Pediatric trauma surgery in Iraq and Afghanistan: Mortality, indicators, and most common operating room interventions from 2007 to 2016.

BACKGROUND: The wars in Afghanistan and Iraq produced thousands of pediatric casualties, using substantial military medical resources. We sought to describe characteristics of pediatric casualties who underwent operative intervention in Iraq and Afghanistan. METHODS: This is a retrospective analysis of pediatric casualties treated by US Forces in the Department of Defense Trauma Registry with at least one operative intervention during their course. We report descriptive, inferential statistics, and multivariable modeling to assess associations for receiving an operative intervention and survival. We excluded casualties who died on arrival to the emergency department. RESULTS: During the study period, there were a total of 3,439 children in the Department of Defense Trauma Registry, of which 3,388 met inclusion criteria. Of those, 2,538 (75%) required at least 1 operative intervention totaling 13,824 (median, 4; interquartile range, 2-7; range, 1-57). Compared with nonoperative casualties, operative casualties were older and male and had a higher proportion of explosive and firearm injuries, higher median composite injury severity scores, higher overall blood product administration, and longer intensive care hospitalizations. The most common operative procedures were related to abdominal, musculoskeletal, and neurosurgical trauma; burn management; and head and neck. When adjusting for confounders, older age (unit odds ratio, 1.04; 1.02-1.06), receiving a massive transfusion during their initial 24 hours (6.86, 4.43-10.62), explosive injuries (1.43, 1.17-1.81), firearm injuries (1.94, 1.47-2.55), and age-adjusted tachycardia (1.45, 1.20-1.75) were all associated with going to the operating room. Survival to discharge on initial hospitalization was higher in the operative cohort (95% vs. 82%, p < 0.001). When adjusting for confounders, operative intervention was associated with improved mortality (odds ratio, 7.43; 5.15-10.72). CONCLUSION: Most children treated in US military/coalition treatment facilities required at least one operative intervention. Several preoperative descriptors were associated with casualties' likelihood of operative interventions. Operative management was associated with improved mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Primary vs. salvage liver transplantation for biliary atresia: A retrospective cohort study.

INTRODUCTION: Kasai hepatoportoenterostomy is the standard of care for children with biliary atresia, but a majority of patients progress to end-stage liver disease and require a salvage liver transplant. Given the high failure rates of the hepatoportoenterostomy operation, some have advocated for primary liver transplantation as a superior treatment approach. The aim of this study was to compare outcomes of pediatric candidates with biliary atresia listed for primary vs. salvage liver transplantation. METHODS: The SRTR/OPTN database was retrospectively reviewed for all children with biliary atresia listed for liver transplant between March 2002 and February 2021. Candidates were categorized as primary liver transplant if they had not undergone previous abdominal surgery prior to listing and salvage liver transplant if they had. Salvage transplants were further categorized as early failure if listed within the first year of life or late failure if listed at an older age. RESULTS: 3438 children with biliary atresia were listed for transplant during the study period, with 15% of them listed for a primary transplant, 17% for salvage transplant after early failure, and 67% after late failure. Recipients of salvage liver transplant with late failure had lower bilirubin levels and were less critically ill as demonstrated by MELD/PELD scores and hospitalization status. Correspondingly, these recipients had higher waiting list and graft survival, though this did not remain statistically significant after adjustment in multivariable models. There were no differences in waiting list, recipient, or graft survival with primary vs. salvage liver transplant after early failure. CONCLUSION: Kasai hepatoportoenterostomy should remain the standard of care in biliary atresia as it may delay need for transplant beyond the first year of life in a subset of recipients and does not jeopardize subsequent transplant outcomes, even with early failure. LEVELS OF EVIDENCE: Retrospective cohort study (Level III).

Filling the gap: Objective data to guide pediatric surgery applicants who do not match on the first attempt.

PURPOSE: Acquiring a pediatric surgery fellowship is an arduous process, with less than half of applicants matching each year. For those who fail to match initially but remain steadfast in their goal to become a pediatric surgeon, choosing a valuable postresidency path can be challenging. Furthermore, objective data to evaluate the utility of pediatric surgical subspecialty fellowships (PSSF) are lacking. METHODS: PSSF training programs were identified on the APSA website. Names and contact information of PSSF graduates between 2014 and 2018 were obtained from individual training programs. Each graduated fellow was then contacted to participate in a voluntary 14-question survey. RESULTS: Names of 47 graduated fellows were obtained from programs listed on the APSA website. Among them, 30 (64%) ultimately matriculated into a pediatric surgery fellowship, 11 (37%) of whom matched at the same institution they completed their PSSF. The type of PSSF was not predictive of matriculation into a pediatric surgical fellowship (p = 0.43). Thirty-two (68%) of the 47 study participants completed a satisfaction survey. While all but two graduates found their fellowships to be at least satisfactory, those who matched were more likely to recommend their PSSF compared to those who did not (100% vs 67%, respectively, p = 0.02). Within the cohort of fellows who did not ultimately match into pediatric surgery (n = 17) and completed a survey (n = 9), all who completed a critical care fellowship (4/4) currently use/or plan to use the skills obtained during their PSSF while only two of five (40%) completing other PSSFs use them. CONCLUSION: The matriculation rate from a PSSF into a pediatric surgery fellowship was 64% with no significant difference among subspecialties. Of fellows who did not match, those completing a critical care PSSF were more likely to use their fellowship training than those completing a different PSSF. TYPE OF STUDY: Clinical research paper. LEVEL OF EVIDENCE: III.

Error traps and culture of safety in biliary atresia.

Biliary atresia is a progressive inflammatory sclerosing disease of the bile ducts in the neonatal liver. Without surgical intervention these patients are destined to succumb to the disease. The development of the hepatoportoenterostomy in 1959 and liver transplantation in 1963 ushered a new era of success treating these patients. While many surgical modifications and adjuncts to treatment have been attempted over the last 50 years, the mainstay of treatment to give the child the best chance at prolonged survival with the native liver is a properly performed operation, in a timely fashion, with minimal post-operative complications. This review presents the authors current practice guideline to achieve these goals.

Late complications of biliary atresia: hepatopulmonary syndrome and portopulmonary hypertension.

Children with biliary atresia (BA) following Kasai portoenterostomy have a high risk for portal hypertension, however, while variceal and hemorrhagic complications have been more commonly studied, less frequent but no less possibly devastating complications of hepatopulmonary syndrome (HPS) and portopulmonary hypertension (PPH) remain less well understood. HPS and PPH both occur in a setting of portal hypertension, however, paradoxically patients with HPS develop pulmonic vasculature dilation leading to shunting and hypoxia, while those with PPH develop an opposite progression of pulmonary vasoconstriction eventually leading to cor pulmonale and decompensation. Given the near diametric evolution of diseases, HPS and PPH differ widely in therapy, though liver transplantation can have a role for treatment in either disease state. We reviewed our series of 320 pediatric patients with biliary atresia treated at our institution over 44 years, highlighting two cases that developed HPS and PPH, respectively, using these cases in further discussion of hepatopulmonary syndrome and portopulmonary hypertension regarding disease etiology, diagnosis, management, and prognosis. The complicated nature of these processes demand a careful multidisciplinary approach to optimize patient outcomes, including mindful evaluation for when transplantation may offer benefit.

Beyond morbidity and mortality: the social and legal outcomes of non-accidental trauma.

BACKGROUND: Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the pediatric population. We aimed to assess the social and legal outcomes of AHT and determine if the rates of successful prosecution have changed over recent years. METHODS: We utilized the trauma database at a single institution to identify all cases of AHT during two time periods: 1996-2001 and 2006-2010 then collected data from the Child Advocacy and Protection Team database. We characterized the social and legal outcomes and compared them between the two cohorts. RESULTS: A total of 254 patients (120 historic and 134 modern cohort) were included. Mortality rate was 19.7% and did not differ between the two cohorts. Thirty-seven percent of patients were discharged to foster care, this rate did not change across the two time periods. Suspected perpetrators pled guilty or were found guilty in only 74 cases (29%). However, when a case involved a fatality, perpetrators pled or were found guilty more often than in cases of a non-fatality (50 vs. 21.5%; p=0.0001). CONCLUSIONS: AHT results in fatality in approximately 1 in 5 cases, perpetrators are identified and found guilty in only 29% of the cases. Trauma surgeons need to be strong advocates for these vulnerable patients and actively participate in legal proceedings.

Contrast blush in pediatric blunt splenic trauma does not warrant the routine use of angiography and embolization.

BACKGROUND: Splenic artery embolization (SAE) in the presence of contrast blush (CB) has been recommended to reduce the failure rate of nonoperative management. We hypothesized that the presence of CB on computed tomography has minimal impact on patient outcomes. METHODS: A retrospective review was conducted of all children (<18 years) with blunt splenic trauma over a 10-year period at a level 1 pediatric trauma center. Data are presented as mean ± standard error of mean. RESULTS: Seven hundred forty children sustained blunt abdominal trauma, of which 549 had an identified solid organ injury. Blunt splenic injury was diagnosed in 270 of the 740 patients. All patients were managed nonoperatively without SAE. CB was seen on computed tomography in 47 patients (17.4%). There were no significant differences in the need for blood transfusion (12.5% vs 11.1%) or length of stay (3.1 vs 3.3 days) or need for splenectomy when compared in children with or without CB. CONCLUSION: Pediatric trauma patients with blunt splenic injuries can be safely managed without SAE and physiologic response and hemodynamic stability should be the primary determinants of appropriate management.

Head injury pattern in children can help differentiate accidental from non-accidental trauma.

OBJECTIVES: Our aim was to define the radiographic findings that help differentiate abusive head trauma (AHT) from accidental head injury. METHODS: Our trauma registry was queried for all children ≤5 years of age presenting with traumatic brain injury (TBI) from 1996-2011. RESULTS: Of 2,015 children with TBI, 71% had accidental injury and 29% had AHT. Children with AHT were more severely injured (ISS 22.1 vs 14.4; p < 0.0001) and had a higher mortality rate (15 vs 5%; p < 0.0001). Patients with AHT had higher rates of diffuse axonal injury (14 vs 8%; p < 0.0001) and subdural hemorrhage (76 vs 23%; p < 0.0001). Children with accidental injury had higher rates of skull fractures (52 vs 21%; p < 0.0001) and epidural hemorrhages (11 vs 3%). CONCLUSIONS: AHT occurred in 29% of children and resulted in increased mortality rates. These children had higher rates of subdural hemorrhages and diffuse axonal injury. Physicians initially evaluating injured children must maintain a high index of suspicion for abuse in those who present with subdural hematoma or diffuse axonal injury.

Preoperative imaging does not predict intrahepatic involvement in choledochal cysts.

INTRODUCTION: Choledochal cyst (CDC) is a congenital malformation of the bile ducts, which can include the intrahepatic or extrahepatic bile ducts. We hypothesize that preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic involvement. METHODS: We retrospectively reviewed all cases of CDC in children diagnosed at a single institution between 1991 and 2013. RESULTS: Sixty-two patients were diagnosed with CDC during the study period with a median follow-up time of 2.25 (range 0-19.5) years. Forty-two patients (68%) were diagnosed with type I disease preoperatively, and 15 patients (24%) were diagnosed with type IV-A disease. The most common presenting symptoms included pain (34%), jaundice (28%), and pancreatitis (25%). There were no deaths or malignancies and only one postoperative stricture. Forty-two patients (68%) had intrahepatic ductal dilation preoperatively. Only four patients (9%) had intrahepatic ductal dilation following resection (P<0.0001). In one patient, this dilation resolved following stricture revision. Of the four patients with postoperative dilation, two were diagnosed with type I disease, and the other two were diagnosed with type IV-A disease preoperatively. CONCLUSION: Preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic ductal involvement in children with CDC. The preoperative distinction between type I and IV disease is not helpful in treating these patients.

Appendicitis in children less than 5 years old: influence of age on presentation and outcome.

PURPOSE: Appendicitis is the most common emergency surgical condition of the abdomen in children. This study sought to delineate the presentation and the outcome of appendicitis in children younger than 5 years old. METHODS: A retrospective review was conducted of all children younger than 5 years of age who underwent appendectomy for acute appendicitis over a 12-year period. RESULTS: One thousand eight hundred thirty-six patients younger than 19 years of age underwent appendectomy. Two hundred eighty-one children with an age range of 6 months to 4.9 years were included in this study. Perforation rates were higher in the younger patients (86% <1 year, 74% 1-1.9 years, 60% 2-2.9 years, 64% 3-3.9 years, and 49% 4-4.9 years), but the youngest children had fewer postoperative abscesses. CONCLUSIONS: In children less than 5 years old with appendicitis, age has a direct correlation to the stage of disease. The youngest children present with more advanced appendicitis but are less likely to develop postoperative abscesses.

Cytomegalovirus-specific T-cell reactivity in biliary atresia at the time of diagnosis is associated with deficits in regulatory T cells.

UNLABELLED: Biliary atresia (BA) is a progressive, inflammatory cholangiopathy that culminates in fibrosis of extrahepatic and intrahepatic bile ducts. A leading theory on the pathogenesis of BA is that the bile duct damage is initiated by a virus infection, followed by a bile duct-targeted autoimmune response. One mechanism of autoimmunity entails a diminished number or function of regulatory T cells (Tregs). The aim of this study was to identify potential virus-specific liver T cells from infants with BA at the time of diagnosis, implicating the virus involved in early bile duct damage. A subaim was to determine if the presence of virus infection was associated with quantitative changes in Tregs. Liver T cells from BA and control patients were cultured with antigen-presenting cells in the presence of a variety of viral or control proteins. 56% of BA patients had significant increases in interferon-gamma-producing liver T cells in response to cytomegalovirus (CMV), compared with minimal BA responses to other viruses or the control group CMV response. In addition, a positive correlation between BA plasma CMV immunoglobulin M (IgM) and liver T-cell CMV reactivity was identified. Investigation of peripheral blood Tregs revealed significant deficits in Treg frequencies in BA compared with controls, with marked deficits in those BA patients who were positive for CMV. CONCLUSION: Liver T-cell responses to CMV were identified in the majority of BA patients at diagnosis, suggesting perinatal CMV infection as a plausible initiator of bile duct damage. Deficiency of Tregs in BA implies decreased inhibition of inflammation and autoreactivity, potentially allowing for exaggerated bile duct injury.

The anatomic pattern of biliary atresia identified at time of Kasai hepatoportoenterostomy and early postoperative clearance of jaundice are significant predictors of transplant-free survival.

OBJECTIVE: The goals of this study were to describe the clinical and anatomic features of infants undergoing Kasai portoenterostomy (KPE) for biliary atresia (BA) and to examine associations between these parameters and outcomes. METHODS: Infants enrolled in the prospective Childhood Liver Disease Research and Education Network, who underwent KPE were studied. Patients enrolled in a blinded, interventional trial were excluded from survival analysis. Primary endpoints were successful surgical drainage (total bilirubin less than 2 mg/dL within the first 3 months), transplant-free survival (Kaplan-Meier), and time to transplant/death (Cox regression). RESULTS: KPE was performed in 244 infants (54% female; mean age: 65 ± 29 days). Transplant-free survival was 53.7% and 46.7% at 1 and 2 years post-KPE. The risk of transplant/death was significantly lower in the 45.6% of patients who achieved successful bile drainage within 3 months post-KPE (HR: 0.08, P < 0.001). The risk of transplant/death was increased in patients with porta hepatis atresia (Ohi type II and III vs type I; HR: 2.03, P = 0.030), nonpatent common bile duct (Ohi subtype: b, c, and d vs a; HR: 4.31, P = 0.022), BA splenic malformation syndrome (HR: 1.92, P = 0.025), ascites > 20 mL (HR: = 1.90, P = 0.0230), nodular liver appearance compared to firm (HR: = 1.61, P = 0.008), and age at KPE ≥ 75 days (HR: 1.73, P < 0.002). Outcome was not associated with gestational age, gender, race, ethnicity, or extent of porta hepatis dissection. CONCLUSION: Anatomic pattern of BA, BASM, presence of ascites and nodular liver appearance at KPE, and early postoperative jaundice clearance are significant predictors of transplant-free survival.

Contemporary pediatric splenectomy: continuing controversies.

PURPOSE: We undertook the current study to update the literature on pediatric splenectomy in the age of minimally invasive proficiency among pediatric surgeons. The study is designed to address specific concerns among surgeons about the suitability of the laparoscopic approach in specific situations and among hematologists about the relative benefits and risks of splenectomy in children. METHODS: Retrospective analysis of clinicopathologic data for 118 children who underwent open (OS) or laparoscopic (LS) splenectomy at an urban tertiary children's hospital from January 2000 to July 2008. RESULTS: One hundred and three cases (87%) were started as LS. Operative times were equivalent for LS and OS (P = 0.8). In the LS group, there were four conversions (3.9%) from LS to OS and five early post-operative complications (4.9%). Median length of stay was 2 days for LS and 4 days for both OS and LS converted to OS (P < 0.0001). The ten largest spleens removed by LS had greater mass (P = 0.02) and tended to have greater volume (P = 0.1) than those removed by OS. Children with hereditary spherocytosis, ITP, and hemoglobinopathy had favorable clinical outcomes, regardless of operative approach. There were no cases of overwhelming post-splenectomy sepsis in this series. CONCLUSIONS: Laparoscopic splenectomy is the preferred approach for splenectomy in children with hematological diseases, with or without splenomegaly. Compared to open splenectomy, laparoscopic splenectomy has equivalent operative time and improved length of stay. Both approaches have excellent therapeutic outcomes for appropriate indications.

Management of button battery-induced hemorrhage in children.

OBJECTIVES: Button battery ingestions are potentially life threatening for children. Catastrophic and fatal injuries can occur when the battery becomes lodged in the esophagus, where battery-induced injury can extend beyond the esophagus to the trachea or aorta. Increased production of larger, more powerful button batteries has coincided with more frequent reporting of fatal hemorrhage secondary to esophageal battery impaction, but no recommendations exist for the management of button battery-induced hemorrhage in children. MATERIALS AND METHODS: We reviewed all of the reported pediatric fatalities due to button battery-associated hemorrhage. Our institution engaged subspecialists from a wide range of disciplines to develop an institutional plan for the management of complicated button battery ingestions. RESULTS: Ten fatal cases of button battery-associated hemorrhage were identified. Seven of the 10 cases have occurred since 2004. Seventy percent of cases presented with a sentinel bleeding event. Fatal hemorrhage can occur up to 18 days after endoscopic removal of the battery. Guidelines for the management of button battery-associated hemorrhage were developed. CONCLUSIONS: Pediatric care facilities must be prepared to act quickly and concertedly in the case of button battery-associated esophageal hemorrhage, which is most likely to present as a "sentinel bleed" in a toddler.

Choledochoduodenostomy in pediatric liver transplantation.

UNLABELLED: Reconstruction of the bile ducts during pediatric liver transplantation is generally performed by a Roux-en-Y CDJ because direct duct-to-duct anastomosis CC is often not possible. Anastomosis of the donor liver bile duct to the duodenum CDD provides another option. We provide preliminary evidence that CDD is an alternative technique for biliary reconstruction when CC is not possible in pediatric liver transplant recipients that have a hostile abdomen or to preserve bowel length. METHODS: From 2007 to 2008, a total of 19 pediatric cadaveric liver transplants were performed at our center. Four of the 19 had a bile duct reconstruction by CDD. RESULTS: CDD reconstruction was used in patients who received a liver transplant for a diagnosis of PSC, congenital hepatic fibrosis, biliary atresia, and Alagille syndrome. The ages of the patients were 17 and 10 yr and 10 and 17 months. Three grafts were whole cadaveric livers, and one was a reduced left lobe. CDD was used to revise a prior anastomosis in one patient who had a previous Roux-en-Y that was unusable during the retransplant, and another to repair a stricture in a second patient with a CC. We also performed a CDD in a patient with a hostile abdomen from previous surgery, and another patient to avoid short gut syndrome that a Roux-en-Y may have created. All patients are alive with functioning grafts with a follow-up of at least one yr. None of the patients developed clinically significant biliary complications (leak, stricture, cholangitis). CONCLUSION: Our preliminary experience suggests that CDD is an option for biliary reconstruction in pediatric transplant patients with hostile abdomens or to preserve bowel length.

Complicated appendicitis in children: a clear role for drainage and delayed appendectomy.

INTRODUCTION: Children presenting with complicated appendicitis represent a common and challenging problem. Conflicting data exist concerning optimal treatment of these patients with primary versus delayed appendectomy. METHODS: A retrospective review of all children undergoing appendectomy over a 5-year period was performed. RESULTS: We identified 1,106 children: 360 had evidence of perforation and 92 had an intra-abdominal abscess or right lower quadrant phlegmon. Of these 92, 60 underwent primary appendectomy and 32 underwent drainage and/or antibiotic therapy with delayed appendectomy. Children undergoing delayed appendectomy had a longer prodrome of symptoms (6.9 vs 4.6 days, P = .002), slightly higher presenting white blood cell count (19.3 vs 16.6, P = .08), and had the same hospital length of stay, yet had a lower complication rate requiring readmission to the hospital (0% vs 10%) compared to those undergoing immediate appendectomy. CONCLUSION: In children presenting with prolonged symptoms and a discrete appendiceal abscess or phlegmon, drainage and delayed appendectomy should be the treatment of choice.

Nonaccidental trauma is a major cause of morbidity and mortality among patients at a regional level 1 pediatric trauma center.

BACKGROUND: Traumatic injuries are a major cause of morbidity and mortality in children. The purpose of the present study was to determine the incidence of nonaccidental trauma (NAT) and to compare the outcomes of accidental trauma (AT) patients with NAT patients at a large pediatric trauma center. METHODS: A retrospective chart review of 6186 trauma patients younger than 18 years evaluated during the period of 1996 to 2004. RESULTS: During the period of study, NAT accounted for 7.3% (n = 453) of trauma evaluations (n = 6186). Compared to AT, the NAT patient was younger, 12 vs 76 months (P < .05); were more severely injured, injury severity score 18 vs 9 (P < .05); and required both longer intensive care unit stay, 2 vs 1 day (P < .05), and overall hospital stay, 6 vs 3 days (P < .05). Craniotomy was required in 4.4% of NAT patients compared with 2.7 % of AT patients (P < .05). Abdominal exploration was necessary in 3.5% of NAT patients compared to 1.6% of AT patients. The mortality rate for NAT was 9.7% compared to 2.2% for AT (P < .05). CONCLUSIONS: The surgeon caring for children must appreciate the high incidence of NAT with its increased morbidity and mortality relative to AT patients. A surgical evaluation should be performed promptly in NAT patients because of their frequent need for emergent intervention.

Resection of neurogenic tumors in children: is thoracoscopy superior to thoracotomy?

BACKGROUND: Minimally invasive resection of solid tumors is controversial because of concerns of inadequate resection and local recurrence. Thoracoscopy has been used in the diagnosis of mediastinal tumors in children, but its role in resection is unproved. The purpose of this study was to compare thoracoscopic and open approaches to the resection of thoracic neurogenic tumors in children. STUDY DESIGN: The tumor registry of a regional children's hospital was queried to identify patients who underwent resection of neurogenic tumors over a 6-year period. Thoracoscopic and open groups were compared for demographic, operative, oncologic, and outcomes characteristics. RESULTS: Seventeen children underwent resection of mediastinal neurogenic tumors (10 thoracoscopic resections, 7 open resections). Mean age was 4.7 years (range 6 months to 12 years). The thoracoscopic and open groups showed no difference in operative time or blood loss. Tumors in the two groups were comparable in size (5.2+/-2.2 cm versus 5.7+/-2.6 cm), histology, surgical margin, and stage. Hospital stay was shorter after thoracoscopic resection (1.9+/-0.7 days versus 4.1+/-2.5 days, p<0.05). There were no regional recurrences. Distant metastases developed in one patient in each group. Eight of 10 children with malignant tumors remain disease-free at an average of 25 months of followup (range 3 to 80 months). CONCLUSIONS: Thoracoscopic resection of neurogenic tumors achieved similar local control and disease-free survival when compared with open resection in this preliminary series. These results were accompanied by a shorter hospital stay. These findings suggest that thoracoscopic resection of neurogenic tumors in children may offer advantages to open resection and should be studied in the context of a large, cooperative trial.