Trends in Management of Index Adhesive Small Bowel Obstruction in Children.

INTRODUCTION: To examine practice patterns and surgical outcomes of nonoperative versus operative management (OPM) of children presenting with an index adhesive small bowel obstruction (ASBO). METHODS: A California statewide health discharge database was used to identify children (<18 y old) with an index ASBO from 2007 to 2020. The primary study outcome was evaluating initial management patterns (nonoperative versus OPM and early [≤3 d] versus late surgery [>3 d]) of ASBO. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. RESULTS: Of the 2297 patients identified, 1948 (85%) underwent OPM for ASBO during the index admission. Of these, 14.7% underwent early surgery within 3 d. Teaching hospitals had higher operative intervention than nonteaching centers (87.1% versus 83.7%, P = 0.034). OPM was the highest in 0-5-year-olds compared to other ages (89% versus 82%, P < 0.001). In comparison to early surgery, late surgery was associated with longer length of stay (early 7[interquartile range 5-10], late 9[interquartile range 6-17], P < 0.001), increased infectious complications (16.4% versus 9.8%, P = 0.004), and greater use of total parenteral nutrition (28.0% versus 14.3%, P = 0.001); there was no difference in bowel resection (21% versus 18%, P = 0.102) or mortality (P = 0.423). CONCLUSIONS: Our pediatric study demonstrated a high rate of OPM for index ASBO, especially in newborns and toddlers. Although operative intervention, especially late surgery, was associated with increased length of stay, increased infectious complications, and increased total parenteral nutrition use, the rates of bowel resection and mortality did not differ by management strategy. These trends need to be further evaluated to optimize outcomes.

Evaluating Outcomes of Nonaccidental Trauma in Military Children.

BACKGROUND: Nonaccidental trauma (NAT), or child abuse, is a leading cause of childhood injury and death in the US. Studies demonstrate that military-affiliated individuals are at greater risk of mental health complication and family violence, including child maltreatment. There is limited information about the outcomes of military children who experience NAT. This study compares the outcomes between military-dependent and civilian children diagnosed with NAT. STUDY DESIGN: A single-institution, retrospective review of children admitted with confirmed NAT at a Level I trauma center was performed. Data were collected from the institutional trauma registry and the Child Abuse Team's database. Military affiliation was identified using insurance status and parental or caregiver self-reported active-duty status. Demographic and clinical data including hospital length of stay (LOS), morbidity, specialty consult, and mortality were compared. RESULTS: Among 535 patients, 11.8% (n = 63) were military-affiliated. The median age of military-associated patients, 3 months (interquartile range [IQR] 1 to 7), was significantly younger than civilian patients, 7 months (IQR 3 to 18, p < 0.001). Military-affilif:ated patients had a longer LOS of 4 days (IQR 2 to 11) vs 2 days (IQR 1 to 7, p = 0.041), increased morbidity or complication (3 vs 2 counts, p = 0.002), and a higher mortality rate (10% vs 4%, p = 0.048). No significant difference was observed in the number of consults or injuries, trauma activation, or need for surgery. CONCLUSIONS: Military-affiliated children diagnosed with NAT experience more adverse outcomes than civilian patients. Increased LOS, morbidity or complication, and mortality suggest military-affiliated patients experience more life-threatening NAT at a younger age. Larger studies are required to further examine this population and better support at-risk families.

A Comparative Study of Laparoscopic versus Open Management of Index Small Bowel Obstruction in Children.

INTRODUCTION: There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO. METHODS: A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively. RESULTS: Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190). DISCUSSION: The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed. LEVEL OF EVIDENCE: III.

Evaluating the Benefits of Ventriculostomy Compared to Intracranial Pressure Monitoring for Severe Pediatric Traumatic Brain Injury.

BACKGROUND: In this study, we compared outcomes between intracranial pressure monitoring (ICP) only versus ventriculostomy (VT) using a nationwide database of pediatric trauma patients. METHODS: Pediatric patients (<18 years) with severe blunt TBI who underwent ICP monitoring with or without VT were identified from the 2017-2021 ACS Trauma Quality Programs. We excluded patients who experienced death or craniotomy/craniectomy within 48 h. The primary outcome was discharge disposition. Secondary outcomes were subsequent intracranial surgery, length of stay (LOS), and infectious complications. Competing risks survival analysis was used to evaluate the multivariable association between ICP vs. VT and outcomes. RESULTS: Of 1719 eligible patients, 65.9% were male and 54.1% had VT. Between the ICP and VT groups, there were no differences in mean age (11.4 vs. 11.0 years, p = 0.145), injury severity score (30.9 vs. 30.9, p = 0.937), or median GCS (3 vs. 3, p = 0.120). Multivariable analysis showed a robust association between VT and discharge home (compared to rehabilitation center; sHR 0.85, 95% CI 0.74-0.97, p = 0.017). VT use was not associated with increased mortality compared to ICP (p = 0.342). Finally, VT patients had longer median LOS (20.5 vs. 18.0 days, p < 0.001) but there was no difference in subsequent craniotomy/craniectomy (8.6 vs. 6.5%, p = 0.096) or infectious complications (1.2 vs. 0.9%, p = 0.549). CONCLUSION: VT was associated with greater discharge to home. Although VT patients had a greater LOS, the risk for other secondary outcomes did not vary, suggesting that VT may have benefits for the treatment of severe TBI with respect to discharge disposition. LEVEL OF EVIDENCE: III.

Navigating the Impact of the Dobbs Decision: Perspectives from Pediatric Surgeons on Reproductive Healthcare.

Nationwide abortion restrictions resulting from the Dobbs v Jackson Women's Health Organization (2022) decision have generated confusion and uncertainty among healthcare professionals, with concerns for liability impacting clinical decision-making and outcomes. The impact on pediatric surgery can be seen in prenatal counseling for fetal anomaly cases, counseling for fetal intervention, and recommendations for pregnant children and adolescents who seek termination. It is essential that all physicians and healthcare team members understand the legal implications on their clinical practices, engage with resources and organizations that can help navigate these circumstances, and consider advocating for patients and themselves. Pediatric surgeons must consider the impact of these changing laws on their ability to provide comprehensive and ethical care and counseling to all patients.

Multi-institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients.

BACKGROUND: In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance. METHODS: A multicenter, retrospective review of pediatric (<18 years) and adult patients with choledocholithiasis managed from 2018 to 2024 was performed. Demographic and clinical data were obtained. Rate of successful duct clearance with LCBDE was compared. Surgical and endoscopic complications (infections, bleeding, pancreatitis, bile leak) were also compared. RESULTS: 724 patients, 333 (45.9%) pediatric and 391 (54.0%) adults, were included. The median age of pediatric vs adult patients was 15.2 years [13.1, 16.6] vs 55.5 years [34.1, 70.5], respectively. Of these, 201 (60.4%) pediatric vs 169 (43.2%) adult patients underwent SF, p < 0.001. LCBDE was attempted in 84 (41.7%) pediatric vs 140 (82.8%) adults, p = 0.002. LCBDE success was higher in pediatric vs adult patients (82.1% vs 71.4%, p = 0.004). Complications rates were similar however, pediatric patients who underwent EF had higher endoscopic complications (9.1% vs 3.6%, p = 0.03). CONCLUSION: LCBDE is highly successful in children vs adults with no increased surgical complications. This data, coupled with the limited ERCP access for children, supports that LCBDE is an equally effective tool for managing choledocholithiasis in children as is accepted in adults. LEVEL OF EVIDENCE: Level III.

Patient Safety and Radiation Exposure in Transcystic Laparoscopic Common Bile Duct Exploration: A CARES Working Group Multicenter Study.

BACKGROUND: Treatment of choledocholithiasis with laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile duct exploration (LCBDE) is associated with fewer procedures and shorter length of stay (LOS) compared to preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC. Fluoroscopy is required for both LCBDE and ERCP but fluoroscopic time (FT) and radiation dose (RD) in LCBDE has not been studied. METHODS: The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis who received IOC. Demographics, type of LCBDE, FT and RD during IOC ± LCBDE, were analyzed. Statistical analysis was completed using Microsoft Excel and R software. RESULTS: From five centers, 157 patients were identified (79 without LCBDE, 78 with LCBDE). Wire access into the duodenum was successful in 67 patients (86%) and 64 patients (82%) had successful duct clearance. Median FT for all LCBDE cases was 3.3 min [1.6, 6.7] and RD was 59.8 mGy [30.1, 125.0] with no difference between successful and unsuccessful duct clearance (66.7 mGy [29.0, 115.0], 55.8 mGy [35.8, 154.1], respectfully; p = 0.51). CONCLUSION: Although both ERCP and LCBDE approaches result in fluoroscopic radiation exposure, FT, and RD in LCBDE have not previously been studied and are inadequately described in ERCP. Limiting radiation exposure in children is essential and fluoroscopy stewardship is a key component of pediatric safety in LCBDE. LEVEL OF EVIDENCE: Level III.

Reducing MRCP Utilization Through a "Surgery First" Approach for Pediatric Choledocholithiasis: A CARES Working Group Retrospective Study.

BACKGROUND: Choledocholithiasis in children is rising and frequently managed with an endoscopy-first (EF) approach that utilizes endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Magnetic resonance cholangiopancreatography (MRCP) is a resource intensive modality that often precedes ERCP to gain further assurance of choledocholithiasis prior to intervention. MRCP can lead to a longer length of stay (LOS) and strain healthcare resources. We hypothesized that the use of MRCP is decreased with a surgery-first (SF) approach. METHODS: The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis. SF patients underwent LC + intraoperative cholangiogram (IOC) ± laparoscopic common bile duct exploration (LCBDE). Imaging studies included ultrasound (US), MRCP, and computed tomography (CT). RESULTS: From seven institutions, 357 pediatric patients were identified. The SF (n = 220) group received fewer imaging studies then EF (n = 137) (1.29 vs. 1.62; p < 0.05). US was more commonly employed and the number of US and CT scans was similar. The SF group had lower MRCP utilization than EF (29% vs. 59%; p < 0.05). EF patients that received an MRCP had the longest LOS (4.0 d [2.4, 6.3]) compared to SF that did not (1.9 d [1.2, 3.2]) (p < 0.05). CONCLUSION: Children with choledocholithiasis managed with an EF approach receive more diagnostic imaging, especially MRCP. While MRCP remains a powerful diagnostic tool, a surgery-first approach can minimize the resource utilization and LOS associated with magnetic resonance imaging. LEVEL OF EVIDENCE: Level III.