Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study.

OBJECTIVE: Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children. BACKGROUND: Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited. METHODS: We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery. RESULTS: We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration. CONCLUSIONS: The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.

Development of a Prediction Model for Surgery or Early Mortality at the Time of Initial Assessment for Necrotizing Enterocolitis.

OBJECTIVE: No available scale, at the time of initial evaluation for necrotizing enterocolitis (NEC), accurately predicts, that is, with an area under the curve (AUC) ≥0.9, which preterm infants will undergo surgery for NEC stage III or die within a week. STUDY DESIGN: This is a retrospective cohort study (n = 261) of preterm infants with <33 weeks' gestation or <1,500 g birthweight with either suspected or with definite NEC born at Parkland Hospital between 2009 and 2021. A prediction model using the new HASOFA SCORE (H: yperglycemia, H: yperkalemia, use of inotropes for H: ypotension during the prior week, A: cidemia, Neonatal S: equential O: rgan F: ailure A: ssessment [nSOFA: ] score) was compared with a similar model using the nSOFA score. RESULTS: Among 261 infants, 112 infants had NEC stage I, 68 with NEC stage II, and 81 with NEC stage III based on modified Bell's classification. The primary outcome, surgery for NEC stage III or death within a week, occurred in 81 infants (surgery in 66 infants and death in 38 infants). All infants with pneumoperitoneum or abdominal compartment syndrome either died or had surgery. The HASOFA and the nSOFA scores were evaluated in 254 and 253 infants, respectively, at the time of the initial workup for NEC. Both models were internally validated. The HASOFA model was a better predictor of surgery for NEC stage III or death within a week than the nSOFA model, with greater AUC 0.909 versus 0.825, respectively, p < 0.001. Combining HASOFA at initial assessment with concurrent or later presence of abdominal wall erythema or portal gas improved the prediction surgery for NEC stage III or death with AUC 0.942 or 0.956, respectively. CONCLUSION: Using this new internally validated prediction model, surgery for NEC stage III or death within a week can be accurately predicted at the time of initial assessment for NEC. KEY POINTS: · No available scale, at initial evaluation, accurately predicts which preterm infants will undergo surgery for NEC stage III or die within a week.. · In this retrospective cohort study of 261 preterm infants with either suspected or definite NEC we developed a new prediction model (HASOFA score).. · The HASOFA-model had high discrimination (AUC 0.909) and excellent calibration and was internally validated..

An International Consensus Survey among Pediatric Surgeons on the Role of Appendectomy in Malrotation.

Introduction: Ladd's procedure, originally described in 1936 for the treatment of malrotation, does not traditionally include appendectomy as a standard step. We conducted a multinational survey to investigate the current consensus on the role of appendectomy in Ladd's procedure. Methodology: An anonymous online survey was distributed to pediatric surgeons worldwide. The survey collected demographic data and explored surgical preferences related to the management of malrotation. Open-ended questions were used to assess the opinions regarding the necessity of appendectomy, decision-making factors, and complications associated with appendectomy during Ladd's procedure. Results: A total of 343 responses were received from 46 countries. Of the respondents, 319 (93%) were consultants and 24 (7%) were residents/trainees. When asked about the choice between open and laparoscopic Ladd's procedure, 292 (85%) preferred open surgery. Overall, 184 (53%) respondents favored appendectomy in both open and laparoscopic Ladd's procedure. Furthermore, 172 (50%) surgeons advocated for appendectomy in all malrotation cases, citing concerns about potential future appendicitis. While differences existed between all comparisons, none of them reached statistical significance. The factors influencing the decision to preserve the appendix included the risk of postoperative complications and the potential future use of the appendix as a surgical conduit. The surgical complications following appendectomy included surgical site infections in 14 (33%) patients, adhesive obstruction in 13 (31%) patients, intrabdominal abscesses in 10 (24%) patients, and fecal fistulas in 5 (12%) patients. Conclusion: The majority of surgeons aim to perform appendectomy in all malrotation cases, considering the potential risks and benefits of this approach. These findings offer valuable insights for clinical practice and may inform future guidelines and decision-making algorithms.

Twin-twin transfusion syndrome complicated by single ventricle physiology: A case report.

Clinically significant extrauterine twin-twin transfusion syndrome in conjoined twins is rare and carries a high risk of perinatal mortality. The ensuing postnatal imbalance in circulation across connecting vessels results in hypovolemia in the donor and hypervolemia in the recipient. Data on management and treatment are sparse especially in the setting of a single ventricle congenital heart defect. We present a case of a pair of omphalopagus conjoined twins, one with a single ventricle physiology (Twin B), who developed twin-twin transfusion syndrome shortly after birth. The resulting pathophysiology in the setting of a single ventricle congenital heart defect created added layers of complexity to their management and expedited surgical separation. Shunting from Twin B to Twin A-with an anatomically normal heart-resulted in mal-perfusion and rapid deterioration jeopardizing the health of both twins. In the preoperative course, steps taken to medically optimize the twins prior to surgery and the anesthetic considerations are detailed in this report.

Physician-Estimated Depth as a Screening Tool for Computed Tomography Evaluation of Pectus Excavatum.

BACKGROUND: Pectus excavatum (PE) is the most common congenital chest wall anomaly with a reported incidence of 1/300 to 1/400 live births and a male predominance. Preoperative evaluation of defect severity typically requires a calculation of the Haller index (HI) and/or correction index (CI) using computed tomography (CT) or x-rays. The purpose of this study was to determine whether physician-estimated depth (PED), a bedside screening tool, could be used to identify a subset of pediatric patients in whom CT was unnecessary. METHODS: After institutional review board approval (IRB #032018-091), we retrospectively reviewed all patients with a diagnosis of PE between 2009 and 2018 at our academic pediatric center. Demographic information including age, sex, and body mass index were abstracted. Imaging was reviewed to obtain HI and CI and to retrospectively calculate PED. The PED is calculated at the bedside by measuring the depth of the pectus at the site of greatest depression relative to a horizontal surface laid across the deformity. For this retrospective study, we calculated the CT-derived PED by measuring the depth from the horizontal on the respective CT images. Patients without imaging studies and patients with pectus carinatum, arcuatum, or mixed deformities were excluded from this study. RESULTS: A total of 94 patients met inclusion criteria. Of these, 82% were male, with a median age of 15 y. Patients were further subdivided by BMI, with 46% of patients having a BMI of <18.5 kg/m2 (i.e., underweight), whereas 54% of patients had a BMI of ≥18.5 kg/m2. Using a threshold PED of 2 cm, patients with a BMI of <18.5 kg/m2 had correct classification rates of 93% and 95% using PED relative to HI and CI, respectively. Patients with a BMI of ≥18.5 kg/m2 had correct classification rates of 80% and 88% using PED relative to HI and CI, respectively, at the same 2 cm threshold. CONCLUSIONS: PED is a viable screening tool for the preoperative evaluation of PE with a 2 cm threshold providing the combination of high sensitivity, specificity, and correct classification rates especially in underweight patients.

Creation of Three-dimensional Anatomic Models in Pediatric Surgical Patients Using Cross-sectional Imaging: A Demonstration of Low-cost Methods and Applications.

BACKGROUND: Pediatric surgery patients often present with complex congenital anomalies or other conditions requiring deep understanding of their intricate anatomy. Commercial applications and services exist for the conversion of cross-sectional imaging data into three-dimensional (3D) models for education and preoperative planning. However, the associated costs and lack of familiarity may discourage their use in centers with limited resources. The purpose of this report is to present a low-cost, reproducible method for generating 3D images to visualize patient anatomy. METHODS: De-identified DICOM files were obtained from the hospital PACS system in preparation for assorted pediatric surgical procedures. Using open-source visualization software, variations in anatomic structures were examined using volume rendering and segmentation techniques. Images were further refined using available editing tools or artificial intelligence-assisted software extensions. RESULTS: Using the described techniques we were able to obtain excellent visualization of desired structures and associated anatomic variations. Once structures were selected and modeled in 3D (segmentation), they could be exported as one of several 3D object file formats. These could then be retained for 3D printing, visualization in virtual reality, or as an anatomic reference during the perioperative period. Models may also be imported into commercial gaming engines for rendering under optimal lighting conditions and with enhanced detail. CONCLUSION: Pediatric surgeons are frequently tasked with the treatment of patients with complex and rare anomalies. Visualization and preoperative planning can be assisted by advanced imaging software at minimal to no cost, thereby facilitating enhanced understanding of these conditions in resource-limited environments. LEVEL OF EVIDENCE: V, Case Series, Description of Technique.

A Pilot Study for Biliary Atresia Diagnosis: Fluorescent Imaging of Indocyanine Green in Stool.

BACKGROUND: Biliary atresia is the most common cause of obstructive jaundice in infants and conventional cholangiography is the current diagnostic gold standard. Fluorescent cholangiography with indocyanine green can enhance biliary tree visualization during surgery because it is exclusively excreted into the bile ducts and eventually into the intestine. Therefore, we hypothesized that indocyanine green presence in stool could confirm bile duct patency in infants. METHODS: A prospective single center cohort study was performed on infants (age ≤ 12 months) with and without jaundice after obtaining IRB approval. Indocyanine green was administered intravenously (0.1 mg/kg). Soiled diapers collected post-injection were imaged for fluorescence. RESULTS: After indocyanine green administration, fluorescence was detected in soiled diapers for control patients (n = 4, x = 14 h22 m post-injection) and jaundiced patients without biliary atresia (n = 11, x = 13 h28 m post-injection). For biliary atresia patients (n = 7), post-injection soiled diapers before and after Kasai portoenterostomy were collected. Fluorescence was not detected in stool from 6 of 7 biliary atresia patients. As a test, indocyanine green detection in stool was 97% accurate for assessing biliary patency. CONCLUSION: Fluorescent Imaging for Indocyanine Green (FIInd Green) in stool is a fast and accurate approach to assess biliary patency non-invasively in infants. LEVEL OF EVIDENCE: Level III.

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.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

The Sensitivity of Limited-Sequence MRI in Identifying Pediatric Cervical Spine Injury: A Western Pediatric Surgery Research Consortium Multicenter Retrospective Cohort Study.

INTRODUCTION: Clinical clearance of a child's cervical spine after trauma is often challenging due to impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the gold standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence MRI (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared to gold standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury. METHODS: We conducted a ten-center, five-year retrospective cohort study (2017-2021) of all children (0-18y) with a cervical spine MRI after blunt trauma. MRI images were re-reviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site. RESULTS: We identified 2,663 children less than 18 years of age who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (age < 5 years) were more likely to be electively intubated or sedated for cervical spine MRI. CONCLUSION: LSMRI is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic exam. LEVEL OF EVIDENCE: 2 (Diagnostic Tests or Criteria).

Noniatrogenic neonatal gastric perforation: the role of interstitial cells of Cajal.

Noniatrogenic neonatal gastric perforation is a rare and life-threatening condition whose etiology is often unclear. Interstitial cells of Cajal act as gastrointestinal pacemaker cells and express the proto-oncogene c-Kit. Six new cases were identified at our institution which presented with no mechanical, pharmacologic, or otherwise medical-related intervention prior to rupture. The number of interstitial cells of Cajal in nonnecrotic muscularis propria from five random high-power fields per specimen was compared using immunohistochemical stains for c-Kit. The authors show that a lack of interstitial cells of Cajal in the stomach musculature may be implicated in the development of noniatrogenic gastric perforation (p = 0.008). Further large-scale studies, including molecular and genetic analysis, may help to better understand this phenomenon.

Pediatric robotic surgery: An overview.

Pediatric robotic surgery offers children a minimally invasive approach with numerous advantages over open or thoracoscopic and laparoscopic surgery. However, despite its widespread adoption for adult patients, the utilization of robotic surgery within pediatrics has been relatively slower to progress. This paper provides an overview of pediatric robotic surgery and discusses benefits, limitations, and strategies for successful implementation of robotics within pediatric surgical practice.

The Sinister Surgeon: Advanced Pediatric Minimally Invasive Surgery for Left-Handed Surgeons.

Purpose: Left-handed (LH) surgeons face unique challenges in their training and practice. Contrary to the historical and unjust perception of technical inferiority, LH surgeons can thrive under appropriate mentorship and support. Here, we describe modifications to pediatric minimally invasive surgeries to benefit the LH surgeon. Methods: The surgical approaches to common and complex pediatric surgical operations were modified to facilitate training of an LH pediatric surgical fellow. Results: Preoperative preparation, including communication with the operating room team, patient positioning, and provision of appropriate equipment, allowed the procedures to be accomplished in a safe and efficient manner. Conclusions: Modifying complex minimally invasive surgery to allow for use of the dominant hand is feasible and safe.

Robotic repair of pediatric hernias: Current techniques and practices.

The use of minimally invasive surgical techniques has gained popularity in pediatric surgery due to decreased length of stay, improved post-operative pain and smaller incisions. Laparoscopic assisted robotic surgical procedures are becoming more common in adults as they carry all of the benefits of traditional MIS but also allow for improved dexterity, visualization and surgeon ergonomics. In adults, hernia repairs are one of the most commonly performed robotic cases but adaption to pediatric repairs has been slower. Case reports and small case series have described a number of various types of pediatric hernia repairs including congenital diaphragmatic hernias, paraesophageal hernias and inguinal hernias. These cases have demonstrated that robotic repair of pediatric hernias is safe and feasible with minimal documented post-operative complications or recurrence. Future directions should focus on larger patient volume in order to assess outcomes between traditional laparoscopic and robotic approaches.

Utilization of robotics in pediatric surgical oncology.

Despite increasing implementation of robotic surgery and minimally invasive techniques within adult surgical oncology and pediatric general surgery, the utilization of robotic-assisted resections for pediatric tumors has been met with controversy. The robotic platform affords numerous advantages over conventional surgical techniques. However, limited data and guidelines regarding patient selection, indications for the robotic approach, and long-term oncologic outcomes have delayed the widespread adoption of robotic-assisted resection of pediatric tumors. This paper reviews the benefits, limitations, and existing guidelines and data regarding the utilization of robotics in pediatric surgical oncology.

Improving Billing and Collections in a High-Volume Pediatric Surgery Practice: Denials-Based Approach.

BACKGROUND: Despite minimal coding and billing training, surgeons are frequently tasked with both in clinical practice. This often results in denials for reimbursement based on incorrect or insufficient documentation, and reduced collections for work performed. We sought to evaluate how to correct these deficits while improving reimbursement for the most frequently rejected procedures at a high-volume academic center. STUDY DESIGN: Hospital billing data were analyzed for a 4-year period (2018 to 2021) to determine the CPT code denials with the largest overall cost. The denials were then stratified according to payor, reason for denial, and preventability. Assigned ICD-10 codes were categorized based on specificity as related to the procedure. The distribution of denials according to ICD-10 specificity was evaluated using the chi-square test. RESULTS: A total of 8,833 denials representing $11,009,108 in billing were noted during the study period. The CPT code 44970 (laparoscopic appendectomy) was the code associated with the largest financial impact, representing 12.8% of the total denied amount ($1.41M). Of the 823 denials for CPT 44970, 93.3% were associated with nonspecific ICD-10 codes, whereas only 42.0% had been associated with procedure-specific ICD-10 codes. Of the patients with nonspecific codes, 80.7% of denials were due to criteria that could be remedied with supplemental information or timely filing, representing $1,059,968 in collections. CONCLUSIONS: This is the first study to systematically evaluate a pathway for using denial data to improve collections for work performed at a high-volume academic pediatric surgery practice. Using this methodology, targets for improvement in coding and/or documentation can be identified to improve the financial performance of a surgical department. This study also provides evidence that association with nonspecific diagnostic codes is correlated with initial denial of payment by insurance companies.

Pediatric DUCT Score: A Highly Specific Predictive Model for Choledocholithiasis in Children.

BACKGROUND: Current adult guidelines for the management of choledocholithiasis (CDL) may not be appropriate for children. We hypothesized adult preoperative predictive factors are not reliable for predicting CDL in children. STUDY DESIGN: A multicenter retrospective cohort study was performed evaluating children (≤18 years of age) who underwent cholecystectomy for gallstone disease at 10 children's hospitals. Univariate and multivariable analyses were used to identify factors independently associated with CDL. Patients were stratified into risk groups demonstrating the presence of predictive factors for CDL. Statistical analyses were performed, and chi-square analyses were used with a significance of p < 0.05. RESULTS: A total of 979 cholecystectomy patients were analyzed. The diagnosis of CDL was confirmed in 222 patients (22.7%) by magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, or intraoperative cholangiography. Three predictive factors were identified: (1) Dilated common bile duct ≥6 mm; (2) Ultrasound with Choledocholithiasis; and (3) Total bilirubin ≥1.8 mg/dL (pediatric DUCT criteria). Risk groups were based on the number of predictive factors: very high (3), high (2), intermediate (1), and low (0). The pediatric DUCT criteria demonstrated accuracies of >76%, specificity of >78%, and negative predictive values of >79%. Adult factors (elevated aspartate aminotransferase/alanine aminotransferase, pancreatitis, BMI, and age) did not independently predict CDL. Based on risk stratification, the high- and very-high-risk groups demonstrated higher predictive capacity for CDL. CONCLUSIONS: Our study demonstrated that the pediatric DUCT criteria, incorporating common bile duct dilation, choledocholithiasis seen on ultrasound, and total bilirubin ≥1.8 mg/dL, highly predicts the presence of choledocholithiasis in children. Other adult preoperative factors are not predictive of common bile duct stone in children.

Machine learning to predict pediatric choledocholithiasis: A Western Pediatric Surgery Research Consortium retrospective study.

BACKGROUND: The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm. METHODS: A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset. RESULTS: A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935. CONCLUSION: This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis.

Delayed Surgical Management of an Unusual Classic Bladder Exstrophy Variant.

Anterior abdominal wall defects are rare anomalies that can affect multiple organ systems including gastrointestinal, genitourinary, musculoskeletal, and the neurospinal axis. The highly varied, complex anatomy in this patient population creates a challenging reconstruction scenario that merits careful surgical planning. We present an unusual female variant with an anorectal malformation as well as musculoskeletal and genital abnormalities consistent with classic bladder exstrophy in which the urinary bladder, sphincter, and urethra were largely uninvolved.

Standardized perioperative care reduces colorectal surgical site infection in children: A Western Pediatric Surgery Research Consortium multicenter analysis.

PURPOSE: Surgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery. METHODS: We conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or "colon bundle", we divided patients into low (1-4 elements) or high (5-8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days. RESULTS: Three hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI. CONCLUSION: Standardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity. TYPE OF STUDY: Clinical Research Paper LEVEL OF EVIDENCE: Level II.