraoperative findings, and postoperative outcomes. We hypothesized that CA would be associated with improved pain scores, lower doses of total inpatient opioid requirement, and shorter length of stay (LOS). RESULTS: One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). CA significantly decreased median LOS from 4 days in NCA to 2 days; the use of CA was the only significant predictor of LOS on linear regression. CA was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time. However, CA was associated with significantly decreased postoperative complications. CONCLUSIONS: The use of cryoablation during MIRPE significantly decreases LOS, perioperative opioid requirements, and postoperative complications, with a minimal increase in operative time. Cryoablation is an effective pain control modality in the surgical management of chest wall deformities in children.

Global dissemination of knowledge through virtual platforms: Reflections and recommendations from APSA/IPEG.

BACKGROUND: The COVID-19 pandemic forced the cancelation of conventional in-person academic conferences due to the risk of virus transmission and limited ability to travel. Both the American Pediatric Surgical Association (APSA) and International Pediatric Endosurgery Group (IPEG) converted to a virtual format for their 2020 annual meetings. The purpose of this article is to review the successful implementation of the APSA and IPEG virtual meetings and reflect upon lessons learned for future virtual conferences. METHODS: Logistics, structure, and attendance statistics were reviewed. Informal interviews were conducted with key stakeholders and the number of presenters and participants were analyzed. Finally, post-meeting attendee surveys were conducted to elicit feedback after both virtual meetings. RESULTS: The meetings were organized in different ways, with APSA spreading a mix of scientific and clinical educational content over several months and IPEG keeping the meeting compressed, similar to previous in-person versions. Both meetings were free and therefore attracted a high proportion of participants (720 for APSA and 834 for IPEG). The meetings were felt to be educationally appropriate by most, although timing and lack of Continuing Medical Education (CME) opportunities were detractors. Most attendees said they would be willing to pay fees similar to in-person amounts. IPEG compressed presentations into four 2-hour sessions spread over 4 weeks, but also made material available on-line through a proprietary application. There was a broad range of international attendees. IPEG attracted a larger percentage of non-members than did APSA (3:1 nonmember to member ratio). Both societies reported net losses, largely due to lost registration revenue and non-refundable costs from having to switch from an in-person meeting. CONCLUSIONS: The main advantage of the virtual meeting was increased participation while disadvantages included the lack of networking. The key lessons learned from the meetings include methods to increase interactivity, adjustments of technical logistics, and creation of enduring material. In the future, hybrid conferences will likely become more prevalent with advantages of both platforms. LEVEL-OF-EVIDENCE: Level V - Expert Opinion.