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Background: Traumatic injuries remain the leading cause of death in children aged 1-14. Previous research demonstrates a link between lower socioeconomic status (SES) and higher pediatric injury morbidity and mortality. There is scant research exploring the relationship between neighborhood disadvantage and pediatric trauma. This study utilizes Area Deprivation Index (ADI) to understand the relationship between pediatric traumatic injury mechanisms, severity, and outcomes and neighborhood disadvantage., Methods: We performed a single-center cross-sectional analysis of pediatric trauma patients aged 0-18 presenting to our Level 1 Pediatric Trauma Center from 2016 to 2021. Patients were stratified into quintiles by national ADI. Injury mechanisms and severity markers were analyzed across ADI quintiles. A subset analysis was also performed, comparing complications and outcomes across ADI quintiles for severely injured patients., Results: Children from areas of higher disadvantage experienced higher rates of injuries related to automobiles, non-accidental trauma (NAT)/assault/neglect, penetrating injuries, and thermal injuries (p < 0.001). Children from areas of low disadvantage incurred more injuries related to sports (p < 0.001) and falls (p = 0.002). Multiple markers of trauma severity increased with increasing neighborhood disadvantage. No differences were found in clinical outcomes in the subset of most severely injured children., Conclusions: Mechanisms and severity of traumatic injuries among children vary with degree of neighborhood disadvantage. Outcomes did not differ by ADI quintile in the most severely injured children. ADI may be a tool for identifying children at higher risk for certain injury mechanisms and more severe injuries and could be used to target injury prevention interventions to more vulnerable communities., Type of Study: Retrospective cross-sectional analysis., Level of Evidence: Level IV., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations., Methods: Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized., Results: The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management., Conclusions: Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy., Level of Evidence: Level 3-4., Type of Study: Systematic Review of Level 3-4 Studies., Competing Interests: Conflict of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee conducted a systematic review to describe the epidemiology of venous thromboembolism (VTE) in pediatric surgical and trauma patients and develop recommendations for screening and prophylaxis., Methods: The Medline (Ovid), Embase, Cochrane, and Web of Science databases were queried from January 2000 through December 2021. Search terms addressed the following topics: incidence, ultrasound screening, and mechanical and pharmacologic prophylaxis. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available literature., Results: One hundred twenty-four studies were included. The incidence of VTE in pediatric surgical populations is 0.29% (Range = 0.1%-0.48%) and directly correlates with surgery type, transfusion, prolonged anesthesia, malignancy, congenital heart disease, inflammatory bowel disease, infection, and female sex. The incidence of VTE in pediatric trauma populations is 0.25% (Range = 0.1%-0.8%) and directly correlates with injury severity, major surgery, central line placement, body mass index, spinal cord injury, and length-of-stay. Routine ultrasound screening for VTE is not recommended. Consider sequential compression devices in at-risk nonmobile, pediatric surgical patients when an appropriate sized device is available. Consider mechanical prophylaxis alone or with pharmacologic prophylaxis in adolescents >15 y and post-pubertal children <15 y with injury severity scores >25. When utilizing pharmacologic prophylaxis, low molecular weight heparin is superior to unfractionated heparin., Conclusions: While VTE remains an infrequent complication in children, consideration of mechanical and pharmacologic prophylaxis is appropriate in certain populations., Type of Study: Systematic Review of level 2-4 studies., Level of Evidence: Level 3-4., Competing Interests: Conflicts of interest The authors have no potential competing interests to disclose. The views expressed in this presentation are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, nor the U.S. Government (CDR Donald Lucas, MC, USN). One author is a military Service member or employee of the U.S. Government. This work was prepared as part of his official duties. Title 17, U.S.C., §105 provides that copyright protection under this title is not available for any work of the U.S. Government. Title 17, U.S.C., §101 defines a U.S. Government work as a work prepared by a military Service member or employee of the U.S. Government as part of that person's official duties (CDR Donald Lucas, MC, USN)., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Predicted 1-year survival of children with trisomy 18 (T18) has increased to 59.3%. We aimed to systematically review the characteristics, management, and outcomes of children with T18 and hepatoblastoma., Methods: A systematic literature review of the PubMed, Embase, Scopus, Web of Science, and Cochrane Library databases was performed according to the PRISMA 2020 statement (end-of-search date: 03/03/2024)., Results: Fifty studies reporting on 70 patients were included. The median age at diagnosis was 11.5 months, 85.9% were female (n = 55/64), and 15.0% had mosaic T18 (n = 6/40). Diagnosis was made during symptom evaluation (most commonly hepatomegaly or abdominal mass) in 45.5% (n = 15/33), incidentally in 24.2% (n = 8/33), during surveillance with abdominal ultrasound in 18.2% (n = 6/33), and at autopsy in 12.1% (n = 4/33). The median tumor size was 6.4 cm, 33.3% had multiple tumors (n = 14/42), and metastasis was present in one patient (3.8%; n = 1/26). Neoadjuvant chemotherapy was administered in 42.6% (n = 26/61) and adjuvant chemotherapy in 31.6% (n = 18/57). Surgical treatment was performed in 64.2% (n = 43/67). Of the patients not diagnosed on autopsy, overall mortality was 35.5% (n = 22/62) over a median follow-up of 11.0 months. Among the 26 deceased patients (including those diagnosed on autopsy), the most common causes of death were cardiopulmonary disease (38.5%, n = 10/26) and tumor progression (30.8%, n = 8/26)., Conclusions: T18 does not preclude resection with curative intent for hepatoblastoma. Combination of surgery and chemotherapy should be considered in children on an individualized basis depending on tumor characteristics and underlying cardiopulmonary comorbidities. Locoregional modalities may have a role in the setting of severe comorbidities., Level of Evidence: Level IV evidence., Competing Interests: Conflicts of interest The authors have no competing interests to declare., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: There is wide variation in the cost of disposable operating room supplies between surgeons performing the same operation at the same institution. The general relationship between variation in disposable supply cost and patient outcomes is unknown. We aimed to evaluate the relationship between disposable supply cost and patient outcomes for sixteen common operations., Methods: Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For procedure, the median disposable OR costs were calculated. Each operation performed was categorized as low cost (below the group median) or high cost (above the group median. We compared the rates of adverse events (clinic visit within 5 days, 30-day emergency department visit, unplanned reoperation, unplanned readmission, anesthesia complications, prolonged hospital length of stay, need for blood product transfusion, or death) between procedures with low and high disposable supply costs., Results: 1139 operations performed by 48 unique surgeons from five specialties were included; 596 (52%) were low-cost and 543 (48%) high-cost. The low and high-cost groups did not differ regarding most demographic characteristics. Overall, 21.9% of children suffered any adverse outcome; this rate did not differ between the low and high-cost groups when evaluated individually or in aggregate (20.5% vs 23.6%, p = 0.23)., Conclusion: Our data demonstrate that across a wide range of pediatric surgical procedures, the cost of disposable operating room supplies was not associated with the risk of adverse outcomes., Level of Evidence: Level 3., Competing Interests: Conflicts of interest The authors have no conflicts of interest, financial or otherwise, to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children., Methods: Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients., Results: We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %)., Conclusions: Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection., Level of Evidence: V., Competing Interests: Conflict of interest None of the authors has any competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: There is limited literature on the optimal approach to treat adhesive small bowel obstruction (ASBO) in children. We sought to compare rates and outcomes of laparoscopic (LAP) and open (OPEN) surgery for pediatric ASBO., Methods: A California statewide database was used to identify children (<18 years old) with an index ASBO from 2007 to 2020. The primary outcome was the type of operative management: LAP or OPEN. Secondary outcomes were hospital characteristics, patient demographics, and postoperative complications. We excluded patients treated non-operatively., Results: Our study group had 545 patients. 381 (70%) underwent OPEN and 164 (30%) LAP during the index admission. Over the study period, there was increasing use of laparoscopic surgery, with higher use in older children (p < 0.001). LAP was associated with fewer overall complications (65.2% vs. 81.6%, p < 0.001), with a decreasing trend in complications over time (p < 0.001). The LAP group had significantly lower rates of bowel resection (4.9% vs. 17.1%, p < 0.001), length of stay (LOS) (17 vs. 23 days, p < 0.001), and TPN use (12.2% vs. 29.1%, p < 0.001). Mortality rates were equivalent. Although the LAP group had lower readmission rates (22.6% vs. 37.3%, p < 0.001), the length of time between discharge and readmission was similar (171 vs. 165 days, p = 0.190)., Discussion: The use of laparoscopic surgery for index ASBO increased over the study period. However, it was less commonly utilized in younger children. LAP had fewer overall complications as well as shorter LOS, decreased TPN use, and fewer readmissions. The benefits and risks of each approach must be weighed., Level of Evidence: III., Competing Interests: Conflict of interest None of the authors have a financial or other conflict of interest. Dr. Ignacio is a voluntary Associate Editor for the Journal of Surgical Research. There is no financial support or additional aid provided by the Journal of Surgical Research for this position, and he was excluded from the entire peer-review and editorial process for this manuscript. The views in this paper are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States Government., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Healthcare-associated pressure injuries (HAPI) are known to be associated with medical devices and are preventable. Cervical spine immobilization is commonly utilized in injured children prior to clinical clearance or for treatment of an unstable cervical spinal injury. The frequency of HAPI has been quantified in adults with cervical spine immobilization but has not been well-described in children. The aim of this study was to describe characteristics of children who developed HAPI associated with cervical immobilization., Methods: We analyzed a retrospective cohort of children (0-18 years) who developed a stage two or greater cervical HAPI. This cohort was drawn from an overall sample of 49,218 registry patients treated over a five-year period (2017-2021) at ten pediatric trauma centers. Patient demographics, injury characteristics, and cervical immobilization were tabulated to describe the population., Results: The cohort included 32 children with stage two or greater cervical HAPI. The median age was 5 years (IQR 2-13) and 78% (n = 25) were admitted to the intensive care unit. The median (IQR) time to diagnosis of HAPI was 11 (7-21) days post-injury. The majority of cervical HAPI (78%, 25/32) occurred in children requiring immobilization for cervical injuries, with only four children developing HAPI after wearing a prophylactic cervical collar in the absence of a cervical spine injury., Conclusion: Advanced-stage HAPI associated with cervical collar use in pediatric trauma patients is rare and usually occurs in patients with cervical spine injuries requiring immobilization for treatment. More expedient cervical spine clearance with MRI is unlikely to substantially reduce cervical HAPI in injured children., Level of Evidence: Level III (Epidemiologic and Prognostic)., Competing Interests: Conflicts of interest None of the authors have any personal or financial conflicts to disclose., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Introduction: Appendicitis is the most common indication for emergency general surgery in the pediatric population. Computed tomography (CT) or magnetic resonance imaging (MRI) may be used for diagnosis when ultrasound findings are equivocal. However, CT involves unnecessary radiation exposure if MRI is available. After introducing a rapid sequence MRI (rsMRI) appendicitis protocol at our institution, CT was still preferentially used. We therefore implemented a quality improvement (QI) campaign to reduce the rate of CTs and increase the rate of rsMRI. Here, we assess the effectiveness of the QI campaign while evaluating potential barriers to using rsMRI., Methods: We conducted a mixed methods study, first performing stakeholder interviews which informed the design of a QI campaign initiated in May 2021 and a midway feedback survey in December 2021. A retrospective cohort study was then performed of children evaluated for appendicitis at our institution between January 1, 2016, and April 30, 2022. CT and rsMRI rates were compared before and after QI campaign implementation., Results: There was a significant decrease in rate of CTs and increase in rate of rsMRIs performed following the initiation of the QI campaign (p < 0.0001). The rate of CT scans decreased by a factor of 0.4 while the rate of rsMRI increased by a factor of 9.5., Conclusion: A successful QI campaign was initiated at our institution, resulting in decreased utilization of CT and increased use of rsMRI for the evaluation of suspected appendicitis. These results highlight the potential impact of QI projects., Level of Evidence: III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations., Methods: Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed., Results: Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment., Conclusions: The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention., Level of Evidence: Level 4., Type of Study: Systematic Review of Level 1-4 studies., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Operating room (OR) costs account for 40% of hospital costs. Disposable supplies make up a portion of OR costs and are the only cost that is under control of the surgeon. There are little data to explain how surgeons select surgical supplies and what factors predict supply selection. Our goal with the current work was to assess variation in cost of disposable OR supplies at the surgeon level, hypothesizing high variability would be observed., Study Design: Cost data were reviewed for the most common procedures performed by five surgical divisions at a single children's hospital over a six-month period in 2021. For each procedure, the average disposable OR costs for each surgeon were tabulated and compared to the median supply cost for a given procedure at the group level., Results: For each procedure, the variation ranged from 149% (gastrostomy tube placement) to 758% (tonsillectomy and adenoidectomy). The median supply cost for an individual surgeon was not always above or below the median supply cost for that procedure for the group. No relationship was observed between whether the supply cost was above or below the median for a given case and a surgeon's case volume, years in practice, or operative length. There was also no relationship between surgeon volume and median cost, surgery length, and years of experience., Conclusion: These data demonstrate variation in the cost of disposable OR supplies at the individual surgeon level at a single institution. This variation is not explained by case volume, years in practice, or operative length., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: Most children in the US live more than one hour from a Level 1 PTC. The Need For Trauma Intervention (NFTI) score was developed to assess trauma triage criteria and is dependent on whether someone requires one of six urgent interventions (NFTI+). We sought to determine if a novel scoring tool, rSIG, could predict NFTI and facilitate the transfer decision making process., Methods: Children 1-18 years old transferred to our level 1 PTC from 2010 - 2020 with complete vital signs and Glasgow Coma Scale (GCS) score at the transferring facility were included. rSIG was calculated as previously described [(SBP/HR) x GCS], and the following cutoffs were used for each age group: ≤13.1, ≤16.5, and ≤20.1 for 1-6, 7-12, and 13-18 years, respectively. Clinical outcomes upon arrival to the PTC were collected to determine if patients met any NTFI criteria., Results: A total of 456 patients met inclusion criteria. The proportion of patients with an abnormal rSIG was 60.1% (274) and 37.0% (169) were NFTI+. Patients with an abnormal rSIG had an odds ratio of 6.18 (95% CI: 3.90, 10.07), p < 0.001 of being NFTI+ compared to those with a normal rSIG., Conclusion: Children with an abnormal rSIG are more likely to be NFTI+ and require higher levels of care, indicating this scoring tool can identify pediatric trauma patients who may benefit from expedited transfer. Incorporating rSIG into initial evaluation and triage of traumatically injured children may expedite the transfer decision making process and limit delays in transport to a PTC., Type of Study: Retrospective Comparative Study LEVEL OF EVIDENCE: III., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest, financial or otherwise, to disclose., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Surgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery., Methods: We conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or "colon bundle", we divided patients into low (1-4 elements) or high (5-8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days., Results: Three hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI., Conclusion: Standardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity., Type of Study: Clinical Research Paper LEVEL OF EVIDENCE: Level II., Competing Interests: Declaration of Competing Interest The authors have no financial disclosures., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: There is a paucity of data on the frequency of transfusion during pediatric surgery index cases and guidelines for pretransfusion testing, defined as type and screen and crossmatch testing, prior to operation are not standardized. This study aimed to determine the incidence of perioperative blood transfusions during index neonatal operations and identify risk factors associated with perioperative blood transfusion to determine which patients benefit from pretransfusion testing., Methods: A retrospective review of infants who underwent index neonatal cases between 2013 and 2019 was performed. Data were collected for patients who underwent operations for Hirschsprung's disease, esophageal atresia/tracheoesophageal fistula (EA/TEF), biliary atresia, anorectal malformation, omphalocele, gastroschisis, duodenal atresia, congenital diaphragmatic hernia (non-ECMO) or pulmonary lobectomy. Infants under 6 months were included except in the case of lobectomy where infants up to 12 months were included., Results: Analysis was performed on 420 patients. Twenty-five (6.0%) patients received perioperative blood transfusion. Patients who received perioperative transfusion most commonly underwent EA/TEF repair. Patients who received perioperative transfusion had higher rates of structural heart disease (52.0% vs 17.7%, p<0.001), preoperative transfusion (48.0% vs 8.9%, p<0.001), and prematurity (52.0% vs 25.6%, p = 0.005). Presence of all three risk factors resulted in a 48% probability of requiring perioperative transfusion., Conclusions: Blood transfusion during the perioperative period of neonatal index operations is rare. Factors associated with increased risk of perioperative transfusion include prematurity, structural heart disease, and history of previous blood transfusion., Level of Evidence: III., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest. No grant funding was used to support this research. Institutional funding was provided by the Colorado Firefighter Endowed Chair, Children's Hospital Colorado Center for Research in Outcomes in Children's Surgery, and generous support from the Colorado Firefighter Calendar., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Neutropenic enterocolitis is uncommon but potentially life-threatening, with the cornerstone of treatment being medical management (MM), and surgical intervention reserved for clinical deterioration or bowel perforation. We hypothesized that the Shock Index Pediatric Age-Adjusted (SIPA) is elevated in patients who are at greatest risk for surgical intervention and mortality. We also sought to identify computed tomography (CT) findings associated with surgical intervention and mortality., Methods: A single-center cancer registry was reviewed for neutropenic enterocolitis patients from 2006 -2018. Survival models compared patients with normal versus elevated SIPA throughout their hospitalizations for the time to surgical management (SM), as well as in-hospital mortality., Results: Seventy-four patients with neutropenic enterocolitis were identified; 7 underwent surgery. In-hospital mortality was 12% in MM and 29% in SM; mortality among patients with elevated SIPA was 4.7 times higher compared to those with normal SIPA (95% CI: 1.1, 19.83, p = 0.04). CT findings of bowel obstruction, pneumatosis, and a greater percentage of large bowel involvement were associated with surgical intervention (all ps < 0.05)., Conclusion: Select pre-operative CT findings were associated with need for operative management. Elevated SIPA was associated with increased mortality. Elevated SIPA in pediatric cancer patients with neutropenic enterocolitis may help to identify those with more severe disease and expedite beneficial interventions., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to report. No grant funding was used to support this research. Institutional funding was provided by the Colorado Firefighter Endowed Chair, Children's Hospital Colorado Center for Research in Outcomes in Children's Surgery, and generous support from the Colorado Firefighter Calendar. The funder/sponsor did not participate in the work., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period., Methods: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data., Results: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality., Conclusions: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred., Competing Interests: Declaration of Competing Interest There are no conflicts of interest., (Copyright © 2021. Published by Elsevier Inc.)

Introduction: Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies., Methods: All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy)., Results: We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period., Conclusions: Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy., Level of Evidence: IV TYPE OF STUDY: Treatment study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Purpose: Acquiring a pediatric surgery fellowship is an arduous process, with less than half of applicants matching each year. For those who fail to match initially but remain steadfast in their goal to become a pediatric surgeon, choosing a valuable postresidency path can be challenging. Furthermore, objective data to evaluate the utility of pediatric surgical subspecialty fellowships (PSSF) are lacking., Methods: PSSF training programs were identified on the APSA website. Names and contact information of PSSF graduates between 2014 and 2018 were obtained from individual training programs. Each graduated fellow was then contacted to participate in a voluntary 14-question survey., Results: Names of 47 graduated fellows were obtained from programs listed on the APSA website. Among them, 30 (64%) ultimately matriculated into a pediatric surgery fellowship, 11 (37%) of whom matched at the same institution they completed their PSSF. The type of PSSF was not predictive of matriculation into a pediatric surgical fellowship (p = 0.43). Thirty-two (68%) of the 47 study participants completed a satisfaction survey. While all but two graduates found their fellowships to be at least satisfactory, those who matched were more likely to recommend their PSSF compared to those who did not (100% vs 67%, respectively, p = 0.02). Within the cohort of fellows who did not ultimately match into pediatric surgery (n = 17) and completed a survey (n = 9), all who completed a critical care fellowship (4/4) currently use/or plan to use the skills obtained during their PSSF while only two of five (40%) completing other PSSFs use them., Conclusion: The matriculation rate from a PSSF into a pediatric surgery fellowship was 64% with no significant difference among subspecialties. Of fellows who did not match, those completing a critical care PSSF were more likely to use their fellowship training than those completing a different PSSF., Type of Study: Clinical research paper., Level of Evidence: III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Nonoperative management protocols of blunt liver and spleen injury in children usually call for serial monitoring of the child's hemoglobin and hematocrit (H/H) at scheduled intervals. We previously demonstrated that the need for emergent intervention is triggered by changes in vital signs, not the findings of scheduled blood draws and changed our protocol accordingly. The current aim is to evaluate the safety of this change., Methods: We performed a retrospective review of all children admitted following blunt liver or spleen injury during two periods; the historic cohort 1/09-12/13 and the protocol cohort 8/15-7/17. Data evaluated included the need for intervention, number of H/H checks, and outcomes., Results: 330 children were included (216 historic; 114 protocol). Groups did not differ in percentage of male patients, injury severity score, or GCS. Median age in the historic cohort was younger than the protocol cohort (9 vs 12 years; p = 0.02). More children in the protocol group had a grade 5 injury (1% vs 9%; p < 0.0001). Groups did not differ in the number who required intervention or discharge disposition (including mortality). The protocol group had fewer H/H checks (median 5 vs 4, p < 0.0001); the two groups did not differ in their nadir H/H. The historic group had a longer median hospital length of stay (3 days vs 2, p = 0.0007)., Conclusions: Decreasing the number of scheduled blood draws following a blunt liver or spleen injury in children is safe. Additional benefits include a decrease in the number of blood draws and a decrease in length of hospital stay., Study Type: Cost-effectiveness., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Early and accurate identification of pediatric trauma patients who will require massive transfusion (MT) remains difficult, and MT activation criteria are not well established. In children, the addition of shock index-pediatric age-adjusted (SIPA) to the ABC score (ABC-S) only modestly improves the sensitivity of the ABC score. We hypothesized that the discriminate ability of the ABC-S score would improve with the addition of elevated serum lactate and base deficit (ABCD score)., Methods: We identified children between 1 and 18 years old who received a pRBC transfusion between 2008 and 2018 from our trauma registry. We calculated sensitivity, specificity, and accuracy of the ABC, ABC-S, and ABCD scores to determine the need for MT., Results: We included 211 children, of which 66 required MT. The best predictor of MT was achieved by adding BD and lactate to the ABC-S score, with an AUC of 0.805. An ABCD score of 3 or greater was 77.4% sensitive and 78.8% specific at predicting the need for MT. Pediatric trauma patients that required MT had higher injury severity score (p = 0.005), lactate (p = 0.002), base deficit (p = <0.0001). Mortality was higher in the MT group (45.5% vs 15.3%, p = 0.0004)., Conclusions: The ABCD score improves the sensitivity of activating MT in pediatric trauma patients., Study Type: Treatment Study., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Initiatives exist to prevent pediatric injuries, but targeting these interventions to specific populations is challenging. We hypothesized that mapping pediatric injuries by zip code could be used to identify regions requiring more interventions and resources., Methods: We queried the trauma registries of two level I trauma centers for children 0-17years of age injured between 2009 and 2013 with home zip codes in our state. Maps were created to identify outlier zip codes. Multivariate linear regression analysis identified predictors within these zip codes., Results: There were 5380 children who resided in the state and were admitted for traumatic injuries during the study period, with hospital costs totaling more than 200 million dollars. Choropleth mapping of patient addresses identified outlier zip codes in our metro area with higher incidences of specific mechanisms of injury and greater hospital charges. Multivariate analysis identified demographic features associated with higher rates of pediatric injuries and hospital charges, to further target interventions., Conclusions: We identified outlier zip codes in our metro area with higher frequencies of pediatric injuries and higher costs for treatment. These data have helped obtain funding for prevention and education efforts. Techniques such as those presented here are becoming more important as evidence based public health initiatives expand., Level of Evidence: Type of Study: Cost Effectiveness, II., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics., Methods: We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14. We compared outcomes including ED and hospital readmission rates, and development of postoperative complications, between those children who were discharged on IV antibiotics and those discharged on PO antibiotics., Results: 325 children were discharged with antibiotics following appendectomy (n=291 PO antibiotics group; n=34 IV group). On both univariate and multivariate analysis, rate of each complication did not differ between the two groups including inpatient readmission (5% PO vs. 6% IV; p=0.8), ED readmission (10% vs. 11%; p=0.8), postdischarge complications related to the operation (10% vs. 15%; p=0.4), or abscess development post-discharge (4% vs. 3%; p=1)., Conclusions: Among children with complicated appendicitis who are discharged home with ongoing antibiotic therapy, our data demonstrate no differences in outcomes between those children who receive IV and PO antibiotics. Further data, collected in a prospective fashion, are needed to clarify the role of IV and PO antibiotics among children with perforated appendicitis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: Peritoneal dialysis (PD) is a common method of renal replacement therapy for children. However, placement of PD catheters has risk, and some are never used., Methods: We conducted a retrospective chart review of children with a PD catheter placed between 2000 and 2014. Logistic regression analyses were used to identify covariates associated with complications., Results: We identified 175 children with PD catheters. 110 complications developed in 80 children (45.7%). Complications including unexpected return to the operating room and peritonitis increased as the length of time a catheter was in place increased. Children who weighed <12.4 kg had 3.2 times greater odds of developing a leak (95% CI 1.21-8.63, p=0.02). Twelve children never used their PD catheters, 9 with acute kidney injury (AKI) who recovered from their disease more quickly than expected. No covariate was associated with nonuse., Conclusions: Complications with PD catheters are common and increase the longer catheters are in place. Lower weight children are at greater risk of PD catheter leak. Decreased initial volumes of dialysate in smaller children may mitigate this risk. Nonuse may be reduced if dialysis is permitted the day of placement for children with AKI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy., Methods: We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant., Results: Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications., Conclusion: In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: We hypothesized that the finding of diffuse slowing on bedside EEG in children with moderate to severe traumatic brain injury (TBI) is associated with prolonged hospital stay and worse functional outcomes., Methods: We reviewed the medical records of all patients admitted to a single level I pediatric trauma center with moderate or severe TBI from 1/10-12/12 (defined by GCS<10 on admission). EEG monitoring results, patient demographics, clinical characteristics, length of stay and postinjury outcomes were recorded. We compared outcomes between patients with and without diffuse slowing on EEG. Data are presented as mean±SEM; p<0.05 was considered statistically significant., Results: 219 children with TBI were identified; 81 had a bedside EEG performed within 48 hours of admission. Diffuse slowing was present in 50 (mean age 5.7+0.7 years) and absent in 31 (n=31, mean age 4.2+0.9 years). Patients with diffuse slowing had a significant increase in ventilator days, ICU LOS, need for rehabilitation, and rehabilitation length of stay., Conclusion: The presence of diffuse slowing on EEG in children with TBI is associated with prolonged patient recovery and poor functional outcomes. This finding should prompt early consideration for rehabilitation and the need for intensive therapy., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Anterior mediastinal masses (AMM) pose a diagnostic challenge to surgeons, oncologists, anesthesiologists, intensivists, and interventional radiologists as induction of general anesthesia can cause airway obstruction and cardiovascular collapse. We hypothesized that in the majority of patients, diagnosis can be obtained through biopsy of extrathoracic tissue., Methods: We performed a retrospective review of all patients in the solid tumor oncology clinic with a diagnosis of AMM between 2002 and 2012 including preoperative evaluation and management prior to obtaining a tissue diagnosis, clinical course and complications., Results: We identified 69 patients with AMM (mean age 12.2±4.4years, 64% male) secondary to Hodgkin lymphoma (34), Non-Hodgkin lymphoma (26), and other diagnoses (9). The majority of patients (56, 81.2%) underwent biopsy of tissue outside of the mediastinal mass. Local anesthesia with sedation was used for successful biopsy in 21 (30%) patients. Four (5.8%) required repeat biopsy due to inadequate sample obtained at initial procedure. Three (4.4%) suffered respiratory complications with no fatalities or severe complications., Conclusions: Our data demonstrate that in the majority of children with AMM, tissue biopsy can be successfully obtained from tissue outside of the mass itself with minimal complications and highlight the importance of multidisciplinary preoperative planning to minimize anesthetic risks., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the pediatric population. We aimed to assess the social and legal outcomes of AHT and determine if the rates of successful prosecution have changed over recent years., Methods: We utilized the trauma database at a single institution to identify all cases of AHT during two time periods: 1996-2001 and 2006-2010 then collected data from the Child Advocacy and Protection Team database. We characterized the social and legal outcomes and compared them between the two cohorts., Results: A total of 254 patients (120 historic and 134 modern cohort) were included. Mortality rate was 19.7% and did not differ between the two cohorts. Thirty-seven percent of patients were discharged to foster care, this rate did not change across the two time periods. Suspected perpetrators pled guilty or were found guilty in only 74 cases (29%). However, when a case involved a fatality, perpetrators pled or were found guilty more often than in cases of a non-fatality (50 vs. 21.5%; p=0.0001)., Conclusions: AHT results in fatality in approximately 1 in 5 cases, perpetrators are identified and found guilty in only 29% of the cases. Trauma surgeons need to be strong advocates for these vulnerable patients and actively participate in legal proceedings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Shock index (SI) (heart rate/systolic blood pressure)>0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children., Methods: Retrospective review of children age 4-16 years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS)>15 was performed. We evaluated the ability of SI>0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI>1.22 (age 4-6), >1.0 (7-12), and >0.9 (13-16)., Results: Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24 hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%., Conclusion: A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Introduction: Excessive crystalloid resuscitation of blunt injured adults is deleterious. We hypothesize that children, unlike adults, are resistant to the adverse effects of high volume resuscitation., Methods: We reviewed the trauma databases at two level-one trauma centers, including all children age 4-16years admitted following blunt trauma with an injury severity score (ISS) ≥15 to determine the relationship between crystalloid volume received and clinical outcomes., Results: A total of 384 children were included. After controlling for age, sex, AIS head, ISS, GCS on presentation, hemoglobin, blood transfusion, and surgical procedures in the first 24hours, crystalloid volume greater than 60ml/kg in the first 24hours was associated with increased length of stay (LOS) and need for mechanical ventilation. On univariate analysis, initial crystalloid volume of >60ml/kg was associated with anemia and thrombocytopenia. Volume of resuscitation was not associated with ARDS, ACS, MOF, urinary tract infection, or blood stream infection. However, these complications were exceedingly rare, with no children developing MOF., Conclusions: Excessive crystalloid resuscitation was associated with increased hospital LOS and need for mechanical ventilation. Increased rates of other complications including ARDS, ACS, and MOF were not observed. Injured children appear relatively resistant to some of the adverse effects of early high volume fluid resuscitation., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Traditionally, chest tubes are left following video assisted thoracoscopic surgery (VATS) to treat a potential air leak or significant drainage. Recognizing the potential complications, our aim was to determine if intraoperative chest tube removal in children undergoing VATS lung biopsy is safe and if outcomes differ from when a chest tube is left in place., Methods: We identified all children who underwent VATS lung biopsies from 2009 to 2013 and performed a retrospective review of the medical records. Pulmonary resection patients were excluded as were those with an air leak present in the operating room., Results: A total of 90 VATS lung biopsies were performed. 41 children had a postoperative chest tube left in place (Group A), and 49 children had it removed intraoperatively (Group B). Mean age was 9 ± 6.4 years. One child in Group A and 2 children in Group B required replacement of a chest tube (p=NS). Group B patients had a lower postoperative pain score on day one, fewer postoperative chest X-rays, and a shorter length of postoperative stay., Conclusions: These data suggest that intraoperative chest tube removal is safe and may be associated with improved outcomes following lung biopsy in children., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Purpose: Head injury secondary to abusive head trauma (AHT) is a major cause of morbidity and mortality in susceptible young infants and children. Diagnosing AHT remains challenging and is often complicated by a questionable mechanism of injury. Concern of ionizing radiation risk to children undergoing head CT imaging warrants a selective approach. We aimed to evaluate initial findings that could direct further investigation of AHT., Methods: A retrospective review of the trauma databases at a two level one pediatric trauma centers was performed. We reviewed all patients age five years and under with a diagnosis of traumatic brain injury (TBI) from 2002-2011., Results: A total of 1129 patients (mean age 1.7 ± 1.7 years; 64% male) with TBI were identified, 429 (38%) of which were the result of AHT. Complete data was available for 921 patients (82%) and were included in statistical evaluation. Forty-eight percent of patients in the AHT group had a hematocrit ≤ 30% on presentation compared to 19% of patients in the non-AHT group. On univariate analysis, a hematocrit of ≤ 30% was predictive of AHT as the cause of injury (P<.0001), as was a platelet count of greater than 400,000 (P<.0001). After controlling for age, sex, ISS, GCS on presentation, need for CPR, and survival to hospital discharge, hematocrit of ≤ 30% and platelets of greater than 400,000 were predictive of AHT as the cause of TBI (P<.05)., Conclusions: In the setting of head injury and unclear history of trauma, a hematocrit of ≤ 30% on presentation increases the likelihood of abusive head trauma in children up to the age of 5 years., (© 2014.)

Introduction: Choledochal cyst (CDC) is a congenital malformation of the bile ducts, which can include the intrahepatic or extrahepatic bile ducts. We hypothesize that preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic involvement., Methods: We retrospectively reviewed all cases of CDC in children diagnosed at a single institution between 1991 and 2013., Results: Sixty-two patients were diagnosed with CDC during the study period with a median follow-up time of 2.25 (range 0-19.5) years. Forty-two patients (68%) were diagnosed with type I disease preoperatively, and 15 patients (24%) were diagnosed with type IV-A disease. The most common presenting symptoms included pain (34%), jaundice (28%), and pancreatitis (25%). There were no deaths or malignancies and only one postoperative stricture. Forty-two patients (68%) had intrahepatic ductal dilation preoperatively. Only four patients (9%) had intrahepatic ductal dilation following resection (P<0.0001). In one patient, this dilation resolved following stricture revision. Of the four patients with postoperative dilation, two were diagnosed with type I disease, and the other two were diagnosed with type IV-A disease preoperatively., Conclusion: Preoperative intrahepatic ductal dilation is not predictive of postoperative intrahepatic ductal involvement in children with CDC. The preoperative distinction between type I and IV disease is not helpful in treating these patients., (© 2013 Elsevier Inc. All rights reserved.)