A Decade of Firearm Injuries: Children Caught in the Crossfire.

INTRODUCTION: Firearm injuries (FIs) are the leading cause of preventable morbidity and mortality in pediatric patients. In this study, we aim to define evolving trends and avenues for prevention. METHODS: Following institutional review board approval, medical records of patients presenting to our two State-Designated Level 1 Pediatric Trauma Centers for treatment of FIs from 2010 to 2019 were retrospectively reviewed. Data was analyzed with Chi-Squared and Student's t-test; P-value <0.05 was significant. RESULTS: 1037 FI encounters from 1005 unique patients aged 0-21 y were included. 70.4% (n = 730) were determined to be assaults, 26.1% (n = 271) unintentional, and 1.7% (n = 18) self-inflicted injuries. Overall mortality was 4.5% (n = 45). FI victims were most commonly African American (n = 836, 80.6%), male (n = 869, 83.8%), aged 13-17 (n = 753, 72.6%), and from single-parent families (n = 647, 62.4%). The incidence of FIs increased significantly over the last 5 y of the study (2010-2014, 6.8 FIs/month), compared to 2015-2019 (averaging 10.6 FIs/month, P < 0.0001). Concurrently, FI related fatality increased from an average of 2.6 deaths/year (2010-2014) to 6.4 deaths/year (2015-2019, P = 0.064). Results were subanalyzed for pediatric patients aged 0-14 y. For the entire cohort, 12.1% (n = 116) recidivists were identified. Geographic patterns of injury were identified, with 75% of all FIs clustered in a single urban region. CONCLUSIONS: Incidence of pediatric FIs is increasing in recent years, with high mortality rates. Violence and recidivism are geographically concentrated, offering an opportunity for targeted interventions.

Management of long-gap esophageal atresia.

A uniquely challenging subset of infants diagnosed with esophageal atresia (EA) are those born with long-gap EA (LGEA). The common unifying feature in infants with LGEA is that the proximal and distal segments of the esophagus are too far apart to enable primary anastomosis via a single operation in the newborn period. Although any type of EA can technically result in a long gap, the Gross type A variant occurs in 8% of all EA cases and is most commonly associated with LGEA. In this review, we provide an evidence-based approach to the current challenges and management strategies employed in LGEA. There are fortunately a range of available surgical techniques for LGEA repair, including delayed primary repair, staged repair based on longitudinal traction strategies to lengthen both ends (e.g., Foker procedure, internal traction), and esophageal replacement using other portions of the gastrointestinal tract. The literature on the management of LGEA has long been dominated by single-center retrospective reviews, but the field has recently witnessed increased multi-center collaboration that has helped to increase our understanding on how to best manage this challenging patient population. Delayed primary repair is strongly preferred as the initial approach in management of LGEA in the United States as well as several European countries and is supported by the American Pediatric Surgery Association recommendations. Should esophageal replacement be required in cases where salvaging the native thoracic esophagus is not possible, gastric conduits are the preferred approach, based on the relative simplicity of the operation, low postoperative morbidity, and long-term durability. Long-term followup for monitoring of swallowing function, nutritional status, aspiration/respiratory illnesses, gastroesophageal reflux, and associated comorbidities is essential in the comprehensive care of these complex patients.

Operative Volumes and Postoperative Outcomes After Elective Resection of Congenital Lung Malformations in Infants.

OBJECTIVE: To determine whether hospital- and surgeon-level operative volumes are associated with differences in postoperative outcomes among infants undergoing elective lung surgery for a congenital lung malformation (CLM). SUMMARY BACKGROUND DATA: Infant lung surgery is a relatively uncommon procedure performed by pediatric surgeons nationwide. The relationship between surgical volume and postoperative outcomes remains unknown. METHODS: A retrospective cohort study of asymptomatic infants who underwent elective lung resection of a CLM was conducted using the Pediatric Health Information System database (2016-2020). Multivariable linear and poisson regressions were performed based on annual lung resection tertiles. RESULTS: There were 1420 infants managed by 48 hospitals and 309 primary surgeons. Institutions that performed seven or fewer CLM resections per year (56%) were associated with significantly higher postoperative complication rates compared to medium- and high-volume hospitals (low: 134 [34%], medium: 110 [21%], high: 144 [29%]; P<0.001). Surgeons who performed one or fewer CLM resections per year (82%) were associated with significantly higher complication rates compared to medium- and high-volume surgeons (low: 171 [31%], medium: 75 [26%], high: 119 [24%]; P=0.02). Multivariable analyses confirmed that low-volume hospitals were associated with higher complications (OR 1.81, CI 1.38-2.37; P<0.001), and low-volume surgeons had an increased risk of complications (overall: OR 1.37, CI 1.01-1.84; P=0.04). CONCLUSIONS: In this cohort study of infants undergoing elective lung resection for a CLM, lower volume providers were associated with higher postoperative patient morbidity. These findings represent an opportunity to inform quality improvement initiatives on pediatric lung resection and the debate on surgical subspecialization for this unique patient population.