Outcomes and Evidence-based Practice Articles of Interest

Articles

Association of Gangrenous, Suppurative, and Exudative Findings With Outcomes and Resource Utilization in Children With Nonperforated Appendicitis [1]. Cramm SI, et al. JAMA Surg. 2022 Aug 1;157(8):685-692-292.

Appendectomy is the most commonly performed surgery in children, and surgical site infection remains the leading postoperative complication. There is controversy regarding the implications of gangrenous, suppurative and exudative (GSE) appendicitis and what it means for postoperative management and resource utilization. Existing studies have provided conflicting data regarding the outcomes and the benefit of postoperative antibiotics in this subset of patients. There is a paucity of high-quality data as reflected by the variation in postoperative management across the existing published literature.

In a large multicenter cohort study (Eastern Pediatric Surgery Network) utilizing the Peds NSQIP Targeted Appendectomy merged with institutional operative notes, the prevalence of GSE appendicitis was 14.1%. GSE findings were associated with increased odds of any surgical site infection (Odds ratio 1.9), increased postoperative imaging, and prolonged length of stay. The findings of GSE in non-perforated appendicitis have increased surgical site infections and resource utilization, though the optimal postoperative management still requires further investigation.

Nationwide Management of Trauma in Child Abuse: Exploring the Racial, Ethnic, and Socioeconomic Disparities [2]. Joseph B, et al. Ann Surg. 2022 Sep 1;276(3):500-510. Epub 2022 Jun 28.

Child abuse is a major cause of childhood injury, morbidity, and death. It is estimated that 1 in every 58 children in the US experienced maltreatment, with half being subjected to abuse, with the remainder subjected to neglect. Studies have demonstrated that there are significant racial and ethnic difference in the incidence of child maltreatment. For child abuse victims, contact with the healthcare system is an important timepoint where screening and interventions for abuse may occur. Large national samples of clinical outcomes and factors associated with child abuse are lacking.

Using retrospective data from 2017-2018 ACS Pediatric TQIP program, patients with suspected/confirmed child abuse were identified (n=7,774). Initiation of abuse investigations and change of caregiver at discharge were the assessed outcomes. Black children were more likely to have abuse investigated, and Black and Hispanic children were more likely to experience change of caregiver after investigation. Privately insured children were less likely to experience both of the aforementioned outcomes. Using a validated large national clinical registry, significant racial, ethnic, and socioeconomic disparities were demonstrated in the management of child abuse.

Use of Cold-Stored Whole Blood is Associated With Improved Mortality in Hemostatic Resuscitation of Major Bleeding: A Multicenter Study [3]. Hazelton JP, et al. Ann Surg. 2022 Oct 1;276(4):579-588. Epub 2022 Jul 18.

The practice of balanced blood product resuscitation with equal (1:1:1) ratio of plasma packed red blood cells (pRBC), and platelets has been the standard of care in trauma resuscitation. Recent literature, particularly from the military experience, has demonstrated successful outcomes and improved survival with fresh whole blood resuscitation. There is lack of corresponding large or prospective series examining the use of cold-stores type O whole blood available in civilian trauma centers. In institutional series, the use of cold-stored whole blood transfusion in hemorrhagic shock in trauma patients has been associated with improved survival.

This is a large multi-center (14 centers) prospective observational trial sponsored by the Eastern Association for the Surgery of Trauma demonstrating a mortality reduction in trauma patients using cold-stored whole blood resuscitation. The whole blood product used at all centers was leukoreduced, low-titer cold-stored type O whole blood. A total of 1623 patients were included with 53% penetrating vs. 47% blunt injury. Patients who received whole blood had a higher shock index, more comorbidities, and more blunt mechanism of injury. Whole blood patients were 9% less likely to experience bleeding complications and 48% less likely to die than blood component therapy patients. The study supports the use of whole blood over blood component therapy in the resuscitation of trauma patients.

Routine contrast enema prior to stoma reversal seems only required following treatment for necrotizing enterocolitis: An evaluation of the diagnostic accuracy of the contrast enema [4]. Eeftinck Schattenkerk RM, et al. J Pediatr Surg. 2022 Jun 25:S0022-3468(22)00433-X. doi: 10.1016/j.jpedsurg.2022.06.013. Online ahead of print.

Routine contrast enema, either via antegrade or retrograde approach, is often obtained in children prior to ostomy reversal. These contrast studies are used to identify distal strictures that could lead to obstruction following reanastomosis. Historically, contrast enemas have been utilized for a range of diagnoses including necrotizing enterocolitis (NEC), Hirschsprung disease, atresia, meconium ileus and complicated gastroschisis. This study aimed to evaluate the diagnostic accuracy of contrast enemas with an interesting finding to support more discerning use of the study in a certain patient population.

A 20 year retrospective review was performed at a tertiary academic medical center identifying all children less than 3 years with a small or large intestine stoma. Children with anorectal malformations were excluded (as contrast enema is used to evaluate for distal fistula not stricture). In total 224 patients were included. The most common indications for stomas were NEC (42%), Hirschsprung disease (26%), and atresia (13%). Twenty three patients (10%) had a distal stricture on imaging. Twenty two of those patients had a history of NEC; one had a complicated atresia with volvulus. There were three false positives in the NEC group with concerns for a stricture at the splenic flexure. When looking at the overall cohort, there was a sensitivity of 100%, specificity of 98%, positive predictive value of 88%, negative predictive value of 100% and the AUC was 0.98. In NEC patients alone, the sensitivity was 100%, specificity 97%, positive predictive value 91%, negative predictive value 100%, and AUC 0.98. This study concludes that contrast enema should be utilized in patients with NEC given the high rate of post-NEC strictures (20%) and suggests that children with other diagnoses should be spared the additional radiation, cost, and time.

STOPS: A Coping Framework for Surgeons Who Experience Intraoperative Error [5]. D’Angelo JD, et al. Ann Surg. 2022 Aug 1;276(2):288-292. Epub 2022 Jul 4.

Intraoperative error is an unavoidable reality. Yet, there is little to no training on how to handle errors both in the operating room and following the procedure. Surgeons learn coping strategies by observing others and trial and error; but inappropriate handling of errors leads to poorer patient outcomes and influences surgeon well-being.

This study used a thematic analysis of surgeons from three separate academic hospitals ranging in experience from second year attendings to late career surgeons. A semistructured interview was performed by a PhD educator with prior experience in psychologic processes and medical education. The transcripts were reviewed with three emerging themes: exigency, learning, and response. Surgeons expressed a need to discuss and normalize the reality of intraoperative errors. Although M&M conferences often highlight technical steps, there is little to no attention to psychological impact or response frameworks. Participants admitted to learning how to handle errors only through personal experience, no prior training. Finally, they focused on the response to error and selected the most positive to create a framework for surgeons in the future:

STOPS. Stop: Surgeons should pause when an error occurs, collect their thoughts, utilize a calming strategy, and prepare for the next required steps. Talk to your team: Surgeons should notify the operating room team what has occurred and align focus in the room. Obtain help: Both early career and senior surgeons found benefit in soliciting a colleague’s assistance for a new perspective and second pair of trained hands. Plan: Developing a plan is the key to forward motion rather than feeling helpless. Succeed: Execute the plan; if necessary, transition focus from education to safely completing the operation. Additional reflection or teaching can occur after the procedure.

The Outcome of Patients With Cystic Biliary Atresia With Intact Proximal Hepatic Ducts Following Hepatic-Cyst-Jejunostomy [6]. Asai A, Pacific Biliary Atresia Study Group (PaBAS), et al. J Pediatr Gastroenterol Nutr. 2022 Aug 1;75(2):131-137.

Biliary atresia is a disorder characterized by progressive obliteration of the extrahepatic bile ducts. It is the most common indication of pediatric liver transplant. Biliary atresia presents with phenotypic variation wherein some patients have a cyst formation in the extrahepatic bile ducts. Cystic variation occurs in 10% of all patients with biliary atresia. This cyst formation is present proximal to the obliterated bile ducts and may be associated with patent intact hepatic bile ducts. A hepatoportenterostomy or Kasai portoenterostomy has been the preferred surgical treatment for treatment of biliary atresia and has been successful in the subset of patients with cystic variation. Patients with cystic variants with patent intact hepatic ducts may be treated with a hepatic-cyst-jejunostomy.

A multinational clinical research collaboration was created for this study. A retrospective review of all children who underwent surgical intervention at one of 5 centers (2 in Japan, 1 in Taiwan, 2 in the United States) was conducted. Patients who underwent surgical intervention between 2005 and 2019 were included. A total of 287 patients were included in the study. Of these, 33 patients were found to have a cystic variation defined as cystic variation of any part of the extrahepatic bile ducts. These patients were then subdivided into patients with: patent intact hepatic ducts (> 1mm), patent hypoplastic hepatic ducts (< 1mm) or obliterated hepatic ducts. Ten patients were found to have patent intact hepatic ducts while 13 were noted to have hypoplastic ducts. Of the 10 with patent intact hepatic ducts all 10 underwent hepatic-cyst-jejunostomy. Two year follow-up was achieved in all patients. Of this subset, 9 patients had bile drainage and native liver survival. The only patient in this subgroup who required liver transplant underwent surgical correction for the biliary atresia at 149 days of life. Furthermore portal hypertension and episodes of ascending cholangitis were less prevalent in this subgroup. The authors conclude that the subset of patients with cystic variation of biliary atresia who exhibit patent intact hepatic ducts (> 1mm in diameter) may have favorable outcomes with hepatic-cyst-jejunostomy.

Demographic and Clinical Characteristics Associated With the Failure of Nonoperative Management of Uncomplicated Appendicitis in Children Secondary Analysis of a Nonrandomized Clinical Trial [7]. Minneci PC, et al. JAMA Network Open. 2022;5(5):e229712.

Appendicitis remains the most common indication for emergency intra-abdominal surgery in the pediatric patient population with 60,000-80,000 children undergoing appendectomy each year. Although typically well tolerated, 5-15% of patients undergoing laparoscopic appendectomy for uncomplicated appendicitis will experience at least 1 complication, with serious complications occurring in 1-7% of these patients. An approach of antibiotics alone has been advocated to treat appendicitis in select patient populations as an alternative to appendectomy. Recently, a multi-institutional interventional study demonstrated a 67% 1-year success rate with the antibiotics alone approach. To better risk stratify patients when deciding on management, it is imperative to understand patient-specific factors associated with the probability of treatment failure. Additionally, satisfaction with treatment decisions are important to consider when determining effectiveness of treatment options. Given this, the authors sought to determine factors associated with failure of nonoperative management of appendicitis and compare patient-reported outcomes between those patients for whom a nonoperative approach was successful with those for whom this approach failed.

This study was a planned subgroup analysis of data collected by the Midwest Pediatric Surgery Consortium in which 1068 children 7-17 years with uncomplicated appendicitis were enrolled in a prospective, nonrandomized clinical trial between May 1, 2015 and October 31, 2018. The cohort underwent 1-year follow-up comparing surgery with nonoperative management of uncomplicated appendicitis. Of the 370 patients whose caregivers chose the nonoperative approach primarily, 125 patients underwent surgery by 1 year following appendicitis with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5) returning for surgery following initial hospital discharge. In-hospital treatment failure was associated with higher patient-reported pain at presentation (RR=2.1, 95%CI 1.0-4.4). Delayed treatment failure was decreased with pain duration exceeding 24 hours (RR=0.3, 95%CI 0.1-1.0), a finding which was not associated with in-hospital treatment failure (RR=1.2, 95%CI 0.5-2.7) or treatment failure at 1 year (RR=0.7, 95%CI 0.4-1.2). No other socioeconomic factors or clinical characteristics at the time of presentation were associated with delayed treatment failure after hospital discharge or overall treatment failure at 1 year. Although overall satisfaction was high across all patients, higher mean satisfaction with decision scores were noted among patients for whom nonoperative management at 30 days was successful compared to the remainder of the cohort. Antibiotics alone do have a role in the management of uncomplicated appendicitis in the right clinical setting, and discussions around pursuing this approach should engage the family about all treatment options available.

Accuracy of Chest Computed Tomography in Distinguishing Cystic Pleuropulmonary Blastoma From Benign Congenital Lung Malformation in Children [8]. Engwall-Gill AJ, et al. JAMA Network Open. 2022; 5(6):e2219814.

Congenital lung malformations occur in up to 1 in 2000 children in the US with an incidence that has been increasing during the past 20 years secondary to improved and increasing utilization of imaging. Although symptomatic lesions are routinely managed surgically, asymptomatic lesions have an unclear natural history with some advocating for observation alone. The rate of malignant transformation is thought to be low, however this has not been well delineated. It was recently shown via a multicenter study that 10% of cystic lung lesions diagnosed in the postnatal period were pleuropulmonary blastoma (PPB). Many PPBs have a similar appearance to macrocystic CPAMs on computed tomography (CT) scans and therefore the reliability of CT in this case remains unknown. Discerning benign versus malignant processes is crucial for guiding counseling and deciding optimal management approach. As such, this study sought to evaluate the accuracy of CT chest in distinguishing malignant PPBs from benign CLMs among postnatally detected lung lesions in children.

A retrospective multicenter case-control study using the Midwest Pediatric Surgery Consortium database between January 1, 2009 to December 31, 2015 was designed to assess diagnostic accuracy of 521 pathologically confirmed primary lung lesions. Preoperative CT scans of children with cystic PPBs were age-matched to those of children with CLMs. The sensitivity and specificity for detecting PPB via CT chest were 58% and 83%, respectively with a high suspicion for malignancy correlating with PPB (OR=13.5; 95%CI 2.7-67.3; p=0.002). The overall diagnostic accuracy rate for benign or malignant lesions was 81% with no significant difference in specific imaging characteristics such as bilateral disease, midline shift, pneumothorax or pleural effusion between PPB and benign cystic CLMs. As such, operative management with complete surgical resection of any cystic lung lesions without prenatal diagnosis is warranted to confirm pathologic diagnosis and optimize outcome.

Prenatal ultrasonographic markers for prediction of complex Gastroschisis and adverse perinatal outcomes: a Systematic Review and Meta-analysis [9]. Sun RC, et al. Arch Dis Child Fetal Neonatal. Ed 2022; 107:F371-F379.

Gastroschisis has a reported incidence of 4.3 per 10,000 births in the US and has increased in recent years. It follows necrotizing enterocolitis as the second most common cause of intestinal failure with many neonates having problems of intestinal dysmotility leading to prolonged hospitalizations and subsequent need for medical care. To date, there is no accepted standard of care for the prenatal diagnosis of gastroschisis other than frequent surveillance and engagement of a multidisciplinary team. Unlike simple gastroschisis which typically has mortality rates of 3.6-4.6%, complex gastroschisis has been associated with intestinal atresias, perforations, volvulus and necrosis with a mortality rate of 17%. The predictive value of antenatal ultrasound findings of bowel dilation, gastric dilation, polyhydramnios and abdominal circumference for complex gastroschisis and adverse perinatal outcomes remain unclear. As such, the authors sought to better evaluate diagnostic performance of antenatal ultrasound findings as they relate to complex gastroschisis and adverse perinatal outcomes by conducting a meta-analysis.

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, thirty-six studies up to December 2020 were included for analysis. The included studies reported prenatal ultrasonongraphic findings of intra-abdominal bowel dilation (IABD), extra-abdominal bowel dilation (EABD), bowel wall thickness, polyhydramnios, abdominal circumference < 5th percentile, gastric dilation and bowel dilation not otherwise specified (BD-NOS). The primary outcome was prediction of complex gastroschisis of which both intra- and extra- bowel dilation were significantly associated. This is particularly true in the second trimester with specificity of 95.6% (95% CI 58.1 to 99.7) and specificity 94.6% (95% CI 86.7 to 97.9). The secondary outcome of evaluation of predictors of adverse perinatal outcomes found that IABD during second or third trimester was significantly associated with postnatal short bowel syndrome (OR=14.26; 95%CI 4.45 to 45.71; p< 0.001) and increased length of hospital stay (MD=28.94, 95%CI 4.70 to 53.18; p=0.02), a finding which was not seen with EABD. Prognostic indicators facilitate prenatal counseling and resource utilization so to improve postnatal care and outcomes and may potentially play a role in determining patient populations for whom fetal intervention may be beneficial.

10-year Analysis of Pediatric Surgery Fellowship Match and Operative Experience: Concerning trends?[10]. Farooqui Z, et al. Ann Surg 2021 Sept 9. Epub ahead of print.

Board certification in pediatric surgery requires completion of a two-year fellowship following fiver years of general surgery training. There are currently 51 accredited pediatric surgery fellowship training programs. Entry into pediatric surgery training is selective. The opportunity to perform complex procedures and have a career addressing the unique surgical problems and critical care needs of neonates and children is thought to motivate surgical residents to pursue pediatric surgical training. Recent data demonstrate that operative experience has decreased for practicing pediatric surgeons with fewer index cases performed each year. It is unclear if this decrease in index case volume is also true among pediatric surgical trainees.The authors reviewed data regarding both the match as well as fellowship operative case logs. Match statistics were obtained from the National Resident Matching Program (NRMP) from 2010-2019. Operative case logs were obtained from the ACGME from 2009-2019. Match statistics were compared across fellowships and case logs were evaluated over time. The proportion of ACGME-graduating general surgery residents pursuing pediatric surgery fellowship has remained stable at 5.66% (range 4.8-6.6%, p=0.98). There has been a steady but not statistically significant increase in the number of pediatric surgery fellows and programs over time. Among surgical fellowships, pediatric surgery had the highest proportion of applicants per position (1.88+/-0.18, p< 0.05) and highest proportion of unmatched applicants (47.2%+/- 5.3%, p< 0.05). With regard to operative case volume for graduating fellow, there was a significant decrease in primary surgeon (-6.3 cases/year) and all roles (-5.3 cases/year), but not teaching assistant cases. The median operative volume for primary surgeon, teaching assistant, and all roles was 1281, 57, and 1334 respectively. There was no change in case volume in seven of ten domains (abdomen, hernia, thoracic, endoscopy, skin/soft tissue, head and neck, diaphragm) but a decrease in cardiovascular (-3.2 cases/year), genitourinary (-1.3 cases/year) and liver/biliary (-1.3 cases/year) cases. There was a decrease in complex cases (-2.7 cases/year) but stable volume in common cases. Graduates in 2009 completed 59 fewer core cases than graduates in 2010. These data highlight the need to evaluate training paradigms to ensure adequate operative exposure during fellowship training.

Optimizing skin antisepsis for neonatal surgery: a quality improvement initiative [11]. Carr S, et al. J Pediatr Surg 57 (2022) 1235-1241.

Surgical site infections are a significant source of morbidity in the neonatal ICU (NICU). The two primary options available for preoperative skin prep include povidone-iodine (PI) and chlorhexidine gluconate/isopropyl alcohol (CHG-IPA). In the adult population, CHG-IPA has skin-safety equivalence to PI with increased effectiveness at preventing surgical site infections. Similar data are not available in children. Current FDA language cautions against the use of CHG-IPA in infants under 2 months of age due to the “potential for excessive skin irritation and increased drug absorption”. However, PI is also not without risk in neonates as it has the potential for systemic toxicity through cutaneous absorption of iodine leading to subclinical hypothyroidism. The safety and effectiveness of CHG-IPA in neonates is unknown.

The authors aimed to determine the safety and effectiveness of CHG based skin prep in neonates through a quality improvement initiative at their institution. They first performed a literature review to understand what is known about the safety and effectiveness of CHG skin prep in infants. They then presented these data to a multidisciplinary surgical quality and safety team and created a neonatal CHG surgical skin prep protocol. The protocol was implemented and was used to assess prep associated skin injury in 50 consecutive neonates >1500g and > 34 weeks gestational age (GA)undergoing abdominal or thoracic operations. The protocol included using 2% CHB, 70% IPA for term infants >4 weeks of age and preterm infants >44 weeks GA and 0.5%CHG, 70% IPA for term infants < 4 weeks of age and preterm infants < 44 weeks GA. Infants were observed for at least 5 days postoperatively so that skin integrity scoring could be completed. Comparisons were made to historic controls who underwent surgery after PI prep. Controls were identified from the institution’s NSQUIP database based on CPT codes. None of the CHG infants experienced adverse skin prep outcomes; 8% of CHG prep infants developed SSIs compared to 14% in historical PI controls (p=0.53). The study was not designed to prove superiority of CHG over PI, however CHG is unlikely to be inferior to PI in its ability to reduce SSI in this population.

Perianal Crohn disease is more common in children and is associated with more complicated disease course despite higher utilization of biologics: A population-based study from The epidemiology group of the Israeli IBD Research Nucleus (epiIIRN) [12]. Atia O, et al. JPGN Vol 74, Number 6, June 2022.

The incidence of perianal disease in patients with Crohns disease (CD) is reported between 12-47% 10 years following CD diagnosis with one third of cases being severe perianal disease. Perianal disease is associated with poorer disease course and higher drug utilization. Guidelines for both adult and pediatric CD management recommend early biologic treatment with perianal involvement. Separate from perianal disease, pediatric CD also portends a worse prognosis with higher drug utilization and worse disease outcomes. The relationship between these two risk factors for severe disease (pediatric onset and presence of perianal disease) has not been evaluated previously.

The authors performed a population-based study utilizing an administrative database to evaluate a cohort of CD patients. Data originate from two large HMOs in Israel which combined, encompass 78% of the population. They included all patients diagnosed with CD from 2005 to 2019, totaling 12,905 patients (2186 pediatric onset, 10,719 adult onset). Children had a higher incidence of perianal disease (14% vs 11%, p< 0.001) and when perianal disease was present, a higher incidence of severe perianal disease (47% vs 35%, p< 0.001). Perianal disease was associated with poorer disease outcomes including need for surgery (12% vs 8%, p=0.02) and steroid dependency (17% vs 13%, p< 0.001). Multivariable modeling showed that severity of perianal disease was a stronger predictor of disease course than age. Disease course was similar among those with non-severe perianal disease and those without any perianal involvement. There was no association between perianal involvement or severity of perianal disease in pediatric onset CD.

Anti-reflux surgery in children with congenital diaphragmatic hernia: A prospective cohort study on a controversial practice [13]. Montalva L, et al. on behalf of the French Center for Rare Diseases “Congenital Diaphragmatic Hernia”. J Pediatr Surg. 2022 Apr 27:S0022-3468(22)00323-2. Online ahead of print.

Congenital diaphragmatic hernia (CDH) is a severe birth defect that affects 1 in 3000 live births. Mortality and morbidity rates remain high despite advances in prenatal and neonatal management. Long-term comorbidities include gastro-esophageal reflux disease (GERD) which has been reported to affect up to 50% of children with CDH as well as oral aversion and failure to thrive. Given the long-term negative effects of GERD on growth, respiratory status, neurodevelopment and quality of life – some authors advocate for a preventive fundoplication the time of initial surgical repair of CDH especially with a large defect. The authors sought to: analyze the variability in practices regarding preventive fundoplication; identify predictive factors for fundoplication, and evaluate the impact of preventive fundoplication on gastro-intestinal outcomes in children with a CDH patch repair.

The authors performed a prospective multi-institutional cohort study, in France, between January 1st, 2010 and December 31st, 2018. Children with a patch repair included those who had a muscle flap repair or a synthetic patch placed to repair the defect. The primary outcomes were: need for curative fundoplication, tube feed supplementation, failure to thrive, and oral aversion. A total of 762 children were identified with CDH, of which 81 underwent fundoplication (either preventative or curative). In neonates with patch CDH, preventive fundoplication did not decrease the need for curative fundoplication (15% vs 11%, p=0.53), and was associated with higher rates of failure to thrive at discharge (81% vs 51%, p=0.03) and at 6-months (81% vs 45%, p=0.008). There was also a higher need for tube feeds and a higher rate of oral aversion. The authors conclude that children with a CDH patch repair have a higher risk of undergoing curative fundoplication. However, performing a preventive fundoplication during the initial CDH repair does not decrease the need for curative fundoplication but increases the rates of failure to thrive, tube feed supplementation, and oral aversion.

Trends in Routine Opioid Dispensing After Common Pediatric Surgeries in the United States: 2014–2019 [14]. Sutherland TN, et al. Pediatrics. 2022 May 1;149(5):e2021054729.

Children who undergo common outpatient surgeries are routinely prescribed opioids, although available evidence suggests opioids should be used with discretion for procedures associated with mild to moderate pain. The aim of this study was to determine whether there was a trend towards decreased opioid prescriptions over time.

The authors utilized a private insurance database to study opioid-naïve patients under the age of 18 who underwent one of eight surgical procedures from 2014 to 2019. The authors utilized the likelihood of receiving an opioid prescription within 7 days of surgery as a primary outcome and the total amount of opioids dispensed as a secondary outcome. A total of 124,249 patients were included in the study. The percentage of adolescents who received an opioid prescription during the study period decreased from 78.2% to 48%. Prescriptions amongst school-aged children decreased from 53.9% to 25.5% and prescriptions amongst preschool aged children decreased from 30.4% to 11.5%. The average morphine milligram equivalent that was prescribed also decreased amongst each age group during the study period. The authors concluded that between 2014 and 2019, study results identified a substantial decrease in both the percentage of children filling an opioid prescription and the opioid quantity dispensed beginning in 2017. The onset of this decline differed by age group and surgery.

Preoperative Transfusion and Surgical Outcomes for Children with Sickle Cell Disease [15]. Salvi PS, et al. JACS: May 09, 2022 - Volume - Issue - 10.1097/XCS.0000000000000267

Sickle cell disease (SCD) affects approximately 100,000 individuals in the United States. Children with SCD are predisposed to cholelithiasis and splenic sequestration which may require surgical management. Additionally, children with SCD may also present with other common diseases processes such as appendicitis that require surgical management. Surgical bleeding and physiologic stress may lead to vaso-occlusive crisis and worsening anemia adversely affecting surgical outcomes. Current recommendations advise pre-operative transfusions to achieve a hemoglobin of 9 or 10 g/dL in all children undergoing operations that require a general anesthetic lasting over one hour. Recent studies have called into question these guidelines as well as demonstrating variability in compliance. The authors goal is to evaluate whether preoperative transfusion of packed red blood cells affects surgical outcomes including postoperative sickle cell crisis and other complications.

The authors utilized the National Surgical Quality Improvement Project-Pediatric database from 2013 to 2019. Patients who underwent cholecystectomy, splenectomy or appendectomy and had a preoperative hematocrit of less than 30% were included. The primary outcomes was admission for sickle cell crisis within 30 days of surgery. In the matched cohort of 278 patients (139 per group), there was no statistically significant difference in 30-day readmission for sickle cell crisis in the transfused and non-transfused groups (5.8 vs. 7.2%; p=0.80). The rate of 30-day surgical complications did not differ between matched groups (10.8 vs. 9.4%; p=0.84). The authors concluded that preoperative transfusion for children with SCD undergoing semi-elective surgery was not associated with improved outcomes or a decreased readmission rate for sickle cell crisis. They recommended further studies to strengthen current guidelines and minimize unnecessary transfusions.

Association of Emergency Department Pediatric Readiness With Mortality to 1 Year Among Injured Children Treated at Trauma Centers [16]. Newgard CD, et al. JAMA Surg. 2022 Apr 1;157(4):e217419. Epub 2022 Apr 13.

There is considerable variability in Pediatric Readiness in emergency departments (ED) across the United States. Pediatric Readiness has been assessed using a scale from 0-100 (100 being the most ready). Two prior studies have shown that injured children who present to trauma centers with high ED Pediatric Readiness Scores have improved in-hospital survival compared to children who present to trauma centers with low ED Pediatric Readiness. The authors sought to determine whether high ED Pediatric Readiness was associated with improved long-term (one-year) survival.

Of 88,071 children younger than 18 years old who presented to 146 trauma centers in 8 states, 1974 (2.2%) died within 1 year of their ED visit. 1768 (2.0%) died in-hospital, while 206 (0.2%) died after discharge. The authors found that injured children who presented to trauma centers in the highest quartile (most Pediatric ready) for ED readiness as assessed by the 2013 National Pediatric Readiness Project were 30% more likely to be alive one-year after their injury compared to children who presented to trauma centers in the lowest quartile (least Pediatric ready). This association remained after removing children with early death from analysis. Therefore, high Pediatric ED readiness is independently associated with improved long-term survival for injured children. The findings of this study are particularly relevant given the recent updates to the verification standards required by the American College of Surgeons Committee on Trauma for Trauma Center Verification, which now mandate that trauma centers have a process in place to assess and maintain Pediatric Readiness in their ED’s.

Patient Factors Associated With Appendectomy Within 30 Days of Initiating Antibiotic Treatment for Appendicitis [17]. Writing Group for the CODA Collaborative; Monsell SE, et al. Randomized Control Trial. JAMA Surg. 2022 Mar 1;157(3):e216900. Epub 2022 Mar 9.

Surgery has long been considered the standard treatment for appendicitis. In the last two decades, 10 randomized controlled trials in adults have shown that most adults treated with antibiotics alone for simple appendicitis can avoid surgery in the first 30 days. The CODA (Comparison of Outcomes of Antibiotic Drugs and Appendectomy) group conducted a non-blinded, non-inferior randomized controlled trial of laparoscopic appendectomy compared to antibiotics alone for adults with imaging-confirmed simple appendicitis. 776 people were randomized to antibiotics and 776 participants to appendectomy between May 2016 and February 2020 at 25 US medical centers. Of 776 participants randomized to antibiotics alone, 735 had known outcomes at 30 days and 154 (21%) of these participants underwent appendectomy within 30 days. The factors associated with failure of antibiotics for simple appendicitis are incompletely understood.

In a relatively large and recent randomized controlled trial of antibiotics vs appendectomy for simple appendicitis in adults in the United States, the authors assessed factors associated with appendectomy at 30 days in participants initially randomized to antibiotic therapy. Presence of an appendicolith on imaging was associated with a 1.99 relative risk of undergoing appendectomy at 30 days. Thirty-one percent of patients with an appendicolith ultimately underwent appendectomy within 30 days compared to 16% of participants without an appendicolith. Clinical characteristics often used to describe the severity of appendicitis (such as symptom duration longer than one day, white blood cell count, and fever) were not associated with increased odds of 30-day appendectomy. Therefore, the presence of an appendicolith on imaging should be considered when counseling patients considering antibiotics alone for acute appendicitis. As this study was conducted in adults, the generalizability to children with acute appendicitis may be limited.

Utilization and Performance Benchmarking for Postoperative Imaging in Children With Complicated Appendicitis: Results From a Multicenter Collaborative Cohort Study [18]. Kashtan MA, et al. Ann Surg. 2022 Apr 1;275(4):816-823.

There is wide variation in the work-up and care of children with acute appendicitis. In particular, the authors have shown that variation exists in pre-operative imaging used to diagnose appendicitis in children. However, variation across hospitals with regard to postoperative imaging to diagnose organ space infection after appendectomy has not been studied. Given the prevalence of appendicitis and the lack of consensus guidelines for post-operative imaging, the authors hypothesized that significant variation likely existed in obtaining ultrasound (US) and computed tomography (CT) scans. The authors sought to characterize hospital-level variation and establish diagnostic benchmarks for postoperative imaging in children with complicated appendicitis.

The authors conducted a retrospective, multicenter study of postoperative imaging practices in 1316 children (age 3-17 years) who underwent appendectomy for complicated appendicitis at 20 hospitals between January 2013 – June 2015. They used data from the National Surgical Quality Improvement Project (NSQIP) – Pediatric Appendectomy Pilot Collaborative. Overall, 18.3% had either US or CT imaging; individual hospitals ranged from 4.8% to 33.3, reflecting a 6.9-fold variation (P < 0.01). The rate of postoperative CT utilization was 14.7% ranging from 2.1% to 31.7% across institutions, reflecting a 15.1-fold variation (P < 0.01). The overall US rate was 7.6% ranging from 1.2% to 20.3% across hospitals, reflecting a 16.9-fold variation (P < 0.01). The authors suggest that we should consider the diagnostic efficiency of postoperative imaging, defined as how often an organ space infection is found by the imaging study. In this study, the overall imaging-associated diagnostic efficiency ratio was 0.56 OSIs per study performed and ranged from 0 to 1.00 between hospitals (P < 0.01). Half of the hospitals in the study were an outlier in at least one measure suggesting considerable variability between the centers. These findings have important implications for radiation stewardship in vulnerable population. Opportunity exists for consensus guideline development and quality improvement efforts to efficiently identify children in need of postoperative imaging for complicated appendicitis and minimize radiation.

Impact of Cryoablation on Pectus Excavatum Repair in Pediatric Patients [19]. Clark RA, et al. J Am Coll Surg. 2022 Apr 1;234(4):484-492.

Minimally Invasive Repair of Pectus Excavatum (MIRPE) has evolved as the standard of care for the management of Pectus Excavatum. While providing a minimally invasive approach to the care of this patient population, postoperative pain remains a significant factor in determining the postoperative length of stay. Cryoablation of the intercostal nerves has been shown to be effective in the management of postoperative pain following pectus excavatum repair.

This is a single-institution retrospective review of all children (< 18 years old) who underwent minimally invasive pectus excavatum repair from 2009 to 2020. The institution added cryoablation in 2018. Patients who received cryoablation were compared to historical controls with the primary outcome noted to be length of stay. One hundred sixty-one patients met inclusion criteria: 75 underwent intraoperative CA and 86 underwent MIRPE without CA (NCA group). Cryoablation therapy was associated with a significantly decreased median length of stay from 4 days in patients who did not receive cryoablation to two days for those who did receive cryoablation. Cryoablation was also associated with decreased total PCA, intravenous opioid, and oral opioid dosages. There was no difference in inpatient pain scores and a slight increase in mean procedure time.

Management of Complicated Biliary Disease in the Pediatric Population [20]. Doud A, et al. Surgery. 2022 Mar;171(3):736-740. Epub 2021 Nov 27.

Biliary disease is increasing in prevalence in the pediatric population and is associated with an increase in childhood obesity. While hemolytic disease previously accounted for the main indication for biliary disease, cholesterol stones and biliary dyskinesia are now the main indications for cholecystectomy in the pediatric population. The authors presume that there is an concomitant increase in complicated biliary disease (choledocholithiasis, gallstone pancreatitis) similar to what is seen in the adult population.

The authors conducted a retrospective review of all cholecystectomies performed over 15 years admitted to the surgical service at a single free-standing children’s hospital. Patient factors, indications for cholecystectomy, and final treatment were recorded. The authors defined complicated gallbladder disease as having image-confirmed choledocholithiasis or gallstone pancreatitis. They stratified these patients into high-risk patients with imaging that demonstrated definitive choledocholithiasis or cholelithiasis with common bile duct enlargement. Low risk patients were defined as those with cholelithiasis or gallbladder sludge on imaging combined with an elevated bilirubin and/or lipase. Results: A total of 695 cholecystectomies were performed during the study period. The majority of patients had cholesterol stones. Of these patients, 103 had complicated gallbladder disease. Nearly 60% of patients with high-risk findings required ERCP/sphincterotomy while 23% of low risk patients required ERCP/sphincterotomy. These findings confirm that complicated gallbladder disease is seen at similar rates to adult patients. ERCP may be necessary in the management of those patients with complicated biliary disease.

A Statewide Analysis of Pediatric Liver Injuries Treated at Adult Versus Pediatric Trauma Centers [21]. Pulido OR, et al. J Surg Res. 2022 Apr;272:184-189. Epub 2022 Jan 12.

The management of hemodynamically normal pediatric trauma patients with solid-organ injury is typically non-operative in nature. Studies have shown that pediatric patients treated at adult trauma centers typically have a higher rate of operative intervention. The authors elected to evaluated whether pediatric patients with liver injury treated at an adult trauma center had a higher rate of operative intervention.

The authors utilized The Pennsylvania Trauma Outcome Study database and retrospectively evaluated all patients ( < 15 years of age) who had a liver injury treated from 2003 to 2018. Patients were categorized based on admission to the PTC or ATC. The primary endpoint was mortality with secondary endpoints being operative intervention and length of stay. There were 1600 patients in the trauma database with liver injury during this time period of whom 607 met inclusion criteria. The vast majority of patients (78.4%) were treated at a pediatric trauma center. The authors noted that Patients underwent hepatobiliary surgery more frequently at adult trauma centers (11.5% versus 2.74%). Additionally, they noted that there was a decrease in mortality at pediatric trauma centers when compared to patients treated at adult trauma centers (adjusted odds ratio: 0.38). The authors concluded that patients treated at adult trauma centers were associated with having higher odds of mortality and higher incidence of operative management for hepatobiliary injuries.

Treatment and Outcomes of Congenital Ovarian Cysts: A Study by the Canadian Consortium for Research in Pediatric Surgery (CanCORPS) [22]. Safa N, et al. Ann Surg. 2022 Feb 15. Online ahead of print.

Congenital ovarian cysts have an estimated incidence of 1 in 2,625 live births. They are commonly detected in the prenatal period and are typically asymptomatic. They are thought to result from maternal hormonal stimulation. While they are benign in nature, they have been associated with complications such as ovarian torsion and hemorrhage. Many cysts can be observed with serial ultrasound as they regress spontaneously, however, surgical intervention has also been proposed due to the known complications in an attempt for ovarian preservation, potentially leading to oophorectomy. Tremendous variation exists in the evaluation and management of these lesions.

A multi-center retrospective evaluation of children diagnosed with congenital intra-abdominal cysts between 2013-2017 was performed. A total of 189 neonates were included in the study. The study looked at sonographic characteristics, median time to cyst resolution, incidence of ovarian preservation and predictors of surgery. A subgroup analysis was performed in infants found to have a complex cysts and those with cysts greater than 40mm in diameter. The cyst resolved spontaneously in 117 patients (62%). Sixty-one patients had an intervention including 2 with prenatal aspiration, 14 with ovarian sparing resection and 45 with oophorectomy. Independent predictors of surgical intervention included cyst diameter greater than or equal to 40mm and sonographic findings of a complex cyst. The authors concluded that most congenital cysts are asymptomatic and will spontaneously resolve. Surgical intervention does not seem to increase ovarian preservation.

Index Admission Cholecystectomy and Recurrence of Pediatric Gallstone Pancreatitis: Multicenter Cohort Analysis [23]. Muñoz Abraham AS, et al. J Am Coll Surg. 2022 Mar 1;234(3):352-358.

Gallstones are the second most common etiology of pancreatitis in children following idiopathic pancreatitis. As obesity and biliary disease become more common in the pediatric population, it is expected that gallstone pancreatitis may become more prevalent. Treatment of gallstone pancreatitis in adults consists of cholecystectomy following resolution of pancreatitis, typically during the index admission. Data has shown that there is a recurrence rate of pancreatitis as high as 40% in children prior to their cholecystectomy. The authors sought to evaluated the recurrence and readmission rates for children with gallstone pancreatitis when treated with early versus interval cholecystectomy.

A multicenter, retrospective review of pediatric patients admitted with gallstone pancreatitis from 2010 to 2017 was performed. The authors compared children undergoing early cholecystectomy versus a delayed operation. Early cholecystectomy was defined as surgery during the index admission while delayed operation was surgery following discharge or no surgery at all. The study included 246 patients from 6 centers. The majority, 72%, of patients were female. Early cholecystectomy was performed in 68% of patients, with similar rates across all institutions. The recurrent pancreatitis rate in the early cohort was 2% compared to 22% in the delayed surgery cohort. This rate increased to 60% when cholecystectomy was delayed greater than 6 weeks following discharge from the index admission. The authors conclude that cholecystectomy during the index admission for gallstone pancreatitis in children decreases the recurrent pancreatitis rate.

Same-day discharge following the Nuss repair: A comparison [24]. Rettig RL, et al. J Pediatr Surg. 2022 Jan;57(1):135-140.

Pectus excavatum is a common complex congenital condition that results in inward displacement of the sternum leading to exercise limitations, shortness of breath and chest pain. This congenital condition occurs in one in every 400 to 1000 births. Minimally invasive repair, Nuss Procedure, has become the mainstay of surgical therapy. Despite the minimally invasive approach, pain control is one of the most common barriers to discharge following surgical correction. Intercostal nerve cryoablation has been shown to significantly reduce length of stay. The authors evaluate the use of intercostal nerve cryoablation (INC) in the setting of an enhanced recovery after surgery (ERAS) program.

A retrospective study was performed evaluating patients who underwent a Nuss repair of pectus excavatum with an ERAS protocol comprising INC and intercostal nerve blocks (INB) from June 2020 to September 2020. These patients were compared to patients who underwent surgery from June 2017 to December 2019. Patient matching was based upon age, sex and number of bars. The procedures were performed at 3 institutions by 5 surgeons with a standardized surgical technique. The authors had a standardized perioperative approach to pain control including preoperative counseling, physical therapy and a multimodal pain regimen. Individuals who received INB in addition to INC were discharged home from the hospital following a mean length of stay (LOS) of 11.8 hours while those patients who underwent INC without INB and an ERAS protocol were discharged home with a mean LOS of 58.2 hours. Ten of 15 patients who underwent surgery with INB and INC were discharged home on the day of surgery. No patients in the INB arm of the study returned to the emergency department for pain control. The authors conclude that the majority of patients pectus excavatum repair in the setting of INB, INC and an ERAS protocol were discharged home on the day of surgery without adverse outcomes and unanticipated return to the hospital.

Healthcare Burden and Cost in Children with Anorectal Malformation During the First 5 Years of Life [25]. Rollins MD, et al. J. Pediatr. 2022 Jan; 240:122-128.e2.

Patients with anorectal malformations (ARMs) interact extensively with the healthcare system for these diagnoses, but also, often have other associated congenital anomalies that require prolonged care. Early in life they interact with our healthcare systems for innumerable evaluations, interventions, prolonged hospital stays and subsequent long-term follow up. The patients are often followed by their pediatric providers throughout their childhood and often, well into adulthood.

This retrospective case-controlled study compares healthcare days and cost of children with ARMs with healthy children, children born prematurely and those with congenital heart disease (CHD). The authors demonstrated that the healthcare burden and cost of children with ARMs just during their first 5 years of life is comparable to children with prematurity and CHD. Additionally, the outpatient management of these children is an opportunity for improvement. Summary: ARM = $273K average healthcare expenditures (1st 5 years) Irrespective of ARM severity In addition to cost, patients and families suffer a significant burden of inpatient and outpatient days in the first 5 years. Ongoing improvements to the outpatient experience can improve quality of life for these patients and their families. Multi-disciplinary clinics!

In-Hospital Morbidities for Neonates with CDH: The Impact of Defect Size and Laterality [26]. Chock VY, et al. J Pediatr. 2022 Jan;240:94-101. E6.

CDH defect size = most reliable indicator of morbidity. Survival is lower in R-CDH, but morbidity related to laterality has not been compared.

R-CDH and larger defect size yields Increased in-hospital morbidities (pulmonary 1.7x, GI and cardiac 1.4x, multiple organ system morbidity 1.6x)

Closing the Gender Pay Gap in Medicine [27]. Gottlieb A, et al. N Engl J Med. 2021 Dec 30;385(27):2501-2504.

The AAMC confirmed the persistence of the gender pay gap for academic physicians in the US, even after adjusting for confounders. Women earn less than their male counterparts, regardless of racial and ethnic group, at every area assessed – practice type, specialty, rank.

The details of the long-standing dilemma. “The findings are both striking and familiar.” 60K Academic Physicians: White Women 77 cents vs White Men 100 cents Black Women 79 cents vs Black Men 100 cents Asian Women 75 cents vs Asian Men 100 cents Compensation = Base Salary (formula) + $ Rewards (seniority, leadership, productivity) Women: Increased Organizational Service + Increased Time with patients yields Better outcomes but decreased volumes. Suggestions to close the gap: Scrutinize basic assumptions, Create new approaches, Address biases, Track and report gender metrics, and Consider alternative payment models that prioritize quality and value.

Ten-Year Outcomes of Children and Adolescents Who Underwent Sleeve Gastrectomy:Weight Loss,Comorbidity Resolution, Adverse Events, and Growth Velocity [28]. Alqahtani A, et al. J Am Coll Surg 2021 Dec;233(6):657-664.

In the United States, approximately 1 in 5 youth (18.5%) are affected by morbid obesity. By the year 2020, it is expected that 250 million children and adolescents worldwide will be classified as obese. Childhood obesity is associated with considerable risk for type 2 diabetes, systemic and pulmonary hypertension, nonalcoholic fatty liver disease, cardiovascular disease, psychosocial difficulties, poor quality of life, and premature death. Current literature has shown benefit to weight loss surgery in adolescents although these studies typically have short term follow-up. This study aims to evaluate long-term outcomes following sleeve gastrectomy in children and adolescents.

This is a single institution ongoing prospective trial evaluating weight loss surgery in pediatric patients aged 5 to 21 years diagnosed with obesity. The current analysis includes patients recruited from June 2008 to June 2021. Children and adolescents with obesity, defined as a BMI > 95th percentile for age and sex, were referred to a multidisciplinary team, which followed a standardized clinical pathway. A total of 2,504 children and adolescents underwent laparoscopic sleeve gastrectomy (LSG) during the study period. Fifty-five percent of the patients were female. The mean baseline BMI was 44.8 kg/m2. The mean estimated weight loss during short- (1 to 3 years; n-2,051), medium- (4 to 6 years; n-1,268) and long-term (7 to 10 years; n-632) follow-up was 82.3%, 76.3%, and 71.1% respectively. At more than 7 years of follow-up, complete remission was observed in 188 (71.5%), 130 (57.3%), and 219 (58.1%) patients with type 2 diabetes, dyslipidemia, and hypertension, respectively. The authors conclude that long-term follow-up after LSG in children and adolescents demonstrates durable weight loss, maintained comorbidity resolution, and unaltered growth.

The Baby and the Board: A Step Toward Normalizing Childbearing During Surgical Training [29]. Letica-Kriegel AS, et al. Ann Surg 2021 Dec 1;274(6):925-926.

At the present time, surgical trainees are afforded two weeks of parental leave by the American Board of Surgery (ABS). This is far shorter than what is allowed in other residency programs such as Obstetrics and Gynecology which allows for 8 weeks of parental leave, separate from vacation. Many trainees will utilize their vacation time to ensure six weeks of parental leave, however, current policies prohibit vacation time greater than 6 weeks in an academic year without borrowing from other clinical years. Trainees also time their pregnancies during non-clinical years, less strenuous rotations or simply defer pregnancy until after residency.

This brief clinical report highlights concerns raised by many surgical residents regarding pregnancy during surgical residency. Two case scenarios are provided by the authors illustrating the effect of current policies on the health of trainees. The authors of the manuscript provide a detailed review of current ABS policies and provide recommendations for the future. This manuscript touches on other areas such as determinations of clinical competency which impact the current policies in place for surgical trainees and vacation time/parental leave time. They propose the creation of a task force between the Accreditation Council for Graduate Medical Education, ABS, and surgical training programs to create policies that adapt with our generation and provide surgical trainees with the flexibility to succeed both personally and professionally. The same issue of Annals of Surgery has a response from the American Board of Surgery which can be found at the following address: https://journals.lww.com/annalsofsurgery/Fulltext/2021/12000/Parental_Leave_Revisited__The_ABS_Responds.9.aspx

Parental Leave Revisited: The ABS Responds . Nelson MT,et al. Ann Surg. 2021 Dec 1;274(6):927.

The ABS agrees that flexibility around leave during training is crucial. Normalizing parental leave can be achieved through identifying core rotations that are essential to training, adding redundancy to staffing, and opening the discussions among stakeholders including the ACGME, ABS, employers, and training programs. ABS was instrumental in moving the start date of fellowships to August 1. As much as 4 weeks can be added to any leave by allowing students to extend training into the summer if needed and entering the certification process and fellowship training on schedule. Flexibility extends to allowing residents to take the the first of two required general surgery certifications examinations after PGY 4 years.

The ABS participated in the ABMS Parental Leave Task Force in 2019 and 2020, as well as the ABMS/ACGME Parental and Family Leave Workshop in 2020. With representaion at all levels of programs from directors to trainees, it was determined that the present ABS Family Leave Policy was identified as a best practice. The ABMS and ACGME minimum leave expectations was used as a model as ABMS developed their standards. The ABS has tasked a working group to review the present policy, recent literature, ABMS and ACGME reports and all other sources to submit proposed changes to the ABS family leave policy to the ABS board.

Outcomes of Primary Ileocolic Resection for Pediatric Crohn Disease in the Biologic Era [30]. Spencer EA, et al. J Pediatr Gastroenterol Nutr 2021 Dec 1;73(6):710-716.

The rate of pediatric Crohn disease (CD) is on the rise worldwide. Despite the increased prevalence of Crohn disease, the rate of surgery for CD has decreased over time in population based studies. This is in part due to the introduction of biologics which have significantly impacted the medical management of inflammatory bowel disease. Surgery is often considered the last therapeutic option in consensus guidelines. Nutrition and linear growth have been shown to improve significantly postoperatively. There is scant data in the pediatric literature evaluating recurrence (endoscopic and histologic) following surgical resection in the biologic era. The authors aim to evaluate the postoperative outcomes in a pediatric CD cohort who underwent ileocolic resection (ICR) at a North American tertiary care center over the last decade

This is a single institution retrospective study evaluating the outcomes of pediatric patients, age 18 years and under, who have undergone primary ileocolic resection between 2008 and 2019. Primary ileocolic resection was defined as any ileocolic resection that was the index surgery for a patient with CD. Children who underwent ICR at an outside facility were excluded. A total of 78 patients underwent ICR during the study period. The median disease duration was 17.8 months with 10 patients undergoing resection within 30 days of diagnosis. In the 41 patients who underwent more than 1 post-operative endoscopy, the rate of endoscopic recurrence was 46% at 2 years with a median time to recurrence of 10 months. Histologic recurrence was present in 44% in endoscopic remission. Endoscopic recurrence was associated with younger age at diagnosis and longer disease duration. All anthropometric measures significantly improved after surgery. The authors conclude that children undergoing ICR for CD carry an inherent risk of recurrence that is related to their age at diagnosis and length of disease duration. Pediatric patients may therefore benefit from early postoperative surveillance as well as effective prophylaxis. Additionally, they note that surgery should be considered a viable treatment option in pediatric patients as it does improve anthropometric measures.

Ceftriaxone with Metronidazole versus Piperacillin/tazobactam in the Management of Complicated Appendicitis in children: Results from a multicenter pediatric NSQIP analysis [31]. Kashtan MA, et al. J Pediatr Surg. 2021 Nov 20;S0022-3468(21)00784-3. Online ahead of print.

Antibiotic management of complicated appendicitis has evolved over time into shorter courses and fewer agents as supported by a growing body of comparative effectiveness data. Ceftriaxone combined with metronidazole (CM) and piperacillin/tazobactam (PT) have emerged as the two most frequently used regimens. The potential advantages of PT include the convenience of a single agent and extended coverage against Pseudomonas and beta-lactamase producing organisms, while disadvantages include more frequent dosing and increased selection for multi-drug resistant Pseudomonal species, a problem identified by the CDC as a high-priority public health crisis. Existing studies comparing CM and PT have provided conflicting results and have largely been limited by single center data, use of non-standardized definitions for exposures and outcomes, and lack of adjustment for the continuum of disease severity associated with complicated appendicitis. Multicenter data are needed to address this question in the context of a wide range of patient populations, practice settings, and regional antimicrobial susceptibility profiles, all which could potentially influence outcomes.

In this multicenter cohort study of 14 NSQIP-Pediatric hospitals, no differences were found in organ space infection rates or postoperative resource utilization between children receiving piperacillin/tazobactam (PT) and those receiving ceftriaxone combined with metronidazole (CTX-MTZ). A total of 654 patients were included, of which 37.9% received CM and 62.1% received PT. Following adjustment for patient characteristics, hospital-level clustering, and disease-severity based on intraoperative findings, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]). The results of this study add to the growing body of evidence suggesting that routine use of anti-pseudomonal agents may not be necessary in the absence of antibiotic susceptibility data to dictate otherwise.

IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial) Randomized Clinical Trial of Monotherapy Versus Multi-drug Antibiotic Therapy [32]. Lee J, et al. Ann Surgery. 2021 Sep 1;274(3):406-410.

Perforated appendicitis is the most common cause of intra-abdominal abscess (IAA) in children. The optimum postoperative antibiotic regimen has evolved over time. Transition from the previously standard, triple-drug regimen to the newer 2-drug regimen of CM (ceftriaxone/metronidazole) was supported by both retrospective and prospective studies. The primary driver to transition from the 3 to 2-drug regimen was the convenience and cost-effectiveness of once daily dosing. However, the initial prospective, randomized trial did not show a reduction in postoperative IAA with the 2-drug regimen. The postoperative IAA rates in studies utilizing CM remain between 9-20%. These rates represent an opportunity to improve patient-centered outcomes such as ED visits, readmissions, use of postoperative imaging, and cost of care.

In this prospective, randomized trial, a broad-spectrum, single-drug regimen of PT (piperacillin/tazobactam) resulted in a significantly lower postoperative abscess rate compared to the standard 2-drug regimen. A total of 162 children were randomized between May 2017 and May 2020. All underwent laparoscopic appendectomy. There were 82 in the PT group and 80 in the CM group. The mean ages were 9.1 and 9.7 years. No significant differences in age, gender, BMI, days of preoperative symptoms, or postoperative complications were identified. The incidence of IAA formation was significantly lower in the PT group (6.1% versus 23.8%, OR 4.797, P=0.002). The result was sustained on multivariate logistic regression analysis which identified postoperative antibiotic regimen as the strongest predictive variable of postoperative IAA formation (OR 9.211, P=0.021). This study adds prospective randomized data to the literature and corroborates the finding that PT reduces postoperative IAA compared to CM. The post discharge rate of emergency department visits was also lower.

Ceftriaxone Combined with Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children [33]. Kashtan MA, et al. Ann Surg. 2021 Dec 1;274(6):e995-e1000.

Acute appendicitis is the source of most surgical site infections (SSIs) in pediatric surgery and the third-highest number of antibiotic treatment days in freestanding children’s hospitals. Efforts to balance infection prevention with antibiotic stewardship are, therefore, critical given that overuse of broad-spectrum antibiotics has been associated with the emergence of multidrug-resistant organisms. Evaluation of data from several administrative databases suggest that extended-spectrum agents are not necessary for treatment of uncomplicated appendicitis in children. In a recent multicenter study of children with uncomplicated appendicitis, treatment equivalence was found between extended-spectrum (antipseudomonal) and narrow-spectrum antibiotics in preventing SSIs. However, comparative data describing the relative effectiveness of different narrow-spectrum antibiotics are currently lacking.

This is the first comparative effectiveness study to address the paucity of data for the most commonly utilized narrow-spectrum antibiotics. This multicenter retrospective study of 846 children with uncomplicated appendicitis from 14 hospitals, found that treatment with ceftriaxone (CTX) and metronidazole (MTZ) was associated with a significant reduction in the odds of an SSI compared to treatment with cefoxitin alone. The cohort was derived from merged NSQIP-Pediatric and PHIS data. Patients were included if they underwent laparoscopic or open appendectomy between January 1, 2013, and June 30, 2015, were 3–17 years old at the time of surgery, received a narrow-spectrum antibiotic agent preoperatively, and were diagnosed with uncomplicated appendicitis. Patients were assigned to 1 of 2 treatment groups, either CTX & MTZ or cefoxitin alone, depending on which antibiotics they received on the day of surgery. The primary outcome was incisional or organ space SSI occurring during the 30-day postoperative period as defined by NSQIP-Pediatric data. The results suggest that CTX and MTZ should be the preferred antibiotic regimen for children with uncomplicated appendicitis. When considering the relatively high incidence of acute appendicitis in the pediatric population, and the significant proportion of children currently treated with cefoxitin alone, broad practice change may lead to a substantial reduction in the burden of SSIs associated with uncomplicated appendicitis at the population level.

Sex Differences in the Pattern of Patient Referrals to Male and Female Surgeons [34]. Dossa F, et al. JAMA Surg. 2021 Nov 10;e215784.

A pay gap between men and women in medicine is found in virtually every health care system where it has been measured and is largest for surgeons. A substantial portion of the disparity is unexplained by lifestyle and career choices. Studies have found that female surgeons have fewer opportunities to perform highly remunerated operations, a circumstance that contributes to the inequity. Procedures performed by surgeons are, in part, determined by the referrals they receive.

Despite the importance of the referral process for patient outcomes, factors that influence referral networks are not well studied. In the fee-for-service system in Ontario, Canada, referrals are unrestricted by contracts, insurance schemes, or employment. Physicians are free to refer patients to any specialist who accepts patients. Ontario is therefore an ideal setting to explore gender bias in referral networks. A population-based, cross-sectional study was conducted of out-patient referrals to surgeons in Ontario, Canada, from January 1, 1997, to December 31, 2016, using linked administrative databases. The proportion of referrals (overall and those referrals that led to surgery) made by male and female physicians to male and female surgeons was compared to assess associations between surgeon, referring physician, patient characteristics and referral decisions. Discrete choice modeling was used to examine the extent to which gender differences in referrals were associated with physicians’ preferences for same-sex surgeons. A total of 39 710 784 referrals were made by 44 893 physicians (27 792 [61.9%] male) to 5660 surgeons (4389 [77.5%] male). Female patients made up a greater proportion of referrals to female surgeons (76.8% vs 55.3%, P < .001). Male surgeons accounted for 77.5% of all surgeons but received 87.1% of referrals from male physicians and 79.3% of referrals from female physicians. Female surgeons less commonly received procedural referrals (25.4% vs 33.0%, P < .001). After adjusting for patient and referring physician characteristics, male physicians referred a greater proportion of patients to male surgeons; differences were greatest among referrals from other surgeons (rate ratio, 1.14; 95% CI, 1.13-1.16). Female physicians had a 1.6% (95% CI, 1.4%-1.9%) greater odds of same-sex referrals, whereas male physicians had a 32.0% (95% CI, 31.8%-32.2%) greater odds of same-sex referrals; differences did not attenuate over time. Physicians exhibit preferences for male surgeons, and these preferences are strongest among male physicians. Female surgeons were less likely to receive referrals, including procedural referrals. All else being equal, male physicians referred a greater proportion of patients to male surgeons than to female surgeons and female surgeons received greater fractions of nonoperative referrals.

Ten-year experience with staged management of Pectus Carinatum: Results and lessons learned [35]. Kelly RE, et al. J Pediatr Surg. 2021 Oct;56(10):1835-1840.

Compressive orthotic bracing has become the primary method of treatment for chondrogladiolar pectus carinatum with its success reported in multiple studies. Open repair or more recently a minimally invasive repair, Abramson repair, has been reserved for those who fail orthotic bracing. The authors report their ten year experience in the management of pectus carinatum to provide insight into clinical management strategies.

A single center review of patients with pectus carinatum was performed from 2008 to 2018. A total of 695 patients were enrolled, of whom 430 were treated. In those patients treated for pectus carinatum, 339 had bracing only; 65 underwent surgery without a trial of bracing, while 26 underwent surgery after a failed attempt at bracing. In the subset of 364 patients who were braced, 144 (40%) were successful, 77 (21%) are ongoing, 25 (7%) failed, and 118 (32%) dropped out. A 50% decrease in pressure of correction beginning one month after starting treatment was predictive of success with bracing. In those patients who underwent operation, all obtained good initial results, however, the complication rate was higher in the Abramson technique when compared to open repair. The authors conclude that compressive orthotic brace treatment can be guided by pressure of correction to determine whether it will be successful. If pressure of correction does not fall accordingly, surgery should be considered. Open repair is generally successful with a lower complication rate.

Economic Trends of Racial Disparities in Pediatric Postappendectomy Complications [36]. Mpody C, et al. Pediatrics. 2021 Oct;148(4):e2021051328. Epub 2021 Sep 16.

Despite significant advances in surgical outcomes over the last several decades, minority patients continue to lag behind white patients with regard to morbidity and mortality. Increased complications tend to correspond to an increase in hospital cost, however, little is published regarding the excess costs to the healthcare system based upon these disparities.

The authors utilized the Nationwide Inpatient Sample evaluating children under 18 who underwent appendectomy from 2001 through 2018. A total of 100,639 children were included of whom 89.9% were non-Hispanic White and 10.1% were non-Hispanic Black. The authors examined inflation-adjusted hospital costs attributable to racial disparities in surgical complications and perforation status. Irrespective of perforation status at presentation, complications were consistently higher for Black children when compared to White children. This resulted in higher hospital costs with a median difference of $629 per hospital stay. The authors concluded that although all patients had a progressive decline in post appendectomy complications, Black children consistently had higher rates of complications and perforation, imposing a significant economic burden.

Gender Disparity in Surgical Society Leadership and Annual Meeting Programs [37]. Tirumalai AA, et al. J Surg Res. 2021 Oct;266:69-76.

Women represent approximately half of all medical students, yet they account for only approximately 25% of surgical residents. Medical students who are women are more likely to have a positive perception of surgery as a specialty and are more likely to choose surgery as a career if they are exposed to more surgical role models who are also women. During the 2015 #ilooklikeasurgeon social media movement, the underrepresentation of women in surgical leadership roles resonated across the world, beginning with the words –‘Be the Role Model You Always Wanted But Never Had’. The authors utilized leadership in national surgical organizations as well as moderators and plenary speakers to gain a better understanding of women role models in surgery.

The authors evaluated gender distribution through publicly reported data. Fifteen major surgical societies and 14 conferences from 2014 to 2018 were included. The proportion of leadership positions held by women increased slightly from 2014 to 2018 from 20.6% to 26.6%. There was also an increase in the proportion of moderators and plenary speakers. The proportion of women in each role varied significantly across all societies: leaders (range 0.0%-52.0%), moderators (12.5%-58.8%), and plenary speakers (11.3%-60.0%). The authors conclude that despite increasing numbers of women surgical trainees and graduates over the past decades, women leaders remain under-represented in most surgical societies and there continues to be reduced visibility of women surgical role models. While a few societies have already achieved gender parity and others are showing improvement, some organizations consistently have an under-representation of women.

Initial Laparotomy Versus Peritoneal Drainage in Extremely Low Birthweight Infants With Surgical Necrotizing Enterocolitis or Isolated Intestinal Perforation: A Multicenter Randomized Clinical Trial [38]. Blakely ML, et al. Ann Surg. 2021 Oct 1;274(4):e370-e380.

Necrotizing enterocolitis (NEC) involves ischemia of variable portions of the intestine and may result is extensive bowel necrosis and perforation. On the other hand, isolated intestinal perforation (IP) involves a small perforation in otherwise well-perfused intestine. Both NEC and IP occur most often in premature infants. Initial surgical treatment for both NEC and IP is usually laparotomy with possible bowel resection and ostomy or bedside peritoneal drainage with later laparotomy, if needed. Two previous randomized trials found no significant difference between laparotomy and drainage for ELBW infants, but did not assess the diagnosis of NEC vs. IP and did not assess the neurodevelopmental outcomes.

In this prospective, randomized trial, 310 infants with birth weight ≤ 1,000g and age ≤ 8 weeks with suspected IP or NEC were randomized to initial laparotomy (n=148) versus peritoneal drainage (n=168). The primary outcomes were death or neurodevelopmental impairment at 18-22 months of age. Death and NDI were similar for initial laparotomy (69%) and initial drainage (70%). If the preoperative diagnosis was NEC, 29/42 (69%) died or had NDI after initial laparotomy vs. 44/52 (85%) after initial drainage. The Bayesian posterior probability that laparotomy resulted in a lower rate of death or NDI than drainage was 97%. There was no significant difference if the preoperative diagnosis was IP.

Esophageal Atresia and Respiratory Morbidity [39]. Lejeune S, et al. Pediatrics. 2021 Sept; 148 (3): e2020049778.

Esophageal atresia (EA) is a rare congenital foregut malformation with a lack of development of part of the esophagus during fetal development, with a fistula to the airway approximately 90% of the time. EA is frequently associated with airway anomalies such as tracheomalacia, laryngeal and bronchial malformations. These anomalies and other associated conditions such as gastroesophageal reflux disease, neurologic, and cardiac issues can lead to pulmonary complications and chronic lung disease, particularly in the first year of life.

1287 French patients with EA who survived to one year of life were prospectively studied to assess the factors associated with readmissions and treatments for respiratory disease within the first year of life. The most common respiratory reasons for readmission were respiratory infections (64%), brief unexplained events (12%), and other causes (23%). Respiratory treatments were ongoing on 35% of the patients at one year. Factors associated with readmission were need for antireflux surgery, tube feeding at one year, recurrence of tracheoesophageal fistula, and severe tracheomalacia requiring aortopexy. The authors support multidisciplinary, long-term care of patients with esophageal atresia with respiratory complications.

The Morbidity of Open Tumor Biopsy for Intraabdominal Neoplasms in Pediatric Patients [40]. Devin C, et al. Pediatr Surg Int. 2021 Oct;37(10):1349-1354.

Both percutaneous core biopsy and open biopsy are utilized for tissue diagnosis in pediatric tumors. Complications of open biopsy must be weighed with the risk of inadequate tissue samples with percutaneous core biopsy. Infection and bleeding complications can significantly delay the initiation of chemotherapy.

Using the National Surgical Quality Improvement Program- Pediatric (NSQIP-P) from 2012 to 2018, this study measures the 30-day complications of 454 pediatric patients undergoing laparotomy for open tumor biopsies. The overall complication rate was 12.1%, with postoperative infection (6%) and postoperative transfusion (20.8% >10cc/kg and 4.2% >25cc/kg transfused) being the most common complications. Sepsis occurred in 4% and unplanned reintubation in 3.5%.

Imposter Syndrome in Surgical Trainees: Clance Imposter Phenomenon Scale [41]. Bhama AR, et al. J Am Coll Surg 2021 Aug 9; S1072-7515(21)01230-8.

Imposter syndrome is a phenomenon whereby high-achieving individuals have a pervasive sense of self-doubt along with a fear of being exposed as a fraud. This occurs despite the presence of objective measures of success. These fears and concerns pose a threat to mental health and well-being of the individual. The prevalence of imposter syndrome and the severity of its impact has not been studied amongst general surgery residents on a large scale.

The authors evaluated general surgery residents at 6 academic general surgery resident training programs using the Clance Imposter Phenomenon Scale. A total of one hundred and forty-four residents completed the assessment with a response rate of 46.6%. A total of 47.2% of respondents were male. Most respondents (76%) were found to have either significant or severe imposter syndrome. There was no difference in scores between male and female respondents. Furthermore, there was no significant difference in scores based upon year of training (PGY-1 vs. PGY-5) or based upon USMLE or ABSITE scores. The authors concluded that imposter syndrome is prevalent amongst general surgery residents. The note that it is unable to predict which residents will be affected based upon demographics or documented academic success. Further studies evaluating the impact of imposter syndrome on resident well-being and patient outcomes are needed.

Longitudinal Outcomes for Multisystem Inflammatory Syndrome in Children [42]. Farooqi KM, et al. Pediatrics. 2021 Aug;148(2): e2021051155.

Multisystem Inflammatory Syndrome in children (MIS-C) after severe acute respiratory syndrome coronavirus 2 infection or exposure is known to result in a clinical syndrome highlighted by fever, hypotension, gastrointestinal symptoms, and findings of myocardial inflammation, requiring hospitalization in the acute phase. The authors developed a dedicated inpatient and outpatient interdisciplinary MIS-C follow-up program to monitor the cardiac and immunologic course of these patients.

Forty-five patients were admitted to a single center diagnosed with MIS-C. The median time to last follow-up was 5.8 months. Of those admitted, 76% required intensive care and 64% required vasopressors and/or inotropes. Most inflammatory markers normalized by 1 to 4 weeks, although 32% of patients exhibited persistent lymphocytosis. At 1 to 4 months, the proportion of double negative T cells remained elevated in 92% (median 9%). At 4 to 9months, only 1 child had persistent mild dysfunction. This is the first comprehensive cardio- and immune-centric report on longitudinal follow-up of multisystem inflammatory syndrome in children. The interdisciplinary follow-up program allowed for assessment of both cardiac and immunologic progression of this novel disease in a controlled and rigorous fashion. The authors concluded that most children within the cohort had rapid resolution of inflammatory and cardiac manifestations.

Contemporary General Surgery Resident Learning Experience in Pediatric Surgery [43]. Potts JR 3rd, et al. J Am Coll Surg. 2021 Oct;233(4):564-574.

Most fellowship-trained pediatric surgeons practice in medium-size urban to large metropolitan areas. There is growing concern about the availability of basic surgical care for children in the extensive ex-urban areas of the U.S. One study has suggested that 13% of individuals practicing general surgery do so in large rural, small rural or isolated areas. These general surgeons can provide care to a significant number of pediatric patients substantially contributing to their surgical care. Unfortunately, longitudinal studies have shown a decrease in the exposure of general surgery residents to pediatric surgical cases.

The authors evaluated the general surgery resident experience with pediatric surgery by analyzing information regarding pediatric surgery rotations gleaned from block schedules obtained from the ACGME and correlated that with PS operative experience of the residents. The data included the residency year of the first PS rotation, the residency years of each PS rotation, the total number of months of PS rotations, the presence of a co-located ACGME accredited pediatric surgery fellowship (PSF) program and whether the program’s PS rotations occurred in the primary teaching hospital of such a PSF program. A total of 225 residency programs met inclusion criteria. Approximately half of the programs (n=120, 53.3%) include rotations in both junior and senior years, whereas 36 (16.0%) and 69 (30.7%) offer rotations only in the junior and senior years, respectively. the median number of months that residents rotate on PS is 2. Both the number of resident years in which PS rotations are assigned and the total months residents spend on PS in a program are significantly correlated with the number of PS cases performed. The authors conclude there is a clear link between time on pediatric surgery rotations and operative experiences and recommend that pediatric surgery remain an essential content area of general surgery residency.

Randomized Trial of Fetal Surgery for Severe Left Diaphragmatic Hernia [44]. Deprest JA et al. N Engl J Med 2021 Jul 8;385(2):107-118. Epub 2021 Jun 8.

Children born with congenital diaphragmatic hernias continue to face a high mortality rate due to respiratory failure and pulmonary hypertension despite advances in both neonatal and surgical management. Severity of the diaphragmatic hernia can be assessed by evaluating for chromosomal abnormalities, the presence of other major defects as well as the fetal lung-to-head ratio. Fetuses with a quotient of observed-to-expected lung-to-head ratios of less than 25.0% are referred to as having severe pulmonary hypoplasia, and their chance of survival is less than 25%. Fetal lung growth can be obtained through tracheal occlusion during the prenatal period. Fetoscopic endoluminal tracheal occlusion (FETO) has been shown to promote lung growth as well as increase survival in the neonatal period when compared to historical controls.

The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial (www.totaltrial.eu) was designed to test the hypothesis that in fetuses with severe pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, the use of FETO, as compared with expectant prenatal care. This trial was stopped early after the third interim analysis due to efficacy. In an intention-to-treat analysis that included 80 women, 40% of infants (16 of 40) in the FETO group survived to discharge, as compared with 15% (6 of 40) in the expectant care group. Survival to 6 months of age was also identical to survival to discharge with improved survival in the FETO group. Prenatal complications including rupture of membranes was higher in women in the FETO group as well as the incidence of preterm birth. One neonatal death occurred after emergency delivery for placental laceration from fetoscopic balloon removal, and one neonatal death occurred because of failed balloon removal. The authors concluded that in fetuses with isolated severe congenital diaphragmatic hernia on the left side, FETO performed at 27 to 29 weeks of gestation resulted in a significant benefit over expectant care with respect to survival to discharge, and this benefit was sustained to 6 months of age.

Randomized Trial of Fetal Surgery for Moderate Left Diaphragmatic Hernia [45]. Deprest JA. et al. N Engl J Med. 2021 Jul 8;385(2):119-129. Epub 2021 Jun 8.

Children born with congenital diaphragmatic hernias continue to face a high mortality rate due to respiratory failure and pulmonary hypertension despite advances in both neonatal and surgical management. Severity of the diaphragmatic hernia can be assessed by evaluating for chromosomal abnormalities, the presence of other major defects as well as the fetal lung-to-head ratio. Fetuses with a quotient of observed-to-expected lung-to-head ratios of between 25% and 34.9% irrespective of liver position, or 35.0 to 44.9% with intrathoracic liver herniation, are referred to as having moderate pulmonary hypoplasia. Fetal lung growth can be obtained through tracheal occlusion during the prenatal period. Fetoscopic endoluminal tracheal occlusion (FETO) has been shown to promote lung growth as well as increase survival in the neonatal period when compared to historical controls.

The Tracheal Occlusion to Accelerate Lung Growth (TOTAL) trial (www.totaltrial.eu) was designed to test the hypothesis that in fetuses with moderate pulmonary hypoplasia due to isolated congenital diaphragmatic hernia on the left side, had increased survival with the use of FETO, as compared with expectant prenatal care. In an intention-to-treat analysis that included 196 women, 62 of 98 infants in the FETO group (63%) and 49 of 98 infants in the expectant care group (50%) survived to discharge. At 6 months of age, 53 of 98 infants (54%) in the FETO group and 43 of 98 infants (44%) in the expectant care group were alive without oxygen supplementation. Prenatal complications including rupture of membranes was higher in women in the FETO group as well as the incidence of preterm birth. The authors concluded that in fetuses with isolated moderate congenital diaphragmatic hernia on the left side, FETO performed at 30 to 32 weeks of gestation did not result in a significant benefit over expectant care with respect to survival to discharge.

Clinical and Genetic Factors impact Time to Surgical Recurrence After Ileocolectomy for Crohn’s Disease [46].Kline BP et al. Ann Surg. 2021 Aug 1;274(2):346-351.

Crohn’s disease is an inflammatory bowel disease most commonly seen in Western countries. While it can affect anywhere in the gastrointestinal tract, it most commonly affects the terminal ileum. Numerous advances have been made over the last several decades with regard to medical management including biologic therapy. Surgery is often required both for medically refractory CD and for complications of the disease, with 50% of patients requiring resection of diseased bowel within 10 years of disease diagnosis. Surgery, however, is not curative and nearly half of all patients will have a recurrence of symptoms within 10 years of surgery. No long-term study has evaluated both genetic and clinical factors to identify a severe phenotype of Crohn’s patients that would warrant more aggressive therapy.

A retrospective single center study was performed evaluating patients who had undergone at least one ileocolectomy. A total of 409 patients were include in the study with 286 patients undergoing a single ileocolectomy and 123 requiring multiple ileocolectomies. Six single-nucleotide polymorphisms (SNPs) associated with CD were evaluated in these patients: rs2076756, rs2066844, and rs2066845 in NOD2, rs4958847 and rs13361189 in IRGM, and rs2241880 in ATG16L1. The study found that an ileocolectomy in a patient with rs2066844 in NOD2 was associated with decreased time to surgical recurrence by multivariate analysis. With regard to medical therapy, individuals who received postoperative biologic therapy that were naïve to preoperative biologic therapy had a 40% decreased incidence of surgical recurrence. The authors suggest that assessing NOD2 status may be helpful in surgical and medical decision-making by identifying patients at high risk for surgical recurrence following ileocolectomy.

Actual and Potential Impact of a Home Nasogastric Tube Feeding Program for Infants Whose Neonatal Intensive Care Unit Discharge is Affected by Delayed Oral Feedings [47]. Lagatta JM et al. J Pediatr. 2021 Jul;234:38-45.e2.Epub 2021 Mar 28.

The acquisition of full oral motor skills is typically one of the many criteria used for determining appropriate discharge to home. For those children who do not achieve enteral independence with oral feeds, many are discharged home after placement of a gastrostomy tube. The use of a nasogastric tube has been introduced as an option for early discharge in children who do not achieve enteral independence with oral feeds while also avoiding the complications associated with surgical placement of a gastrostomy tube. It is believed that the use of a nasogastric tube can benefit the patient by decreasing length of stay with associated reduction in hospital costs while improving quality of life for both patients and parents.

A single center prospective cohort study was performed. Patients were enrolled from September 2018 to March 2020. Children were followed weekly to determine eligibility for discharge. Patients were then reassessed at 3 months post-discharge for acute healthcare use due to tube related issues as well as parent satisfaction. A total of 180 infants were enrolled. Eighty children reached enteral autonomy with oral feeds, 35 were discharged with NG tubes and 65 were discharged with gastrostomy tubes. Children discharged with gastrostomy tubes were shown to have more tube related or feeding related readmissions when compared with NG tubes. Quality of life was not different between the three groups at 3 months after discharge. Infants discharged home with NG tubes saved 1574 NICU days. The authors concluded that use of a home nasogastric feeding tube can decrease NICU length of stay while avoiding acute healthcare use issues seen in patients with gastrostomy tubes.

Surgical Repair of Congenital Diaphragmatic Hernia After Extracorporeal Membrane Oxygenation Cannulation: Early Repair Improves Survival[48]. Dao DT. Ann Surg. 2021 Jul 1;274(1):186-194.

Children born with congenital diaphragmatic hernias continue to face a high mortality rate despite advances in both neonatal and surgical management. Approximately 30% of these children will require management with extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support. Timing of repair, especially for children who are placed on ECMO, remains controversial with no clear consensus management based upon current literature. The authors of this manuscript seek to determine whether repair during ECMO or after ECMO is proven to be beneficial. Additionally, they seek to answer whether early or late repair while on ECMO is beneficial.

A retrospective, multi-center cohort study using the Congenital Diaphragmatic Hernia Study Group (CDHSG) was performed. The study included 2 aims: comparing the survival of those repaired on ECMO versus after ECMO and comparing the survival of those who underwent early versus late repair on ECMO. A propensity scoring system was utilized. This was performed to allow children who did not undergo repair to be included in the analysis as it was felt exclusion of these patients would have a significant selection bias. Children who had repair during ECMO therapy demonstrated a lower mortality rate and lower incidence of non-repair, 5.9% vs. 33.8% when compared to children who underwent repair after ECMO. When evaluating repairs performed on ECMO, children who had an early repair had a lower mortality rate and lower incidence of non-repair. The authors concluded that early repair following ECMO cannulation was associated with improved survival when compared to delayed surgical correction.

A Real-time Risk-Prediction Model for Pediatric Venous Thromboembolic Events[49]. Walker SC. Pediatrics. 2021 Jun;147(6):e2020042325.

Hospital-associated venous thromboembolism (HA-VTE) is a rare complication in the pediatric population. Despite its low incidence, the rate of HA-VTE has been shown to be increasing annually and can have significant long-term morbidity associated with its presence. Much of the management and treatment recommendations for pediatric HA-VTE have been extrapolated from adult data. Pediatric patients have risk factors for hospital-associated venous thromboembolism events that are different from adults, and these risks are not well captured by an existing risk prediction model based on patients’ characteristics available at hospital admission. The authors sought to develop a predictive model to determine which children will be at increased risk for the development of HA-VTE.

This study utilized admissions to a single institution from January 1, 2010, through October 31, 2017. Potential variables were identified a priori. The derivation cohort included 111 352 admissions. The model was subsequently validated by using a separate cohort with 44 138 admissions. Variables strongly associated with HA-VTE include the history of thrombosis, presence of a central line, and patients with cardiology conditions. Eleven variables were included, which yielded excellent discriminatory ability in both the derivation cohort (concordance statistic = 0.908) and the validation cohort (concordance statistic = 0.904). The authors concluded that they developed and validated a general pediatric HA-VTE risk-prediction model that can be automatically calculated from the electronic medical record and available on admission. They anticipate that this will improve the detection of high-risk patients before HA-VTE events occur.

Delayed Administration of Antibiotics Beyond the First Hour of Recognition Is Associated with Increased Mortality Rates in Children with Sepsis/Severe Sepsis and Septic Shock[49]. Sankar J. J Pediatr 2021 Jun;233:183-190.

Severe sepsis and septic shock remain significant causes of morbidity and mortality in the pediatric population. Reported mortality rates range from 25% to 50% for children with septic shock. Early diagnosis and rapid treatment including the use of antibiotic therapy are the mainstays of treatment. Current guidelines recommend the provision of antibiotic therapy within one hour of the diagnosis of septic shock for all patients and within 3 hours for children with sepsis-associated organ dysfunction without associated shock. The authors sought to compare outcomes of mortality, ventilator-free days, and hospital-free days in children with sepsis, severe sepsis, or septic shock who received antibiotics within the first hour of recognition those who received antibiotics after the first hour.

A single-institution prospective cohort study was performed from June 2017 through September 2019. A total of 441 patients were enrolled with 200 in the early administration group (antibiotics within 1 hour of diagnosis) and 241 in the delayed administration group. About three-fourths (77%) of the 441 children enrolled had septic shock. Children in the delayed group had significantly higher odds of mortality than those in the early group (29% vs 20%). The time to shock reversal was significantly shorter, and the ventilator-free days and hospital-free days were significantly greater, in the early antibiotic group. There was no difference between the groups with regard to any of the other clinical outcomes. The authors recommended that antibiotics should be provided within one hour of diagnosis for children with sepsis, severe sepsis, and septic shock.

Effect of Posterior Tracheopexy on Risk of Recurrence in Children after Recurrent Tracheo-Esophageal Fistula Repair [50], Kamran et al. J Am Coll Surg. 2021 May;232(5):690-698.

Recurrent trachea-esophageal fistulas (TEF) occur in approximately 10-15% of children after initial repair of esophageal atresia (EA) and TEF. Multiple strategies for the management of recurrent TEF have been proposed including endoscopic therapy using cauterization, sclerosants, or injection of adhesive into the fistula. Operative repairs include positioning of a vascularized piece of tissue between the esophagus and trachea. The authors describe their use of a posterior tracheopexy in the management of children with recurrent TEF.

A retrospective review of children with recurrent TEF managed by posterior tracheopexy at two institutions was performed. A total of 62 patients were included in this study over a 10 year period. The children underwent repair of the recurrent TEF with a posterior tracheopexy and rotational esophagoplasty described within the manuscript. Of these patients, 29 had an associated esophageal stricture that required surgical treatment. Children who underwent posterior tracheopexy with rotational esophagoplasty were noted to have complete resolution of preoperative symptoms and no recurrence of the fistula with a median follow-up of 2.5 years. Reported morbidity was low with an anastomotic leak reported in 3 patients and 1 patient was noted to have a temporary vocal cord dysfunction. The authors conclude that posterior tracheopexy and rotational esophagoplasty should be offered as a primary treatment of recurrent TEF given the low recurrence rate when compared with other treatment strategies.

Management of Gastroschisis: Results From the NETS2G Study, a Joint British, Irish, and Canadian Prospective Cohort Study of 1268 Infants [51] , Allin et al. Ann Surg. 2021 Jun 1;273(6):1207-1214.

Gastroschisis is one of the most common congenital anomalies encountered by a pediatric surgeon. Several options are available for the initial management of the fascial defect. Two options include primary closure and silo reduction. Primary closure (PC) involves reduction of the abdominal contents within the first 24 hours with suture closure of the fascia. Silo reduction (SR) is defined as the use of a silo to facilitate delayed closure, defined as a closure that takes place more than one day after birth. The aim of this study was to utilize existing prospectively collected databases to determine which patients with gastroschisis should receive either PC or SR as the primary means of abdominal wall closure.

This study utilized data collected prospectively by 3 population-based systems, the British Association of Pediatric Surgeons Congenital Anomalies Surveillance System (BAPS-CASS), the Canadian Pediatric Surgery Network (CAPSNet), and the Canadian Neonatal Network (CNN). A total of 1600 patients with gastroschisis were identified during the study period, of these 1268 patients were included. PC was performed in 671 patients and SR was performed in 597 patients. The study revealed that use of SR in infants without intestinal necrosis, perforation, or matting was associated with an approximately 75% reduction in the incidence of severe gastrointestinal complications in the first 28 days of life. However, these patients were noted to have a 40% increase in the number of operations, a doubling in the risk of experiencing 1 or more infections, and potentially an 8% increase in the number of days on which PN. In children noted to have intestinal perforation necrosis or matting, the use of SR was associated with a 30% increase in the number of operations infants undergo in the first 28 days of life, and potentially a 6% increase in the number of days on which they receive PN, but no reduction in the number of severe gastrointestinal complications. The authors concluded SR appears to be the most appropriate treatment for children with gastroschisis without intestinal perforation, necrosis or matting. In children with intestinal necrosis, perforation or matting it seems that PC is the operation of choice, as there are demonstrable benefits to its use, but no demonstrable drawbacks.

Association of Cryoprecipitate Use With Survival After Major Trauma in Children Receiving Massive Transfusion [52], Tama et al. JAMA Surg 2021 May 1;156(5):453-460.

Trauma is the leading cause of death for children in the United States. Hemorrhage is one of the leading causes of trauma-associated mortality, second only to head injury. Massive transfusion protocols (MTP) have come to the forefront in the management of traumatically injured pediatric patients with massive blood loss. MTPs attempt to provide patients with blood products in a ratio similar to whole blood. While most MTPs incorporate cryoprecipitate, evidence to support its use has only been shown in adult studies. This study attempts to define the effects of cryoprecipitate use in MTP on mortality when transfused within the first 4 hours.

A retrospective, multi-center cohort study using the Pediatric Trauma Quality Improvement Program Database was performed. Pediatric patients, defined as age 18 or younger, who received a massive transfusion defined as greater than 40ml/kg of blood products within the first four hours after emergency department arrival were included. The study evaluated mortality at 24 hours, comparing patients who received cryoprecipitate as part of the MTP within the first 4 hours with those who did not. A propensity scoring system was utilized. A total of 1948 patients were included in the study, of whom 547 received cryoprecipitate within the first 4 hours. After propensity score weighting, patients who received cryoprecipitate within the first four hours as part of a massive transfusion protocol were found to have a lower mortality rate at 24 hours. Additionally, patients who sustained penetrating injury as well as received greater than 100ml/kg of blood products had a lower mortality rate at 7 days. This study supports the use of cryoprecipitate as part of a massive transfusion protocol.

Influence of Oral Antibiotics Following Discharge on Organ Space Infections in Children With Complicated Appendicitis [53] , Anandalwar et al. Ann Surg 2021 Apr 1;273(4):821-825.

Appendicitis is very common in the pediatric population and approximately 30% of children with appendicitis have complicated appendicitis which puts them at significant risk for post-operative organ space infection. Data regarding the appropriate duration of antibiotics and the potential benefit of oral antibiotics at the time of discharge have been conflicting. This study sought to assess the potential risks and benefits of oral antibiotics at the time of discharge following complicated appendicitis.

Using retrospective data obtained from 17 hospitals that contributed to the NSQIP-P Appendectomy Pilot Collaborative Project and the PHIS database, study subjects were identified as children undergoing appendectomy between January 1, 2013, and June 30, 2015, and who met the criteria for having complicated appendicitis. Children who were discharged home on IV antibiotics and/or who underwent imaging that demonstrated OSI during their index stay were excluded from the study. Ultimately 711 patients were included; there was a slight male predominance and the median age was 10 years. The overall rate of postdischarge OSI was 5.2% with a higher risk in children discharged after a prolonged (> 6 days) length of stay and >1 intraoperative finding of complication appendicitis. Patients discharged home on oral antibiotics demonstrated a trend toward lower OSI rate (4.4% vs 6.2%). In patients with the high severity of disease, oral antibiotics at discharge were associated with a 61% reduction in odds of developing OSI (4.3% vs 10.5%). While the addition of oral antibiotics demonstrated a reduction in OSI, it did not show a similar decrease in the rate of revisits. The authors conclude that discharge on oral antibiotics may be beneficial for children with more severe complicated appendicitis. They suggest that further studies are necessary to better identify the patients who would most benefit from oral antibiotics.

Multisystem Inflammatory Syndrome in Children Mimicking Surgical Pathologies [54], Gerall et al. Ann Surg 2021;273:e146-e148.

Now that we are more than a year into the COVID-19 pandemic we know that children rarely become severely ill from the infection. However, we also now know that children can develop a severe hyperinflammatory state following COVID-19 infection, Multisystem Inflammatory Syndrome in Children (MIS-C). The authors sought to educate on common presentations of MIS-C and how they can mimic the presentations of common surgical diagnoses in children.

The authors provided two case examples of children presenting with symptoms similar to common surgical diagnoses in children (appendicitis and ovarian torsion) who ultimately were diagnosed with MIS-C. They described their experience caring for 44 children with MIS-C including that 95.5% of these children presented with GI symptoms. The children presenting with abdominal pain most frequently had right lower quadrant pain mimicking appendicitis. The authors suggest that surgeons should keep MIS-C in their differential diagnosis when evaluating a child for abdominal surgical pathologies. They recommend that rash, tachycardia and/or hypotension, and elevated inflammatory markers out of proportion to the degree of inflammation seen on imaging may indicate MIS-C and should prompt testing for SARS-CoV-2 infection and antibodies.

Fish Oil Emulsion Reduces Liver Injury and Liver Transplantation in Children with Intestinal Failure-Associated Liver Disease: A Multicenter Integrated Study [55], Gura et al. Peds 2021 Mar;230:46-54.e2

Children who require prolonged parental nutrition for intestinal failure are at risk for developing intestinal failure-associated liver disease (IFALD), which can lead to end-stage liver disease requiring liver transplantation. IFALD has been linked to soybean oil intravenous lipid emulsions (SOLE). In comparison to SOLE, children who receive fish oil intravenous lipid emulsions (FOLE) have an early resolution of cholestasis and had no evidence of essential fatty acid deficiency or growth failure.

This is a multicenter analysis of 189 children who received FOLE and 73 who received SOLE, comparing resolution of cholestasis, time to liver transplantation, number of patients undergoing liver transplantation, and mortality. Biochemical markers of liver injury and adverse events were also examined. FOLE recipients experienced resolution of cholestasis more often than SOLE recipients. The median APRI (aspartate aminotransferase to platelet ratio index) score at baseline, resolution of cholestasis, and at the end of study improved in FOLE recipients, but worsened in SOLE recipients. Although the PELD score was higher for FOLE recipients, fewer underwent liver transplantation compared to SOLE recipients. There was no difference in mortality. This study demonstrates that for children with IFALD, FOLE is the preferred intravenous lipid emulsion.

Early Vasopressor Administration in Pediatric Blunt Liver and Spleen injury: An ATOMAC+ Study [56], Notrica et al. J Pediatr Surg. 2021 Mar;56(3):500-505

Adult studies have shown that early vasopressor use in traumatic injuries is associated with higher short-term mortality rates. End-organ damage may result from decreased perfusion secondary to vasoconstriction when vasopressors are given for hemorrhagic shock without aggressive crystalloid resuscitation. However, vasopressor use for abdominal injuries may reduce hemorrhage by splanchnic vasoconstriction. Polytrauma patients with traumatic brain injury often require vasopressor use to maintain cerebral perfusion.

This is the first multicenter study to assess early vasopressor use in children with blunt liver and spleen injuries. 1004 children under age 18 were included from ten Level 1 pediatric trauma centers in the ATOMAC + group, and 65 of those received vasopressors. Children given their first vasopressor dose at any time within the first 48 hours had more than seven times increased odds of mortality (adjusting for blood loss, hypotension, severe TBI, and cardiac arrest). Other risk factors associated with mortality were hypotension in the Pediatric Trauma Center Emergency Department (PTC ED) and GCS less than 8 at the first ED where the patient presented. Three vasopressor administration timing cut points were identified by Kaplan-Meier survival analysis. Vasopressor given within one hour after was a significant independent risk factor for mortality. There was no associated risk for patients who received vasopressors within 1-2.5 hours from injury or later. Risk factors for failure of non-operative management (NOM) included spleen injury grade >3 and initiation of massive transfusion protocol; vasopressor use was not a risk factor. No patients died when vasopressors were initiated later than 12 hours post-injury. Early vasopressor use, particularly in the first hour after injury, should be avoided in children with blunt traumatic injuries. Outcomes of

Bariatric Surgery in Older Versus Younger Adolescents [57], Ogle et al. Pediatrics. 2021 Mar; 147(3):e2020024182

Obesity rates in children continue to rise, with an increasing number of children developing chronic diseases of adulthood (such as hypertension and type 2 diabetes). Metabolic and bariatric surgery (MBS) is an effective and durable treatment for obesity, particularly because medical and lifestyle interventions may be difficult to sustain and the percent weight loss is lower. MBS in adolescents has shown similar weight loss and superior comorbidity resolution compared to adults.

This is a multicenter prospective observational study of 242 adolescents who underwent MBS (vertical sleeve gastrectomy or Roux-en-Y gastric bypass). Participants were divided into two age groups: younger (13-15 years) and older (16-19 years) adolescents and followed up to 5 years after surgery. The mean baseline BMI was 52.6. Younger and older adolescents had a similar percent BMI change 5 years after surgery. The remission of hypertension and dyslipidemia was similar by age group. Younger adolescents were less likely to achieve remission of type 2 diabetes compared with older adolescents. The prevalence of micronutrient abnormalities (ferritin, transferrin, vitamin B12, vitamin A) was also examined. Younger adolescents were less likely to have elevated transferrin and low vitamin D levels. For each group, quality-of-life measures improved significantly by 6 months and there were no differences by age. Adolescent children who suffer from obesity and its complications can benefit from MBS and should be considered candidates even if they are of younger age.

Prenatal Repair and Physical Functioning Among Children With Myelomeningocele [58], Houtrow et al. JAMA Pediatr 2021 Feb 8; e205674.

Myelomeningocele (MMC) is a form of spina bifida associated with hydrocephalus, hindbrain herniation, and motor dysfunction. The Management of Myelomeningocele Study (MOMS) trial demonstrated that at 12 to 30 months of age, children who underwent a prenatal MMC repair have a lower rate of hydrocephalus and hindbrain herniation as well as improved motor function compared to standard postnatal repair.

This report is a secondary analysis of 154 children from the MOMS trial. In this study, the authors compared the functional mobility and motor levels of school age children (five to 10 years of age) between those who underwent standard postnatal MMC repair and prenatal MMC repair. When compared to those who underwent postnatal repair, children who underwent a prenatal repair were more competent with self care skills and were twice as likely to be community ambulators. In addition, those who underwent a prenatal MMC repair performed a 10-meter walk test faster, had better gait quality and could perform higher-level mobility skills. This secondary analysis of the MOMS trial demonstrates that the improved motor function reported early in life in the original MOMS trial persists into school age children, reinforcing the benefit of prenatal MMC repair.

Increased Incidence of Inflammatory Bowel Disease after Hirschsprung Disease: A Population-based Cohort Study [59], Bernstein et al. J Pediatr 2021 Feb 2;S0022-3476(21)00094-9

Hirschsprung Disease Associated Enterocolitis (HDAE) presents in approximately 50% of children with Hirschsprung Disease (HD). While HDAE may develop at any point either before or after a pullthrough has been performed, most cases occur before five years of age. While children may “outgrow” HDAE, inflammatory bowel (IBD) disease may develop in this population later in life. The incidence of IBD in persons with HD is unknown.

Bernstein et al. explored population-based datasets from three Canadian provinces to determine the incidence of IBD among individuals previously diagnosed with HD. Of the 719 reported patients diagnosed with HD in Ontario dating back to 1991, 2.5% ultimately developed IBD. The incidence of IBD among those who were not previously diagnosed with HD was only 0.2%. The authors concluded that within Ontario, children diagnosed with HD had a 12-fold increased risk of developing IBD. Similarly, using a case control study design applied to smaller datasets for Alberta and Manitoba, the authors found that persons with IBD were 25 to 40 times more likely to have had HD, compared to matched controls. The mean age at IBD diagnosis was 7.5 years and Crohn disease was more frequently diagnosed than ulcerative colitis. While HDAE is common early in life among those with HD, IBD should be considered among patients beyond a few years of age who have gastrointestinal issues as the management is drastically different.

Fertility preservation for female patients with childhood, adolescent, and young adult cancer: recommendations from the PanCareLIFE Consortium and the International Late Effects of Childhood Cancer Guideline Harmonization Group [60], Mulder et al. Lancet Oncol. 2021; 22: e45-56 PMID: 33539754

Survival rates for children and adolescents diagnosed with cancer have increased dramatically over the past four decades with five-year survival rates now exceeding 80%. Late effects of radiation and chemotherapy may manifest as reduced fertility and premature gonadal insufficiency. Female fertility preservation options include embryo cryopreservation, oocyte cryopreservation, ovarian tissue cryopreservation (OCT), oophoropexy and hormone suppressive therapy.

The authors provide clinical practice guidelines for fertility preservation in females with childhood, adolescent and young adult cancers using GRADE Evidence to Decision frameworks. The panel agreed that all children and adolescents with cancer have the right to be informed about the potential risks of infertility and premature ovarian insufficiency associated with anticipated radiation and chemotherapy treatment. The panel emphasized a shared decision making model when determining the method of fertility preservation dependent on pubertal status, individual cancer diagnosis, urgency of treatment, geographical and financial access to fertility preservation services. The panel recognized that oocyte cryopreservation may be more pragmatic for adolescents as they are unlikely to have a sperm donor for embryo cryopreservation but recognizes the limitations of oocyte cryopreservation including delay in therapy. The panel reported a moderate recommendation for oocyte or embryo cryopreservation for patients receiving low-dose alkylating agents, cranial radiotherapy or undergoing unilateral oophorectomy. A moderate recommendation was made by the panel to offer OCT for both pre- and postpubertal patients as standard of care for those at high-risk, but not low-risk, of infertility. The panel considered autotransplantation as the only mechanism to utilize cryopreserved tissue to restore fertility. The panel also recognized the risks of potential reintroduction of malignant cells during autotransplantation, specifically those with the diagnosis of leukemia, Hodgkin lymphoma or metastasized solid tumors as well as the limited data for transplantation of cryopreserved prepubertal ovarian tissue. For high-risk patients who receive ovarian radiotherapy, the panel reported a moderate recommendation for oophoropexy prior to initiation of radiation. The panel recognizes the gap in knowledge in fertility preservation outcomes and further research in this field.

Risk of Hematologic Malignant Neoplasms From Abdominopelvic Computed Tomographic Radiation in Patients Who Underwent Appendectomy [61]. Lee et al. JAMA Surg epub January 2021.

Several epidemiologic studies have shown an association between radiation exposure from computed tomographic (CT) scans and subsequent development of malignancy later in life. This has prompted an effort to minimize radiation exposure and preferential use of ultrasound for imaging for appendicitis. Concern with previous studies have been raised due to several confounding variables and potential bias as well as an inability prove true causal association. Studies addressing these potential concerns would be beneficial to prove a causal association.

This is a national study in Korea evaluating 825,820 patients with a median age of 28 years who underwent appendectomy from 2005 through 2015. Individuals with pre-existing malignancies prior to appendectomy, an increased risk of malignancy or previous CT scans were excluded. Patients were divided into CT exposed and CT unexposed cohorts based upon undergoing examination with abdominopelvic CT from seven days before to seven days after appendectomy. The primary outcome was occurrence of a hematologic malignancy. The authors noted an increased use of CT scans during the study period with a rate of 10.7% of patients in 2005 and 45.1% in 2015. A total of 823 patients developed a hematologic malignancy. Leukemia and lymphoma were the most common hematologic malignancies. The incidence rate ratio was increased for all hematologic malignancies in individuals in the CT exposed group. When divided by specific malignancy this also remained true for leukemia. These risks were greatest in the pediatric population - specifically in the age range 0 to 15 years. There was no difference in rate of abdominopelvic organ cancers. This study provides further evidence regarding the risk of malignancy in individuals undergoing CT scan for appendectomy.

Variation in Oophorectomy Rates for Children with Ovarian Torsion across US Children’s Hospitals [62]. Lipsett et al. J Pediatrics 2020 Dec 17.

Pediatric ovarian torsion is rare and most commonly treated by pediatric surgeons rather than gynecologists. Despite low concern for malignancy in this age and the potential for a necrotic appearing ovary to regenerate, the rate of oophorectomy after pediatric torsion is high - up to 78% in some series. The American College of Obstetricians and Gynecologists recommends minimally invasive detorsion and ovarian preservation in all cases, unless oophorectomy is unavoidable, for example when a severely necrotic ovary falls apart.

A Pediatric Health Information System (PHIS) database analysis of 48 US children’s hospitals from 2012 to 2017 looked at 1783 operative cases of ovarian torsion. Encouragingly, the rate of oophorectomy decreased over time, from 36% in 2012 to 17% in 2017. However, there was marked variability in oophorectomy between institutions ranging from the low single digits to well over 50%. Strong predictors of oophorectomy included preadolescence, complex chronic conditions and public insurance. After risk adjustment, pediatric surgeons did not have significantly higher odds of oophorectomy than gynecologists. This study should be viewed as good news—but also as a reminder to continue efforts to drive down rates of unnecessary oophorectomy after torsion.

Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants [63]. Kirpalani et al. NEJM 2020 Dec 31.

Trials of restrictive red blood cell transfusion practices across all age groups in children and adults have generally shown equivalent or improved outcomes with lower hemoglobin targets. In the neonatal intensive care unit, a prior multicenter randomized controlled trial in 451 extremely low birth weight neonates (PINT Study) found no difference in death, retinopathy, bronchopulmonay dysplasia or brain injury upon discharge home for restrictive versus liberal transfusion strategies. However, a post-hoc secondary analysis of two-year neurodevelopmental outcomes suggested a benefit in the liberal threshold group.

This much larger multicenter RCT of lower transfusion thresholds in 1824 ELBW infants looked at two-year neurodevelopmental impairment or death as the primary outcome measure. Hemoglobin targets were specified on a sliding scale based on age and physiology, ranging from 7 to 11 g/dL in the restrictive group and 10 to 13 g/dL in the liberal group. There were no differences in serious adverse events, survival at discharge and death or neurodevelopmental impairment at two years. A similar large European study also published in 2020 had the same finding. While research looking at optimal tailoring of transfusion to individual physiology is ongoing, this study likely provides the definitive answer in favor of restrictive red blood cell transfusion practices in ELBW neonates.

Management of Central Venous Access in Children with Intestinal Failure: A Position Paper from the NASPGHAN Intestinal Rehabilitation Special Interest Group [64]. Wendel et al. J Pediatr Gastroenterology and Nutrition 2020 Dec 30.

Children with intestinal failure require long term access for parenteral nutrition. As hepatotoxicity from parenteral nutrition has greatly improved over time, inability to preserve central venous access has become one of the most common indications for intestinal transplantation.

The North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Intestinal Failure Special Interest Group conducted a literature review and created guidelines on central venous access in intestinal failure. Tunneled, single lumen, internal jugular or subclavian, cuffed silicone catheters of the smallest reasonable diameter should be used. Meticulous dressing changes using a chlorhexidine-impregnated disk are recommended. Prophylactic ethanol lock therapy should be considered in children who have ever had a catheter associated blood stream infection. Damaged catheters should be repaired rather than replaced if possible and catheter related thromboses or fibrin sheaths should be treated with fibrinolytics, anticoagulation or stripping as appropriate, rather than replacement. If removal is necessary, replacement over a wire at the same site should be considered except in the case of infection.

Public Perception of General Surgery Resident Autonomy and Supervision [65], Dickinson et al, J Am Coll Surg. 2021 Jan;232(1):8-15.

Patients are an integral part of the resident training experience for all medical specialties. Surgical training is dependent upon interaction with patients in and out of the operating room for residents to obtain the technical skills to be become proficient as surgeons. Despite the fact that patients are stakeholders in the training of residents, input from patients has rarely been used in the redesign of resident education. While smaller studies have looked at patient perception regarding resident autonomy and involvement in surgical care, these studies are limited to established patients and may not reflect the beliefs of the general United States population. To address these issues the authors sought to obtain the perception of a random sample of individuals with regards to resident involvement in their surgical care.

The authors used SurveyGizmo to send an anonymous electronic survey to adult panelists older than 18 years of age. The survey response rate was 93% with 2,005 individuals completing the survey. The majority (87%) of respondents had health insurance and half of respondents were younger than 40 years of age. Fifty-seven percent of respondents were female. The remainder of demographic characteristics with regard to race, age, gender were nationally representative. The authors found that the majority of the respondents (93%) were comfortable with resident participation in their operation and were most comfortable with senior resident involvement. Several important factors were identified however as one-third of respondents felt that their risk of complication was greater with resident involvement and a similar percentage were not comfortable with residents performing the case without attending supervision. On multivariable analysis, factors associated with participants who would never allow a resident to perform any portion of the procedure included female gender, Black race, Hispanic ethnicity and those individuals without health insurance. This study shows that the general US population does not universally accept resident autonomy for surgical procedures. Future efforts should be directed to education and involvement in this important stakeholder population when developing resident training programs.

Development and Assessment of a Systematic Approach for Detecting Disparities in Surgical Access [66], Wong et al, JAMA Surg. 2020 Dec 16:e205668.

Disparity in healthcare is related to multiple factors - one of which is access to appropriate care in a timely fashion. Surgical access to care has been shown to be dependent upon numerous factors including race/ethnicity, socioeconomic status and willingness to undergo surgical procedures. Limited access to surgical care has been shown to be closely related to surgical healthcare disparities. Determining the burden of surgical disease in any population can be difficult and is typically based upon procedures performed and does not account for surgical conditions that do not lead to a surgical procedure. The authors utilize a novel approach to define expected utilization of surgical services to determine whether this can be used to detect potential disparities in surgical access in North Carolina.

The authors utilized the University of Wisconsin Population Health Institute Robert Wood Johnson Foundation to define the health rankings of the 100 counties in North Carolina. Those having high rankings were deemed to be “healthier” when compared to lower ranking counties. The five highest ranked counties (HRC) were used as a reference and compared to the five lowest ranked counties (LRC) with regards to surgical access. A total of 28,924 inpatient general surgery procedures were performed in the 10 counties during the study period. Of these, 4521 were performed in the five LRCs. Residents in the five LRCs were noted to be 40% more likely to undergo an urgent or emergent inpatient general surgical procedure than residents in the five HRCs. Residents in the five LRCs were also noted to be less likely to undergo an elective surgical procedure such as bariatric surgery when compared to a HRC. This manuscript provides a framework by which surgical access can be evaluated to determine whether disparity exists across a population for specific surgical conditions.

Safety and Efficacy of the BNT162b2 mRNA Covid-19 Vaccine [67], Polack et al.N Engl J Med 2020 Dec 31;383(27):2603-2615.

Severe acute respiratory coronavirus 2 (SARS-CoV-2) has infected millions of individuals during the worldwide pandemic. Efforts to produce a safe and effective vaccine against this novel virus have been ongoing in an effort to contain the pandemic and to avoid the medical and economic consequences of ongoing infection. Previous studies have reported safety in phase 1 trials of nanoparticle formulated, nucleoside-modified RNA (BNT162b2) vaccines.

This study reports the safety and efficacy findings of the phase 2 and 3 part of the global trial evaluating the safety and efficacy of the same vaccine. This trial evaluated the outcomes after administration of two 30 μg doses of BNT162b2 vaccine in individuals older than 16 years of age. This was a 1:1 trial with individuals receiving two doses of the vaccine separated by 21 days or two doses of saline placebo. Outcomes of the trial included efficacy of the vaccine against severe Covid-19 and safety of the vaccine. A total of 43,548 individuals underwent randomization with 43,448 individuals receiving injections – 21,720 received the vaccine and 21,728 received placebo. There were eight cases with onset after seven days of the second dose in individuals receiving the vaccine compared to 162 cases in individuals receiving placebo. The safety profile was characterized by short term pain at the injection site, fatigue and headache. Four serious adverse effects were documented in the vaccine groups. While two patients receiving the vaccine and four patients receiving placebo died during the trial, no deaths were attributed to the vaccine. This trial shows the short term efficacy and safety of the BNT162b2 vaccine against Covid-19.

Diversity, Equity, and Inclusion: A strategic priority for the American Pediatric Surgical Association [68], Morrison et al. J Pediatr Surg 2020 Dec 8.

The majority of children in the United Staes are from minority populations - many of which are underprivileged or underrepresented. There is a broad body of research demonstrating poorer healthcare outcomes in these populations in medicine as a whole, in pediatrics and in children’s surgery. Furthermore, racial and ethnic concordance between health care providers and their patients is associated with better outcomes and diverse organization in a wide variety of fields tend to have increased innovation, fewer blind spots and better results. APSA recognizes that its membership and leadership are not reflective of the broad demographic, cultural and cognitive diversity of the United States population.

The APSA Board of Governors has set out on a strategic initiative committed to advancing diversity, equity, and inclusion (DEI) in all aspects of pediatric surgery. It has adopted “Equity and Social Justice” as a fifth pillar of the APSA mission statement and “Inclusion, representation, and participation for all” as the foundation of the five pillars. It created a standing DEI committee to guide this ongoing process. APSA has endorsed a series of position statements published here that promote diversity in pediatric surgery from the medical student to faculty, organizational and leadership levels, recognize and combat implicit as well as explicit bias and work to eliminate outcome disparities in pediatric surgery due to social determinants of health.

Factors Associated With the Professional Success of Female Surgical Department Chairs A Qualitative Study [69], Columbus et al. JAMA Surg 2020 Nov 1;155(11):1028-1033.

There has been a continued increase in the number of female surgeons in the workforce in the United States. In 2017, 51% of first year medical students were female and 40% of surgical residents were female. Despite this positive trend, female surgeons remain underrepresented in leadership roles. Known barriers to professional advancement include lack of mentorship, work life balance concerns and stress, gender bias, structural challenges, sexual harassment and job dissatisfaction. This study sought to identify common themes associated with career success in females in surgical leadership positions.

Twenty female chairs of an identified twenty six current or former chairs of academic departments participated in a semistructured interview conducted by an interview guide. Sixteen of the participants were active department chairs and four were former chairs. The mean length of time serving as chair was 5.6 years. The main outcome was to determine common themes that allowed for career success to reach a leadership role. These factors were identified as internal or external factors. Internal factors such as adaptability, confidence, resilience and selflessness were associated with success. External factors such as support from mentors of both sexes as well as institutional factors including gender norms on institutional and cultural levels affected the success of the individual. These findings can be used to assist towards developing internal strengths along with institutional and work system redesign to facilitate career success in female surgeons.

Guidelines for Opioid Prescribing in Children and Adolescents after Surgery. An Expert Panel Opinion [70]. Kelley-Quon et al. JAMA Surg 2020 Nov 11. doi: 10.1001/jamasurg.2020.5045.

Opioids are commonly prescribed to children and adolescents following surgical procedures. Opioid misuse in adolescents is associated with later opioid use and high risk behavior that persists into adulthood. Prescription narcotics remain the leading reason for excess opioid pills that are available in children’s homes. Efforts to promote opioid stewardship have been instituted at numerous institutions across the nation, however, no evidence based guidelines for opioid prescribing following surgical procedures exists. The authors sought to assemble a diverse group of health professionals who participate in the perioperative care of children to develop a framework for evidence based opioid prescribing patterns in children.

What this study adds

Twenty guidelines were created from a two day in person meeting and subsequent review by pediatric surgical specialists. The authors underscored the following three primary themes in guideline creation: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery. This manuscript provides well defined recommendations for responsible opioid prescribing patterns and management of pediatric patients in the perioperative period.

Severe Acute Respiratory Syndrome Coronavirus 2 Clinical Syndromes and Predictors of Disease Severity in Hospitalized Children and Youth [71], Fernandes et al. J Pediatr 2020 Nov 13:S0022-3476(20)31393-7.

COVID-19, the disease associated with SARS-CoV-2, has been shown to predominantly affect adults although there have been numerous case series that have shown children may also be affected with severe disease. These series have shown that children may develop a respiratory disease similar to adults as well as multisystem inflammatory syndrome - designated MIS-C. Much remains unknown about the full spectrum of disease in children. This study sought to define the spectrum of disease, clinical course and outcomes of children hospitalized with SARS-CoV-2 infections as well as to identify prognostic factors for becoming critically ill during hospitalization.

A retrospective, multicenter review of children (defined as age 22 or younger) was performed including children with laboratory confirmed SARS-CoV-2 infection or MIS-C at eight hospitals in New York, New Jersey or Connecticut (areas delineated as an early epicenter of the virus). A total of 315 children were identified as having the virus during the study period with 34 patients excluded due to being hospitalized for reasons unrelated to the infection leaving a final cohort of 281 patients. The majority of patients had respiratory disease. Twenty-five percent of the patients had MIS-C. The children with MIS-C were more likely to identify as nonHispanic black when compared with children with respiratory disease. Obesity and hypoxia on admission were factors predictive of severe respiratory disease. Additionally, lower absolute lymphocyte count and higher CRP on admission were predictive of severe MIS-C. In this study, race/ethnicity or socioeconomic status were not predictive of disease severity.

Effects of Liberal vs Restrictive Transfusion Thresholds on Survival and Neurocognitive Outcomes in Extremely Low-Birth-Weight Infants: The ETTNO Randomized Clinical Trial [72], Franz et al. JAMA 2020 Aug 11;324(6):560-570.

Standardized transfusion thresholds are not established in extremely low birth weight (ELBW) neonates with transfusions provided based upon clinical symptoms. Restrictive transfusion thresholds have been adopted in both adult and pediatric intensive care units. Recent studies have suggested that a restrictive transfusion threshold in the ELBW infant increases the risk of long -term cognitive impairment.

This multi-institutional randomized controlled trial was conducted evaluating the outcomes of ELBW infants assigned to a liberal or restrictive transfusion protocol. Transfusion triggers were a hematocrit of 28% for the liberal transfusion group and 21% for the restrictive transfusion group. The trial enrolled 1013 patients, with 928 patients completing the trial. Median volume transfused was 40 mL (IQR, 16-73 mL) vs 19 mL (IQR, 0-46 mL) for the liberal and restrictive groups respectively; and weekly mean hematocrit was 3 percentage points higher with liberal thresholds. There were no statistical differences noted in the rate of death or cognitive impairment between the two groups. The authors concluded that a liberal transfusion threshold does not decrease the risk of death or cognitive disability at 24 months corrected age.

Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis [73], Minneci et al. JAMA 2020 Jul 27;324(6):581-593.

Although studies in children have shown the success of nonoperative management when compared to appendectomy, appendectomy remains the most common treatment in children. This study sought to evaluate the success rate and effect of nonoperative management on health-related quality of life, disability days and patient satisfaction.

This multi-center, prospective, nonrandomized trial was performed evaluating appendectomy versus nonoperative management. Inclusion criteria included uncomplicated appendicitis by imaging of an appendix with a diameter of 1.1 cm or less and no abscess, fecalith or phlegmon; white blood cell count between 5000 and18000/μL; and abdominal pain for less than 48 hours prior to the start of antibiotics. The study enrolled 1068 patients with 370 selecting to participate in the nonoperative management group. Nonoperative management was successful in 67.1% of children at one year of follow-up. In the nonoperative management group, it was noted that they had fewer patient disability than the surgical group (6.6 vs. 10.9 days).

Multisystem Inflammatory Syndrome in U.S. Children and Adolescents [74], Feldstein et al. N Engl J Med 2020;383:334-46.

The 2019 Coronavirus pandemic has caused catastrophic disease worldwide with relative sparing of the pediatric population. Clusters of children with cardiovascular shock, fever and hyperinflammatory states have been reported. This study sought to better understand the epidemiology and clinical course of multisystem inflammatory syndrome in children (MIS-C).

Targeted surveillance was performed in pediatric centers. The case definition included six criteria: serious illness leading to hospitalization, age of less than 21 years, fever that lasted for at least 24 hours, laboratory evidence of inflammation, multisystem organ involvement and evidence of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
In a period of approximately two months, 186 patients with MIS-C were identified in 26 states. The median age was 8.3 years and the majority of patients were male. Organ system involvement included gastrointestinal (92%), cardiovascular (80%), hematologic (76%), mucocutaneous (74%) and respiratory (70%). The median hospitalization time was seven days with 80% requiring an intensive care unit. Death was noted in four children (two percent). This study provides a review of the multisystem inflammatory syndrome as seen in children associated with SARS-CoV-2. Serious and life threatening illness can be seen in previously healthy children.

Is Abdominal Sonography a Useful Adjunct to Abdominal Radiography in Evaluating Neonates with Suspected Necrotizing Enterocolitis? [75], Tracy et al. J Am Coll Surg. 2020 Jun;230(6):903-911.e2.

Distracted Driving Laws and Motor Vehicle Crash Fatalities [76], Flaherty et al. Pediatrics. 2020;145(6):e20193621.

The Perceived Ostomy Educational Needs of Pediatric Patients With Inflammatory Bowel Disease and Their Caregivers [77], David et al. J Pediatr Gastroenterol Nutr. 2020;70(6):849-852.

Nonoperative Treatment Versus Appendectomy for Acute Nonperforated Appendicitis in Children: Five-year Follow Up of a Randomized Controlled Pilot Trial [78], Patkova et al Ann Surg 2020 Jun;271(6):1030-1035.

The safety of nonoperative treatment of acute nonperforated appendicitis has been established but long-term outcomes beyond one year after treatment are lacking.

Overall, 46% of children treated with antibiotics for acute nonperforated appendicitis had undergone an appendectomy at five years after initial treatment. None of the children previously treated nonoperatively re-presented with complicated appendicitis.
This is a single center RCT performed in Sweden which limits its external validity. This is a pilot study so the groups are small, with 26 children randomized to surgery and 24 to nonoperative management. Five-year follow-up for enrolled children was 100%. The most common indication for appendectomy after nonoperative management was mild abdominal pain and histologically confirmed appendicitis was only confirmed in 17% of delayed appendectomies.

Population-Based Analysis of Hepatocellular Carcinoma in Children: Identifying Optimal Surgical Treatment [79], Ziogas et al J Am Coll Surg. 2020 Jun;230(6):1035-1044.e3.

Hepatocellular carcinoma (HCC) is a rare childhood malignancy associated with a poor prognosis. Liver transplantation and liver resection are the only curative treatments. Liver transplantation has historically had poor outcomes leaving liver resection as the most common treatment.

Liver transplantation had superior cancer-specific survival rates (87% vs 63%) compared to liver resection for children with nonmetastatic advanced-stage HCC. Liver transplant has equivalent survival to resection for T1 disease but liver transplant is superior for children with T2 or more disease. Early consultation for liver transplantation after initial diagnosis is warranted – especially in children with unresectable HCC or when complete tumor extirpation with liver resection is not feasible. This is a retrospective study of 127 children treated between 2004-2015 were identified from the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) database. Limitations include reliance on TNM staging, absence of central pathology in the database and inability to identify underlying liver cirrhosis, neoadjuvant versus adjuvant chemotherapy and resection margin status in the study cohort.Association of Surgical Resident Wellness with Medical Errors and Patient Outcomes [80], Hewitt et al Ann Surg 2020 Apr 8.

Effectiveness of Intrapleural Tissue Plasminogen Activator and Dornase Alfa vs Tissue Plasminogen Activator Alone in Children with Pleural Empyema: A Randomized Clinical Trial [81], Livingston et al JAMA Pediatr 2020 Feb 3.

Up to 50% of children admitted to a hospital with community-acquired pneumonia develop an associated parapneumonic effusion. While the underlying infection often improves with antibiotics alone, some effusions become purulent and/or loculated – a condition known as pleural empyema. Recent estimates suggest a rate of 2.0 hospital discharges related to empyema per 100 000 children in the United States. Similar estimates have been reported in other countries. Systematic reviews of small randomized clinical trials of children with empyema have reported similar outcomes but increased costs associated with upfront VATS. A factorial randomized clinical trial of 210 adults with pleural empyema reported improved outcomes with the use of DNase and tPA compared with tPA alone, DNase alone, or normal saline flushes only. It remains unclear whether these findings can be extrapolated to children.

This is a randomized controlled study where participants underwent chest tube insertion and three daily administrations of intrapleural tPA, 4 mg, followed by DNase, 5 mg (intervention group), or 5 mL of normal saline (placebo; control group). The addition of DNase to intrapleural tPA for children with pleural empyema had no effect on hospital length of stay or other outcomes compared with tPA with placebo. Clinical practice guidelines should continue to support the use of chest tube insertion and intrapleural fibrinolytics alone as first-line treatment for pediatric empyema

No pain is gain: A prospective evaluation of strict non-opioid pain control after pediatric appendectomy [82], Gee et al J Pediatr Surg 2020 Feb 27.

Duty Hour Reform and the Outcomes of Patients Treated by New Surgeons [83], Kelz et al Ann Surg 2020 Apr;271(4):599-605.

Umbilical access in laparoscopic surgery in infants less than 3 months of age: A survey of the American Pediatric Surgical Association [84], Landman et al J Pediatr Surg 2020 Feb 13.

While laparoscopy is commonplace in pediatric surgery, complications with umbilical access in infants less than three months of age is rarely reported in the literature. Abdominal access via the umbilicus may present a risk factor in neonates and young children.

This survey demonstrated that 10% of practicing pediatric surgeons have had a complication with entry at the umbilicus for laparoscopic surgery: CO2 embolism, hypotension, bleeding, umbilical vein cannulation and others. Given these results, pediatric surgeons should be aware of the possible complications and know how to manage them acutely.

Clinical and CT features in pediatric patients with COVID‐19 infection: Different points from adults [85], Xia et al. Pediatr Pulmonol. 2020 Mar 5.

Features, Evaluation and Treatment Coronavirus (COVID-19) [86], Cascella et al. StatPearls [Internet].

Conservative versus Interventional Treatment for Spontaneous Pneumothorax [87], Brown et al. N Engl J Med. 2020;382(5):405–415.

The care of spontaneous pneumothorax is highly variable with multiple treatment options.

This is a randomized trial that compares immediate interventional management of pneumothorax (intervention group) to a conservative observational approach (conservative-management group) for patients aged 14 to 50 years. The study randomized over 300 patients who were followed for 12 months. The primary outcome was lung re-expansion within eight weeks. The study acknowledges that some follow-up data is missing from both groups (about 15%). It concludes, however, that the trial provides modest evidence that conservative management of primary spontaneous pneumothorax is equivocal to interventional management, with a lower risk of serious adverse events.

Cost-effectiveness of Imaging Protocols for Suspected Appendicitis [88], Jennings et al. Pediatrics. 2020;145(2):e20191352.

An evidence-based algorithm decreases computed tomography use in hemodynamically stable pediatric blunt abdominal trauma patients [89], Odia et al. Am J Surg Jan 8, 2020.

The evaluation of blunt abdominal trauma in pediatric patients is challenging. While performing computerized tomography (CT) is a common practice in the pediatric blunt abdominal trauma patient with potential intra-abdominal injury, (e.g. free fluid on a sonography) or hemodynamic instability, there is variation in the management of hemodynamically stable patients without these signs. There are also concerns about the overuse of abdominopelvic CT in pediatric blunt abdominal trauma given the malignancy risks of radiation exposure.

This study uses a two-year retrospective single institution design at a level 1 adult and pediatric trauma center. The authors compared CT rates before and after implementation of an evidenced based protocol. A detailed clinical decision algorithm was produced and is provided in the manuscript. This study demonstrates a 27% decrease in abdominopelvic CT rates in pediatric blunt abdominal trauma patients after implementation of this algorithm. This decrease was accompanied by decreases in emergency department/trauma center length of stay without an increase in hospital admission rates and any significant missed injuries.

Telephone follow up for emergency general surgery procedures: safety and implication for health resource use [90], Carlock et al. J Am Coll Surg 2019 October.

Insurance coverage for children impacts reporting of child maltreatment by healthcare professionals [91], Puls et al J Pediatr 2020;216:181-8.

The extent of the transition zone in Hirschsprung disease [92], Coyle et al J Pediatr Surg 2019 Nov; 54(11):2318-2324.

Prescription vs. consumption: opioid overprescription to children after common surgical procedures [93], Pruitt et al J Pediatr Surg 2019 Nov; 54(11):2195-2199.

Endoscopic or surgical myotomy in patients with idiopathic achalasia [94], Werner et al N Engl J Med 2019 Dec 5; 381(23):2219-2229.

Guidelines for synoptic reporting of surgery and pathology in Hirschsprung disease [95], Veras et al J Pediatr Surg 2019: 10:2017-2023.

Despite increasing attention to quality improvement projects across the entire spectrum of patient care, including surgical safety checklists, there has not been significant attention to the standardization of surgical documentation and pathology reporting.

The authors provide recommendations for a standardized template and approach to surgical documentation and pathologic reporting of Hirschsprung disease. This documentation includes initial biopsy, leveling ostomy (if performed) and surgical management. Standardized reporting will improve communication with current or future caregivers of the patient. Additionally, a standardized approach to the reporting of key pathologic and surgical findings will improve data for research related to Hirschsprung disease.

Association between age and umbilical hernia repair outcomes in children: A multistate population-based cohort study [96], Halleran et al J Pediatr 2019 Nov 8.

Discrimination, Abuse, Harassment and Burnout in Surgical Residency Training [97], Hu et al. N Engl J Med 2019 Oct 31;381(18):1741-1752.

Controlled Trial of Two Incremental Milk-Feeding Rates in Preterm Infants [98], Dorling et al. N Engl J Med 2019 Oct 10;381(15):1434-1443.

Observational studies have shown a higher risk of necrotizing enterocolitis with the rapid advancement of feeding volumes in premature and/or low birthweight infants although slower advances may increase the risk of line sepsis.

This is a multicenter, parallel group, randomized, controlled trial of 2793 infants who were less than 32 weeks or weighed less than 1500g at birth, no known severe congenital anomalies or reasons to be untraceable for follow-up and receiving less than 30 mL/kg/d of milk. They were randomized to either faster (advancements by daily increments of 30 mL/kg) or slower (advancements by daily increments of 18 mL/kg). Individual units were allowed to stop or alter the rate of increase if clinically indicated.
A modified intention-to-treat analysis revealed that the faster group reached full volumes at median of seven days versus 10 days in slower group; no significant difference in survival without moderate or severe neurodevelopmental disability at 24 months corrected for gestational age, individual components of composite outcome, late onset sepsis, Bell’s stage 2-3 necrotizing enterocolitis, death during hospitalization, weight and head circumference standard deviation scores at discharge, duration of intensive care unit stay and duration of hospital stay. After adjusting for collaborating hospital, single versus multiple birth, gestational age at birth and birthweight less than 10th percentile, there was a significantly greater risk of moderate or severe motor impairment in the faster increment group. There was a weak interaction of type of milk with feeding increment (i.e lower survival without moderate/severe neurodevelopmental disability in formula fed fast-increment group vs formula fed slow-increment group), but since only 2.8% were fed formula alone, the authors feel this may be a chance finding.

Poisson Probability of Failing to Meet Minimal Case Volumes in Pediatric Surgery Fellowships [99], Lucas et al Ann Surg 2019 Aug 13.

The number of pediatric surgery fellowship programs has expanded. The ACGME has established minimum required case requirements that are monitored at the program level. The ABS is proposing minimum required case requirements for individuals seeking board certification.

Using 2008 to 2018 ACGME data for graduating pediatric surgery fellows, the authors compared median case volumes to minimum ACGME defined categories. The probability of a fellow at the median program to fail to meet category minimums was calculated using Poisson regression and then compared across years using linear regression. The analysis was repeated using minimum complex ABS-defined categories. The ACGME categories on which fellows were most likely to fall short were: Hirschsprung’s/pull through, biliary atresia and choledochal cyst. The cumulative probability of a fellow in the median program failing to meet ACGME criteria for one or more categories was 16.6%. There was no significant change in this annual probability over the last 10 years. The ABS categories on which fellows were most likely to fall short were: trauma/critical care, head and neck/endocrine/genitourinary/anorectal malformation. The cumulative probability of a fellow in the median program failing to meet the ABS minimums was 44.1%. There was no significant change in this annual probability over the last 10 years. If these ABS volumes are enforced, many graduating fellows will not be board eligible.

Does Peritoneal Lavage Influence the Rate of Complications Following Pediatric Laparoscopic Appendicectomy with Complicated Appendicitis? A Prospective Randomized Clinical Trial [100], Nataraja et al J Pediatr Surg. 2019 Aug 30.

Esophagitis in Pediatric Esophageal Atresia: Acid May Not Always Be the Issue [101], Yasuda et al J Pediatr Gastroenterol Nutr. 2019 Aug;69(2):163-170.

Children with esophageal atresia are frequently found to have esophagitis. Estimates of prevalence of in this patient population show that 25 to 90 percent of children with EA will have esophagitis. Many of these children are treated with long term acid-suppressive therapy or anti-reflux surgery in line with ESPGHAN-NASPGHAN guidelines. Long-term data on effectiveness of therapy in this patient population is lacking.

Three hundred ten patients with a diagnosis of esophageal atresia (33.5% of whom had long gap EA) were retrospectively evaluated. These patients were treated at a tertiary care center and underwent at least one upper endoscopy with biopsy over a 2 year period. A total of 576 endoscopies were performed. Endoscopy was preceded by acid suppressive therapy in 86.9% of the procedures. Fundoplication had been performed in over 25% of the patients. Twenty seven patients had gross erosive esophagitis on endoscopic biopsy during this time period. Histologic eosinophilia was seen in 56.8% of patients undergoing endoscopic biopsy. Two patients were found to have Barret’s esophagitis. The authors note that acid suppression therapy was the only significant factor associated with reduced odds of abnormal esophageal biopsy. The authors did not see a significant change in esophagitis following fundoplication. Given the prevalence of esophagitis, even in children on acid suppressive therapy, the authors recommend continued surveillance endoscopy even in children receiving acid suppressive therapy.

esophagitis after esophageal atresia
Descriptive text is not available for this image
visual abstract courtesy of Francois Luks

A Novel Streamlined Trauma Response Team Training Improves Imaging Efficiency for Pediatric Blunt Abdominal Trauma Patients [102], Nti et al J Pediatr Surg 2019 Sep;54(9):1854-1860.

Defining Barriers and Facilitators to Advancement for Women in Academic Surgery [103], Thompson-Burdine et al JAMA Netw Open 2019 Aug 2;2(8):e1910228.

State Gun Laws and Pediatric Firearm-Related Mortality [104], Goyal et al Pediatrics 2019 Aug;144(2).

Firearms are the second leading cause of pediatric death in the United States. There has been recent increased interest in legislation to help lower pediatric firearm-related mortality. One proposed approach is universal background checks. This study examined firearm-related pediatric mortality in states that require universal background checks versus those with less strict gun laws.

Pediatric firearm-related mortality was lower in states with stricter gun laws. In addition, states with universal background checks in effect for more than 5 years had a significantly lower pediatric firearm-related mortality rate. This research provides more evidence for a national discussion regarding prevention of pediatric firearm-related mortality.

gun laws
Descriptive text is not available for this image
visual abstract courtesy of Allison Speer

Predictors of the Performance of Early Antireflux Surgery in Esophageal Atresia [105], Francois et al J Pediatr 2019 Aug;211:120-125.e1.

Survival and Scoliosis Following Resection of Chest Wall Tumors in Children and Adolescents – A Single-center Retrospective Analysis [106], Saltsman et al Ann Surg 2019 Jul 25.

Firearm Legislation Stringency and Firearm-Related Fatalities among Children in the US [107], Madhavan et al J Am Coll Surg 2019 Aug;229(2):150-157.

Firearm injuries are the second leading cause of pediatric deaths in the United States. Due to the rising incidence and frequency of child firearm related deaths, some states have enacted child access prevention laws in order to prevent firearms from children and youth. This study examined firearm child access prevention laws between states to determine their effectiveness in reducing pediatric fatalities.

Fewer pediatric related fatalities were identified in states with stricter firearm legislation and child access prevention laws. Stricter firearm legislation was also associated with a decreased pediatric firearm suicide rate. This research speaks to the national conversation about how to address and decrease firearm related deaths, especially in the pediatric population.

The Role of Oral Antibiotic Preparation in Elective Colorectal Surgery: A Meta-Analysis [108], Rollins et al Ann Surg 2019 Jul; 270(1):43-58.

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults [109], Inge et al N Engl J Med 2019 May 30;380(22):2136-2145.

Bariatric surgery can be safe and efficacious in adolescents and adults and results in significant weight loss and improvement in weight-associated comorbidities when other treatments have failed. Roux-en-Y gastric bypass (RYGB) is increasingly considered for the treatment of adolescents with severe obesity and it is unclear whether long term outcomes differ between adolescents and adults.

The health effects of Roux-en-Y gastric bypass were compared between adolescents and adults enrolled in the Teen–Longitudinal Assessment of Bariatric Surgery (Teen–LABS) and the Longitudinal Assessment of Bariatric Surgery (LABS) studies. Weight loss after RYGB was similar in magnitude for adolescents and adults five years after surgery. Adolescents had remission of type 2 diabetes and of hypertension more often than adults but differences in hypertriglyceridemia and high-density lipoprotein (HDL) cholesterol levels were not statistically different.

This study builds on previous findings of durable weight loss after gastric bypass in adolescents. This study suggests that young patients undergoing RYGB may have better potential for recovery of islet cell secretory capacity and that the histologic remodeling and increased vascular stiffness due to obesity-related hypertension may be more readily reversed in adolescents.

Further research and long-term follow-up is needed to understand if the increased reversal of the complications in adolescents may be attributed to a shorter duration of exposure to the harmful effects of obesity. Consideration of early bariatric surgery may be warranted in severely obese adolescents who develop type 2 diabetes and hypertension.

Factors that Predict the Need for Early Surgeon Presence in the Setting of Pediatric Trauma [110], McGaha et al J Pediatr Surg 2019 May 16.

Identification of New Wilms Tumour Predisposition Genes: An Exome Sequencing Study [111], Mahamdallie et al Lancet Child Adolesc Health. 2019 May;3(5):322-331.

Predicting Intestinal Adaptation in Pediatric Intestinal Failure. A Retrospective Cohort Study [112], Belza et al Ann Surg 2019 May;269(5):988-993.

Short bowel syndrome results from resection of a large amount of small intestine – usually in the neonatal period – secondary to a variety of diagnoses. Intestinal failure, which is the inability of the intestine to absorb enough nutrients to sustain growth and life, is most often secondary to short bowel syndrome in pediatric patients. These patients often require prolonged parenteral nutrition and there remains high rates of morbidity and mortality. Recent studies have shown that implementation of novel lipid strategies as well as formal multidisciplinary intestinal rehabilitation programs can have positive impacts on outcomes.

The authors of this study looked at a large contemporary group of intestinal failure patients to evaluate factors that were related to attainment of intestinal autonomy and specifically assess the relationship of residual bowel length. A high proportion (70%) of patients achieved autonomy. Longer residual bowel length and the presence of the ileocecal valve was correlated with a higher chance of achieving autonomy, as well as was. The number of episodes of sepsis were negatively correlated with achieving enteral autonomy. The authors conclude that in a contemporary cohort managed by a multidisciplinary team, residual bowel length remains an important factor in the prediction of enteral autonomy and that continued avoidance of central line associated sepsis is necessary.

Management of Pediatric Gastroesophageal Reflux Disease [113], Barfield et al JAMA Pediatr 2019 Mar 18.

Gastroesophageal reflux is common in infants and children. Gastroesophageal reflux disease (GERD) occurs when the reflux leads to worrisome symptoms or complications. Symptoms in infancy can be vague. The diagnosis of GERD has increased rapidly.

NASPGHAN and ESPGHAN have updated their clinical guideline from 2009. The process followed the Institute of Medicine standards for development and use of evidence. Separate algorithms were developed for those younger and older than 12 months of age. Major recommendations were to avoid imaging and diagnostic studies in infants and children (barium, EGD, manometry). They recommended against positioning in sleeping infants (i.e. head of bed raised) and to avoid PPI or H2 blockers for regurgitation in otherwise healthy infants without extraesophageal symptoms. In older children and adolescents, a four- to eight-week trial of therapy is suggested followed by weaning. They note that 39/49 recommendations were made on the basis of expert opinion given the lack of robust data. They acknowledge that there is clearly a need for further studies to determine optimal medical therapy.

Effect of New Fellowship Programs on Resident Case Volume in Pediatric Surgery [114], Potts et al J Am Coll Surg 2019 Mar 21.

Association of In Vitro Fertilization With Childhood Cancer in the United States [115], Spector et al JAMA Pediatric 2019 Apr 1.

Molecular Genetic Anatomy and Risk Profile of Hirschsprung’s Disease [116], Tilghman et al N Engl J Med 2019 Apr;380(15):1421-1432.

Wounding Patterns Based on Firearm Type in Civilian Public Mass Shootings in the United States [117], Sarani et al J Am Coll Surg 2019 Mar. 228(3). 228-234.Family

Firearm Ownership and Firearm-Related Mortality Among Young Children: 1976-2016 [118], Prickett et al Pediatrics 2019;143(2):e20181171.

Antibiotic Treatment and Appendectomy for Uncomplicated Acute Appendicitis in Adults and Children: A Systematic Review and Meta-analysis [119], Podda et al Ann Surg 2019 Jan 31.

For many years, appendectomy has been the mainstay of therapy for acute appendicitis. More recently, antibiotic therapy alone for acute, uncomplicated appendicitis has become an alternative treatment. While some previous studies have promoted antibiotic therapy as a safe approach for uncomplicated appendicitis there is still limited data on the effectiveness and safety of nonoperative management of uncomplicated appendicitis.

This study is a meta-analysis of 20 studies with evidence on the nonoperative management of uncomplicated appendicitis in adults and children. The study included 3,618 patients with appendicitis, with 1743 patients treated with antibiotic therapy (AT) and 1875 patients treated with surgery (ST). Complication-free treatment was higher for the ST group as opposed to the AT group (82% vs.67%). Treatment efficacy (based on one-year follow-up) was 93% in the ST group and 73% in the AT group. There was a trend toward a higher perforation rate in the patients who failed AT (22% versus those who underwent initial ST 13% (p=0.07)). However, the rate of postintervention adverse events was significantly lower in the AT group in adults (AT 6.6% vs. ST 14.5%) but this difference was not significant in children (AT 9.6% vs. ST 12.5%). The costs for AT were approximately $1,000 less than the ST group even when accounting for antibiotic therapy failure and subsequent surgery.

Although there is a lower efficacy rate than surgery, antibiotic therapy for uncomplicated appendicitis may be a safe option for the majority of patients wishing to avoid appendectomy. Further studies are required to determine the optimal management and to understand the long-term outcomes for patients with uncomplicated appendicitis.

antibiotics versus appendectomy
Descriptive text is not available for this image
visual abstract courtesy of Celeste Hollands

Does Retrieval Bag Use During Laparoscopic Appendectomy Reduce Postoperative Infection? [120], Fields et al Surgery 2018 Dec 24.

Laparoscopy is used for the majority of appendectomies in the United States. Patients who undergo laparoscopic appendectomy are still at risk for infectious complications. There is little data on how operative technique affects the infection rate following laparoscopic appendectomy.

Using the NSQIP Procedure Targeted Appendectomy 2016 database, the authors investigated whether the use of a retrieval bag for removal of the appendix during a laparoscopic appendectomy is associated with the risk of infectious complications. In this study, 10,578 patients underwent laparoscopic appendectomy with a retrieval bag and 897 patients without. On multivariate analysis, use of a retrieval bag was an independent predictor of decreased intra-abdominal infection (OR: 0.6, 95% CI: 0.42-0.95, p=0.03). Other predictors of increased likelihood of intra-abdominal infection included diabetes, preoperative sepsis, complicated appendicitis and male sex. The authors recommend the use of retrieval bags for all laparoscopic appendectomies.

appendectomy retrieval bag
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visual abstrcat coutetsy of Allison Speer


Transition of care: A Growing Concern in Adult Patients Born with Colorectal Anomalies [121], Acker et al Pediatr Surg Int 2019. 35:233-237.

Impact of Steroid Therapy on Early Growth in Infants with Biliary Atresia: The Multicenter Steroids in Biliary Atresia Randomized Trial [122], Alonso et al J of Pediatr 202:179-85, 2018.

The use of steroids following hepatoportoenterostomy (HPE) for biliary atresia is controversial. The START trial, a multicentered randomized control trial with 70 patients in each study arm compared high dose steroid therapy following HPE to placebo. 58.6% of patients in the steroid group achieved a total bilirubin less than 1.5 mg/dL compared to 48.6% in the placebo group (not statistically significant) although a small clinical benefit could not be excluded. The trial also showed that steroid treatment was associated with an earlier onset of serious adverse events in children with biliary atresia although complications were equivalent in both groups.What this article adds: This article is a continuation of the START trial and investigates the impact of steroids in the growth of the children involved in the trial. The study showed that steroid therapy following HPE is associated with impaired length, weight and head circumference growth trajectories for at least six months following HPE – especially for infants with successful bile drainage. Ultimately, there was some catch up growth for the infants but it is not known whether the delayed growth in the first six months will have a long term impact on growth of this patient population.

Opioid Prescribing Guidelines for Common Surgical Procedures: An Expert Panel Consensus, [123], Overton et al JACS 227:411-418, 2018.

The Department of Health and Human Services reports that over two million people in the United States have an opioid problem and more than 11 million people have misused prescription opioids resulting in over 17,000 deaths in 2017. As a result, there is continued interest in optimizing the use of opioids following surgical procedures.What this article adds: This study used a three-step modified Delphi method involving a multidisciplinary expert panel of surgeons, pain specialists, outpatient surgical nurse practitioners, surgical residents, patients and pharmacists to develop consensus ranges for outpatient opioids after 20 common procedures in eight surgical specialties. The study noted that patients who had a procedure consistently voted for lower opioid amounts than the surgeons who performed the operation indicating that inclusion of patients in postoperative pain regimens is likely to decrease the amount of opioids prescribed. The article also noted that many patients do not want opioids at all and prefer acetaminophen and nonsteroidal anti-inflammatory drugs for postoperative analgesia.

Intestinal Microbiota in Hirschsprung Disease [124], Neuvonen et al J Ped Gastr Nutr 67:594-600, 2018.

Sodium Thiosulfate for Protection from Cisplatin-Induced Hearing Loss [125], Brock et al N Engl J Med 378:2376-2385, 2018.

Endoscopic Electrocautery Incisional Therapy as a Treatment for Refractory Benign Pediatric Esophageal Strictures [126], Manfredi et al JPGN 2018;67(4):464-8.

The traditional treatment for esophageal strictures is balloon or bougie dilatation. There is no agreed upon definition for refractory esophageal strictures in children.
A refractory esophageal stricture is defined as inability to achieve an age appropriate esophageal lumen with five dilatations within five months or requiring seven or more dilatations without time frame.

In a retrospective review, 61% of children with refractory anastomotic strictures were successfully treated with endoscopic electrocautery incisional therapy requiring less than seven dilatations and no stricture resection at two years after treatment. The esophageal leak rate was 5.3% overall with 3% contained and 2.3% noncontained. Although none of the patients required surgery, all of the noncontained leaks were treated with advanced endoscopic therapy.

incising esophageal strictures
Descriptive text is not available for this image
visual abstract courtesy of David Darcy


Population-Based Validation of a Clinical Prediction Model for Congenital Diaphragmatic Hernias [127], Bent et al J Pediatr 2018;201:160-5.

Comparing Percutaneous to Open Access for Extracorporeal Membrane Oxygenation in Pediatric Respiratory Failure [128], Cairo et al Pediatr Crit Care Med 2018;19(10):981-91.

Remnant Small Bowel Length in Pediatric Short Bowel Syndrome and the Correlation with Intestinal Dysbiosis and Linear Growth [129], Engelstad et al J Am Coll Surg 2018 Oct;227(4):439-449.

Short bowel syndrome places patients at risk for malnutrition, dehydration and bacterial overgrowth. Little is known about the effects of the remnant small bowel length on the intestinal microflora.This study evaluated the gut microbiome in patients with pediatric short bowel syndrome. The gut microbiome was compared between patients with less and more than 35 cm of remaining small bowel and a normal control population. The group with shorter bowel length had more pathogenic Proteobacteria (Shigella/Escherichia) than those with longer bowel lengths. These patients also required more parenteral nutrition, had stunted linear growth and a higher body mass index. The study results suggested that enteral adaptation resulted in normalization of the gut microbiome.

microbiome in short bowel
Descriptive text is not available for this image
visual abstract courtesy of Sarah Walker


Repeat Head CT for Expectant Management of Traumatic Epidural Hematoma [76], Flaherty et al Pediatrics 2018 Sep;142(3).

Outpatient Opioid Prescriptions for Children and Opioid-Related Adverse Events [130], Chung et al Pediatrics 2018 Aug;142(2).

There is continued discussion regarding the use of opioid analgesics in the United States. The majority of current literatures has focused on use in adult patients. Little is known about opioid prescriptions for acute, self-limited conditions in children. This retrospective cohort study evaluated outpatient opioid prescriptions in Tennessee Medicaid patients aged two to 17 years. Fifteen percent of children filled outpatient opioid prescriptions for acute, self-limited conditions. The most common indications for opioid prescriptions were dental procedures, outpatient surgical procedures, trauma and infections. There were 437 opioid related adverse events with 71.2% of these events occurring without deviation from the prescribed regimen. Adverse events occurred in older children and in higher opioid doses.

Heterotaxy Syndrome and Intestinal Rotation Abnormalities [131], Ryerson et al Pediatrics 2018 Aug;142(2).

Infants with heterotaxy syndrome have abnormal lateralization of organs along the right-left body axis. Intestinal rotation abnormalities are commonly associated with heterotaxy syndrome. Continued debate exists as to the best management of an asymptomatic patient with heterotaxy syndrome and an intestinal rotational abnormality.

A multi-institutional prospective observational study was performed evaluating children with heterotaxy syndrome. Thirty-eight infants were included, of which 21 patients were found to have an associated intestinal rotational abnormality on examination using upper gastrointestinal imaging. Eight infants were evaluated due to concerning symptoms with an average age of 46 days (5 to 171 days). Three symptomatic and four asymptomatic patients underwent Ladd procedure. No child was found to have midgut volvulus.

It is common to find intestinal rotational abnormalities in children with heterotaxy syndrome. Symptoms usually presented by six months of age. Expectant management of the asymptomatic patient is reasonable because no infant managed as such developed midgut volvulus at a median follow-up of 1.6 years.

Lower Distending Pressure Improves Respiratory Mechanics in Congenital Diaphragmatic Hernia Complicated by Persistent Pulmonary Hypertension [132], Guevorkian et al J Pediatr 200:38-43, 2018.

Association Between the New York Sepsis Care Mandate and In-Hospital Mortality for Pediatric Sepsis [133], Evans JAMA 320:358-367, 2018.

Contemporary clinical practice guidelines recommend prompted recognition of sepsis and initiation of treatment. New York state mandates the initiation of blood cultures, broad spectrum antibiotics and a 20 mL/kg intravenous fluid bolus in pediatric patients with sepsis within one hour of diagnosis.

A statewide cohort study of patients younger than 18 years with sepsis and septic shock were reviewed. A total of 1179 patients were identified. The entire sepsis bundle was completed within one hour in 294 patients. Antibiotics were administered to 798 patients, blood cultures were obtained in 740 patients and a fluid bolus was completed in 548 patients. Completion of the entire bundle within one hour was associated with a lower risk adjusted odds of in hospital mortality. Completion of each individual element, however, was not predictive of decreased in-hospital mortality.

The New York State mandate on sepsis bundle has a positive effect on the management of pediatric patients with sepsis and septic shock.

Attitudes Surrounding the Management of Neonates with Severe Necrotizing Enterocolitis [134], Pet et al J Pediatr 199:186-193, 2018.

Association Between Early Postoperative Acetaminophen Exposure and Acute Kidney Injury in Pediatric Patients Undergoing Cardiac Surgery [135], Van Driest et al JAMA Pediatr 172:655-663, 2018.

Association of Exposure to Formula in the Hospital and Subsequent Infant Feeding Practices With Gut Microbiota and Risk of Overweight in the First Year of Life [136], Forbes et al JAMA Pediatr 2018 Jul 2;172(7):e181161.

Restrictive versus Liberal Fluid Therapy for Major Abdominal Surgery [137], Myles et al N Engl J Med 2018 Jun 14;378(24):2263-2274.

Review Shows that Implementing a Nationwide Protocol for Congenital Diaphragmatic Hernia was a Key Factor in Reducing Mortality and Morbidity [138], Storme et al Acta Paediatr 2018 Jul;107(7):1131-1139.

Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children [139], Bhatt et al JAMA Pediatr 2018 May 7.

Preprocedural fasting guidelines have been established by consensus opinion to decrease the risk of adverse and serious adverse events, particularly pulmonary aspiration, during procedural sedation. In this large study, almost half of children did not meet ASA fasting guidelines for solids whereas 5% did not meet ASA fasting guidelines for liquids. No adverse events were characterized as clinically apparent pulmonary aspiration. There was no difference in the length of fasting duration among those who did or did not experience an adverse event, serious adverse event or vomiting. Furthermore, after adjusting for age, sex, sedation medication and procedure type, the odds ratio of an adverse event occurring did not change with additional hours of fasting duration. In summary, this large, prospective study did not show an association between pre-procedure fasting duration and the development of an adverse event, particularly pulmonary aspiration. Implications of this study may help guide protocols to decrease the duration of preprocedural fasting in the emergency department.

Ramifications of the Children’s Surgery Verification Program for Patients and Hospitals [140], Baxter et al JACS 2018 226: 917-924.

Data exists to show that for complex procedures and medical conditions, high volume medical centers have improved outcomes compared to low volume centers. With this in mind, the American College of Surgeons developed the Children’s Surgery Verification (CSV) program which has categorized medical institutions as Levels I through III based on their ability to provide high level care to pediatric surgery patients. The goal of this study was to evaluate the effects of the CSV on neonates undergoing one of five complex procedures using data available through the Kids’ Inpatient Database (KID). Outcomes analyzed included the need for children to relocate to a Level I center, the distance required to do so, as well as the crude and adjusted mortality comparing Level I to Level II/III centers. Almost 8,000 neonates with one of five qualifying diagnoses (necrotizing enterocolitis, patent ductus arteriosus (PDA), esophageal atresia, diaphragmatic hernia, gastroschisis/omphalocele) were identified in the 2009 version of the KID. In this cohort, 34.6% of neonates would have required transport to a Level I center. Based on zip code calculations the majority of neonates (72.5%) would have had to travel fewer than 20 miles to the closest Level I facility (range of zero to 384.3 miles). Regarding mortality, the adjusted odds ratio of death was significantly lower at Level I facilities compared to Level II/III facilities; this was particularly true for those with gastroschisis/omphalocele or a PDA. In an unadjusted analysis it was estimated that 32 neonates would need to be transferred to a Level I center to prevent a single death.

Opioid Use After Discharge in Postoperative Patients [141], Feinberg et al Ann Surgery 2018 267:1056-1062.

Aggressive Surgical Management of Congenital Diaphragmatic Hernia: Worth the Effort? [142], Harting et al Ann Surg 2018 May;267(5):977-982.

Approximately 20% of children born with congenital diaphragmatic hernia (CDH) do not undergo repair. Using the CDH study group database this group noted, unsurprisingly, that unrepaired patients had worse APGAR scores and were more likely to have a concomitant anomaly when compared to repaired patients. Specific reasons for nonrepair included presence of an anomaly, intraventricular hemorrhage, hypoxia and parental request. After considerable risk adjustment, high volume centers that had lower rates of nonrepair (i.e. aggressive managers) were noted to have an additional 2.7 survivors per 100 patients treated. This study suggests that marginal survival gains continue to accrue for patients provided maximal therapy.

Concurrent Surgery and the Role of the Pediatric Attending Surgeon: Comparing Parents’ and Surgeons’ Expectations [143], Choe et al J Am Coll Surg 2018 Apr 12.

This study surveyed parents, surgeons and trainees regarding the concurrent delivery of surgical care for children – when two operations occur simultaneously under the auspices of a single attending. The authors noted that parents overwhelmingly expected surgeons to be present throughout the entire operative process (sign in to sign out). While attending surgeons agreed that they necessarily be present during critical components of a procedure, they frequently responded being comfortable not being present during other operative time points. This study highlights the importance of a clear and transparent informed consent process regarding surgical team members and operative processes.

A Checklist to Elevate the Science of Surgical Database Research [144], Haider et al JAMA Surg 2018 Apr 4.

Healthcare Utilization and Comorbidities Associated with Anorectal Malformations in the United States [145], Kovacic et al J Pediatr 2018; March; 194: 142-6.

Anorectal malformations (ARMs) are a broad spectrum of anomalies that involve the anorectal and genitourinary tract with an incidence of 1-2 per 5000 live births. Previous studies have found that 50-70% of patients with ARMs have other congenital abnormalities. This large nationally representative study of 2396 patients with ARMs from the Kids Inpatient Database examines the significant morbidities and increased healthcare expenditures associated with patients having congenital anomalies in addition to their ARM. This study found that 80% of patients had congenital anomalies other than ARMs; urogenital malformations (38.5%), other GI anomalies (35.3 %), cardiac anomalies (21.2%), and genetic disorders (14.1%) being the most common. The study also highlights the direct relationship between the numbers of congenital anomalies and both length of stay and hospital charges.

Outcomes in Children Undergoing Surgery in Congenital Pulmonary Airway Malformations in the First Year of Life [146], Dukleska et al J Am Coll Surg 2018 March; 226 (3): 287-293

Congenital Pulmonary Airway Malformations (CPAMs) are anomalies encompassing infants born with abnormal lung tissue, blood vessels, or airways. Symptomatic CPAM lesions are typically large and require immediate treatment after birth, or even prenatally. There are no established guidelines, however, for the treatment of asymptomatic CPAMs. This study evaluated 541 patients (20.7% neonates and 79.3% non-neonates) undergoing surgery for CPAMs using the National Surgical Quality Improvement Program and analyzed their outcomes. In the uncontrolled analysis, compared to surgery on older patients neonatal surgery was associated with increased peri-operative comorbidities and worse post-operative outcomes. Multivariate analysis, however, showed that only pre-operative symptoms were independently associated with increased morbidity, and that CPAM surgery on asymptomatic neonates had no difference in overall morbidity when compared to CPAM surgery on older infants.

Pediatric Gastroesophageal Reflux Clinical Practice Guidelines: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) [147], Rosen et al J Pediatr Gastroenterol Nutr 2018 March 66(3): 516-554.

Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD) are one of the most frequently discussed and treated gastroenteric disease processes in children. This latest guideline from NASPGHAN and ESPGHAN evaluates studies through June 1 2015 and forms recommendations for the diagnosis and management of GER and GERD in infants and children based on this literature review and expert opinion. The latest recommendations: 1) focus on reducing acid suppression; 2) shift away from attributing respiratory/laryngeal symptoms to GER; 3) add algorithms for typical symptoms in both infants and older children to differentiate between GERD versus functional diagnoses; and 4) add a recommendation for change of formula to a protein hydrolysate or amino acid formula before acid suppression in infants.

Factors Associated with Outcomes and Costs After Pediatric Laparoscopic Cholecystectomy [148], Akhtar-Daneshet al JAMA Surgery 2018 Jan 17.

Pediatric Cholelithiasis is increasing in prevalence along with childhood obesity and is no longer predominantly attributable to hemolytic diseases. Correspondingly, rates of laparoscopic cholecystectomy have increased. In this retrospective, population-based study of all Canadian pediatric patients undergoing laparoscopic cholecystectomy from 2008 – 2015, the researchers demonstrated an association between patient indication for operation, patient comorbidities, surgeon volume with cost and post-operative morbidity. Although indication and comorditites cannot be changed, the authors suggest that surgeon volume rather than specialty training (general surgery vs. pediatric surgery) may be more important when considering referrals for pediatric cholecystectomy.

Radiation Exposure and Attributable Cancer Risk in Patients with Esophageal Atresia [149], Yousef and Baird J Pediatr Gastroenterol Nutr 2018 Feb;66(2):234-238.

Radiation exposure of patients with esophageal atresia is significant. A single-institution, retrospective study of 53 esophageal patients with a mean follow-up of 5.7 years allowed the calculation of effective dose of radiation exposure. Additionally, using pre-existing normative data, the median and maximum increases in mortality risk were found to range from 130 to 1575-fold higher in this patient population. The authors suggest that eliminating unnecessary studies and restricting exposure during essential studies should be emphasized during the care of esophageal atresia patients both during their initial admission as well as outpatient follow up. Measurement by patient specific direct dosimeters may draw the attention of caregivers to cumulative exposure over the patient’s lifetime.

Intraoperative Clonidine for Prevention of Postoperative Agitation in Children Anaesthetized with Sevoflurane (PREVENT AGITATION): a Randomized, Placebo-controlled, Double-blind Trial [150], Ydemann et al Lancet Child Adolesc Health 2018; 2:15-24.

Postoperative agitation continues to be a common problem in children. Although there is data regarding use of alpha-2-receptor agonists to treat postoperative agitation, information is limited in children especially regarding optimal dosing. Children ages 1-5 years were enrolled in this randomized, placedbo-controlled, double-blind trial in three hospitals in Denmark with the goal of reducing postoperative agitation while assessing the potential benefits and harms of clonidine in this patient population. The authors enrolled 379 children (191 in the treatment group and 188 in the placebo group) and were able to analyze data for 187 and 183 patients respectively. Analysis showed that clonidine reduced the risk of postoperative agitation in boys (relative risk 0.43, 95% CI 0.30-0.61; p< 0.0001) without increasing the need for interventions for hypotension or bradycardia. An increased recovery time was also noted as were secondary benefits of reduced opioid administration, increased time to first analgesic administration, and decreased postoperative nausea and vomiting.

Diagnosis and Management of Congenital Diaphragmatic Hernia: a Clinical Practice Guideline [151], Canadian Congenital Diaphragmatic Hernia Collaborative CMAJ 2018 Jan 29;190(4):E103-E112

Congenital diaphragmatic hernia (CDH) occurs in ~1:3300 live births and is accompanied by both short- and long-term morbidity and mortality. A defining attribute of CDH is its requirement for integrated multidisciplinary care across three distinct phases: prenatal, perinatal/postnatal and childhood/adolescent. This report from the Canadian CDH Collaborative contains evidence-based guidelines to standardize CDH care. The guidelines were developed by a multidisciplinary panel of experts (maternal-fetal medicine, pediatric surgery, pediatric anesthesia, neonatal intensive care, neonatal follow-up, pediatric intensive care and pediatric cardiology) using a modified Delphi consensus framework. The guideline encompasses prenatal diagnosis, ventilation strategies, hemodynamic support, echocardiography usage, management of pulmonary hypertension, use of extracorporeal life support, surgical approaches, and long-term follow-up.

Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients [152], Cairo et al JAMA Surg 2017 Dec 1;152(12):1106-1112.

Appendicitis is the most common indication for urgent surgery in children in the US. Multiple studies in the adult population have demonstrated safety of same-day discharge (SDD) following multiple types of operations (including appendectomy) and small series have suggested this concept applies to children as well. In this study, the authors utilized the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) to evaluate outcomes in children that were discharged from the hospital on the same day as undergoing appendectomy for non-perforated/non-complicated appendicitis versus those discharged 1-2 days postoperatively. They found no differences in odds for 30-day readmission or wound complication rates. This suggests that, in selected patients, SDD is a safe alternative to overnight admission after appendectomy.

Persistent Opioid Use Among Pediatric Patients After Surgery [153], Harbaugh et al Pediatrics 2018 Jan;141(1). pii: e20172439

The “opioid crisis” is a major public health problem in the US, with rapidly rising hospitalization and mortality rates from prescription and non-prescription opioid mis/use. However, opioids are an important adjunct in analgesia for acute pain following surgery and very little is known about opioid use in the post-operative pediatric patient population. In this study, the authors used a national data set of employer-based insurance claims to evaluate prolonged opioid refills in the 13-21-year-old patient population. They found that ~60% of patients received an opioid prescription post-operatively and ~5% demonstrated persistent opioid use (>90 days postoperative), with variation based on type of surgery, age, gender and other factors. The authors suggest these data may assist in developing methods to minimize opioid exposure in those patients at highest risk for subsequent misuse.

Antibiotic Stewardship in the Newborn Surgical Patient: A Quality Improvement Project in the Neonatal Intensive Care Unit [154], Walker et al Surgery 2017;162:1295-303

• No consensus exists regarding perioperative antibiotic usage in neonatal patients.
• Wide variability exists in perioperative and postnatal antibiotic therapy nationally.
• Elimination of postnatal antibiotics in surgical neonates without signs and symptoms of infections or perinatal risk factors for sepsis was not associated with increased rates of surgical site infections or hospital acquired infections.
• Limiting perioperative antibiotics to less than 72 hours was not associated with increased rates of surgical site infections or hospital acquired infections.
• Antibiotic stewardship with the implementation of antibiotic usage guidelines in surgical neonates was associated with a decrease in median antibiotic days.

Combination Analgesia for Neonatal Circumcision: A Randomized Controlled Trial [155], Sharara-Chami et al Pediatrics 2017;140(6): e20171935.

• Circumcision is often performed without analgesia or only a local anesthetic cream
• Penile nerve blocks have been shown to be more effective than cream analgesia or sucrose alone.
• In a 4-arm double-blinded randomized controlled trial, penile ring block combined with oral sucrose and EMLA cream was the most effective analgesia during neonatal circumcision.
• No adverse effects were reported with ring block.

Diagnostic Performance of Magnetic Resonance Enterography for Detection of Active Inflammation in Children and Adolescents With Inflammatory Bowel Disease: A Systematic Review and Diagnostic Meta-analysis [156], Yoon HM et al JAMA Pediatr 2017;171(12):1208-1216.

• Magnetic resonance enterography has the advantage of being a noninvasive, radiation-free imaging modality that can evaluate extraintestinal disease.
• The diagnostic performance of magnetic resonance enterography for detection of active inflammation in children and adolescents with inflammatory bowel disease has not been systematically evaluated.
• Systematic review and meta-analysis of 18 articles including 687 patients found a sensitivity of 83% and a specificity of 93% for magnetic resonance enterography using histopathology as the reference standard in pediatric and adolescent inflammatory bowel disease patients.
• There was substantial heterogeneity (I2 > 65%) across the included studies and scanner manufacturer was a statistically significant and clinically meaningful cause of heterogeneity in meta-regression analysis.

Extended Versus Narrow-Spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-Matched Comparative Effectiveness Study [157], Cameron et al Ann Surg 2017 Jun 26.

In children with uncomplicated appendicitis, is extended spectrum antibiotics necessary to improve outcomes?
A total of 1389 patients were included using PHIS and NSQIP-P data. This was a retrospective database study that did not find a difference in outcomes for surgical site infection comparing extended spectrum (piperacillin/tazobactam) and narrow spectrum (cefoxitin or ceftriaxone + metronidazole) antibiotics.
Cefoxitin or Ceftriaxone + metronidazole provides adequate antibiotic coverage for uncomplicated appendicitis.

Hats Off: A Study of Different Operating Room Headgear Assessed by Environmental Quality Indicators [158], Markel et al J Am Coll Surg. 2017

Are there differences in particulate and bacterial contamination from commonly used operating room head gear?
Disposable bouffant hats have significantly higher microbial shed at the sterile field compared to disposable skull caps and cloth skull caps. Disposable bouffant hats were significantly more permeable than either disposable or cloth skull caps.
Disposable style hats should not be considered superior to skull caps in preventing airborne contamination.

The Effect of Level of Care on Gastroschisis Outcomes [159], Apfeld et al J Pediatr 2017 Nov;190:79-84

Is there a relationship between level of care in NICUs and outcomes?
Outcomes were evaluated for 1588 newborns with gastroschisis using data collected by the California Perinatal Care Collaborative. Outcomes were evaluated by NICU level of care. The adjusted odds of death was higher for infants cared for in level II A/B NICUs (OR 6.66), level IIIA NICUs (OR 5.95), or IIIB NICUs (OR 5.85) when compared to level IIIC NICUs. Overall in-hospital mortality was 2.5 %, it was 1% for level IIIC NICUs.
This study found significantly higher odds of death for patients cared for in lower level NICUs compared to level IIIC NICUs.

Treatment Policy an Liver Histopathology Predict Biliary Atresia Outcomes: Results after National Centralization and Protocol Biopsies [160], Hukkinen et al J Am Coll Surg 2017 Sep 25. pii: S1072-7515(17)31971-3.

Hospitals with low caseloads may have inferior outcomes compared to more experienced centers, prompting centralization of biliary atresia treatment in the United Kingdom and Finland. Portoenterostomy success rates are influenced by liver histological features at time of portoenterostomy, including degrees of fibrosis and ductal reaction. BA outcomes improved significantly after centralization and standardized management within Finland. Resolution of cholestasis and reduction of high-grade portal inflammation postoperatively predict slower fibrosis progression and improved native liver survival.• Persisting ductal reaction parallels progressive native liver fibrosis despite clearance of jaundice.

The Cumulative Burden of Surviving Childhood Cancer: an Initial Report from the St. Jude Lifetime Cohort Study (SJLIFE) [161], Bhakta et al Lancet 2017 Sep 7. pii: S0140-6736(17)31610-0.

10-year survival for pediatric cancer is now > 80% and late mortality is decreasing for long-term survivors. Because of their curative treatment-related exposures, survivors of childhood cancer are at increased risk for a broad range of chronic health conditions.

For survivors of childhood cancer, the cumulative incidence of chronic health conditions at age 50 years was 99.9%, compared to 9.2% in healthy community controls.• Second neoplasms, spinal disorders and pulmonary disease were major contributors to the excess total cumulative health burden. The cumulative burden of chronic health conditions at age 50 years was highest in survivors of CNS malignancies and lowest in survivors of germ cell tumors. Older age at diagnosis, treatment era, and higher doses of brain and chest radiation are significantly associated with a greater cumulative burden and severity of chronic health conditions.

Risk Factors for Adverse Events in Emergency Department Procedural Sedation for Children [162], Bhatt et al JAMA Pediatr 2017 Oct 1;171(10):957-964.

Procedural sedation, defined as the administration of medications to minimize pain and awareness, is standard practice in pediatric emergency departments worldwide to facilitate procedures. Serious adverse events (i.e. apnea, bradycardia, laryngospasm, pulmonary aspiration, neurologic injury and death) associated with procedural sedation occur infrequently and are thereby difficult to characterize.

Administration of ketamine hydrochloride as a single agent for sedation had the best outcomes. The addition of propofol or fentanyl citrate to ketamine increased the rates of serious adverse events and significant interventions.

Spontaneous Closure of Patent Ductus Arteriosus in Infants ≤1500 g [163], Semberova et al Pediatrics 2017 Aug;140(2).

The management of patent ductus arteriosus (PDA) in very low birth weight infants remains controversial. The presence of a PDA has been associated with multiple complications; however, causality in these relationships has not been established to date. Furthermore, literature on medical and surgical treatment of PDA has not shown definitive long-term benefits. This has led to wide practice variation between institutions. Spontaneous PDA closure has been documented in a significant number of infants. Semberova et al. performed a retrospective review of VLBW patients born at two level-3 NICU’s. The primary outcome was documentation of time of closure of the PDA in patients who did not receive medical or surgical treatment. Secondary outcome was a demographic comparison between those with spontaneous closure and those patients in whom the PDA did not close. Eighty-five percent of non-treated patients achieved spontaneous closure. The conclusion of this study was that the likelihood of spontaneous closure of a PDA in VLBW infants is extremely high. Rates of spontaneous closure are inversely related to gestational age and birthweight. Further studies are required to compare a non-management approach to medical and surgical management to determine the true benefit of a practice that allows for spontaneous closure of PDA.

Variation in Preoperative Testing and Antireflux Surgery in Infants [164], Short et al Pediatrics 2017 Jul 28.

Gastroesophageal reflux disease (GERD) affects approximately 7% of infants in the first year of life. First line management is medical treatment with feeding modifications and pharmacotherapy. Antireflux surgery may be required when medical management fails; however, there are no current established guidelines for determining necessity of surgery. Short et al. performed a multicenter retrospective review using the Pediatric Health Information Systems database evaluating infants less than one year of age with a diagnosis of GERD. Primary outcome was the receipt of anti-reflux surgery within 12 months after index admission date. Relevant clinical studies were also recorded. There was a wide variation, by institution, in both the diagnosis of GERD and the utilization of anti-reflux surgery. The conclusion of the study was that there was a notable variation in the overall utilization of anti-reflux surgery and in the surgical and diagnostic approach to GERD. Fewer than 4% of infants with GERD undergo diagnostic testing. Less than 22.8% of patients who undergo anti-reflux surgery had preoperative diagnostic testing. The authors noted that this variation merits development of consensus guidelines for the management of GERD in infants.

Effect of American College of Surgeons Trauma Center Designation on Outcomes: Measurable Benefit at the Extremes of Age and Injury [165], Grossman et al J Am Coll Surg 2017 Aug;225(2):194-199.

The American College of Surgeons Committee on Trauma (ACS-COT) has provided verification of trauma centers since 1987. Recent data has shown that there was more variability in adverse outcomes with non-ACS level II centers. Grossman et al. sought to determine if there was a difference in outcomes in both pediatric and elderly outcomes when treated at an ACS verified center versus a non-verified center. The authors performed a 1-year retrospective review of the National Sample Program of the National Trauma Databank. Primary outcome was to determine the effect of verification on mortality and major complications. For pediatric and elderly patients, complications were more likely in non-ACS verified centers. There was no difference in mortality in pediatric and elderly patients treated at non-ACS versus ACS centers. The authors concluded that there was a measurable benefit in complications observed in patients at the extremes of age when treated at an ACS verified center versus a non-verified center. Further studies are required to determine which standards, requirements or clinical characteristics make the most difference with regard to outcome when creating basic structural standards across a national trauma system.

Efficacy and Safety of Nonoperative Treatment for Acute Appendicitis: A Meta-analysis [166], Georgiou et al Pediatrics 2017 March;139(3):1-9.

A meta-analysis of 10 articles involving 413 children who received non-operative (antibiotics only) management of pediatric simple appendicitis. Non-operative management of appendicitis was shown to be 97% effective (95% confidence interval [CI] 96% to 99%), meaning discharge without operation. Recurrent appendicitis occurred in 14%, but overall appendectomy rate in the non-operatively managed patients was 18% (95% CI 77% to 87%). Complication rates were similar between operatively and non-operatively managed patients. Based on these data, the authors recommend that non-operative management of appendicitis should be reserved for those patients in the setting of a trial. Routine non-operative management was not recommended.

Comparison of Antibiotic Therapy and Appendectomy for Acute Uncomplicated Appendicitis in Children: A Meta-analysis [167], Huang et al JAMA Pediatr 2017 May;171(5):426-34.

A meta-analysis of 5 prospective trials comparing operative to non-operative (antibiotics only) management of pediatric simple appendicitis, which included 404 patients aged 5-15 years. Four of these trials were nonrandomized and the one randomized study was a pilot study (not fully powered). Overall, 90.5% of patients were successfully treated with antibiotics and discharged, with 9.5% progressing to appendectomy prior to discharge. Within 1 year, 26.8% of antibiotics-only patients underwent appendectomy due to recurrent appendicitis, symptoms, or parent preference. Patients with an appendicolith on imaging had a higher rate of recurrent appendicitis than did patients without an appendicolith (10 of 30 [33.3%] vs 17 of 138 [12.3%]). The complication rate in the antibiotic-only group was equivalent to the operative group (perforation, abscess, gangrene, and/or postoperative complications). Determination of conclusive measures of risk will require the completion of full prospective randomized trials.

Antibiotics Versus Surgical Therapy for Uncomplicated Appendicitis: Systematic Review and Meta-analysis of Controlled Trials [168], Harnos et al Ann Surg 2017 May;265(5):889-900.

A meta-analysis of the adult literature including four trials and four cohort studies totaling 2551 patients comparing operative to non-operative management (NOM) of uncomplicated appendicitis. The paper comes out strongly against non-operative management, with 26.5% of patients having appendectomy within 1 year, along with a higher rate of adverse events and complicated appendicitis in the non-operative arm. Length of stay was longer for NOM in the randomized trials, but that may have been due to study design. Follow-up time is limited to 1 year. The authors state that antibiotics may prevent some patients from appendectomies, but surgery represents the definitive, one-time only treatment with a well-known risk profile, and “the long-term impact of antibiotic treatment on patient quality of life and health care costs is unknown”.

Pediatric Intestinal Failure [169], Duggan and Jaksic N Engl J Med 2017 Aug 17; 377(7):666-675

Association of Same-Day Discharge With Hospital Readmission After Appendectomy in Pediatric Patients [128], Cairo et al JAMA Surg 2017, July

Congenital Diaphragmatic Hernia and Growth to 12 Years [170], Leeuwen et al Pediatrics 2017 Aug;140(2).

Transfusion Requirement in Burn Care Evaluation (TRIBE): A Multicenter Randomized Prospective Trial of Blood Transfusion in Major Burn Injury [171], Palmieri et al Ann Surg 2017 Jul 10.

Effects of Intraoperative Liberal Fluid on Postoperative Nausea and Vomiting in Children – A Randomized Controlled Trial [172], Ashok et al Paediatr Anaesth 2017 Aug;27(8):810-815.

Intravenous Versus Oral Antibiotics for the Prevention of Treatment Failure in Children With Complicated Appendicitis: Has the Abandonment of Peripherally Inserted Catheters Been Justified? [173], Rangel et al Ann Surg 2017 Aug;266(2):361-368.

Centers of Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017 [174], Berrios-Torres et al JAMA Surg 2017 May 3.

Proposed Clinical Pathway for Non-operative Management of High-Grade Pediatric Pancreatic Injuries Based on a Multicenter Analysis: A Pediatric Trauma Society Collaborative [175], Naik-Mathuria et al J Trauma Acute Care Surg 2017 Oct;83(4):589-596.

Focused Assessment with Sonography for Trauma (FAST) in Children Following Blunt Abdominal Trauma: A Multi- Institutional Analysis [176], Calder et al J Trauma Acute Care Surg 2017 Aug;83(2):218-224.

Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Trial [177], Bruzoni et al J Am Coll Surg 2017 Mar.pii:S1072-7515(17)30228-4.

Association of Patent Ductus Arteriosus Ligation With Death or Neurodevelopmental Impairment Among Extremely Preterm Infants [178], Weisz et al JAMA Pediatr 2017 Mar;171(5):443-449.

Survival and Neurodevelopmental Outcomes among Periviable Infants [179], Younge et al N Engl J Med 2017 Feb;376(7):617-628.

Should Extracorporal Membrane Oxygenation Be Offered? An International Survey [180], Kuo et al J Pediatr 2017 Mar;182:107-113.

Development of a Gestation Age-Specific Case Definition for Neonatal Necrotizing Enterocolitis [181], Battersby et al JAMA Pediatr 2017 Mar;171(3):256-263.

Respiratory Morbidity in Infants Born with Congenital Lung Malformation [182], Delestrain et al Pediatrics 2017 Mar;139(3).

Clinical Outcome and Biological Predictors of Relapse after Nephrectomy only for Very Low Risk Wilms Tumor [183], Fernandez et al Ann Surg 2017;265:835-40

Tight Glycemic Control in Critically Ill Children [184], Agus et al NEJM 2017;376:729-41

Clinical Relevance of the Nonvisualized Appendix on Ultrasonography of the Abdomen in Children [185], Nah et al J Pediatr 2017;182:164-9.

Future Supply of Pediatric Surgeons: Analytical Study of the Current and Projected Supply of Pediatric Surgeons in the Context of a Rapidly Changing Process for Specialty and Subspecialty Training [186] , Ricketts et al Ann Surg 2017 Mar; 265(3):609-615.

Diagnosing Surgical Site Infection Using Wound Photography: A Scenario-Based Study [187], Sanger et al J Am Coll Surg 2017 Jan;224(1):8-15.e1.

Neuropsychological Follow-Up After Neonatal ECMO [188], Schiller et al Pediatrics 2016 Nov;138(5).

Association of Anesthesia and Surgery during Childhood with Long-term Academic Performance [189], Glatz et al JAMA Pediatr 2017 Jan 2;171(1):e163470.

Responsible Innovation in Children’s Surgical Care [190], Section on Surgery; Committee on Bioethics; American Pediatric Surgical Association New Technology Committee Pediatrics. 2017 Jan;139(1).

Management of Sepsis and Septic Shock [191], Howell and Davis JAMA Pediatr 2017 Jan 19.

Oral Paracetamol versus Oral Ibuprofen in the Management of Patent Ducts Arteriosis in Preterm Infants: A Randomized Controlled Trial [192], Oncel et al J Pediatr 2014 Mar;164:510-514.

Complications of Endoscopic Retrograde Cholangiopancreatography in Pediatric Patients; A Systemic Literature Review and Meta-Analysis [193], Usatin et al J Pediatr 2016 Dec;179:160-165.

Quantifying the Burden of Interhospital Cost Variation in Pediatric Surgery: Implications for the Prioritization of Comparative Effectiveness Research [194], Cameron et al JAMA Pediatr 2016 Dec

Prevalence of Barrett Esophagus in Adolescents and Young Adults with Esophageal Atresia [195], Schneider et al Ann Surg 2016 Dec;264(6):1004-1008.

Congenital Diaphragmatic Hernia Defect Size and Infant Morbidity at Discharge [196], Putnam et al Pediatrics 2016 Nov;138(5):1-10.

Is Screening of Intestinal Foregut Anatomy in Heterotaxy Patients Really Necessary?: A Systematic Review in Search of the Evidence [197], Cullis et al Ann Surg 2016 Dec;264(6):1156-1161.

Evaluation of Variability in Inhaled Nitric Oxide Use and Pulmonary Hypertension with Congenital Diaphragmatic Hernia [196], Putnam et al JAMA Pediatr 2016 Oct

Association of Preoperative Anemia with Postoperative Mortality in Neonates [198], Goobie et al JAMA Pediatr 2106 Sep 1;170(9):855-62.

Ovarian Torsion in Children: Management and Outcomes [199], Geimanaite and Trainavicious J Pediatr Surg 2013 Sep;48(9):1946-53.

Current Trends in the Surgical Treatment of Pediatric Ovarian Torsion: We can do better [200], Campbell et al J Pediatr Surg 2015 Aug;50(8):1374-7.

Ovarian Torsion in Children: Is Oophorectomy Necessary? [201], Aziz et al J Pediatr Surg 2004 May;39(5):750-3.

Survival and Surgical Interventions for Children With Trisomy 13 and 18 [202], Nelson et al JAMA 2016 Jul 26;316(4):420-8.

Long-term outcomes after pediatric splenectomy [203], Luoto et al Surgery 2016 Jun;159(6):1583-90.

Limiting chest computed tomography in the evaluation of pediatric thoracic trauma [204], Golden et al J Trauma Acute Care Surg 2016 Aug;81(2):271-7.

Effect of Donor Milk on Severe Infections and Mortality in Very Low Birth Weight Infants: The Early Nutrition Study Randomized Clinical Trial [205], Corpeleijn et al JAMA Pediatr 2016;170(7):654-61.

Computed Tomography Evaluation of Esophagogastric Necrosis After Caustic Ingestion [206], Chirica et al Ann Surg 2016 Jul;264(1):107-13.

National Variability and Appropriateness of Surgical Antibiotic Prophylaxis in US Children’s Hospitals [207], Sandora et al JAMA Pediatr 2016 Jun 1;170(6):570-6.

Delaying Appendectomy Does Not Lead to Higher Rates of Surgical Site Infections [208], Boomer et al Ann Surg 2016 Jul;264(1):164-8.

Predictors of Increasing Injury Severity Across Suspected Recurrent Episodes of Non-Accidental Trauma: A Retrospective Cohort [209], Thackeray et al BMC Pediatr 2016 Jan 16;16:8.

Effect of a Clinical Practice Guideline for Pediatric Complicated Appendicitis [210], Willis et al JAMA Surg 2016 May 18;151(5):e160194.

Should Children with Suspected Nonaccidental Injury Be Admitted to a Surgical Service? [211], Magoteaux et al J Am Coll Surg 2016;222:838e 843.

Quality Improvement Initiative to Reduce the Necrotizing Enterocolitis Rate in Premature Infants [212], Talavera et al Pediatrics 2016;137(5):e20151119

Early Versus Late Parenteral Nutrition in Critically Ill Children [213], Fivez et al N Engl J Med 2016 Mar;374(12):1111-1122.

Development of Guidelines for Skeletal Survey in Young Children with Intracranial Hemorrhage [214], Paine et al Pediatrics 2016 Apr;137(4):1-8.

Conventional Ventilation Versus High-frequency Oscillatory Ventilation for Congenital Diaphragmatic Hernia: A Randomized Clinical Trial (The VICI – Trial) [215], Snoek et al Ann Surg 2016;263(5):867-874.

Bowel Function and Quality of Life After Transanal Endorectal Pull-through for Hirschsprung Disease: Controlled Outcomes up to Adulthood [124], Neuvonen et al Ann Surg 2016 Mar 8.

Association of Red Blood Cell Transfusion, Anemia, and Necrotizing Enterocolitis in Very Low-Birth-Weight Infants [216], Patel et al JAMA. 2016 Mar 1;315(9):889-97

Hospital Costs for Neonates and Children Supported with Extracorporeal Membrane Oxygenation [217], Faraoni et al J Pediatr 2016;169:69-75.

Optimal Timing of Appendectomy in the Pediatric Population [218], Gurien et al J Surg Res 2016;202:126-131.

Postoperative Timing of Computed Tomography Scans for Abscess in Pediatric Appendicitis [219], Nielsen et al J Surg Res 2016 200:1-7.

Feeding Post-pyloromyotomy: A Meta-Analysis [220], Sullivan et al Pediatrics 2016 Jan;137(1):1-11.

Racial Disparities in Pain Mangament of Children With Appendicitis in Emergency Rooms [104], Goyal et al JAMA Pediatr 2015 Nov;169(11):996-1002.

Effect of Liver Transplant on Long-term Disease-Free Survival in Children with Hepatoblastoma and Hepatocellular Cancer [221], Pham et al JAMA Surg 2015 Dec;150(12):1150-8.

Pediatric Emergency Appendectomy and 30-Day Postoperative Outcomes in District General Hospitals and Specialist Pediatric Surgical Centers in England, April 2001 to March 2012: Retrospective Cohort Study [222], Giuliani et al Ann Surg 2016;263:184-190.

Critical Elements for the Pediatric Perioperative Anesthesia Environment [223], Section on Anesthesiology and Pain Medicine Pediatrics 2015 Dec;136(6):1200-1205.

Nonoperative management of blunt liver and spleen injury in children: Evaluation of the ATOMAC guideline using GRADE [224], Notrica et al J Trauma Acute Care Surg 2015 Oct;79(4):683-693.

Neurodevelopment Outcome at 2 years of Age after General Anesthesia and Awake-Regional Anesthesia in Infancy (GAS): an international multicentre, randomised controlled trial [225], Davidson et al Lancet 2015 Oct 23.

Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents [226], Inge et al N Engl J Med 2015 Nov 6.

Trimethoprim-Sulfamethoxazole Therapy Reduces Failure and Recurrence in Methicillin-Resistant Staphylococcus aureus Skin Abscesses After Surgical Drainage [227], Holmes et al J Pediatr 2016 Feb;169:128-34.e1.

Does the American College of Surgeons NSQIP-Pediatric accurately represent overall patient outcomes? [228], Gross et al J Am Coll Surg 2015 Oct;221(4):828-36.

Intravascular Complications of Central Venous Catheterization by Insertion Site [229], Parienti et al N Engl J Med 2015 Sep 24;373(13):1220-9.

Same Hospital Readmission Rates as a measure of Pediatric Quality Care [230], Kahn et al JAMA Pediatr 2015 Oct 1;169(10):905-12.

Effect of Reduction in the Use of Computed Tomography on Clinical Outcomes of Appendicitis [231], Bachur et al JAMA Pediatr 2015 Aug 1;169(8):755-60.

Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children [232], Fyhn et al Ann Surg 2015 Jun;261(6):1061-7.

Early Detection of Necrotizing Enterocolitis by Fecal Volatile Organic Compounds Analysis [233], de Meij et al J Pediatr 2015 Sep;167(3):562-567.e1.

Antibiotic Prophylaxis to Prevent Surgical Infections in Children: A Prospective Cohort Study [234], Khoshbin et al Ann Surg 2015;262(2):397-402.

Comparison of Isotonic and Hypotonic Intravenous Maintenance Fluids: A Randomized Clinical Trial [235], Friedman et al JAMA Pedaitr 2015;169(5):445-451.

Predictors of Enteral Autonomy in Children with Intestinal Failure: A Multicenter Cohort Study [236], Khan et al J Peds 2015;167(1):29-34.

Neonatal morphine exposure in very preterm infants-cerebral development and outcomes [237], Steinhorn et al J Pediatr 2015 May;166(5):1200-1207.e4.

Antibiotic therapy vs appendectomy for treatment of uncomplicated acute appendicitis: the APPAC randomized clinical trial [238], Salminen et al JAMA 2015 Jun 16;313(23):2340-8.

Presentation and clinical outcomes of Choledochal Cysts in children and adults: a multi-institutional analysis [239], Soares et al JAMA Surg 2015 Jun 1;150(6):577-84.

Outcomes and costs of surgical treatments of necrotizing enterocolitis [240], Stey et al Pediatrics 2015 May;135(5):e1190-7.

Between-hospital variation in treatment and outcomes in extremely preterm infants [241], Rysavy et al N Engl J Med 2015 May 7;372(19):1801-11.

Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial [242], Marhuenda et al Pediatrics 2014 Nov;134(5):e1301-7.

Stool color card screening for early detection of biliary atresia and long-term native liver survival: a 19-year cohort study in Japan [243], Gu et al J Pediatr 2015 Apr;166(4):897-902.e1.

Brain Oxygenation During Laparoscopic Correction of Hypertrophic Pyloric Stenosis [244], Tytgat et al J Laparoendosc Adv Surg Tech 2015 Apr;25(4):352-7.

Clindamycin versus Trimethoprim–Sulfamethoxazole for Uncomplicated Skin Infections [245], Miller et al N Engl J Med 2015 Mar 19;372(12):1093-103.

Anesthetic neurotoxicity–clinical implications of animal models [246], Rappaport et al N Engl J Med. 2015 Feb 26;372(9):796-7.

Cognitive and behavioral outcomes after early exposure to anesthesia and surgery [247], Flick et al Pediatrics 2011 Nov;128(5):e1053-61.

Very low birth weight is an independent risk factor for emergency surgery in premature infants with inguinal hernia [248], de Goede et al J Am Coll Surg 2015 Mar;220(3):347-52.

Effect of deregionalized care on mortality in very low-birth-weight infants with necrotizing enterocolitis [249], Kastenberg et al JAMA Pediatr 2015 Jan 1;169(1):26-32.

Effect of an enhanced medical home on serious illness and cost of care among high-risk children with chronic illness: a randomized clinical trial [250], Mosquera JAMA 2014 Dec 24-31;312(24):2640-8.

Nonoperative Treatment With Antibiotics Versus Surgery for Acute Nonperforated Appendicitis in Children: A Pilot Randomized Controlled Trial [251], Svensson et al Ann Surg 2014 Jul 28.

Outcomes of Full-term Infants with Bilious Vomiting: Observational Study of a Retrieved Cohort [252], Mohinuddin et al Arch Dis Child 2015 Jan;100(1):14-7.

Propranolol for Infantile Haemangiomas: Single Centre Experience of 250 Cases and Proposed Therapeutic Protocol [253], Solman et al Arch Dis Child 2014 Dec;99(12):1132-6.

Consequences of the affordable care act for sick newborns [254], Profit et al Pediatrics 2014 Nov;134(5):e1284-6.

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Last updated: November 11, 2022