Journal of pediatric surgery最新文献

Background: Women have historically been underrepresented in surgical leadership and in specialty organizations. This study longitudinally examines representation of women across committee leadership within the American Pediatric Surgical Association (APSA).

Methods: Annual APSA committee chair and vice-chair rosters (2003-2023) were obtained. If not self-reported in the membership roster, gender was classified based upon review of publicly available data. Proportions of women who served as chairs and vice-chairs were quantified by committee and by year.

Results: Overall, the proportion of women serving as APSA committee chairs and vice-chairs increased from 11% to 48% during the study period (p = 0.001). In examining each position, the proportion of women chairs increased from 12% to 40% (p = 0.042), while women vice-chairs increased from 10% to 58% (p = 0.009). The committees with the highest cumulative proportion of women chairs were Benjy Brooks (100%), Diversity Equity & Inclusion (100%), Finance (100%), Global Pediatric Surgery (67%), and Wellness (67%). Four committees- Trauma, Access to Surgery for Kids, Practice, and Professional Development - were not led by a woman chair in the entire study period. Additionally, five committees that traditionally have had significant impact on organizational workflow and agendas all had cumulative proportions of women chairs of less than 50% - Education (33%), Publications (28.6%), Outcomes (19%), Surgical Quality & Safety (18.8%) and Program (9.5%).

Conclusion: These results demonstrate encouraging trends in the gender diversity of APSA leadership. However, this progress does not appear to be evenly distributed; leadership of key committees continues to lack substantial women's representation.

Level of evidence: III.

Background: Pediatric trauma management seeks to minimize head computed tomography (HCT) while capturing clinically important traumatic brain injuries (ciTBI). The Pediatric Emergency Care Applied Research Network (PECARN) system stratifies patients as high-, intermediate-, or low-risk for ciTBI. Although designed for free falls, we noted that PECARN criteria often are applied to tumbling down stairs (TDS), with steps estimated at 12", though TDS rarely appeared to result in ciTBI.

Methods: In a retrospective chart review of pediatric TDS patients, data was collected on mechanism of injury, clinical presentation, imaging, and incidence of ciTBI. PECARN scores were developed under three models: TDS-12 (12″ steps), TDS-8 (more accurate 8" steps), and TDS-0 (TDS not a severe mechanism).

Results: 344 patients met criteria for study inclusion. Mean age was 6.3 years and 89 (26%) were <2 years. No patients had ciTBI. This included 88 patients who tumbled down 12 steps or more. Across all models, the same 7 patients (2.0%) were at high-risk for ciTBI. Intermediate- and low-risk cohorts were 287 (83%) and 50 (15%) for TDS-12, 171 (50%) and 166 (48%) for TDS-8, and 16 (4.7%) and 321 (93%) for TDS-0, respectively for each model. Under TDS-8, 116 (34%) patients shifted to the low-risk category. Under TDS-0, 271 (79%) patients shifted to the low-risk category, leaving only 23 patients (6.7%) at high- or intermediate-risk (n = 7, 16, respectively).

Conclusions: In pediatric patients, the risk of ciTBI after TDS is low. TDS should not be treated as a free fall in risk assessment.

Type of study: Retrospective Modeling Study.

Level of evidence: Level III.

Background: Pediatric melanoma is the most common skin cancer in children. Achieving surgical margins recommended by the National Comprehensive Cancer Network (NCCN) for wide local excision (WLE) is challenging in children with less body domain. This study investigated whether surgical margin impacted postoperative clinical outcomes following WLE for melanoma in children and adolescents.

Methods: All patients ≤21 years undergoing WLE between 2007 and 2023 were analyzed. Patients were categorized in groups of surgical margin <2 cm vs. ≥2 cm. The chi-square test/Fisher's exact test and Mann-Whitney U test were used to analyze categorical and continuous variables between groups. Multivariate logistic regression was used to determine the association of age and tumor location with surgical margin group and whether NCCN guidelines for WLE were met.

Results: Of the 59 patients included, 61% had WLE with <2 cm margins. Head/neck melanomas were less likely to have margins ≥2 cm (OR = 0.121, 95% CI 0.022-0.648, p = 0.014) and margins that met the NCCN guidelines (OR = 0.002, 95% CI 0.003-0.215, p < 0.001) when compared to trunk/extremity primaries. There was no difference in the rate of postoperative complications or need for intervention for complications between patients with margins <2 cm and those with ≥2 cm. No patients experienced local recurrence with a median follow-up of 52 months (IQR: 16 to 93).

Conclusion: Pediatric head/neck melanomas undergoing WLE were likelier to have narrow margins <2 cm and less likely to meet NCCN criteria. Narrow margins may achieve excellent results for pediatric melanoma patients.

Type of study: This is a treatment study.

Levels of evidence: This is a Level III retrospective comparative study.

Introduction: Pediatric patients with ileocecal Crohn's Disease (CD) refractory to medical management frequently require ileocecectomy. However, risk factors for post-operative ileocecal recurrence and appropriate management strategies are poorly defined in the pediatric literature in the biologic era.

Methods: We queried our institutional database from 1/1/2012-12/31/2022 for patients aged 1-21 who underwent primary ileocecectomy for CD. We analyzed baseline characteristics, operative details, medical management, recurrence patterns, and management patterns.

Results: We identified 208 patients who underwent primary ileocecal resection, of which 66 (23%) demonstrated endoscopic recurrence at 2.1 ± 0.5 years and 28 (13%) developed clinical recurrence at 2.5 ± 0.8 years. Recurrence was at the surgical anastomosis in 43 (21%). Before surgery, 138 (66%) were treated with a biologic, of which 25 (18%) were transitioned to a second line biologic pre-operatively. Requiring a separate intervention for perianal or intestinal disease increased the odds of recurrence on multivariable analysis, as did requiring a second line biologic. Of those with endoscopic recurrence, most [62/66 (94%)] were successfully managed with medical optimization alone. Only four (6.7%) required procedural intervention with two being managed with endoscopic balloon dilation and two requiring repeat resection and re-anastomosis. Median follow up was 2.6 years [IQR 1.2-4.5].

Conclusion: Requiring separate interventions for perianal or intestinal disease and demonstrating disease difficult to medically control may increase the risk of recurrent post-operative ileocecal CD. Such patients should be closely surveilled for endoscopic recurrence and may warrant more aggressive medical regimens. Recurrence can typically be managed medically with few patients requiring procedural intervention.

Level of evidence: III.

Background: Interdisciplinary long-term health surveillance identifies opportunities to mitigate CDH-related multisystem morbidity, particularly in patients with neurodevelopmental impairment (NDI). However, no studies to date have assessed the impact of these morbidities on the patient/family. Our aim was to describe the clinical trajectory of patients with CDH and NDI (CDH-NDI), and to explore the lived experience and satisfaction of families with existing support resources.

Methods: A multi-phase explanatory study (REB 2023-8964) was conducted. Phase 1: Review of clinical data for CDH-NDI patients attending a longitudinal follow-up clinic; Phase 2: Satisfaction assessment of CDH-NDI families with existing hospital resources. Standard statistical analyses were performed for Phases 1 and 2, respectively.

Results: Of 91 patients included, 27 had NDI, stratified into mild (n = 2), moderate (n = 7), and severe (n = 18) cohorts. Ventilation (16 vs. 8; p < 0.001), ICU (34 vs. 18; p < 0.001) and hospital (41 vs. 22; p < 0.001) days were significantly longer in the severe cohort. The severe cohort required significantly more unscheduled visits, particularly in the first four years of life (p < 0.05). Despite high family satisfaction with existing resources, team communication during ICU-ward transfers could be improved. Parents also desired to share experiences with other CDH families.

Conclusion: CDH children with NDI require increased support, particularly in the first four years of life. While clinic satisfaction is high, improvement of team communication and access to support resources remain high priorities for parents.

Level of evidence: Level II (prospectively collected data, retrospective analysis).

Background: Choledocholithiasis in children is commonly managed with an "endoscopy-first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)). Because ERCP availability is often limited at the end of the week (EoW), we hypothesized that a "surgery-first" (SF) approach (LC with intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile exploration (LCBDE)) would decrease length of stay (LOS) and time to definitive intervention (TTDI).

Methods: A multicenter, retrospective cohort study was conducted on pediatric patients from 2018 to 2023 with suspected choledocholithiasis. Work week (WW) presentation was defined as admission between Monday to Thursday. TTDI was defined as time to LC or postoperative ERCP (if required).

Results: Among seven hospitals, there were 354 pediatric patients; 217 (61%) managed with SF (125 WW, 92 EoW) and 137 (39%) managed with EF (74 WW, 63 EoW). SF groups had a shorter LOS for both WW and EoW presentation (60.2 h and 58.3 h vs 88.5 h and 93.6 h respectively; p < 0.05). TTDI decreased in SF (26.4 h and 28.9 h vs 61.4 h and 72.8 h; p < 0.05). All EF patients underwent at least two anesthetics (preoperative ERCP followed by LC) while the majority (79%) of the SF group had only one procedure (LC + IOC ± LCBDE).

Conclusion: Children who present with choledocholithiasis at EoW have a longer LOS and TTDI. These findings are amplified when children enter an EF pathway. A surgery-first approach results in fewer procedures, decreased TTDI, and shorter LOS, regardless of the time of presentation.

Level of evidence: Level III.

Purpose: Mediastinal position varies in neonates with congenital diaphragmatic hernia (CDH), reflecting contralateral shift due to mass effect. We aimed to create and validate a postnatal measurement of mediastinal positioning using chest radiographs in neonates with CDH who require extracorporeal membrane oxygenation.

Methods: Chart review identified neonates with CDH who required veno-arterial extracorporeal membrane oxygenation between 2017 and 2022. Mediastinal shift index (MSI) is the ratio of the distance between the venous cannula tip and the contralateral chest wall divided by the total width of the contralateral hemithorax. Three raters completed MSI measurements at designated timepoints: after cannulation, post- CDH repair, and immediately before decannulation. Intraclass correlation coefficients (ICC) assessed inter-rater agreement. Initial MSI and observed/expected lung head ratio (O/E LHR) were correlated and compared between survivors and non-survivors. Receiver operative characteristic (ROC) curve analysis evaluated the ability of MSI and O/E LHR to predict survival.

Results: 38 neonates were included. MSI demonstrated excellent agreement (ICC>0.98) amongst raters. Initial MSI and O/E LHR had a moderate positive correlation (Spearman correlation = 0.47, p = 0.014). Initial MSI differed significantly between survivors and non-survivors (0.52 vs. 0.33, p = 0.035) as did O/E LHR (0.36 vs. 0.26, p = 0.036). ROC analysis revealed initial MSI >0.35 was predictive of survival with 73% sensitivity and 70% specificity.

Conclusion: Mediastinal shift index is reliable and predicted survival with a higher specificity than O/E LHR. Future studies will elucidate the role of trending MSI over a patient's course to inform interventions to optimize mediastinal position.

Level of evidence: 3:

Background: In this study, we compared outcomes between intracranial pressure monitoring (ICP) only versus ventriculostomy (VT) using a nationwide database of pediatric trauma patients.

Methods: Pediatric patients (<18 years) with severe blunt TBI who underwent ICP monitoring with or without VT were identified from the 2017-2021 ACS Trauma Quality Programs. We excluded patients who experienced death or craniotomy/craniectomy within 48 h. The primary outcome was discharge disposition. Secondary outcomes were subsequent intracranial surgery, length of stay (LOS), and infectious complications. Competing risks survival analysis was used to evaluate the multivariable association between ICP vs. VT and outcomes.

Results: Of 1719 eligible patients, 65.9% were male and 54.1% had VT. Between the ICP and VT groups, there were no differences in mean age (11.4 vs. 11.0 years, p = 0.145), injury severity score (30.9 vs. 30.9, p = 0.937), or median GCS (3 vs. 3, p = 0.120). Multivariable analysis showed a robust association between VT and discharge home (compared to rehabilitation center; sHR 0.85, 95% CI 0.74-0.97, p = 0.017). VT use was not associated with increased mortality compared to ICP (p = 0.342). Finally, VT patients had longer median LOS (20.5 vs. 18.0 days, p < 0.001) but there was no difference in subsequent craniotomy/craniectomy (8.6 vs. 6.5%, p = 0.096) or infectious complications (1.2 vs. 0.9%, p = 0.549).

Conclusion: VT was associated with greater discharge to home. Although VT patients had a greater LOS, the risk for other secondary outcomes did not vary, suggesting that VT may have benefits for the treatment of severe TBI with respect to discharge disposition.

Level of evidence: III.

Purpose: To investigate whether Leukotriene B4 receptor 2 (BLT-2), an upstream regulator of tight junction protein (TJP) Claudin-4, and TJPs could be etiologic factors in Hirschsprung-associated enterocolitis (HAEC) after pull-through (PT) for Hirschsprung disease (HD).

Methods: Normoganglionic colon (HD-N) and aganglionic rectum (HD-A) specimens from rectal/rectosigmoid (R/RS) or descending/transverse (D/T) HD were assessed using quantitative polymerase chain reaction (qPCR) for Occludin, TJP-1, TJP-2, Junctional adhesion molecule (JAM)-1, JAM-2, Claudin-1, Claudin-3, Claudin-4, and BLT-2 and immunoblotting for Claudin-4 using fresh specimens obtained intraoperatively (2021-2024; n = 17; R/RS = 15 and D/T = 2). Claudin-4 immunohistochemistry was also evaluated quantitatively using preserved (n = 29; R/RS = 20 and D/T = 9; 2009-2021) and fresh HD specimens for comparison with anorectal malformation patients having colostomy closure as controls (n = 42) and between HD-A versus HD-N, R/RS versus D/T, and HAEC (+) versus HAEC (-). Technically inadequate or transitional zone PT were excluded.

Results: Subjects were 123 PT cases. Mean ages at PT/colostomy closure (years) were R/RS: 2.7 ± 2.9, D/T: 1.6 ± 2.2, and controls: 1.4 ± 0.7. Postoperative HAEC occurred 18 times in 14 PT cases (grade I = 5, grade II = 13). Post-PT HAEC was significantly more frequent in D/T (50.0% versus 6.4%; p < 0.001); Claudin-4 was significantly lower in HD-N from post-PT HAEC cases, especially D/T (p < 0.05) on immunohistochemistry. Claudin-4 was significantly lower in HD-N/HD-A compared with controls on immunoblotting (p < 0.05) and immunohistochemistry (p < 0.001). qPCR showed TJP-1, TJP-2, JAM-1, JAM-2, Claudin-4, and BLT-2 were significantly lower in HD-N/HD-A compared with controls.

Conclusions: Lower Claudin-4 and BLT2 in post-PT HAEC HD-N (especially D/T) suggests generalized epithelial barrier derangement with possible etiologic implications for HAEC.

Level of evidence: Ⅱ.