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Background/purpose: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias., Methods: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair., Results: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy., Conclusion: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair., Level of Evidence: Level III., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The prevalence and natural history of patent processus vaginalis (PPV) are unknown. An interim analysis was performed of a multi-institutional, prospective, observational study in neonates undergoing laparoscopic pyloromyotomy during which bilateral inguinal canals were evaluated., Methods: Infants under 4 months undergoing laparoscopic pyloromyotomy were enrolled at 8 children's hospitals. The presence of a PPV was evaluated and measurements recorded. Patients with a PPV are undergoing annual phone follow-up to 18 years of age. Interim analysis was performed., Results: In a cohort of 610 patient, 80 did not have a PPV examined, 4 had consent issues and were excluded, leaving 526 patients. Of these, 433 (82%) were male, median age 1.2 months (IQR 0.9, 1.6), median weight 3.89 kg (IQR 3.4, 4.46), and EGA 39 weeks (IQR 37, 40). There were 283 PPVs, 132 bilateral (47%), 116 right (41%), and 35 left (12%). Patients with a PPV were significantly younger (1.1 months (IQR 0.9, 1.5) vs 1.3 months (IQR 0.9, 1.7), p=0.02), weighed less (3.76kg (IQR 3.35, 4.26) vs 3.9kg (IQR 3.4, 4.5) p=0.03) and had a significantly lower EGA at birth (38 weeks (IQR 37, 40) vs 39 weeks (IQR 38, 40) p=0.003). Of 246 eligible infants, 208 (85%) responded to at least one annual follow-up. Two patients had an inguinal hernia repair for a symptomatic hernia, 49- and 51-days post pyloromyotomy. One had an orchiopexy and incidental inguinal hernia repair 120 days post pyloromyotomy; for a total of 3 (1.2%) hernia repairs. No additional hernias were identified in 116 patients with the PPV patients who have been followed for > 1 year., Conclusions: The presence of a PPV at the time of pyloromyotomy is common but the need for hernia repair is rare within the first year of life. Continued long-term longitudinal follow-up of this cohort is needed., Level of Evidence: II., Competing Interests: Declarations of Competing Interest The authors report no conflicts of interest., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Introduction: We evaluate the incidence, outcomes, and management of peri‑umbilical hernias after sutured or sutureless gastroschisis closure., Methods: A retrospective, longitudinal follow-up of neonates with gastroschisis who underwent closure at 11 children's hospitals from 2013 to 2016 was performed. Patient encounters were reviewed through 2019 to identify the presence of a peri‑umbilical hernia, time to spontaneous closure or repair, and associated complications., Results: Of 397 patients, 375 had follow-up data. Sutured closure was performed in 305 (81.3%). A total of 310 (82.7%) infants had uncomplicated gastroschisis. Peri-umbilical hernia incidence after gastroschisis closure was 22.7% overall within a median follow-up of 2.5 years [IQR 1.3,3.9], and higher in those with uncomplicated gastroschisis who underwent primary vs. silo assisted closure (53.0% vs. 17.2%, p< 0.001). At follow-up, 50.0% of sutureless closures had a persistent hernia, while 16.4% of sutured closures had a postoperative hernia of the fascial defect (50.0% vs. 16.4%, p< 0.001). Spontaneous closure was observed in 38.8% of patients within a median of 17 months [9,26] and most frequently observed in those who underwent a sutureless primary closure (52.2%). Twenty-seven patients (31.8%) underwent operative repair within a median of 13 months [7,23.5]. Rate and interval of spontaneous closure or repair were similar between the sutured and sutureless closure groups, with no difference between those who underwent primary vs. silo assisted closure., Conclusion: Peri-umbilical hernias after sutured or sutureless gastroschisis closure may be safely observed similar to congenital umbilical hernias as spontaneous closure occurs, with minimal complications and no additional risk with either closure approach., Levels of Evidence: Level II., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Firearm sales in the United States (U.S.) markedly increased during the COVID-19 pandemic. Our objective was to determine if firearm injuries in children were associated with stay-at-home orders (SHO) during the COVID-19 pandemic. We hypothesized there would be an increase in pediatric firearm injuries during SHO., Methods: This was a multi institutional, retrospective study of institutional trauma registries. Patients <18 years with traumatic injuries meeting National Trauma Data Bank (NTDB) criteria were included. A "COVID" cohort, defined as time from initiation of state SHO through September 30, 2020 was compared to "Historical" controls from an averaged period of corresponding dates in 2016-2019. An interrupted time series analysis (ITSA) was utilized to evaluate the association of the U.S. declaration of a national state of emergency with pediatric firearm injuries., Results: Nine Level I pediatric trauma centers were included, contributing 48,111 pediatric trauma patients, of which 1,090 patients (2.3%) suffered firearm injuries. There was a significant increase in the proportion of firearm injuries in the COVID cohort (COVID 3.04% vs. Historical 1.83%; p < 0.001). There was an increased cumulative burden of firearm injuries in 2020 compared to a historical average. ITSA showed an 87% increase in the observed rate of firearm injuries above expected after the declaration of a nationwide emergency (p < 0.001)., Conclusion: The proportion of firearm injuries affecting children increased during the COVID-19 pandemic. The pandemic was associated with an increase in pediatric firearm injuries above expected rates based on historical patterns., Competing Interests: Declaration of Competing Interest The authors have no financial disclosures. The study had no source of funding., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: It is unclear how Stay-at-Home Orders (SHO) of the COVID-19 pandemic impacted the welfare of children and rates of non-accidental trauma (NAT). We hypothesized that NAT would initially decrease during the SHO as children did not have access to mandatory reporters, and then increase as physicians' offices and schools reopened., Methods: A multicenter study evaluating patients <18 years with ICD-10 Diagnosis and/or External Cause of Injury codes meeting criteria for NAT. "Historical" controls from an averaged period of March-September 2016-2019 were compared to patients injured March-September 2020, after the implementation of SHO ("COVID" cohort). An interrupted time series analysis was utilized to evaluate the effects of SHO implementation., Results: Nine Level I pediatric trauma centers contributed 2064 patients meeting NAT criteria. During initial SHO, NAT rates dropped below what was expected based on historical trends; however, thereafter the rate increased above the expected. The COVID cohort experienced a significant increase in the proportion of NAT patients age ≥5 years, minority children, and least resourced as determined by social vulnerability index (SVI)., Conclusions: The COVID-19 pandemic affected the presentation of children with NAT to the hospital. In times of public health crisis, maintaining systems of protection for children remain essential., Level of Evidence: III., (Copyright © 2022. Published by Elsevier Inc.)

Background: With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy., Methods: A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests., Results: 466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively)., Conclusion: Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids., (Copyright © 2022. Published by Elsevier Inc.)

Introduction: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation., Methods: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively., Results: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation., Conclusion: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair., Competing Interests: Declarations of Competing Interest None., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: The impact of thoracoscopic surgery on outcomes in children with congenital lung malformations (CLM) remains controversial. The purpose of this study was to determine the effect of operative approach on perioperative outcomes in infants undergoing lobectomy for an asymptomatic CLM., Methods: After IRB approval, a retrospective cohort study was conducted on 506 children with a CLM resected at one of eleven children's hospitals over a seven-year period. Infants undergoing elective lobectomy were identified, and covariates were balanced based on operative approach using propensity scores with full matching. Outcomes were analyzed based on intention to treat with weighted conditional regression., Results: One hundred seventy-five infants met inclusion criteria. There were 67 (38.3%) open, 89 (50.9%) thoracoscopic, and 19 (10.9%) thoracoscopic-converted-to-open lobectomies. Thoracoscopic lobectomy was associated with significantly longer operative times (26 min, 95% CI 6-47 min, p = 0.012) but used less epidural anesthesia (OR 0.02, 95% CI 0.004-0.11, p<0.001) when compared to open lobectomy. There were no significant differences in intraoperative blood loss, postoperative complications, chest tube duration, or length of stay., Conclusions: Thoracoscopy has become the most common operative approach for elective lobectomy in infants with asymptomatic CLMs. The non-inferiority of thoracoscopic lobectomy in postoperative outcomes supports its continued use as an alternative to open lobectomy., Level of Evidence: Treatment study, Level III., Competing Interests: Declaration of Competing Interest The authors indicate no potential conflicts of interest., (Copyright © 2021. Published by Elsevier Inc.)

Background/purpose: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF)., Methods: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively., Results: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029)., Conclusions: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes., Level of Evidence: Level II., Type of Study: Treatment Study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: The social vulnerability index (SVI) is used to assess resilience to external influences that may affect human health. Social vulnerability has been noted to be a barrier to healthcare access for pediatric patients. We hypothesized that Pennsylvania (PA) pediatric trauma patients high on the social vulnerability index would have significantly lower rates of rehab admission following admission to a hospital for traumatic injury., Methods: The SVI was determined for each PA zip code area utilizing the census tract based 2014 SVI provided by the CDC along with a weighted crosswalk between census tracts and zip code areas using the Housing and Urban Development zip code crosswalk files. The rate of the uninsured population was extracted from the CDC SVI files in addition to other US Census variables based upon estimates from the 2014 American Community Survey (ACS). We also included the individual primary payer status of each subject. Pediatric (age <15 years) trauma admissions with in-hospital mortality excluded, were extracted from the PA Healthcare Cost Containment Council (PHC4) for all hospital admissions for the period of 2003-2015 (n = 63,545). Complete case analysis was conducted based upon the final model providing a sample of 52,794. Cases were coded as rehab patients based upon discharge status (n = 603; 1.1%). A multi-level logistic model was used to determine if subjects had a higher odds of being discharged to rehab based on SVI, undertriage rates of their zip code area of residence and their own primary payer status; this was adjusted for age, multi-system injury and a head, chest or abdomen injury with abbreviate injury scale (AIS) severity > = 3., Results: SVI and undertriage rates of the zip code areas of residence were not significantly associated with admission to rehab. The individual primary payer status of the subject was significantly associated with admission to rehab (OR 95%CI vs. self/uninsured; Medicaid 3.65 1.84-7.24; Commercial = 3.09 1.56-6.11; other/unknown = 2.85 1.02-7.93). Admission to rehab was also significantly associated with age, injury severity (ISS), head or chest injury with AIS scores > = 3, year of admission and hospital type., Conclusion: Individual patient level factors (primary payer of patient) may be associated with the odds of rehab admission rather than neighborhood factors., Level of Evidence: Epidemiologic: Level III., (Published by Elsevier Inc.)

Purpose: To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort., Methods: A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared., Results: Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo., Conclusion: Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group., Level of Evidence: Level III., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection., Methods: After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative., Results: Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%)., Conclusion: This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients., Level of Evidence: Level II., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery., Methods: A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion., Results: Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028]., Conclusion: Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS., Type of Study: Prospective pilot study LEVEL OF EVIDENCE: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Firearm injuries continue to be a common cause of injury for American children. This pilot study was developed to evaluate the feasibility of providing guidance about firearm safety to the parents of pediatric patients using a tablet-based module in the outpatient setting., Methods: A tablet-based questionnaire that included a firearm safety message based on current best practice was administered to parents of pediatric patients at nine centers in 2018. Parents were shown a firearm safety video and then asked a series of questions related to firearm safety., Results: The study was completed by 543 parents from 15 states. More than one-third (37%) of families kept guns in their home. The majority of parents (81%, n = 438) thought it was appropriate for physicians to provide firearm safety counseling. Two-thirds (63%) of gun owning parents who do not keep their guns locked said that the information provided in the module would change the way they stored firearms at home., Conclusion: Use of a tablet based firearm safety module in the outpatient setting is feasible, and the majority of parents are receptive to receiving anticipatory guidance on firearm safety. Further data is needed to evaluate whether the intervention will improve firearm safety practices in the home., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine the diagnostic accuracy of tumor markers for malignancy in girls with ovarian neoplasms., Methods: A retrospective review of girls 2-21 years who presented for surgical management of an ovarian neoplasm across 10 children's hospitals between 2010 and 2016 was performed. Patients who had at least one concerning feature on imaging and had tumor marker testing were included in the study. Sensitivity, specificity, and negative and positive predictive values (PPV) of tumor markers were calculated., Results: Our cohort included 401 patients; 22.4% had a malignancy. Testing for tumor markers was inconsistent. AFP had high specificity (98%) and low sensitivity (42%) with a PPV of 86%. The sensitivity, specificity, and PPV of beta-hCG was 44%, 76%, and 32%, respectively. LDH had high sensitivity (95%) and Inhibin A and Inhibin B had high specificity (97% and 92%, respectively)., Conclusions: Tumor marker testing is helpful in preoperative risk stratification of ovarian neoplasms for malignancy. Given the variety of potential tumor types, no single marker provides enough reliability, and therefore a panel of tumor marker testing is recommended if there is concern for malignancy. Prospective studies may help further elucidate the predictive value of tumor markers in a pediatric ovarian neoplasm population., Type of Study: Retrospective Cohort Review., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background/purpose: The morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management., Methods: This study is a chart review of patients <18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition., Results: Time from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation., Conclusion: The implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children., Type of Study: Therapeutic LEVEL OF EVIDENCE: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Isolated tracheoesophageal fistula (TEF) is a rare condition with a previously reported high incidence of vocal cord paresis. A technique using recurrent laryngeal nerve monitoring is described as a strategy to potentially minimize the risk of vocal cord dysfunction in this patient population., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium., Methods: After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015)., Results: Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0)., Conclusions: Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion., Level of Evidence: Level III., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF., Methods: A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up., Results: In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p < 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p > 0.29)., Conclusion: RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach., Level of Evidence: Level III., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: Perioperative management of infants with esophageal atresia and tracheoesophageal fistula (EA/TEF) is frequently based on surgeon experience and dogma rather than evidence-based guidelines. This study examines whether commonly perceived important aspects of practice affect outcome in a contemporary multi-institutional cohort of patients undergoing primary repair for the most common type of esophageal atresia anomaly, proximal EA with distal TEF., Methods: The Midwest Pediatric Surgery Consortium conducted a multicenter, retrospective study examining selected outcomes on infants diagnosed with proximal EA with distal TEF who underwent primary repair over a 5-year period (2009-2014), with a minimum 1-year follow up, across 11 centers., Results: 292 patients with proximal EA and distal TEF who underwent primary repair were reviewed. The overall mortality was 6% and was significantly associated with the presence of congenital heart disease (OR 4.82, p=0.005). Postoperative complications occurred in 181 (62%) infants, including: anastomotic stricture requiring intervention (n=127; 43%); anastomotic leak (n=54; 18%); recurrent fistula (n=15; 5%); vocal cord paralysis/paresis (n=14; 5%); and esophageal dehiscence (n=5; 2%). Placement of a transanastomotic tube was associated with an increase in esophageal stricture formation (OR 2.2, p=0.01). Acid suppression was not associated with altered rates of stricture, leak or pneumonia (all p>0.1). Placement of interposing prosthetic material between the esophageal and tracheal suture lines was associated with an increased leak rate (OR 4.7, p<0.001), but no difference in the incidence of recurrent fistula (p=0.3). Empiric postoperative antibiotics for >24h were used in 193 patients (66%) with no difference in rates of infection, shock or death when compared to antibiotic use ≤24h (all p>0.3). Hospital volume was not associated with postoperative complication rates (p>0.08). Routine postoperative esophagram obtained on day 5 resulted in no delayed/missed anastomotic leaks or a difference in anastomotic leak rate as compared to esophagrams obtained on day 7., Conclusion: Morbidity after primary repair of proximal EA and distal TEF patients is substantial, and many common practices do not appear to reduce complications. Specifically, this large retrospective series does not support the use of prophylactic antibiotics beyond 24h and empiric acid suppression may not prevent complications. Use of a transanastomotic tube was associated with higher rates of stricture, and interposition of prosthetic material was associated with higher leak rates. Routine postoperative esophagram can be safely obtained on day 5 resulting in earlier initiation of oral feeds., Study Type: Treatment study., Level of Evidence: III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background/purpose: Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a rare congenital anomaly lacking contemporary data detailing patient demographics, medical/surgical management and outcomes. Substantial variation in the care of infants with EA/TEF may affect both short- and long-term outcomes. The purpose of this study was to characterize the demographics, management strategies and outcomes in a contemporary multi-institutional cohort of infants diagnosed with EA/TEF to identify potential areas for standardization of care., Methods: A multi-institutional retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals between 2009 and 2014 was performed. Over the 5year period, 396 cases were identified in the 11 centers (7±5 per center per year). All infants with a diagnosis of EA/TEF made within 30days of life who had surgical repair of their defect defined as esophageal reconstruction with or without ligation of TEF within the first six months of life were included. Demographic, operative, and outcome data were collected and analyzed to detect associations between variables., Results: Prenatal suspicion or diagnosis of EA/TEF was present in 53 (13%). The most common anatomy was proximal EA with distal TEF (n=335; 85%) followed by pure EA (n=27; 7%). Clinically significant congenital heart disease (CHD) was present in 137 (35%). Mortality was 7.5% and significantly associated with CHD (p<0.0001). Postoperative morbidity occurred in 62% of the population, including 165 (42%) cases with anastomotic stricture requiring intervention, anastomotic leak in 89 (23%), vocal cord paresis/paralysis in 26 (7%), recurrent fistula in 19 (5%), and anastomotic dehiscence in 9 (2%). Substantial variation in practice across our institutions existed: bronchoscopy prior to repair was performed in 64% of cases (range: 0%-100%); proximal pouch contrast study in 21% (0%-69%); use of interposing material between the esophageal and tracheal suture lines in 38% (0%-69%); perioperative antibiotics ≥24h in 69% (36%-97%); and transanastomotic tubes in 73% (21%-100%)., Conclusion: Contemporary treatment of EA/TEF is characterized by substantial variation in perioperative management and considerable postoperative morbidity and mortality. Future studies are planned to establish best practices and clinical care guidelines for infants with EA/TEF., Level of Evidence: Type of study: Treatment study. Level IV., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background/purpose: Although most pediatric ovarian neoplasms are benign and may be treated with ovary-sparing surgery (OSS), consensus is lacking on the optimal surgical approach. We aimed to determine the proportion of pediatric benign ovarian neoplasms managed with OSS and to assess variability in management across hospitals and specialties., Methods: Using the Pediatric Health Information System, we studied patients aged 6-21 years treated in 2006-2014 for a benign ovarian neoplasm with oophorectomy or OSS. Inter-hospital variability and predictors of the type of surgery were determined using logistic mixed effects models with random hospital effects., Results: Of 1164 patients with benign ovarian neoplasms, 646 underwent oophorectomy, and 518 underwent OSS. Across hospitals, there was significant variability in the proportion of OSS (range: 21.7-76.6%). In multivariable analysis, patients managed by pediatric surgeons (vs. pediatric and adolescent gynecologists) (OR: 0.27, 95%CI: 0.17-0.43, p<0.001), younger patients (OR: 0.94 per year, 95%CI: 0.90-0.98, p=0.007), and those admitted through the emergency department (OR: 0.76, 95%CI: 0.58-0.99, p=0.04) were less likely to undergo OSS. Inter-hospital variability remained significant after adjusting for relevant patient and hospital characteristics (p<0.001)., Conclusions: Significant variability exists in management of benign ovarian neoplasms across hospitals and specialties. Collaborative efforts between treating specialists may improve implementation of evidence-based guidelines for OSS., Type of Study: retrospective study LEVEL OF EVIDENCE: III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: Evaluate national variation in structure and care processes for critically injured children., Methods: Institutions with pediatric intensive care units (PICUs) that treat trauma patients were identified through the Virtual Pediatric Systems (n=72). Prospective survey data were obtained from PICU and Trauma Directors (n=69, 96% response). Inquiries related to structure and care processes in the PICU and emergency department included infrastructure, physician staffing, team composition, decision making, and protocol/checklist use., Results: About one-third of the 69 institutions were ACS-verified Level-1 Pediatric Trauma Centers (32%); 36 (52%) were state-designated Level 1. The surgeon was the primary decision maker in the trauma bay at 88% of sites, and in the PICU at 44%. The intensivist was primary in the PICU at 30% of sites and intensivist consultation was elective at 11%. Free-standing pediatric centers used checklists more often than adult/pediatric centers for DVT prophylaxis (75% vs. 50%, p=0.039), cervical spine clearance (75% vs. 44%, p=0.011), and pain control (63% vs. 34%, p=0.024). Otherwise, protocols/checklists were infrequently utilized by either center type., Conclusion: Variability exists in structure and care processes for critically injured children. Further investigation of variation and its causal relationship to outcomes is warranted to provide optimal care., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this study was to determine the proportion of children who survived after emergency department thoracotomy (EDT) for blunt trauma using a national database., Methods: A review of the National Trauma Data Bank was performed for years 2007-2012 to identify children <18 years of age who underwent EDT for blunt trauma., Results: Eighty-four children <18 years of age underwent EDT after blunt trauma. Every child died during their hospitalization. The median age was 15 (IQR 6-17) years. Mean injury severity score (ISS) was 34.2 (SD 20.8), and 56% had an ISS of 26-75. Data for "signs of life" were available for 21 children. Fifteen (71%) had signs of life upon ED arrival. Sixty percent of children died in the ED. Of those who survived to the operating room (OR), 66% died in the OR. Four children (5%) survived more than 24 hours in the intensive care unit, three of whom had a maximum head abbreviated injury score of 5., Conclusion: There were no survivors after EDT for blunt trauma in the pediatric population in this national dataset. Usual indicators for EDT after blunt trauma in adults may not apply in children, and use should be discouraged without compelling evidence of a reversible cause of extremis., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Whether children with pancreatic trauma should be managed non-operatively or operatively is controversial. We reviewed outcomes of high-grade pancreatic injuries at two high-volume pediatric surgical centres comparing non-operative and operative management strategies., Methods: All pancreatic traumas presenting from January 1993 to July 2010 were reviewed. Patients with high-grade pancreatic injuries were stratified based on early operative or non-operative therapy. Baseline characteristics and outcomes were compared. Regression analyses were performed to assess complication rates, length of stay, and TPN duration while controlling for injury severity score and associated injuries., Results: Of 77 patients with pancreatic injuries, 39 were grade 3 or higher. The mean ISS was 19.2 ± 10.8. Nineteen patients (50%) had associated injuries. Fifteen patients (38%) were managed operatively. Baseline characteristics were similar between groups other than ISS (p=0.03). Duration of hospitalization (p=0.01), days of TPN (p=0.003), and overall complications (p=0.007) were higher in non-operative patients. Controlling for both ISS and any associated injury, non-operative management was associated with more complications (OR 8.11; 95% CI 1.60-41.23) and was a significant predictor of prolonged TPN (13 days longer; p=0.024)., Conclusion: Primary non-operative management of high-grade pancreatic injuries is associated with a significant increase in complications and TPN dependency. Early operative intervention should be pursued whenever feasible., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Purpose: The pathophysiology of necrotizing enterocolitis (NEC) includes prematurity, enteral feeds, hypoxia, and hypothermia. We hypothesized that vasoconstriction of the neonatal intestinal microvasculature is the essential mechanistic event in NEC and that these microvascular changes correlate with alterations in mediators of inflammation., Methods: Sprague-Dawley rat pups were separated into groups by litter. Necrotizing enterocolitis was induced in experimental groups, whereas control animals were delivered vaginally and dam fed. Neonatal pups underwent intravital videomicroscopy of the terminal ileum with particular attention to the inflow and premucosal arterioles. Reverse transcriptase-polymerase chain reaction was performed to evaluate for messenger RNA of mediators of inflammation., Results: Necrotizing enterocolitis animals demonstrated statistically significant smaller inflow and premucosal arterioles than control animals (P < .05). Necrotizing enterocolitis animals had an altered intestinal arteriolar flow with a distinct "stop-and-go" pattern, suggesting severe vascular dysfunction. Reverse transcriptase-polymerase chain reaction confirmed elevation of Toll-like receptor 4 (P = .01) and high-mobility group box protein 1 (P = .001) in the ileum of animals with NEC., Conclusion: Intestinal arterioles were significantly smaller at baseline in animals with NEC compared with controls, and expression of inflammatory mediators was increased in animals with NEC. This represents a novel method of defining the pathophysiology of NEC and allows real-time evaluation of novel vasoactive strategies to treat NEC., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Purpose: Care of infants and children with life-impairing or life-threatening congenital and acquired disorders often raises ethical concerns for pediatric surgeons. The purpose of this survey was to determine the level of interest in clinical ethics and how respondents would manage ethical dilemmas within several clinical case scenarios., Methods: A 12-item validated questionnaire developed by the Ethics and Advocacy Committee was provided for the American Pediatric Surgical Association (APSA; www.eapsa.org) members on the organizational website. General categories of questions included informed consent, patient privacy, and what constitutes research., Results: The survey was completed by 235 of the 825 APSA members; a response rate of 28.4%. The majority (62%) were in academic practice, 22% had additional education or an advanced degree in ethics, and 11% were members of a hospital ethics committee. There was a clear majority response for seven questions. Topics generating the most controversy included the impact of consent by minors, decision making in the neurologically devastated child, what constitutes research in pediatric surgery, the use of interpreters for consent, and patient privacy. Respondents chose a well-referenced manuscript as the preferred modality for ethics education of the APSA members., Conclusion: Pediatric surgeons have a general interest in clinical ethics as it relates to the care of their patients. An important mission of the Ethics and Advocacy Committee can be to provide education that gives guidance and knowledge to the members of APSA on timely topics in surgical ethics.

The authors report the clinical course of a young girl with ovarian torsion who was treated conservatively. This case shows that detorsion of the ovary may be associated with immediate postoperative febrile morbidity and slow resolution of ovarian enlargement. The authors emphasize that these signs can be associated with viable ovarian tissue and are not necessarily an indication for oophorectomy.

Purpose: The goal of this study was to identify symptoms and signs related to central venous catheter (CVC) bloodstream infections (BSI) in neonatal intensive care unit (NICU) patients that would predict infection and to identify factors that might influence CVC longevity., Methods: This was a retrospective cohort study evaluating 268 lines representing a total of 5,212 CVC days placed in 157 NICU patients over 29 months by the pediatric surgery and neonatology services at one children's hospital. Centers for Disease Control (CDC) criteria were used to determine laboratory-confirmed BSI. Data were analyzed by univariate methods and logistic regression and determined significant at the P less than .05 level., Results: Sixty-five lines (24%) from 54 patients had confirmed CVC BSI. Fever (49%) and pulmonary dysfunction (30%) were the most common symptoms of CVC BSI. Erythema or purulent discharge at the insertion site was found in only 20% of cases. Staphylococcus epidermidis was the most common organism isolated. Factors that significantly decreased the incidence of CVC BSI were increasing estimated gestational age (EGA; P < .0013) attime of insertion, associated vancomycin use at the time of catheter placement (P < .0057), and fewer days of catheter use (P < .0291). There were no significant differences noted caused by line location or catheter type., Conclusion: Fever and pulmonary dysfunction were the most common signs of CVC BSI in neonates. Lower EGA and increased catheter duration were significantly correlated with infection. The use of vancomycin concurrent with catheter insertion was associated with a decreased incidence of CVC BSI, howeverconcerns regarding the emergence of vancomycin-resistant organisms preclude support of its use as a prophylactic agent.

Purpose: Microscopic hematuria (> or = 20) RBCs per high-power field [HPF] has been used frequently as an indicator for genitourinary (GU) tract injury in pediatric cases of blunt trauma. The aim of this study was (1) to determine whether a certain threshold of microscopic hematuria was associated with GU tract injury in our patient population, and (2) to identify additional factors warranting evaluation of the GU tract., Methods: The records of 100 patients under 18 years of age whose discharge diagnosis in the trauma registry included hematuria or GU tract injury were reviewed retrospectively (1989 through 1993). The following data were collected: age, sex, mechanism of injury, physical findings, associated injuries, urinalysis results, radiographic study results, disposition, and outcome. Data were analyzed using the SPSS program., Results: The majority of children were victims of motor vehicle accidents. All but one study patient had an intravenous pyelogram and/or computed tomography scan. Twenty-seven patients had GU tract injuries or previously unrecognized congenital anomalies (9 contusions, 5 lacerations, 1 vascular pedicle injury, 4 bladder injuries, 3 urethral/vaginal tears, 5 anomalies). Twenty-seven percent (3 of 11) of children with minor injuries and 25% (2 of 8) of those with major injuries had microscopic hematuria of less than 20 RBCs/HPF. Mechanism of injury and hypotenison were not associated with GU tract injury. One third of the patients with isolated chest or abdominal injuries, and 50% of those with combined chest/abdominal injuries had GU tract injuries or anomalies identified. Pelvic fracture was associated with GU tract injury or anomaly in 50% of cases (P < 0.02)., Conclusion: The authors found that (1) a threshold of > or = 20 RBCs/HPF as an indication for radiograph evaluation would have missed 28% of cases with GU tract injuries or occult anomalies, and (2) pelvic fractures and abdominal/chest injuries help to identify patients who require evaluation of the GU tract. The need for GU tract evaluation in pediatric trauma patients is based as much on clinical judgment as on the presence of hematuria.

The authors' goal was to determine criteria for hospitalization for children with minor head injuries. A retrospective review was performed of the hospital records of 401 children with isolated minor head injuries who were admitted to a level I pediatric trauma center between July 1988 and December 1990. Specific information regarding each patient was documented, including demographic data, pertinent physical findings, diagnostic studies, criteria for admission, and hospitalization costs. Fifty-one patients with a mechanism of injury compatible with minor head injury, a brief or no loss of consciousness, a Glasgow coma score of 15, and no abnormalities on radiographic examination did not have neurological complications. The authors believe that these 51 patients could have been discharged from the hospital to responsible parents, thereby decreasing the costs of hospitalization. Prospective studies to substantiate these data and determine which patients should be hospitalized are warranted.

To determine if there is a widespread problem with personal watercraft (jet ski) injuries throughout the United States, we reviewed the hospital records of patients who were treated at this institution for injuries incurred while they were operating a motorized personal watercraft or jet ski. All of the patients were under the age of 19 and suffered severe fractures or lacerations. To assess the extent of the problem with these injuries regionally, we collected data from 8 midwestern states for 1989. Sixty-four personal watercraft accidents involving 90 victims were reported in the survey. Fifty-three of 90 patients sustained fractures, lacerations, or head injuries. Seventy-nine of 90 were under age 25, and 24 patients were under 16 years of age. The need for supervision and the potential for serious injury while operating personal watercraft is supported by these findings.

We report our experience from May 1985 to January 1991 with surgical complications and procedures performed in neonates on extracorporeal membrane oxygenation (ECMO) (218 venoarterial and 7 venovenous bypass). Eleven children older than 1 month were excluded. Total complications were 96 in 67 patients and included: bleeding (37), problems with initial cannula placement (17), thrombus formation (15), hemothorax, pneumothorax, or effusions (11), mechanical problems (11), and miscellaneous (5). Forty-eight procedures were performed in 37 patients while on ECMO. These were recannulation or reposition of cannulas (14), tube thoracostomy (11), cardiac surgery (6), cardiac catheterization (4), repair of congenital diaphragmatic hernia (5), thoracotomy (4), and others. Twenty-eight complications occurred in 15 of the 27 patients who died. Mortality rate was 12% for the entire group. Primary causes of death were hypoplastic lung (11), cardiac (8), sepsis (4), intraventricular hemorrhage (2), and pulmonary hypertension (2). No deaths were due solely to complications except for the two patients with intraventricular hemorrhage. Mortality in neonates who had complications while on ECMO was significantly higher (P less than .005) than in patients without complications. Hemorrhagic and thoracic complications were associated with higher mortality (P less than .001). Mortality was not affected by mechanical problems, thrombus formation, or catheter-related problems. While on ECMO cardiac defects, diaphragmatic hernia, lobar emphysema, and other conditions can be safely corrected. The use of echocardiography to position the cannulas, better control of coagulation factors and improvement in equipment may ultimately decrease complications.

Cranial nerve palsies developed in 23% of 73 children with basilar skull fractures. The majority occurred in patients 10 years of age or older. Our overall incidence was higher than that in a review in which basilar skull fractures were indiscriminately included with all head injuries. Our experience with meningitis was similar to that present in the literature and would seem to support avoidance of prophylactic antibiotics. Because there was no improvement in neurological deficits in patients treated with steroids (the only case of meningitis in our series was associated with steroids), we believe that their use is unwarranted. It is important to discuss the prognosis with the patient's family, because, although the majority (53.3%) of cases resolve completely, those with residual deficits can have significant morbidity.

Recent morphological analyses of Mullerian duct regression suggested that some ductal cells might survive, in contrast to the previous view that regression was an example of "programmed cell death." The present study was designed to demonstrate survival of Mullerian duct cells after regression, and to map migration into local or distant tissues. Seven or eight-day-old chick embryos received intraabdominal grafts of Mullerian ducts from seven- or eight-day-old quails, creating chick-quail chimeras. Three or four days later the abdomen was serially sectioned and examined histologically using a modified Feulgen stain. Sixty-six of the 230 grafted embryos survived (29%). After sectioning, grafts were found in 34 of the 58 embryos in the body wall, peritoneum or mesenephros, with several adherent to the hosts' Mullerian ducts. Twenty female embryos contained grafts, all of which were developing normally. Fourteen male embryos contained grafts in various stages of regression. Regression was more advanced in mesonephric or body wall grafts while free intraperitoneal grafts showed the least regression. Migration of quail cells was striking when seen in grafts placed in the mesonephros or adherent to the host Mullerian duct. In these, regressing quail cells migrated into and became incorporated in adjacent chick mesenephros. Migration patterns were seen also in non-regressing cells in female hosts, where quail cells "homed" to the host chick Mullerian duct structures.