Giant Omphaloceles-Morbidity, Mortality, and Financial Impact of Early Versus Delayed Repair.

INTRODUCTION: We compared strategy outcomes and financial impact over the first two years of life (F2YOL) for patients with giant omphaloceles undergoing early repair (ER) (primary or staged) versus delayed repair (DR). METHODS: A retrospective review of giant omphaloceles (fascial defect > 5 cm/> 50% liver herniation) at a tertiary children's hospital between 1/1/2010 and 12/31/2019 was performed. Survival, length of stay, age at repair, ventilation days (VD), time to full enteral feeds, readmissions during the F2YOL, incidence of major associated anomalies, and total hospitalization charges during the F2YOL were compared. A subanalysis removing potential confounders and only including patients who underwent fascial closure within the F2YOL was also conducted. RESULTS: Thirty four giant omphaloceles (23DR and 11ER) were identified. The median age (days) at repair was 289 [148, 399] DR versus 10 [5, 21] ER, P < 0.001. Total cohort two-year survival was significantly higher in the DR group (95.7% versus 63.6%, P = 0.03). Including patients with a tracheostomy there was no significant difference in VD during the index hospitalization. Excluding tracheostomy patients, the DR group had significantly fewer VD during the index hospitalization, 15 [0, 15] versus 18 [10, 54], P = 0.02 and over the F2YOL 6.5 [ 0, 21] versus 18 [14, 43], P = 0.03. There were no significant differences in the incidence/type of major associated anomalies, time to full enteral feeds, index length of stay, total hospital days, total admissions, or associated hospital charges. On subanalysis, there was no significant difference in VD or survival at any time. CONCLUSIONS: Delayed and early repair strategies for giant omphaloceles have equivalent outcomes in the index hospitalization and over the course of the first two years of life. These findings are useful for family counseling and expectation setting.

A Review of Covered Abdominal Wall Defects: Cord Hernias Are Associated With Major Anomalies.

INTRODUCTION: Covered abdominal wall defects (CAWD) can be categorized into giant omphaloceles (GOs), nongiant omphaloceles (NGOs), and umbilical cord hernias (UCHs). We sought to evaluate differences in management and outcomes of the different CAWD, treated at a large tertiary children's hospital, with regards to survival and association with other major congenital anomalies. METHODS: A retrospective review of CAWD patients between January 2010 and January 2021 was conducted. GO was defined as a fascial defect >5 cm or >50% liver herniation. UCH were defined as fascial defects ≤ 2 cm. All others were classified as NGO. Type of repair, time to fascial closure, index hospitalization length of stay (LOS), and survival rates were compared. Four major anomaly categories were identified: cardiac, midline, Beckwith-Weidemann Syndrome, and other genetic anomalies. RESULTS: We identified 105 CAWD patients (UCH n = 40; GO n = 34; and NGO n = 31). Ninety percent of UCH underwent primary repair, 10% were never repaired. NGOs were repaired by primary or staged methods in 92.9% of cases and 7.1% by delayed repair. Primary or staged repair occurred in 32.4% of GOs and delayed repair occurred in 67.6%. The median days to repair was 181 [24,427] GO, 1 [1,3] NGO, and 1 [0,1] UCHs (P < 0.01). Index hospitalization median LOS (days) was 90 [55,157] GO, 23 [10,48] NGO, 9 [5,22] UCH, (P < 0.01). There were no statistical differences in survival rates, number of patients with major anomalies (GO 35.4%, NGO 51.5%, UCH 50%), or types of anomalies. CONCLUSIONS: UCHs and omphaloceles have similar incidences of major associated anomalies. Thus, all patients with a covered abdominal wall defect should undergo workup for associated anomalies.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

BACKGROUND: A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. METHODS: Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. RESULTS: Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. CONCLUSIONS: Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

Orientation in Perpetuity: An Online Clinical Decision Support System for Surgical Residents.

BACKGROUND: Limiting variability is an essential element to improving quality of care. Frequent resident turnover represents a significant barrier to clinical standardization. Trainees joining new surgical services must familiarize themselves with the guidelines and protocols that direct patient care as well as their learning objectives and expectations. A clinical decision support system (CDSS) is a dynamic, searchable electronic resource intended for use at the point of care. The CDSS can provide convenient and timely access to relevant information for residents, allowing them to incorporate the most up-to-date protocols and guidelines in their daily care of patients. The objective of this quality improvement intervention was to determine the objective rate of CDSS utilization and its subjective value to residents. MATERIALS AND METHODS: An internally developed, web-based CDSS including essential, clinically useful documents was created for use by trainees on a busy pediatric surgery service. A standardized orientation was provided to each resident and fellow on joining the service, complemented by a summary card to be attached to the trainee's ID badge. CDSS usage was monitored using web analytics. Trainees who rotated before and after the CDSS launch were surveyed regarding attitudes toward clinical resources and confidence in patient management. RESULTS: Documents published to the CDSS included 33 clinical guideline documents and 207 additional educational and support files including reference materials from service orientation were made available to trainees and staff. Goals for resident usage were established by evaluation and adaptation of early traffic patterns. Analysis of web traffic collected over 14 consecutive months revealed utilization above target levels, with 4.0 average weekly page views per trainee (IQR: 1.6-5.6). A total of 60 survey responses were received (54% of trainees invited); majorities of rotating trainees and survey respondents were trainees in general surgery and most were interns. Mean composite scores reflected a trend toward improved satisfaction when seeking CDSM (before intervention 3.18 [SD 0.73], after intervention 3.92 [SD 0.70], range 1-5) which was statistically significant (P = 0.005). Mean scores also improved across five of six components of the composite score (mean improvement 0.75, range: 0.53-0.92), four of which were statistically significant (P = 0.001-0.038). Most (59%) respondents reported that they used the CDSS frequently. CONCLUSIONS: Convenient access to a CDSS resulted in greater than expected utilization as well as higher resident satisfaction with and confidence in materials provided. A CDSS is a promising tool offering quick access to high-quality information in challenging trainee environments.

Multifocal Appendiceal Carcinoid Tumor in an Adolescent: A Case Report and Review of the Literature.

Appendiceal carcinoid tumors in children and adolescents are rare. This report describes a case of a multifocal appendiceal carcinoid tumor identified incidentally following appendectomy in an adolescent. In this report, we describe the staging process and surgical management for focal and locally invasive appendiceal carcinoid tumors and highlight the rarity of multifocality in this location. The diagnostic and pathologic challenges for this case are presented.

Examining length of stay after commonly performed surgical procedures in ACS NSQIP pediatric.

BACKGROUND: The objective of this study was to identify ranges of postoperative length of stay (LOS) for common pediatric procedures using a large multi-institutional database. MATERIALS AND METHODS: A retrospective analysis of the most frequently performed general surgical procedures in the ACS-NSQIP Pediatric (2013-2015) was performed. These included laparoscopic appendectomy (LA), laparoscopic cholecystectomy, laparoscopic gastrostomy, laparoscopic esophagogastric fundoplication (LF), thoracoscopic repair of pectus excavatum (TPE), open appendectomy (OA), enterostomy closure (OEC), gastrostomy closure (OGC), and bowel resection (OBR). Patients aged <6 mo or >18 y, operations with major concurrent procedures, same-day discharges, operations performed >2 d after admission, and inpatient deaths were excluded. Postoperative LOS was examined for each procedure, including multivariable analysis of risk factors for postoperative LOS > 75th percentile. RESULTS: A total of 29,557 cases were identified and included procedure subgroups ranging from 505 (OBR) to 19,260 (LA) cases. Procedure-specific median postoperative LOS (75th percentile; 90th percentile) were LA 1 d (2 d; 5 d); laparoscopic cholecystectomy 1 d (1 d; 2 d); laparoscopic gastrostomy 2 d (2 d, 4 d); laparoscopic fundoplication 3 d (4 d, 6 d); thoracoscopic repair of pectus excavatum 4 d (5 d, 6 d); OA 3 d (6 d, 9 d); OEC 4 d (6 d, 10 d); OGC 1 d (1 d, 2 d); and OBR 6 d (10 d, 20 d). Preoperative risk factors for high postoperative LOS varied by procedure and included patient demographics, admission factors, case characteristics, and comorbidities. CONCLUSIONS: The range of postoperative LOS and risk factors for high postoperative LOS for commonly performed procedures varied considerably. These results may be a useful reference for benchmarking and resource utilization analyses at the institutional and health systems levels.

Postoperative timing of computed tomography scans for abscess in pediatric appendicitis.

BACKGROUND: One-quarter to one half of pediatric appendicitis patients present with ruptured appendicitis and about 3%-25% go on to form postoperative intra-abdominal abscesses. The optimal timing of postoperative imaging for suspected abscess formation has been a subject of debate. METHODS: All patients who underwent appendectomy for complex appendicitis and were not discharged before postoperative day (POD) #5 from April 2012-October 2014 were identified. Patients were stratified into groups for comparison as follows: group 1 had postoperative computed tomography (CT) scans before POD#7 (n = 26) and group 2 did not (n = 169). Group 2 was further divided into those who were afebrile (group 2a, n = 106) or febrile (group 2b, n = 63) at POD#5. RESULTS: A total of 195 patients met criteria. Early use of CT scans resulted in more drainage procedures (group 1, 73.1% versus group 2b, 28.6%, P < 0.001) and a higher recurrent CT scan rate (38.5% versus 9.5%). The groups had equivalent lengths of stay (11.9 versus 9.8 d, P = 0.10) and readmission rates due to abscesses (19.2% group 1 versus 6.3%, group 2b, P = 0.12) with no septic events. In total, 130 of the 169 patients (76.9%) in group 2 had resolution of symptoms before discharge without intervention with readmission for abscess in only 5.9%. CONCLUSIONS: Waiting until POD#7 before scanning led to fewer drainage procedures and recurrent CT scans without increasing length of stay or readmission rates. Most complex appendicitis patients still admitted at POD#5 had resolution of symptoms without need for intervention.

Single-incision laparoscopic surgery (SILS) for children with Crohn's disease.

PURPOSE: Single-incision laparoscopic surgery (SILS) has been described in adults with Crohn's disease, but its use in pediatric Crohn's patients has been limited. The purpose of this study was to review our experience with SILS in pediatric patients with Crohn's disease. METHODS: A retrospective review was performed for patients diagnosed with Crohn's disease who underwent small bowel resection or ileocecectomy at a freestanding children's hospital from 2006 to 2014. Data collected included demographic data, interval from diagnosis to surgery, operative time, length of stay, and postoperative outcomes. RESULTS: Analysis identified 19 patients who underwent open surgery (OS) and 41 patients who underwent SILS. One patient (2.4 %) within the SILS group required conversion to OS. Demographic characteristics were similar between the 2 cohorts. The most common indication for surgery was stricture/obstruction (SILS 70.7 % vs. OS 68.4 %, p = 0.86), and ileocecectomy was the most common primary procedure performed (SILS 90.2 % vs. OS 100 % OS). Operative times were longer for SILS (135 ± 50 vs. 105 ± 37 min, p = 0.02). However, when the last 20 SILS cases were compared to all OS cases, the difference was no longer statistically significant (SILS 123.3 ± 34.2 vs. OS 105 ± 36.5, p = 0.12). No difference was noted in postoperative length of stay (SILS 6.5 ± 2.2 days vs. OS 7.4 ± 2.2 days, p = 0.16) or overall complication rate (SILS 24.4 % vs. OS 26.3 %, p = 0.16). CONCLUSION: SILS ileocecectomy is feasible in pediatric patients with Crohn's disease, achieving outcomes similar to OS. As experience increased, operative times also became comparable.

Utilization and costs associated with robotic surgery in children.

BACKGROUND: To evaluate utilization and costs associated with robotic surgery in children. MATERIALS AND METHODS: We identified patients in the Pediatric Health Information System database who underwent robotic surgery between October 2008 and December 2013. After determining the six most frequently performed surgeries in this group, we identified patients who underwent equivalent nonrobotic surgeries at the same hospitals. Equivalent surgeries were defined as open procedures for urology and laparoscopic procedures for general surgery. We examined trends in the numbers of surgeries performed and compared hospitalization costs between patients undergoing elective robotic and nonrobotic surgery for each procedure. RESULTS: The number of robotic surgeries performed increased by 19.8% per year (P < 0.001). The most common robotic surgeries performed were pyeloplasty (n = 760), ureteral reimplantation (n = 351), nephrectomy (n = 145), partial nephrectomy (n = 56), gastrointestinal antireflux procedure (n = 61), and cholecystectomy (n = 46). Total increase over time was primarily driven by increases in urologic surgeries (17.4% per year, P < 0.001). Postoperative length of stay was shorter after robotic surgeries than equivalent open urologic surgeries but not equivalent laparoscopic general surgery procedures. Total hospitalization costs were higher for robotic surgeries than equivalent urologic or general surgery procedures. CONCLUSIONS: Use of robotic surgery in pediatrics is increasing especially in the management of urologic conditions. Costs of robotic surgery-associated hospitalizations were higher than nonrobotic surgery-associated hospitalizations.

Counselling variation among physicians regarding intestinal transplant for short bowel syndrome.

BACKGROUND: Intestinal transplant in infants with severe short bowel syndrome (SBS) is an emerging therapy, yet without sufficient long-term data or established guidelines, resulting in possible variation in practice. OBJECTIVES: To assess current attitudes and counselling practices among physicians regarding intestinal transplant in infants with SBS, and to determine whether counselling and management vary between subspecialists or centres. METHODS: A national sample of practicing paediatric surgeons and neonatologists was surveyed via the American Academy of Paediatrics listserves. Results were analysed by physician subspecialty and again by presence or absence of intestinal transplant at respondent's centre. RESULTS: The survey was completed by 433 respondents, consisting of 363 neonatologists and 70 paediatric surgeons. Fifty-seven respondents (13.2%) practiced at a centre that performed intestinal transplants in children. The vast majority of respondents (91% for preterm, 95% for term neonates) felt that maintaining a neonate with SBS on total parenteral nutrition for intestinal transplant was ethically optional (neither impermissible nor obligatory), and that parents should be given an informed choice whether to pursue that option. However, only 33% indicated they often/always offer intestinal transplant as a treatment option to families in this situation. CONCLUSIONS: There is a marked disparity between individual physicians' beliefs regarding the acceptability of intestinal transplant for severe SBS and their reported practice. Wide variability exists among physicians with respect to their knowledge, beliefs and practice regarding severe SBS, raising concerns about transparency and justice. Survival data prior to transplant, currently unavailable, are essential to rational decision making and informed parental permission.

Contemporary use of prophylactic probiotics in NICUs in the United States: a survey update.

OBJECTIVE: In 2015, 14.0% of US NICUs administered probiotics to very low birth weight infants. Current probiotic use prior to and after the Fall of 2023 (when FDA warnings were issued) remains unknown. STUDY DESIGN: A survey was distributed to the American Academy of Pediatrics Section on Neonatal and Perinatal Medicine (August-November/2022) and Neonatology Solutions' Level III/IV NICUs (January-April/2023). Probiotic administration practices were investigated. RESULTS: In total, 289 unique NICUs and 406 providers responded to the survey. Of those, 29.1% of NICUs administered prophylactic probiotics to premature neonates, however, this decreased considerably after FDA warnings were issued. Additionally, 71.4% of providers stated willingness to administer probiotics to premature infants if there was an FDA-approved formulation. CONCLUSIONS: Probiotic use in US NICUs increased between 2015 and the Fall of 2023 and then dropped dramatically following warning letters from the FDA. The introduction of an FDA-approved probiotic may further expand administration.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review.

INTRODUCTION: Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility. METHODS: A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed. RESULTS: Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room. CONCLUSIONS: Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Original Clinical Research.

Robotic-Assisted Surgery in Patients Less than 15 kg: A Single Center Review.

Introduction: Robotic-assisted surgery (RAS) is an increasingly utilized tool in children. However, utilization of RAS among infants and small children has not been well established. The purpose of this study was to review and characterize RAS procedures for children ≤15 kg. Methods: We performed a single institution retrospective descriptive analysis including all patients ≤15 kg undergoing RAS between January 2013 and July 2021. Data collection included procedure type, age, weight, gender, and surgical complications. Cases were further categorized according to surgical specialty: pediatric urology (PU), pediatric surgery (PS), and multiple specialties (MS). t-Tests were used for statistical analyses. Results: Since 2013, a total of 976 RAS were identified: 492 (50.4%) were performed by PU, 466 (47.8%) by PS, and 18 (1.8%) by MS. One hundred eighteen (12.1%) were performed on children ≤15 kg, consisting of 110 (93.2%) PU cases, 6 (5.1%) PS cases, and 2 (1.7%) MS cases. Procedures were significantly more common in the PU subgroup, mean of 12 cases/year, compared to PS subgroup, mean of 0.63 cases/year, (P < .01). The mean weight of PU patients (10.5 kg) was significantly less than PS patients (13.9 kg) (P < .01). Mean age was also significantly lower among PU patients (18.6 months) compared to PS (34.2 months) (P < .01). Conclusion: RAS among patients ≤15 kg is safe and feasible across pediatric surgical subspecialties. RAS was performed significantly more frequently by pediatric urologists in younger and smaller patients compared to pediatric surgeons. Further refinement of robotic technology and instrumentation should enhance the applicability of these procedures in this young group.

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease.

BACKGROUND: Children with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention. METHODS: All patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed. RESULTS: There were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1-39.7]. Median operative time was 6.6 h [4.9-7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%). There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3-7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%). CONCLUSION: Colonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications. TYPE OF STUDY: Original research, retrospective cohort. LEVEL OF EVIDENCE: III.

Sacral nerve stimulation leads to long-term improvement in fecal incontinence and quality of life for children with functional and organic defecation disorders.

BACKGROUND: Our objective was to evaluate long-term outcomes of sacral nerve stimulation (SNS) for children with functional and organic defecation disorders. METHODS: We performed a prospective study of children <21 years of age who started SNS treatment between 2012 and 2018. We recorded demographics, medical history, and diagnostic testing. We obtained measures of symptom severity and quality of life at baseline and follow up at 1, 6, 12, 24, 36, 48, and ≥60 months. Successful response was defined as bowel movements >2 times/week and fecal incontinence (FI) <1 time/week. Families were contacted to administer the Glasgow Children's Benefit Inventory and to evaluate patient satisfaction. KEY RESULTS: We included 65 patients (59% female, median age at SNS 14 years, range 9-21) with median follow-up of 32 months. Thirty patients had functional constipation (FC), 15 had non-retentive FI (NRFI), and 16 had an anorectal malformation (ARM). The percentage with FI <1 time/week improved from 30% at baseline to 64% at 1 year (p < 0.001) and 77% at most recent follow-up (p < 0.001). Patients with FC, NRFI, and ARM had sustained improvement in FI (p = 0.02, p < 0.001, p = 0.02). Patients also reported fewer hard stools (p = 0.001). Bowel movement frequency did not improve after SNS. At most recent follow-up, 77% of patients with a functional disorder and 50% with an organic disorder had responded (p = 0.03). Nearly all families reported benefit. CONCLUSIONS AND INFERENCES: SNS led to sustained improvement in FI regardless of underlying etiology, but children with functional disorders were more likely to respond than those with organic disorders.

Damage control surgery in a <1 kg neonate: a brief report.

Damage control surgery is a feasible and successful approach for the management of unstable neonates with intra-abdominal catastrophes, including liver injuries. We report the case of a premature infant with a liver injury secondary to the placement of an umbilical vein catheter who was successfully managed using damage control surgery techniques.

Robotic-assisted vertical sleeve gastrectomy in adolescents: Do BMI limits apply?

BACKGROUND: Robotic-assisted vertical sleeve gastrectomy (VSG) in adolescent patients has been shown to have comparable outcomes to laparoscopic VSG. Recent data suggests that metabolic and bariatric surgery (performed using robotic and laparoscopic techniques) in patients with BMI ≥ 50 kg/m2 have a higher risk of adverse events compared to those with BMI < 50 kg/m2. The aim of this study was to compare the outcomes of robotic-assisted VSG in adolescents with a BMI above and below 50 kg/m2. METHODS: A retrospective analysis of all adolescents undergoing robotic-assisted VSG between January 2014 and December 2020. Subjects were categorized based on preoperative BMI; Group 1 (BMI < 50 kg/m2) or Group 2 (BMI ≥ 50 kg/m2). Data collection included patient demographics, preoperative BMI, total operative time, access time (i.e., total time for port-placement), 30 day complications, and 30 day hospital readmissions. Analysis was performed using chi-square, Fisher's Exact, and student t-test. RESULTS: Total of 115 subjects (Group 1 N = 64 and Group 2 N = 51) were included. No differences in age or ethnicity were detected; however, Group 2 had a higher percentage of male patients (27.5% vs. 4.7%, respectively, p = 0.001). Mean operative times (Group 1 = 122.2 min vs. Group 2 = 121.6 min) and access times (Group 1 = 19.1 min vs. Group 2 = 19.7 min) were similar between groups. Thirty day complication rates were similar between groups (p = 0.133); however, there was a higher rate of hospital readmission in Group 1. CONCLUSION: While recent data demonstrate an increased likelihood of adverse events occurring among patients with BMI ≥ 50 kg/m2 undergoing robotic surgery, we observed no differences in intraoperative or early postoperative outcomes based on BMI in this robotic-assisted pediatric cohort.

Congenital duodenal obstruction - Advances in diagnosis, surgical management, and associated controversies.

Congenital duodenal obstruction (CDO) occurs due to intrinsic and extrinsic mechanisms but is most often caused by intrinsic duodenal atresia and stenosis. This review will summarize the history, epidemiology, and etiologies associated with the most common causes of CDO. The clinical presentation, complex diagnostic considerations, and current surgical repair options for duodenal atresia and stenosis will also be discussed. Finally, both historical and recent controversies which continue to affect the surgical decision-making in the management of these patients will be highlighted.

Rates of Air Embolism in Pediatric Patients Undergoing Surgical Procedures of the Peritoneum.

Background: Air embolism during laparoscopic surgery is a rare but feared complication in the pediatric population. The objective of this study was to identify rates of air embolus in pediatric patients during hospitalization for laparoscopic or open surgical procedures of the peritoneal cavity. Materials and Methods: Patients 0-18 years old within the Pediatric Health Information System who underwent a predefined, common inpatient laparoscopic or open surgical procedure involving the peritoneal cavity from 2015 to 2020 were studied. International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis codes for air embolism were then searched among patients during the same admission. Firth logistic regression was used to compare rates of air embolism in open and laparoscopic cohorts and in patients >1 and ≤1 year. Results: Unadjusted rates of air embolism were higher in patients undergoing open compared with laparoscopic surgery (open: 9/45,080; 20.0/100,000 patients versus laparoscopic: 3/101,892; 2.9/100,000 patients). In patients ≤1 year (45,726), 2 patients undergoing open surgery (2/1,031; 9.5/100,000 patients) and all 3 patients undergoing laparoscopic surgery had an air embolism diagnosis (3/22,329; 13.4/100,000 patients). For laparoscopic surgery, a suggested lower relative risk (RR) of air embolism was demonstrated for children >1 year compared with children ≤1 year (RR: 0.05, P = .05). Conclusion: Air embolism associated with common pediatric surgical procedures of the peritoneum is rare and patients undergoing laparoscopic and open surgery have similar risks for air embolism. Although rare, the risk should be considered during surgical planning and abdominal access, especially in children ≤1 year old.

The cutback revisited - The posterior rectal advancement anoplasty for certain anorectal malformations with rectoperineal fistula.

BACKGROUND: The repair of rectoperineal fistulae can pose a significant challenge to the pediatric surgeon given the proximity of the fistula to the urethra in males and vagina in females. In these children, a simple cutback procedure may leave the neoanus in a position anterior to the center of the sphincter, which theoretically could impair future continence. We devised an adaptation of the cutback anoplasty which we call the posterior rectal advancement anoplasty (PRAA) to treat patients with a rectoperineal fistula that is both narrow in lumen and located within, but at the anterior-most limit of the sphincter complex. MATERIAL AND METHODS: Patient selection, operative steps, and perioperative care of patients undergoing PRAA are detailed. RESULTS: 10 children (6 males, 4 females) underwent PRAA. There were no vaginal wall or urethral injuries. At 6 months postoperatively, all patients were passing stool spontaneously. No patients required dilation of the anoplasty in the postoperative period and there were no anal strictures identified. CONCLUSIONS: A modification of the cutback anoplasty can be performed in patients with a perineal fistula and the distal fistula tract within the sphincter complex. We have demonstrated that this can be performed safely and obviates the need for an anterior rectal wall dissection, thus eliminating the risk of injury to urethra or vagina. LEVEL OF EVIDENCE: IV.