Expedited Laparoscopic Cholangiogram and Liver Biopsy in the Workup of Biliary Atresia.

PURPOSE: Recent studies demonstrate the success of Kasai portoenterostomy for biliary atresia (BA) is linearly related to infant age at time of Kasai. We sought to review the feasibility and safety of laparoscopic needle micropuncture cholangiogram with concurrent core liver biopsy (if needed) for expedited exclusion of BA in patients with direct conjugated hyperbilirubinemia. METHODS: Expedited laparoscopic cholangiogram and liver biopsy were instituted at our facility for infants with direct hyperbilirubinemia for whom clinical exam and laboratory workup failed to diagnose. A retrospective chart review was performed in infants <1 year with hyperbilirubinemia from 2016 to 2021. Demographics, preoperative evaluation, procedure details, and complications were reviewed. RESULTS: Two hundred ninety-seven infants with unspecified jaundice were identified, of which, 86 (29%) required liver biopsy. Forty-seven percutaneous liver biopsies were obtained including 8 (17%) in whom BA could not be excluded. Laparoscopic cholangiogram was attempted in 47 infants following basic workup; BA was diagnosed in 22 infants (47%) of which 3 were <18 days old. Biliary patency was demonstrated laparoscopically in 22 of 25 (88%); 3 (12%) required conversion to open cholangiogram. Infants with percutaneous liver biopsy had an average delay of 3 days (range: 2-36) to cholangiogram. Preoperative studies and liver biopsy alone did not reliably exclude the diagnosis of BA. CONCLUSION: Laparoscopic cholangiogram with liver biopsy is a safe procedure resulting in the confirmation or exclusion of BA in infants. Forty-seven percent of infants who underwent laparoscopic cholangiogram were found to have BA; those who were surgical candidates underwent Kasai during the same operation.

Adolescent Vaping-Associated Trauma in the Western United States.

INTRODUCTION: Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction. METHODS: A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed. RESULTS: 15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury. CONCLUSIONS: In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.

The need for early Kasai portoenterostomy: a Western Pediatric Surgery Research Consortium study.

PURPOSE: The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia. METHODS: A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance. RESULTS: Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99). CONCLUSION: Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.

IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy.

BACKGROUND: Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted. METHODS: A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs. RESULTS: One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA. CONCLUSIONS: In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.

Postoperative Hypoparathyroidism After Total Thyroidectomy in Children.

BACKGROUND: Postoperative hypocalcemia because of hypoparathyroidism is the most common complication of total thyroidectomy in children. We hypothesized that most children with postoperative hypocalcemia would be eucalcemic by 12 mo and sought to define risk factors for permanent hypoparathyroidism. METHODS: We retrospectively reviewed children who underwent total thyroidectomy at a single children's hospital from 2012 to 2019. Patients with prior neck surgery were excluded. Indication for operation, final pathologic diagnosis, and postoperative serum calcium up to 12 mo were recorded. Permanent hypoparathyroidism was defined as supplemental calcium requirement beyond 1 y postoperatively. RESULTS: Sixty-eight patients underwent total thyroidectomy. Graves' disease was the most common benign indication for surgery (38 patients). Twenty-six patients (38%) had cancer on final pathology. Central lymph node dissection (CLND) was performed in 12 cancer patients. Twenty-eight patients (41%) had postoperative hypocalcemia. Eight patients (12%) had hypocalcemia at 6 mo. Risk factors for hypoparathyroidism at 6 mo were a cancer diagnosis (odds ratio [OR] 6.7; P = 0.02), CLND (OR 12.6; P < 0.01), and parathyroid tissue in the surgical specimen on pathologic analysis (OR 19.5; P < 0.01). Only two patients (3%) developed permanent hypoparathyroidism, both of whom had thyroidectomy for cancer and underwent CLND. CONCLUSIONS: Children with thyroid cancer are at high risk for postoperative hypocalcemia after total thyroidectomy. The risk is further increased by CLND, which should be performed selectively. A majority of patients with hypoparathyroidism at 6 mo postoperatively regain normal parathyroid function by 1 y. Permanent hypoparathyroidism in children after total thyroidectomy at a pediatric endocrine surgery center is rare.

The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure.

PURPOSE: Intercostal nerve cryoblation during the Nuss procedure for pectus excavatum decreases pain, opiate requirement, and hospital length of stay (LOS) compared to thoracic epidural analgesia. However, long-term complications of cryoablation, including neuropathic pain development, are not well studied. METHODS: We conducted a multi-institutional retrospective review of patients following intercostal nerve cryoablation during Nuss bar insertion (11/2015-7/2018). Patients completed the Leeds Assessment of Neuropathic Symptoms and Signs, a validated questionnaire for detecting neuropathic symptoms. Primary outcome was neuropathic pain development. Secondary outcomes included duration of chest numbness and LOS. T test was performed; p < 0.05 is significant. RESULTS: 43 patients underwent intercostal cryoablation during the Nuss procedure. Ages at repair ranged 11-47 years (median 16). Patients were grouped by age: ≤ 21 years (30 patients) or older (13 patients). Mean LOS was shorter for the younger group, 2.0 versus 3.9 days (p = 0.03). No patients in the younger group, and three in the older, experienced neuropathic pain. Mean time to numbness resolution was shorter for the younger group, 3.4 versus 10.8 months (p = 0.003). CONCLUSION: In pediatric patients, intercostal cryoablation provides effective analgesia following the Nuss procedure with minimal risk of post-operative neuropathic pain. Adult patients are at greater risk of experiencing neuropathic pain and prolonged numbness.

Silicon Micropore-Based Parallel Plate Membrane Oxygenator.

Extracorporeal membrane oxygenation (ECMO) is a life support system that circulates the blood through an oxygenating system to temporarily (days to months) support heart or lung function during cardiopulmonary failure until organ recovery or replacement. Currently, the need for high levels of systemic anticoagulation and the risk for bleeding are main drawbacks of ECMO that can be addressed with a redesigned ECMO system. Our lab has developed an approach using microelectromechanical systems (MEMS) fabrication techniques to create novel gas exchange membranes consisting of a rigid silicon micropore membrane (SµM) support structure bonded to a thin film of gas-permeable polydimethylsiloxane (PDMS). This study details the fabrication process to create silicon membranes with highly uniform micropores that have a high level of pattern fidelity. The oxygen transport across these membranes was tested in a simple water-based bench-top set-up as well in a porcine in vivo model. It was determined that the mass transfer coefficient for the system using SµM-PDMS membranes was 3.03 ± 0.42 mL O2 min-1 m-2 cm Hg-1 with pure water and 1.71 ± 1.03 mL O2 min-1 m-2 cm Hg-1 with blood. An analytic model to predict gas transport was developed using data from the bench-top experiments and validated with in vivo testing. This was a proof of concept study showing adequate oxygen transport across a parallel plate SµM-PDMS membrane when used as a membrane oxygenator. This work establishes the tools and the equipoise to develop future generations of silicon micropore membrane oxygenators.

Esophagoesophagopexy technique for assisted fistulization of esophageal atresia.

PURPOSE: We describe our experience using a modified suture fistula technique for addressing tension in longer gap esophageal atresia (EA). Esophagoesophagopexy (EEP) is the tacking of the proximal and distal ends of esophageal pouches without formal anastomosis. In this retrospective cohort, we review the outcomes of patients with EA after EEP. METHODS: We reviewed the operative reports of EA cases treated at our institution from 1997 to 2016 and identified all patients described as having EEP. RESULTS: Of 129 EA cases, five patients underwent EEP. Formal anastomosis was not done due to patient's instability, prematurity, or long gap. Median birth weight was 1.4 kg (0.6-2.2 kg), and median gestational age at birth was 29 weeks (25-34 weeks). Age at time of EEP ranged 0-5 months. Esophagoesophageal fistula was confirmed in three patients. All three had strictures requiring weekly dilations. One of these patients died. The two surviving patients underwent fundoplication. CONCLUSION: We describe an alternative technique for esophageal anastomosis in patients for whom a standard anastomosis is not possible. EEP can lead to a functional anastomosis through fistulization and avoid the morbidity of multiple thoracotomies and lengthening procedures. Families should be educated on the potential need for dilations and antireflux procedures.

Sacrococcygeal teratoma: late recurrence warrants long-term surveillance.

BACKGROUND: Sacrococcygeal teratoma (SCT) is a rare childhood malignancy. Although overall survival is favorable, recurrent tumors are associated with poor outcomes. As most recurrences occur within 3 years of presentation, the utility of long-term surveillance is uncertain. METHODS: Patients with SCTs evaluated and managed by our pediatric surgery department between 1986 and 2013 were included. Details pertaining to laboratory values, operative findings, tumor histology, management, recurrence, and outcomes were recorded and analyzed. RESULTS: During the study period, 40 children with the diagnosis of SCT were managed by our practice. Five (13%) developed a recurrence. The median age at the initial resection was day of life two (range day of life 0-2.5 years). The median time to recurrence was 5 years (range 5 months-15 years). Among those with recurrences, mature teratoma was the most common histological type on the initial resection (n = 3), with yolk sac and immature teratomas comprising the other two. At the time of recurrence, three patients had mature teratomas, and all are alive and well following resection. Two patients had yolk sac tumors at the time of recurrence and both died. CONCLUSION: SCT can recur many years after the initial resection. Our findings suggest that all patients with SCT should be closely followed into adulthood.

Wrinkled axicons: shaping light from cusps.

We propose a novel class of refractive optical elements by wrinkling the conical surface of a usual (conical) axicon, which leads to geometrical singularities (cusps). Such wrinkled axicons have been fabricated at the micron scale by using three-dimensional femtosecond-laser photopolymerization technique and we report on their experimental and numerical characterization. The beam shaping capabilities of these structures are discussed for both intensity and phase, which includes topological beam shaping that results from azimuthally modulated optical spin-orbit interaction.

Second malignant neoplasms among children, adolescents and young adults with Wilms tumor.

BACKGROUND: The goal of this study was to describe the incidence, characteristics, and outcomes of secondary malignant neoplasms (SMN) in survivors of Wilms tumor. PROCEDURES: Patients who were 0-20 years of age at time of primary diagnosis with Wilms tumor and reported to the Surveillance, Epidemiology, and End Results [SEER] program between 1973 and 2011 were eligible for inclusion in the cohort. We used competing risks methods to estimate the cumulative incidence of SMNs and assess contributing factors for developing SMN. We estimated standardized incidence ratios (SIR), absolute excess risk and overall survival after SMN using standard methods. RESULTS: Within the SEER database, 2,851 patients were diagnosed with Wilms tumor as their first malignancy. Of these, 34 patients were reported to have a SMN. Cumulative incidence of for a secondary malignancy was 0.6% (95% confidence interval [95% CI] 0.3-1.0%) at 10 years, 1.6% (95% CI 1.0-2.3%) at 20 years, and 3.8% (95% CI 2.4-5.9%) at 30 years. Median time from primary diagnosis to SMN diagnosis was 12.5 years. SIR for SMN for survivors of Wilms tumor was 3.4 (95% CI 2.2-4.9) with an absolute excess risk of 7.6 per 10,000 persons per year. Exposure to radiation did not significantly increase risk for development of second malignancy. Overall survival for patients with SMN was 64.5% at 5 years. CONCLUSION: Survivors of Wilms tumor are at an increased risk of SMN compared to the general population, but the added risk is relatively small compared to other pediatric cancers.

Cervical lung herniation complicating a case of acute asphyxial asthma in a child.

The abrupt onset of respiratory failure secondary to asthma, known as acute asphyxial asthma (AAA) in adults, is uncommonly reported in children. Here, we report a case of a child with the acute onset of respiratory failure consistent with AAA complicated by the finding of a neck mass during resuscitation. This 11-year-old boy with a history of asthma initially presented in respiratory failure with altered mental status after the complaint of difficulty in breathing minutes before collapsing at home. Initially, his respiratory failure was thought to be secondary to status asthmaticus, and treatment was initiated accordingly. However, a neck mass noted during the resuscitation was cause for concern, and other etiologies for his respiratory failure were considered, including an airway obstructing neck mass. After pediatric surgery and anesthesia consultation for intubation and possible tracheostomy placement, general anesthesia was induced in the operating room with an inhaled anesthetic, with prompt resolution of the bronchspasm and decompression of the neck mass. Review of the imaging and clinical course ultimately yielded a diagnosis of cervical lung herniation as the etiology of his neck mass. We report this case of AAA and cervical lung herniation and a review of the literature of these 2 uncommon phenomena in children.

A Survey of Current Approaches to Inguinal Hernia Repair by Pediatric General Surgeons in the United States.

INTRODUCTION: Inguinal hernia repair (IHR) is a common pediatric operation performed via open or laparoscopic approaches. The objective of this survey study was to assess current approaches to IHR in a national sample of pediatric general surgeons. METHODS: A REDCap survey was distributed to all pediatric general surgeons at 21 US institutions in 2023. Descriptive statistics were used to analyze responses. RESULTS: The response rate was 70.0% (145/207) with median fellowship graduation year of 2011. Respondents reported they were primarily taught either an open (73.1%) or laparoscopic (6.9%) technique in fellowship, while 18.6% reported being taught both techniques equally. Overall, 60.7% of respondents reported currently performing both laparoscopic and open IHR, while 27.6% reported performing only open IHR and 11.7% reported performing only laparoscopic IHR. During unilateral open IHR, 75.8% of respondents check for and repair a contralateral inguinal hernia, most commonly by placing a laparoscope via the hernia sac (76.3%). Selective mesh use in adolescents was similar between laparoscopic and open repair approaches. For recurrent hernias, 37.2% of respondents indicated performing the approach that was not performed previously, while 38.6% and 22.8% indicated they routinely perform a laparoscopic or open approach, respectively, regardless of initial repair approach. CONCLUSION: Over two thirds of surgeons reported incorporating laparoscopic IHR into their practice despite nearly three-quarters of respondents indicating they were primarily taught an open approach in training. Training in laparoscopic IHR has been increasing over time, and respondents reported a wide variety of laparoscopic and open repair techniques. LEVEL OF EVIDENCE: IV.

Long-Term Sensory Function 3 years after Minimally Invasive Repair of Pectus Excavatum with Cryoablation.

INTRODUCTION: Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo. METHODS: A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire. RESULTS: The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment. CONCLUSION: In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare. LEVEL OF EVIDENCE: Level IV.

Preoperative Metal Allergy Testing for Pectus Excavatum Repair Does Not Effectively Identify Patients Who Develop Metal bar Allergy.

BACKGROUND: Metal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT. METHODS: A retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing). RESULTS: The cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05). CONCLUSION: The incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported. LEVEL OF EVIDENCE: III.

Opioid Prescriptions at Discharge After Minimally Invasive Repair of Pectus Excavatum Are Reduced With Cryoablation.

BACKGROUND: The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE. METHODS: A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts. RESULTS: 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833). CONCLUSION: Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions. LEVEL OF EVIDENCE: Treatment study; Level III evidence.

A Prospective Study of Sensory Changes in Pediatric Patients After Minimally Invasive Repair of Pectus Excavatum With Cryoablation.

BACKGROUND: Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation. METHODS: A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated. RESULTS: Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months. CONCLUSION: Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon. LEVEL OF EVIDENCE: II. TYPE OF STUDY: Prognosis Study.

Cervical Collar-Associated Pressure Injury in Pediatric Trauma Patients: A Western Pediatric Surgery Research Consortium Study.

BACKGROUND: Healthcare-associated pressure injuries (HAPI) are known to be associated with medical devices and are preventable. Cervical spine immobilization is commonly utilized in injured children prior to clinical clearance or for treatment of an unstable cervical spinal injury. The frequency of HAPI has been quantified in adults with cervical spine immobilization but has not been well-described in children. The aim of this study was to describe characteristics of children who developed HAPI associated with cervical immobilization. METHODS: We analyzed a retrospective cohort of children (0-18 years) who developed a stage two or greater cervical HAPI. This cohort was drawn from an overall sample of 49,218 registry patients treated over a five-year period (2017-2021) at ten pediatric trauma centers. Patient demographics, injury characteristics, and cervical immobilization were tabulated to describe the population. RESULTS: The cohort included 32 children with stage two or greater cervical HAPI. The median age was 5 years (IQR 2-13) and 78% (n = 25) were admitted to the intensive care unit. The median (IQR) time to diagnosis of HAPI was 11 (7-21) days post-injury. The majority of cervical HAPI (78%, 25/32) occurred in children requiring immobilization for cervical injuries, with only four children developing HAPI after wearing a prophylactic cervical collar in the absence of a cervical spine injury. CONCLUSION: Advanced-stage HAPI associated with cervical collar use in pediatric trauma patients is rare and usually occurs in patients with cervical spine injuries requiring immobilization for treatment. More expedient cervical spine clearance with MRI is unlikely to substantially reduce cervical HAPI in injured children. LEVEL OF EVIDENCE: Level III (Epidemiologic and Prognostic).

A Pediatric Teletrauma Program Pilot Project: Improves Access to Pediatric Trauma Care and Timely Assessment of Pediatric Traumas.

BACKGROUND: Geographic location is a barrier to providing specialized care to pediatric traumas. In 2019, we instituted a pediatric teletrauma program in collaboration with the Statewide Pediatric Trauma Network at our level 1 pediatric trauma center (PTC). Triage guidelines were provided to partnering hospitals (PH) to aid in evaluation of pediatric traumas. Our pediatric trauma team was available for phone/video trauma consultation to provide recommendations on disposition and management. We hypothesized that this program would improve access and timely assessment of pediatric traumas while limiting patient transfers to our PTC. METHODS: A retrospective cohort study was conducted at the PTC between January 2019 to May 2023. All pediatric trauma patients age < 18 years who had teletrauma consults (TC) were included. We also evaluated all avoidable transfers without TC defined as admission for less than 36 hours without an intervention or imaging as a comparison group. RESULTS: A total of 151 TCs were identified: 62% male and median age of 8 years [IQR:4-12]. TC increased from 12 in 2019 to 100 in 2022-2023 and the number of partnering hospitals increased from 2 to 32. PH were 15-554 miles from the pediatric trauma center, with a median distance of 34 miles [IQR:28-119]. Following consultation, we recommended discharge 34%, admission 29%, or transfer to PTC 35%. Of those that were not transferred, 3% (3/97) required subsequent treatment at the PTC. Non-transferred TC had a higher percentage of TBI (61% vs 31%;p < 0.001) and were from farther, (40 miles[IQR:28-150] vs 30 miles[IQR:28-50];p < 0.001) compared to avoidable transferred patients without a TC. CONCLUSIONS: TC is a safe and viable addition to a pediatric trauma program faced with providing care to a large geographical catchment area. The pediatric teletrauma program provided management recommendations to 32 partnering hospitals and avoided transfer in approximately 63% of cases. LEVEL OF EVIDENCE: IV Treatment study.

Outcomes of Extracorporeal Life Support Utilization for Pediatric Patients With COVID-19 Infections.

Outcomes of pediatric patients who received extracorporeal life support (ECLS) for COVID-19 remain poorly described. The aim of this multi-institutional retrospective observational study was to evaluate these outcomes and assess for prognostic factors associated with in-hospital mortality. Seventy-nine patients at 14 pediatric centers across the United States who received ECLS support for COVID-19 infections between January 2020 and July 2022 were included for analysis. Data were extracted from the electronic medical record. The median age was 14.5 years (interquartile range [IQR]: 2-17 years). Most patients were female (54.4%) and had at least one pre-existing comorbidity (84.8%), such as obesity (44.3%, median body mass index percentile: 97% [IQR: 67.5-99.0%]). Venovenous (VV) ECLS was initiated in 50.6% of patients. Median duration of ECLS was 12 days (IQR: 6.0-22.5 days) with a mean duration from admission to ECLS initiation of 5.2 ± 6.3 days. Survival to hospital discharge was 54.4%. Neurological deficits were reported in 16.3% of survivors. Nonsurvivors were of older age (13.3 ± 6.2 years vs. 9.3 ± 7.7 years, p = 0.012), more likely to receive renal replacement therapy (63.9% vs. 30.2%, p = 0.003), demonstrated longer durations from admission to ECLS initiation (7.0 ± 8.1 days vs. 3.7 ± 3.8 days, p = 0.030), and had higher rates of ECLS-related complications (91.7% vs. 69.8%, p = 0.016) than survivors. Pediatric patients with COVID-19 who received ECLS demonstrated substantial morbidity and further investigation is warranted to optimize management strategies.