Is There Still a Role for Peritoneal Drains in Neonatal Pneumoperitoneum? A Single-Center Experience.

INTRODUCTION: Although pneumoperitoneum from necrotizing enterocolitis or spontaneous intestinal perforation is a surgical emergency, risk stratification to determine which neonates benefit from initial peritoneal drainage (PD) is lacking. METHODS: Using a single-center retrospective review of very low birth weight neonates under 1500 g who underwent PD for pneumoperitoneum (January 2015 to December 2023) from necrotizing enterocolitis or spontaneous intestinal perforation, two cohorts were created: drain "responders" (patients managed definitively with PD; includes placement of a second drain) and "nonresponders" (patients who underwent subsequent laparotomy or died after PD). Antenatal/postnatal characteristics, periprocedural clinical data, and hospital outcomes were compared between responders and nonresponders using Student's t-test, chi-squared test, or Kruskal-Wallis test as appropriate, with P < 0.05 considered significant. RESULTS: Fifty-six neonates were included: 31 (55%) drain responders and 25 (45%) nonresponders. Birth weight, gestational age, sex, ethnicity, use of postnatal steroids, and enteral feeds were similar between the cohorts. Nonresponders had higher base deficits (-3.4 versus -5.0, P = 0.032) and FiO2 (0.25 versus 0.52, P = 0.001) after drain placement. Drain responders had significantly shorter lengths of stay (89 versus 148 days, P = 0.014) and lower mortality (6.4% versus 56%, P < 0.001). A subgroup analysis of the nonresponders showed no differences in birth weight, vasopressor requirement, FiO2, or postdrain base deficit between nonresponders who had a drain alone versus laparotomy following drain placement. CONCLUSIONS: PD remains a viable initial therapy for pneumoperitoneum in premature very low birth weight neonates (< 1500 g), demonstrating clinical response in more than half. Ongoing clinical assessment and judgment is imperative after drain placement to ensure continued clinical improvement.

University surgeons: An ideal community for unity amid national discourse.

The current sociopolitical landscape continues to infiltrate our house of surgery, leaving faculty, staff, and learners challenged by uncertainty while introducing downstream interference to cohesive health care delivery for our patients. National surgical associations must cultivate an ethos of unity and intellectual solidarity within the surgical community, thereby reinforcing a foundation for productive and respectful discourse. This is not a call for uniformity in thought but for unity in purpose, action, and mutual respect.

Health Disparities Research: What Every Pediatric Surgeon Should Know.

While the earliest published health disparity research in the United States dates to 1899, the field was not formally established until the late 20th century. Initially focused on race and ethnicity, the field has broadened to include socioeconomic status. Several measures have been developed to quantify socioeconomic disadvantage, including the Social Vulnerability Index, Area Deprivation Index, and Child Opportunity Index. These indices have been validated and demonstrate correlation with health outcomes. However, socioeconomic status cannot fully explain health inequities experienced by people of minoritized racial and ethnic identities. Three generations of health disparities research have been described-identification of disparities, root analysis, and development of interventions to mitigate health inequities. While there has been an increase in publication of health disparity research, there is little third generation work. It is imperative that health disparities research move beyond defining the problem and toward interventions that will reduce health inequities. LEVELS OF EVIDENCE: Level IV.

Diverticulosis and Diverticulitis on YouTube: Is Popular Information the Most Reliable?

Background Patients utilize online health information to inform their medical decision-making. YouTube is one of the most popular media platforms with abundant health-related resources, yet the quality of the disseminated information remains unclear. This study aims to evaluate the quality and reliability of content pertaining to diverticulosis and diverticulitis on YouTube. Methods One author queried the terms "diverticulosis," "diverticulitis," "acute diverticulitis," and "chronic diverticulitis" on YouTube. The first 50 videos per search were selected for analysis. Duplicates, non-English videos, or procedural content were excluded. Video characteristics including view count, likes, comments, duration, days since upload, view ratio, video power index, and video sources (professional organizations (POs), health information websites (HIWs), and entertainment/independent users (EIUs)) were collected. Videos were scored using the mDISCERN and Global Quality Score (GQS). Results Sixty-four videos were included. DISCERN scores significantly differed between POs (n=20, mean=4.35), HIWs (n=29, mean=2.97), and EIUs (n=15, mean=1.83). GQS also significantly differed between POs (n=20, mean=4.47), HIWs (n=29, mean=3.62), and EIUs (n=15, mean=2.5). Video characteristics significantly differed between groups, with most user engagement seen in EIUs. Conclusion POs and HIWs disseminate higher quality health information about diverticular disease on YouTube. The higher viewer engagement with EIUs is concerning, as these sources were found to have lower quality content. Although YouTube has the capability to provide valuable information on diverticulosis and diverticulitis, enhanced content screening is needed to ensure accuracy and validation.

Approach to Constipation in Children: Recommendations for Evaluation and Management.

Constipation is common in childhood, and most patients can be successfully managed by their primary care provider. However, some patients will require more specialized management either due to an underlying congenital colorectal disorder such as Hirschsprung disease or anorectal malformation or due to severe functional constipation that is refractory to medical management.

The pediatric surgeon-scientist: An evolving Breed or endangered phenotype?

INTRODUCTION: National Institute of Health (NIH) funding is a "gold-standard" of achievement; we examined trends in NIH-funded pediatric surgeons. METHODS: NIH Research Portfolio Online Reporting Tools (RePORT) was queried for American Pediatric Surgical Association (APSA) members (2012 vs 2022). Demographics and time-to-award (TTA) from fellowship were compared. Number of grants, funding allotment, award classification, administering institutes/centers, research type were studied. RESULTS: Thirty-eight (4.6%) APSA members were NIH-funded in 2012 compared to 37 (2.9%) in 2022. Of funded surgeons in 2022, 27% were repeat awardees from 2012. TTA was similar (12 vs 14years, p=0.109). At each point, awards were commonly R01 grants (40 vs 52%, p â€‹= â€‹0.087) and basic science-related (76 vs 63%, p = â€‹0.179). Awardees were predominantly men (82% in 2012 vs 78% in 2022, p=0.779) and White (82% in 2012 vs 76% in 2022, p=0.586). Median amount per grant increased: $254,980 (2012) to $364,025 (2022); by $96,711 for men and $390,911 for women. Median awards for White surgeons increased by $215,699 (p=0.035), and decreased by $30,074 for non-White surgeons, though not significantly (p=0.368). CONCLUSION: The landscape of NIH-funded pediatric surgeons has remained unchanged between time points. With a substantial number of repeat awardees, predominance of R01 grants, and a median TTA over a decade after fellowship graduation, the phenotypes of early career pediatric surgeon-scientists are facing academic endangerment.

Early Lessons From Implementation of Holistic Review for Pediatric Surgery Fellowship Applicants.

PURPOSE: Holistic review (HR) considers applicants' unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS). METHODS: Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) [2015-2017] were compared to HR [2018-2022]. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate. RESULTS: For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR. CONCLUSION: Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort. LEVEL OF EVIDENCE: IV.

Mechanisms of spinophilin-dependent pancreas dysregulation in obesity.

Spinophilin is an F-actin binding and protein phosphatase 1 (PP1) targeting protein that acts as a scaffold of PP1 to its substrates. Spinophilin knockout (Spino-/-) mice have decreased fat mass, increased lean mass, and improved glucose tolerance, with no difference in feeding behaviors. Although spinophilin is enriched in neurons, its roles in nonneuronal tissues, such as ß cells of the pancreatic islets, are unclear. We have corroborated and expanded upon previous studies to determine that Spino-/- mice have decreased weight gain and improved glucose tolerance in two different models of obesity. We have identified multiple putative spinophilin-interacting proteins isolated from intact pancreas and observed increased interactions of spinophilin with exocrine, ribosomal, and cytoskeletal protein classes that normally act to mediate peptide hormone production, processing, and/or release in Leprdb/db and/or high-fat diet-fed (HFF) models of obesity. In addition, we have found that spinophilin interacts with proteins from similar classes in isolated islets, suggesting a role for spinophilin in the pancreatic islet. Consistent with a pancreatic ß cell type-specific role for spinophilin, using our recently described conditional spinophilin knockout mice, we found that loss of spinophilin specifically in pancreatic ß cells improved glucose tolerance without impacting body weight in chow-fed mice. Our data further support the role of spinophilin in mediating pathophysiological changes in body weight and whole body metabolism associated with obesity. Our data provide the first evidence that pancreatic spinophilin protein interactions are modulated by obesity and that loss of spinophilin specifically in pancreatic ß cells impacts whole body glucose tolerance.NEW & NOTEWORTHY To our knowledge, these data are the first to demonstrate that obesity impacts spinophilin protein interactions in the pancreas and identify spinophilin specifically in pancreatic ß cells as a modulator of whole body glucose tolerance.

Use of modern three-dimensional imaging models to guide surgical planning for local control of pediatric extracranial solid tumors.

INTRODUCTION: In complex pediatric surgical oncology, surgical planning is contingent upon data gathered from preoperative imaging. Three-dimensional (3D) modeling and printing has been shown to be beneficial for adult presurgical planning, though pediatric literature is less robust. The study reviews our institutional experience with the use of 3D image segmentation and printed models in approaching resection of extracranial solid tumors in children. METHODS: This is a single institutional series from 2021 to 2023. Models were based on computed tomography and magnetic resonance imaging studies, optimized for 3D imaging. The feasibility and creation of the models is reviewed, including specific techniques, software, and printing materials from our institution. Clinical implications for surgical planning are also described, along with detailed preoperative and intraoperative images. RESULTS: 3D modeling and printing was performed for four pediatric patients diagnosed with extracranial solid tumors. Diagnoses included Ewing sarcoma, hepatoblastoma, synovial sarcoma, and osteosarcoma. No intraoperative complications or discrepancies with the preoperative 3D-printed model were noted. No evidence of local recurrence was identified in any patient thus far. CONCLUSION: Our institutional series demonstrates a wide spectrum of clinical application for 3D modeling and printing technology within pediatric surgical oncology. This technology may aid in surgical planning for both resection and reconstruction, can be applied to a diverse breadth of diagnoses, and may potentially augment patient and/or family education about their condition.

Identifying community safety and policy-based injury prevention opportunities to reduce golf cart injuries.

BACKGROUND: In small US communities, golf cart utilization has become increasingly more common. In the past 3 years, the incidence and severity of pediatric golf cart-related trauma evaluated at our trauma center have noticeably increased. Thus, the aim of this study was to analyze trends, identify risk and protective factors, and provide community-level recommendations to improve golf cart safety for children in a coastal community. METHODS: A retrospective cross-sectional study of our institutional trauma registry was performed. The registry was queried for golf cart injuries between 2012 and 2022. Demographics, accident details, hospital course, and outcomes were reviewed. Data analysis involved quantitative statistics. Incident locations were mapped, including additional data from the County emergency medical service. In addition, customer education at four prominent golf rental shops was observed. RESULTS: Annual golf cart-related traumas doubled starting in 2020. Of 235 total patients, 105 (46%) were children. Median age was 11.5 years (range, 2-17 years). Fifty-five percent were female, and 67% were non-Hispanic White. Eighty percent were out-of-county residents. The most common injury location was extremity (56%). The median Injury Severity Score was 4, and 3% died. Only 10% of children were restrained. Forty-one percent were ejected, and most (84%) were front-facing passengers. Ejection was associated with more severe injury (odds ratio, 4.13; p = 0.01). Most injuries occurred during 5 to 10 pm (47%), weekends, and summertime. Nighttime injuries were more severe than daytime ( p = 0.04). A hotspot of crashes was identified in a zone where golf carts were restricted. Rental stores provided education on seat belt use, car seat use for infants, and off-limit zones. However, rules were not enforced. CONCLUSION: Our results inform the following golf cart injury prevention opportunities: raising awareness of injury risks to children in high-tourist areas, partnering with rental stores to enforce rules, improving signage, adding protected lanes, and adopting a no nighttime operation policy. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Palliative Care Training During Surgical Critical Care Fellowship: A Preliminary Needs Assessment at a Major Academic Center.

Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.

Limited English Proficiency can Negatively Impact Disease/Treatment in Children With Cancer Compared to Those Who are English Proficient-an Institutional Study.

BACKGROUND: In 2013, 25.5 million people in the United States self-identified as having limited English proficiency (LEP). LEP in adults has been associated with longer hospital stays, increased adverse events, increased emergency room visits, and decreased understanding of medications prescribed. This study aims to define the relationship between LEP and outcomes in a pediatric oncologic population. METHODS: We performed a matched case-control study utilizing data from our institutional cancer database (children

Temporal Trends of Neonatal Surgical Conditions in Texas and Accessibility to Pediatric Surgical Care.

INTRODUCTION: Texas consistently accounts for approximately 10% of annual national births, the second highest of all US states. This temporal study aimed to evaluate incidences of neonatal surgical conditions across Texas and to delineate regional pediatric surgeon accessibility. METHODS: The Texas Birth Defects Registry was queried from 1999 to 2018, based on 11 well-established regions. Nine disorders (30,476 patients) were identified as being within the operative scope of pediatric surgeons: biliary atresia (BA), pyloric stenosis (PS), Hirschsprung's disease, stenosis/atresia of large intestine/rectum/anus, stenosis/atresia of small intestine, tracheoesophageal fistula/esophageal atresia, gastroschisis, omphalocele, and congenital diaphragmatic hernia. Annual and regional incidences were compared (/10,000 births). Statewide pediatric surgeons were identified through the American Pediatric Surgical Association directory. Regional incidences of neonatal disorder per surgeon were evaluated from 2010 to 2018 as a surrogate for provider disparity. RESULTS: PS demonstrated the highest incidence (14.405/10,000), while BA had the lowest (0.707/10,000). Overall, incidences of PS and BA decreased significantly, while incidences of Hirschsprung's disease and small intestine increased. Other diagnoses remained stable. Regions 2 (48.24/10,000) and 11 (47.79/10,000) had the highest incidence of neonatal conditions; Region 6 had the lowest (34.68/10,000). Three rural regions (#2, 4, 9) lacked pediatric surgeons from 2010 to 2018. Of regions with at least one surgeon, historically underserved regions (#10, 11) along the Texas-Mexico border consistently had the highest defect per surgeon rates. CONCLUSIONS: There are temporal and regional differences in incidences of neonatal conditions treated by pediatric surgeons across Texas. Improving access to neonatal care is a complex issue that necessitates collaborative efforts between state legislatures, health systems, and providers.

Sagittal Craniosynostosis: Treatment and Outcomes According to Age at Intervention.

The purpose of this study is to describe the treatment strategies and outcomes of nonsyndromic single-suture sagittal craniosynostosis based on the patient's age at intervention. Studies from MEDLINE, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched for patients with nonsyndromic single-suture sagittal craniosynostosis. Inclusion criteria encompassed studies with follow-up of at least 12 months, minimum of 25 patients per cohort, and first-time surgical intervention. The risk of bias in nonrandomized studies of intervention tool [Risk Of Bias In Non-randomized Studies-of Interventions (ROBINS-I)] was applied. A total of 49 manuscripts with 3316 patients met criteria. Articles were categorized based on age at intervention; 0 to 6, older than 6 to 12, and older than 12 months. Fifteen of the manuscripts described interventions in more than 1 age group. From the 49 articles, 39 (n=2141) included patients 0 to 6 months old, 15 (n=669) discussed patients older than 6 to 12 months old, and 9 (n=506) evaluated patients older than 12 months old. Follow-up ranged from 12 to 144 months. Over 8 types of open surgical techniques were identified and 5 different minimally invasive procedures were described. Minimally invasive procedures were exclusively seen in the youngest patient cohort, while open cranial vault reconstructions were often seen in the 2 older cohorts. Endoscopic surgery and open conservative procedures are indicated for younger patients, while complex open cranial vault reconstructions are common in older patients. However, there is no consensus on one approach over the other. Even with the analysis of this review, we cannot factor a strong conclusion on a specific technique.

The impact of COVID-19 on clinical outcomes of burn patients.

Background: Multiple studies have shown the SARS-CoV-2 virus (COVID-19) to be associated with deleterious outcomes in a wide range of patients. The impact of COVID-19 has not been well investigated among burned patients. We suspect that patients will have worsened respiratory and thrombotic complications, ultimately leading to increased mortality. The objective of this study is to determine the impact a concurrent infection of COVID-19 has on clinical outcomes after a burn injury. Methods: This is a retrospective, propensity matched, cohort study. We examined a de-identified database of electronic medical records of over 75 million patients across 75 health care associations in the United States for patients treated for thermal burns from 1 January 2020, to 31 July 2021, and those who also were diagnosed with COVID-19 infection within one day before or after injury based on International Classification of Disease, tenth revision (ICD-10) codes. Study participants included adults who were treated for a burn injury during the study period. Results: We included 736 patients with burn injury and concomitant COVID-19 infection matched to 736 patients with burn injury and no concurrent COVID-19 infection (total 1472 patients, mean age 36.3 ± 24.3). We found no significant increase in mortality observed for patients with concurrent COVID-19 (OR 1.203, 95% CI 0.517-2.803; p = 0.6675). We did observe significant increase in infections (OR 3.537, 95% CI 2.798-4.471; p = 0.0001), thrombotic complications (OR 2.342, 95% CI 1.351-4.058; p = 0.0018), as was the incidence of hypertrophic scarring (OR 3.368, 95% CI 2.326-4.877; p = 0.0001). Conclusions: We observed that concurrent COVID-19 infection was associated with an increase in infections, thrombosis and hypertrophic scarring but no increase in mortality in our cohort of burn patients.

Lower extremity complications in children following femoral cannulation for extracorporeal membrane oxygenation.

INTRODUCTION: Extracorporeal membrane oxygenation cannulation strategies vary between adults and children. Femoral approach is common in adults and extremity morbidity is well-documented. Aside from limb ischemia, complications in children are theorized and have yet to be studied. This study aims to comprehensively evaluate implications of pediatric femoral cannulation. METHODS: This is a single-center retrospective review of children <21 years, undergoing femoral venoarterial (VA) or venovenous (VV) cannulation between 2015 and 2022. The primary outcome was incidence of lower extremity complications on ECMO (groin hematoma/hemorrhage, vascular thrombosis, North-South syndrome, compartment syndrome, limb loss). Secondary outcome was incidence of post-decannulation extremity complications (pseudoaneurysm, surgical site infection, vascular thrombosis, motor/sensory deficits). RESULTS: 29 children were cannulated via femoral approach. Most required VA support (89%). Common sites were right femoral artery (70.8%) and right femoral vein (56%). 18 patients (75%) had distal reperfusion cannulas (DPC) placed. Short-term lower extremity complication rate was 59%, most frequently groin hematoma/hemorrhage (30%) and North-South syndrome (19%). Compartment syndrome occurred in 3 patients (11%), though none suffered digit/limb loss. There were no significant differences in complications between cannulation approach (open vs percutaneous) or vessel laterality (ipsilateral vs contralateral). Of those decannulated (n = 15), median ECMO duration was 8 days. Following decannulation, 20% suffered pseudoaneurysm. Ten (63%) experienced ipsilateral motor weakness which resolved in 50% of patients at 1-month follow-up; 20% suffered sensory deficits all resolving by discharge. CONCLUSION: Approximately one third of children who underwent femoral cannulation suffered groin hematoma/hemorrhage and nearly 20% experienced North-South syndrome. Following decannulation, most had extremity weakness while sensory deficits were rarer. This marked risk of extremity morbidity prompts proactive inpatient monitoring and close surveillance after discharge.

The new frontier in ECLS: Artificial placenta and artificial womb for premature infants.

Outcomes for extremely low gestational age newborns (ELGANs), defined as <28 weeks estimated gestational age (EGA), remain disproportionately poor. A radical paradigm shift in the treatment of prematurity is to recreate the fetal environment with extracorporeal support and provide an environment for organ maturation using an extracorporeal VV-ECLS artificial placenta (AP) or an AV-ECLS artificial womb (AW). In this article, we will review clinical indications, current approaches in development, ongoing challenges, remaining milestones and ethical considerations prior to clinical translation.