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Background: Multidisciplinary teams (MDTs) are integral to navigating complex patient care. Implementation of MDTs may improve patient outcomes, reduce physician burnout, and decrease hospital costs. Systemic obstacles to optimizing pediatric MDTs remain unexplored. This study sought to evaluate provider perceptions of a spina bifida MDT and identify barriers of MDT success., Methods: A survey was distributed to staff at a single spina bifida clinic in a pediatric healthcare system. Respondents were asked to rate factors contributing to MDT success, satisfaction, optimized clinical components, and barriers to clinic staff participation. Descriptive statistics characterized survey responses, and free-text comments were thematically analyzed., Results: The survey achieved a 67 % response rate (29/43). Factors deemed crucial for MDT success included clinician collaboration (96 %) and a designated clinical coordinator (86 %). Most respondents indicated feeling "somewhat satisfied" (44 %) or "very satisfied" (22 %) with the MDT. Open communication (77 %) and participation/attendance (71 %) were the most frequently reported optimized clinical components. The most reported barriers to staff participation included clinician workflow inefficiency (71 %) and inadequate clinic preparation (67 %). Respondents expressed a desire for standardized pre-clinic patient updates, either via secure text (57 %), email (50 %), or in-person (20 %). 80 % of participants were unaware of whether the clinic had a mission statement., Conclusion: While most clinical staff reported MDT satisfaction, survey responses revealed clear opportunities to enhance the MDT model. Future goals include collaborating with institutional operations to increase workflow efficiency and build awareness of the clinic's mission statement to encourage staff buy-in., Type of Study: Study of Diagnostic Test., Level of Evidence: Level III., Competing Interests: Declaration of competing interest There are no financial interests to declare for any of the named authors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: The Utah Pediatric Trauma Network (UPTN), established in 2019, is a collaboration of hospitals that have implemented guidelines to optimize pediatric trauma care. The purpose of this study was to determine whether preventable transfer (PT) rates decreased following the establishment of the UTPN and what hospital characteristics were associated with decreased preventable transfers., Methods: Children with traumatic injuries transferred from hospitals in the UPTN to the state's only Level I Pediatric Trauma Center between 2013 and 2023 were retrospectively analyzed. A PT was a child discharged within 48 h of arrival without surgical intervention or advanced imaging studies. The main hospital-level outcome measure was an overall decrease in PT after the UPTN establishment in 2019., Results: After 2019, 34 of the 46 hospitals meeting inclusion criteria saw a decrease in the percentage of PTs, while 12 saw an increase in PT rate, with an overall median change of -7 % (IQR -14 %, 0 %). We observed that hospitals with decreased PT had higher rates of PT before the establishment of the UPTN and had higher overall transfer volume than hospitals without a decreased PT rate. Can we put the overall p value in this?, Conclusion: Most hospitals were able to successfully decrease PT rates following the creation of the UPTN. More smaller hospitals did not successfully decrease PT, so more work may need to be done to target lower-volume hospitals., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: To decrease diversion of unused opioids following the minimally invasive repair of pectus excavatum (MIRPE), we developed an opioid education monitoring and reclamation program. The aim was to evaluate outpatient opioid use and disposal following MIRPE., Materials and Methods: A retrospective review was conducted at a single center among patients <19 ys who underwent MIRPE with intercostal nerve cryoablation. Demographic and clinical data, including outpatient opioid prescriptions, were reviewed. Patients or families were educated on the risk of opioids and encouraged to bring unused opioid to the first postoperative visit for disposal. Questionnaires were administered on opioid use and disposal plan., Results: A total of 72 patients participated in the program: 83.3% (60/72) were male, and the mean age was 15.2 ± 1.6 ys old. A median of 10 tablets per patient were prescribed, with a total of 790 five-mg oxycodone tablets prescribed. Prior to the first postoperative visit, 20.8% (15/72) of patients required an opioid refill. Patients reported using a median of 5 [IQR: 1.6 - 10], five-mg oxycodone tablets for a median of 5 [IQR: 2 - 6.7] ds: 92% (65/72) had unused opioids totaling 420 tablets. Of patients with unused opioid, 50.8% (33/65) reported a plan for opioid disposal, 30.8% (20/65) reported a plan to keep unused opioids, and 28.5% (12/65) did not disclose a plan of disposal., Conclusions: Despite conservative opioid prescribing, 53% of outpatient opioids go unused following MIRPE. After education on opioid risks and providing a convenient means for safe opioid disposal, half of the patients or families intended to dispose of unused opioids., (Copyright © 2025. Published by Elsevier Inc.)

Introduction: The physiologic benefits of the minimally invasive repair of pectus excavatum (MIRPE) on cardiopulmonary function are poorly understood in pediatrics. We sought to examine the effects of MIRPE on exercise response during cardiopulmonary exercise testing (CPET)., Methods: A prospective-pilot study was conduct of patients ≤18 years who presented for pectus bar removal. All patients had CPET prior to MIRPE and following bar removal. Paired sample T tests were used to compare pre- and post-MIRPE CPET results., Results: Twenty-five patients completed post-MIRPE CPET (72 % male, median age 18.6 [IQR:17.5-19.8]). The median Haller and correction indices were 4.5 and 29.4 %, respectively. There was significant increase in O2Pulse, (10.3 vs 12.1 mL/beat, p = 0.004), and percent predicted O2Pulse (79.5% vs 84.4 %, p = 0.046) following MIRPE/bar removal. The peak-VO2/kg and did not change significantly following MIRPE/bar removal; however, peak-VO2 (ml/min) increased. Patients with decreased activity levels at time of bar removal compared to pre-MIRPE had decreased peak-VO2/kg and predicted peak-VO2/kg., Conclusion: Following MIRPE, patients experience increased in O2Pulse, which is a surrogate measure of stroke volume response to exercise and may reflect relief of cardiac compression. Cardiopulmonary function is multifactorial and despite improvement in stroke volume, other factors may impact exercise capacity (VO2) following MIRPE., Study Type: Treatment Study., Level of Evidence: IV., Competing Interests: Conflicts of interest Dr. Padilla, McMahon, and Notrica are education consultants for Atricure. Dr. Notrica receives royalties from KLS. The other authors have no relevant financial or non-financial interests to disclose., (Copyright © 2025 Elsevier Inc. All rights reserved.)

Background: Although Extracorporeal Membrane Oxygenation (ECMO) utilization in pediatric patients with cardiopulmonary failure due to infection improves mortality, it is unclear whether the infectious etiology impacts outcomes. The aim of this study is to compare ECMO outcomes in children with sepsis and severe acute lung injury secondary to infections based on culture data., Methods: A retrospective review was done of patients aged <18 with severe infections whose management included ECMO from 2013 to 2022 at a quaternary children's hospital. Respiratory and blood cultures were reviewed. Mortality for all groups was compared using univariate and multivariate models., Results: A total of 155 patients were included. Overall mortality on ECMO was 36 % and mortality at discharge was 51 %. Using a Cox proportional hazards regression, patients with both positive blood and respiratory cultures at time of cannulation had an adjusted HR (Hazard Ratio) for mortality on ECMO of 7.65 (95 % CI 1.92-30.44, p = 0.004) and adjusted HR for mortality at discharge of 4.48 (95 % CI 1.69-11.88, p = 0.003) compared to those with only positive bacterial respiratory cultures. There was increased mortality on ECMO for patients with more than one virus identified on viral respiratory panel [HR 6.1 (CI 1.1-32.9, p = 0.03)], but no difference in mortality of patients with polymicrobial bacterial pneumonias. There was no relationship between bacterial organism and mortality, but patients with RSV and COVID viral infections demonstrated higher mortality., Conclusions: ECMO outcomes in pediatric patients with cardiopulmonary failure secondary to infection differ based on the infectious source. This information is important when discussing prognosis with families prior to cannulation., Study Type/level of Evidence: Retrospective Review, Cohort study., Competing Interests: Conflict of interest We have no conflicts of interest to disclose., (Copyright © 2025. Published by Elsevier Inc.)

Background: There is no consensus on the appropriate duration of postoperative antibiotics for complicated appendicitis in children. Commonly used antibiotic endpoints include normalization of white blood cell count (WBC) or completion of a minimum number of prespecified treatment days. We compared clinical outcomes resulting from varying postoperative antibiotic protocols for complicated appendicitis in children., Methods: National Surgical Quality Improvement Program Pediatric (NSQIP-P) data from nine children's hospitals was used to identify a retrospective cohort of children (<18 years) who underwent laparoscopic appendectomy from 2021 to 2023 with intraoperative findings of complicated appendicitis. Participating hospitals were classified into four groups based on discharge protocol: 1) no discharge antibiotics, 2) oral antibiotics for elevated WBC on the day of discharge, 3) oral antibiotics to complete a minimum number of total antibiotic days, and 4) routine discharge antibiotics regardless of inpatient antibiotic duration. Univariate analysis was completed between groups., Results: We identified 1342 patients with complicated appendicitis who underwent laparoscopic appendectomy. Patients were similar by age and BMI. Median length of stay (5 days) and rate of post-discharge percutaneous drainage (9.4 %) were highest at the center with a standardized minimum duration of discharge antibiotics. There were no statistical differences among treatment groups for surgical site infection (5.7-9.8 %), emergency department visits (9.0-15.6 %), or readmissions within 30 days (2.9-7.6 %)., Conclusion: The incidence of SSI and readmission following appendectomy did not differ based on the discharge antibiotic protocol, however, the incidence of post-discharge drainage was highest in the center with protocolized discharge antibiotics. These findings highlight an opportunity to minimize unnecessary blood draws and extended postoperative antibiotics., Level of Evidence: III., (Copyright © 2025 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Evaluation of response to blood transfusion after blunt splenic injury (BSI) may prevent the need for splenectomy. The aim of this study was to evaluate factors associated with splenectomy in pediatric patients with isolated BSI who presented with hemodynamic instability with a focus on timing of transfusion., Methods: The 2021 Trauma Quality Improvement Project database was queried for children ≤18 years with BSI who arrived with a shock index>1.1. Interfacility transfer patients and those with additional intra-abdominal injuries were excluded. Demographic, injury characteristic and timing, transfusion, operative, and outcome data were collected. A sub-analysis of patients without brain injury was also performed., Results: 516 patients met inclusion criteria; 60.1% were male, with mean age 12.3 ± 5.5 years. Initial mean shock index was 1.4 ± 0.4, ISS was 31.7 ± 15.1, and GCS was 10.7 ± 5. Splenectomy occurred in 27% of patients. Among splenectomy patients, 26.2% did not receive blood prior to splenectomy. While treatment at a pediatric trauma center showed an increased OR of splenectomy in univariable analysis, when controlling for lack of transfusion, no differences in splenectomy persisted. Patient Age (aOR-1.26, p < 0.001), BSI grade (aOR-2.30, P < 0.001), male gender, (aOR-2.2, p = 0.003), being non-white (aOR-2.0) ISS (aOR-1.03, p = 0.003), and GCS (aOR-0.95, p = 0.034) were associated with splenectomy., Conclusion: More than 26% of patients undergoing splenectomy did not receive blood prior to surgery. Differences in risk of splenectomy by center type seen on univariable analysis were not seen when controlling for transfusion. Evaluating response to blood transfusion may be an opportunity to reduce the frequency of splenectomy., Level of Evidence: Treatment Study Level III., (Copyright © 2024. Published by Elsevier Inc.)

Background: ERCP is the gold standard for evaluating the integrity of the main pancreatic duct (MPD); however, ERCP is underutilized in evaluating MPD integrity in pediatric blunt pediatric injury. The primary aim of this study was to evaluate the discordance of cross-sectional imaging (CSI) and ERCP in children with suspected MPD injury., Methods: A retrospective review of all patients age ≤18 years with CSI or clinical findings suggestive of MPD injury (MPDI) and ERCP was conducted at a level I pediatric trauma center from January 2009 to May 2023. Demographic and clinical data were collected. Pancreatic injury findings were compared between cross-sectional imaging and ERCP., Results: An ERCP was performed in 28 patients with suspected MPDI with a mean age of 7 ± 4.5 years and weight of 25.0 ± 13.6 kg. Based on initial CSI, 23 patients had a suspected MPDI, and 5 had concern for MPDI based on clinical findings. ERCP differed from CSI findings in 39% of patients: 7 with CSI evidence of MPDI without injury on ERCP and 4 patients without imaging concern of MPDI but demonstrated injury on ERCP. Findings on ERCP guided surgical management in 71% (20/28) of patients due to location and completeness of MPDI. All patients without MPDI were managed nonoperatively., Conclusion: Approximately 40% of patients had discordant findings between ERCP and CSI. ERCP can aide in surgical management decision making. All patients with a partial MPDI were managed with endoscopic therapy alone. ERCP should be considered when assessing a child with a suspected MPDI., Level of Evidence: Level III., Type of Study: Diagnostic Study., Competing Interests: Conflicts of interest N/A., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Women have historically been underrepresented in surgical leadership and in specialty organizations. This study longitudinally examines representation of women across committee leadership within the American Pediatric Surgical Association (APSA)., Methods: Annual APSA committee chair and vice-chair rosters (2003-2023) were obtained. If not self-reported in the membership roster, gender was classified based upon review of publicly available data. Proportions of women who served as chairs and vice-chairs were quantified by committee and by year., Results: Overall, the proportion of women serving as APSA committee chairs and vice-chairs increased from 11% to 48% during the study period (p = 0.001). In examining each position, the proportion of women chairs increased from 12% to 40% (p = 0.042), while women vice-chairs increased from 10% to 58% (p = 0.009). The committees with the highest cumulative proportion of women chairs were Benjy Brooks (100%), Diversity Equity & Inclusion (100%), Finance (100%), Global Pediatric Surgery (67%), and Wellness (67%). Four committees- Trauma, Access to Surgery for Kids, Practice, and Professional Development - were not led by a woman chair in the entire study period. Additionally, five committees that traditionally have had significant impact on organizational workflow and agendas all had cumulative proportions of women chairs of less than 50% - Education (33%), Publications (28.6%), Outcomes (19%), Surgical Quality & Safety (18.8%) and Program (9.5%)., Conclusion: These results demonstrate encouraging trends in the gender diversity of APSA leadership. However, this progress does not appear to be evenly distributed; leadership of key committees continues to lack substantial women's representation., Level of Evidence: III., Competing Interests: Conflicts of interest The authors have no disclosures or competing interests., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Introduction: To minimize unused outpatient opioids while providing adequate pain control, we sought to create a model to predict outpatient opioid use following the minimally invasive repair of pectus excavatum with cryoablation MIRPE-C., Methods: A retrospective review was conducted at a single center from May 2023 to January 2024 among patients <21 years who underwent MIPRE-C. Demographic and clinical data, including inpatient and outpatient opioid use were reviewed. Patients completed opioid use questionnaires at their first postoperative visit. Simple linear regression was employed to create a model for outpatient opioid use., Results: Sixty-eight patients underwent MIRPE-C: 84% were male (mean age of 15.2 ± 1.7 years, and median Haller index 4.2[IQR:3.7-5.7]). Daily mean inpatient opioid requirement and daily opioid doses were 0.3 ± 0.2 OME/day/kg and 2 ± 1.2 opioid doses/day. At the first outpatient follow-up visit, patients reported using a median of five 5-mg oxycodone tablets [IQR:1.6-10] for 5 days [IQR:2-7] with 22% of patients needing an opioid refill. On linear regression, inpatient opioid use had a significant relationship with the number of outpatient doses taken, while patient factors were not associated with outpatient opioid use. A simple equation for predicting opioid need based on best fit (R 2  = 0.211) was developed: #OUTPATIENT OPIOID TABLETS = 3 TABLETS + (0.82 x #INPATIENT OPIOID RECIEVED)., Conclusion: The proposed outpatient opioid prescription model is simple to calculate and tailors the prescription to individual patient need. This model has the potential to provide effective pain control and avoid prescription refills, while minimizing over-prescription of opioids., Level of Evidence: Treatment study Level III., Competing Interests: Conflict of interest Dr. Padilla is an education consultant for Atricure. The other authors have no relevant financial or non-financial interests to disclose. No funding was received for conducting this study., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract: Evaluation of the pediatric cervical spine after blunt trauma is an important topic that requires special consideration. In this article, we will review background information and differences between the pediatric and adult cervical spine. We will then give up-to-date guidance on best practice for screening and clearance of the cervical spine in children, including the advantages and disadvantages of different imaging techniques. Finally, we will introduce current topics of study and surmise what changes or innovations may be coming in the future., Level of Evidence: Expert Review, Level VI., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Guidelines recommend three to 5 d of antibiotic prophylaxis after dog bite injury, but variation exists in clinical practice after primary closure of wounds. The purpose of this study was to analyze antibiotic duration and incidence of infection during a study period in which an institutional protocol limiting postrepair antibiotics to a maximum of 3 d was implemented., Methods: Dog bite injuries that underwent primary closure in patients ≤18 y were retrospectively identified from 2018 to 2022 at a level 1 pediatric trauma center. Demographic and clinical data were collected. Protocol compliance and short course of antibiotics were defined as ≤3 d of antibiotics. Multivariable regression analysis for variables associated with wound infection was performed., Results: 455 injuries were included for analysis. After protocol implementation, the mean antibiotic duration decreased from 6.8 to 4.4 d (P < 0.001). Postrepair follow-up data were available for 235 (51.6%) cases in the cohort. Multivariable logistic regression identified superficial wounds and anatomic injury location to be significantly associated with wound infection. Shorter antibiotic duration was not associated with increased risk of wound infection on regression analysis, and there was no difference in postoperative wound infection rate between short-course and long-course groups (7.5% versus 7.1%, P = 0.912)., Conclusions: Standardization of postoperative antibiotic duration was associated with a decrease antibiotic duration without an increase in the incidence of wound infections after closure of dog bite wounds. This study highlights the feasibility of multidisciplinary standardization of pediatric trauma care across specialties and the safety of minimizing antibiotic duration after pediatric dog bite repairs., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Our institution recently transitioned from paravertebral nerve blocks (PVBs) to intercostal nerve cryoablation (INC) for pain control following minimally invasive repair of pectus excavatum (MIRPE). This study aimed to determine how INC affected the operative time, length of stay, complication rates, inpatient opioid use, and outpatient prescription of opioids at a single center., Methods: A retrospective review was performed at a single pediatric referral center of all patients who underwent MIRPE between 2018 and 2023. Patient demographics, operative details, and perioperative course were collected. The use of INC versus PVB was recorded. Univariate analyses were performed using Wilcoxon rank sum tests for continuous variables and chi-squared tests for categorical variables., Results: 255 patients were included with a median age of 15 years, median BMI of 18.50 kg/m 2 , and median Haller index of 4.40. INC was utilized in 41% (105/255), and 59% (150/255) received PVB. The two groups did not differ significantly in BMI, Haller index, or complications, though the INC patients were older by 1 year (15.0 vs. 16.0, p = 0.034). INC was associated with an increased operative time (INC: 92 min vs. PVB: 67 min, p < 0.001), decreased length of stay (3 vs. 4 days, p =  < 0.001), more than twofold decrease in inpatient opioids per day (INC: 16 MME vs. PVB: 41 MME, p < 0.001), and a fourfold decrease in the amount of opioids prescribed at discharge (INC: 90 MME vs. PVB: 390 MME, p < 0.001)., Conclusion: INC after MIRPE significantly decreased both the inpatient opioid utilization and our outpatient prescribing practices while also decreasing our overall length of stay without increasing complications., Level of Evidence: Level III., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Inguinal hernia repair (IHR) is a common pediatric operation performed via open or laparoscopic approaches. The objective of this survey study was to assess current approaches to IHR in a national sample of pediatric general surgeons., Methods: A REDCap survey was distributed to all pediatric general surgeons at 21 US institutions in 2023. Descriptive statistics were used to analyze responses., Results: The response rate was 70.0% (145/207) with median fellowship graduation year of 2011. Respondents reported they were primarily taught either an open (73.1%) or laparoscopic (6.9%) technique in fellowship, while 18.6% reported being taught both techniques equally. Overall, 60.7% of respondents reported currently performing both laparoscopic and open IHR, while 27.6% reported performing only open IHR and 11.7% reported performing only laparoscopic IHR. During unilateral open IHR, 75.8% of respondents check for and repair a contralateral inguinal hernia, most commonly by placing a laparoscope via the hernia sac (76.3%). Selective mesh use in adolescents was similar between laparoscopic and open repair approaches. For recurrent hernias, 37.2% of respondents indicated performing the approach that was not performed previously, while 38.6% and 22.8% indicated they routinely perform a laparoscopic or open approach, respectively, regardless of initial repair approach., Conclusion: Over two thirds of surgeons reported incorporating laparoscopic IHR into their practice despite nearly three-quarters of respondents indicating they were primarily taught an open approach in training. Training in laparoscopic IHR has been increasing over time, and respondents reported a wide variety of laparoscopic and open repair techniques., Level of Evidence: IV., Competing Interests: Conflicts of interest None., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Geographic location is a barrier to providing specialized care to pediatric traumas. In 2019, we instituted a pediatric teletrauma program in collaboration with the Statewide Pediatric Trauma Network at our level 1 pediatric trauma center (PTC). Triage guidelines were provided to partnering hospitals (PHs) to aid in evaluation of pediatric traumas. Our pediatric trauma team was available for phone/video trauma consultation to provide recommendations on disposition and management. We hypothesized that this program would improve access and timely assessment of pediatric traumas while limiting patient transfers to our PTC., Methods: A retrospective cohort study was conducted at the PTC between January 2019 and May 2023. All pediatric trauma patients younger than 18 years who had teletrauma consults were included. We also evaluated all avoidable transfers without teletrauma consults defined as admission for less than 36 hours without an intervention or imaging as a comparison group., Results: A total of 151 teletrauma consults were identified: 62% male and median age of 8 years (interquartile range [IQR], 4-12 years). Teletrauma consults increased from 12 in 2019 to 100 in 2022 to 2023, and the number of PHs increased from 2 to 32. Partnering hospitals were 15 to 554 miles from the PTC, with a median distance of 34 miles (IQR, 28-119 miles). Following consultation, we recommended discharge (34%), admission (29%), or transfer to PTC (35%). Of those who were not transferred, 3% (3 of 97) required subsequent treatment at the PTC. Nontransferred teletrauma consults had a higher percentage of TBI (61% vs. 31%, p < 0.001) and were from farther distances (40 miles [IQR, 28-150 miles] vs. 30 miles [IQR, 28-50 miles], p < 0.001) compared with avoidable transferred patients without a teletrauma consult., Conclusion: Teletrauma consult is a safe and viable addition to a pediatric trauma program faced with providing care to a large geographical catchment area. The pediatric teletrauma program provided management recommendations to 32 PHs and avoided transfer in approximately 63% of cases., Level of Evidence: Prognostic and Epidemiological; Level III., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Pediatric surgeons are experiencing burnout at similar rates to other subspecialists; however, little is known about the prevalence of burnout in pediatric general surgery fellows. This study aims to determine the prevalence of burnout in pediatric general surgery trainees., Methods: The Maslach Burnout Inventory and a survey of personal and training characteristics were distributed to current and recently graduated pediatric surgery fellows. Higher Maslach Burnout Inventory subscores of emotional exhaustion (EE) and depersonalization (DP) indicate higher levels of burnout. Descriptive statistics were used to describe respondent characteristics. Burnout, as a dichotomous variable, was compared by chi-square test, and subscale scores werecompared by nonparametric tests for a variety of factors., Results: The response rate was 41% (52/126); 15% were first-year fellows, 54% were second-year fellows, and 31% were recent graduates. The majority were 30-39 y old (83%) and female (71%). The median [IQR] scores for EE, DP, and personal accomplishment were 23 [17-36], 8 [2-12.3], and 38 [34-41], respectively, with no significant differences by training year. Eighteen percent of respondents met burnout criteria based on high-risk EE subscores in combination with high-risk DP subscores, and 44% and 23.1% of respondents had high-risk EE and DP subscores, respectively. Factors associated with higher EE subscores were fewer hours of sleep and taking home call., Conclusions: Pediatric surgery fellows experience high levels of burnout along with a high frequency of high-risk EE and DP scores. Lack of sleep and home call may be contributory, and efforts to combat burnout should specifically address these factors., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: The minimally invasive repair of pectus excavatum (MIRPE) is associated with significant postoperative pain and opioid use. The objective of this study was to determine the effect of intercostal nerve cryoablation (Cryo) on inpatient and post-hospital opioid prescription practices following MIPRE., Methods: A retrospective review at a single pediatric center was conducted of patients ≤21 years old who underwent MIRPE. Oral morphine equivalents (OME) of inpatient and discharge opioids were compared between Cryo and no-Cryo cohorts., Results: 579 patients were identified (82.8% male, mean age 15.4 ± 2.0 years). Cryo was performed in 73.5% of patients. The total inpatient OME use was less in the Cryo group (0.89 ± 0.68 vs. 1.6 ± 0.5 OME/kg/day; p < 0.001). Patients who underwent Cryo were prescribed significantly less OME at discharge compared to the no-Cryo group (3.9 ± 1.7 vs. 10.0 ± 4.1 OME mg/kg, p < 0.001). There was no statistically significant difference in the proportion of patients who required an opioid prescription refill (Cryo 12.4% vs. no-Cryo 11.5%, p = 0.884) or were readmitted (Cryo 5.3% vs. no-Cryo 4.6%, p = 0.833)., Conclusion: Patients who underwent cryoablation during MIRPE were prescribed significantly less opioid at the time of discharge without increasing the need for opioid refills or hospital readmissions., Level of Evidence: Treatment study; Level III evidence., Competing Interests: Conflicts of interest Dr. Padilla, McMahon, and Notrica are education consultants for Atricure. Dr. Notrica has patents related to pectus repair and receives patent royalties from KLS Martin. The other authors have no relevant financial or non-financial interests to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Metal allergy following placement of a metal pectus bar for minimally invasive repair of pectus excavatum (MIRPE) is a rare complication with potentially significant morbidity. There is no consensus regarding preoperative metal allergy testing (MAT). This study aims to assess incidence of metal allergy and titanium bar use in tested and untested patients and trends in MAT with different approaches to MAT., Methods: A retrospective chart review was performed on patients who underwent MIRPE from July 2009 to June 2022 at a single institution. During this time, MAT was performed routinely (RT; routine testing) and selectively (ST; selective testing)., Results: The cohort included 741 patients for analysis. Metal bar allergy was documented in 1.3 % of all patients; the incidence was 1.3 % in patients with MAT and 1.4 % without MAT. The incidence of bar allergy was 1.1 % in the RT group and 1.6 % in the ST group. In the RT group, bar allergy occurred in 1.4 % (3/216) of patients with a negative MAT. In the ST group, bar allergy occurred in 1.2 % (2/164) of patients with a negative MAT and in 1.9 % (3/162) of untested patients with a stainless-steel bar. Titanium bar use was not significantly different between the RT and ST groups (18.3 % vs 16.3 %, p > 0.05)., Conclusion: The incidence of metal bar allergy after MIRPE was less than 2 %, and titanium bar use was not significantly different in routine and selective testing groups. MAT was not associated with a reduction in bar allergy, and its use remains unsupported., Level of Evidence: III., Competing Interests: Conflict of interest DMN is a consultant for Atricure and KLS and has patents related to pectus excavatum repair. BEP is a consultant for Atricure. LEM has received honoraria for speaking and teaching with Atricure., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Introduction: Minimally invasive repair of pectus excavatum (MIRPE) with intercostal nerve cryoablation (Cryo) decreases length of hospitalization and opioid use, but long-term recovery of sensation has been poorly described. The purpose of this study was to quantify long-term hypoesthesia and neuropathic pain after MIRPE with Cryo., Methods: A prospective cohort study was conducted single-institution of patients ≤21 years who presented for bar removal. Consented patients underwent chest wall sensory testing and completed neuropathic pain screening. Chest wall hypoesthesia to cold, soft touch, and pinprick were measured as the percent of the treated anterior chest wall surface area (TACWSA); neuropathic pain was evaluated by questionnaire., Results: The study enrolled 47 patients; 87% male; median age 18.4 years. The median bar dwell time was 2.9 years. A median of 2 bars were placed; 80.9% were secured with pericostal sutures. At enrollment, 46.8% of patients had identifiable chest wall hypoesthesia. The mean percentage of TACWSA with hypoesthesia was 4.7 ± 9.3% (cold), 3.9 ± 7.7% (soft touch), and 5.9 ± 11.8% (pinprick). Hypoesthesia to cold was found in 0 dermatomes in 62%, 1 dermatome in 11%, 2 dermatomes in 17% and ≥3 dermatomes in 11%. T5 was the most common dermatome with hypoesthesia. Neuropathic symptoms were identified by 13% of patients; none required treatment., Conclusion: In long-term follow up after MIRPE with Cryo, 46.8% of patients experienced some chest wall hypoesthesia; the average TACWSA with hypoesthesia was 4-6%. Hypoesthesia was mostly limited to 1-2 dermatomes, most commonly T5. Chronic symptomatic neuropathic pain was rare., Level of Evidence: Level IV., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Superior mesenteric artery syndrome (SMAS) is a rare and potentially life-threatening cause of small bowel obstruction in which the superior mesenteric artery impinges on the third portion of the duodenum. SMAS is typically encountered in patients with low body fat and a history of rapid weight loss and is often diagnosed as a chronic or subacute condition. Here, we describe a case of a healthy adolescent boy without typical SMAS prodromal symptoms presenting with a severe, hyperacute proximal small bowel obstruction due to SMAS. Complications arising from massive gastric and duodenal distension, including gastric, pancreatic and renal ischaemia, necessitated emergent surgical intervention consisting of the duodenojejunostomy bypass with partial gastric resection. The patient recovered without significant lasting consequences., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Guidelines recommend nonoperative management of blunt splenic injury (BSI) for hemodynamically stable children. The aim of this study was to determine the contemporary national trends of nonoperative management in pediatric BSI., Methods: A retrospective review was preformed utilizing KIDS database between 2012 and 2019. Pediatric BSI cases age ≤16 years were selected for analysis. Patient demographics, severity, and interventions were compared between hospital types., Results: 8,296 BSIs were identified, with 74.3% treated at non-pediatric hospitals. Overall, 96.3% of BSI were nonoperative; 2.5% undergoing angioembolization. Rates of splenectomy from 2012 to 2019 remained stable (6.8% versus 7.1% (p = 0.856)). Splenic injuries treated at adult hospitals were more likely to undergo operative management (11.9% versus 4.4%, OR 2.94, p < 0.001) and more likely to undergo angiography (4.8% vs 1.3%, OR 3.133, p < 0.001). On multivariate regression pediatric BSI treated at adult centers were associated with triple the risk of splenectomy (OR 3.50, p < 0.001). Over seven years, high grade BSI treated at children's hospitals increased from 14.6% to 51.7% (p < 0.001) and, splenectomy rates at children's hospitals increased from 1% to 4% (p < 0.001)., Conclusion: More than 70% of pediatric splenic injuries are treated at adult hospitals, however, children's hospitals predominately caring for high-grade BSI. After controlling for confounding factors, children treated at adult centers continue to have 3-fold likelihood of splenectomy. Over the last 7 years, pediatric hospitals have seen a significant rise in their overall splenectomy rate, which may suggest a shift in case severity to children's hospitals., Level of Evidence: Level III., Type of Study: Treatment study., Competing Interests: Declaration of competing interest All Authors: None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Cryoablation during minimally invasive repair for pectus excavatum (MIRPE) reduces opioid use and hospital length of stay. Skin hypoesthesia of the chest wall also occurs. This study sought to determine the frequency, onset, duration, and location of sensory changes and neuropathic pain after cryoablation., Methods: A prospective study was conducted on patients aged ≤21 years undergoing MIRPE with cryoablation of T3 to T7 dermatomes bilaterally for 120 s at a single institution between March 2021 to December 2022. Patients underwent sensory testing of the chest wall and neuropathic pain surveys (S-LANSS) preoperatively and then postoperatively for 6 months. Incidence and duration of hypoesthesia and neuropathic pain were evaluated., Results: Of 61 patients enrolled in the study, 45 completed evaluations at six months postoperatively. All patients had skin hypoesthesia on postoperative day (POD)1. The mean percentage of the treated anterior chest wall surface area (TACWSA) with hypoesthesia to cold stimulus was 52% (±29.3) on POD 0 and 55% (±19.7) on POD 1. Sensation returned over time, with hypoesthesia affecting 11.1% (±15.5) TACWSA at 6 months. At study completion 58% of patients (26/45) had complete return of sensation; hypoesthesia was found at: 1 dermatome 13% (2/45), 2 dermatomes 22% (11/45), and 3 dermatomes 4% (2/45). Neuropathic pain (S-LANSS ≥12) was documented in 16% (9/55) of patients at hospital discharge but decreased to 6.7% of patients at 6 months., Conclusion: Onset of skin hypoesthesia after cryoablation occurred on POD0 and affected 52% of the TACWSA. All patients experienced return of sensation to varying degrees, with 58% experiencing normal sensation in all dermatomes by 6 months. The etiology of persistent hypoesthesia to select dermatomes is unknown but may be related to operative technique or cryoablation. Chronic neuropathic pain is uncommon., Level of Evidence: II., Type of Study: Prognosis Study., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objectives: Extracorporeal membrane oxygenation (ECMO) is an invaluable life-support resource in the treatment of critically ill children. Traditionally, neck vascular cannulation requires ligation of the carotid artery and jugular vein. In this literature review, we identify rates of postoperative vessel patency, complications, and neurologic outcomes after vascular reconstruction following decannulation., Data Sources: Embase, PubMed, and Cochrane Review., Study Selection: No publication date limits. Inclusion criteria comprised of studies addressing repair of the carotid artery and jugular vein after ECMO decannulation and outcomes from this procedure., Data Extraction: Authors identified publications on vascular reconstruction after ECMO decannulation, including possible technical considerations, complications, and outcomes., Data Synthesis: We identified 18 articles: 13 studies were limited to the neonatal population. The largest series included 51 patients after vascular reconstruction. The rate of postoperative arterial occlusion ranged from 11.8% to 17.8%, and overall patency rate postoperatively was 78.6%. No major thromboembolic events were reported. One study demonstrated an increase in neuroimaging abnormalities for patients undergoing ligation compared with vascular reconstruction. No studies demonstrated differences in functional neurodevelopmental testing., Conclusions: Vascular reconstruction after ECMO decannulation has been reported since 1990. Although reconstruction does not appear to carry significant short-term morbidity, there are no large prospective studies or randomized controlled trials demonstrating its efficacy in improving neurologic outcomes in ECMO patients. There is also a paucity of data regarding outcomes in older children or long-term ramifications of vascular reconstruction., Competing Interests: Dr. Molitor disclosed that he serves as a consultant to Medtronic. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.)

Background: Cryoanalgesia uses the application of cold temperatures to temporarily disrupt peripheral sensory nerve function for pain control. This review outlines the principles of cryoablation, clinical applications, and clinical data for its use in pediatric thoracic surgery. Methods: A comprehensive PubMed search was performed using the principal terms and combinations of cryoablation, cryoanalgesia, Nuss, Nuss repair, pectus, pectus excavatum, thoracic surgery, thoracotomy, and chest wall. Pediatric articles were reviewed and included if relevant. Adult articles were reviewed for supporting information as needed. Reference lists of included articles were reviewed for possible additional sources. Discussion: The scientific and clinical principles of cryoablation are outlined, followed by a focused review of current clinical application and outcome data. Conclusion: Postoperative pain is a major challenge following thoracic surgery. Cryoanalgesia is emerging as an adjunct in pediatric thoracic surgery, particularly for the Nuss procedure or minimally invasive repair of pectus excavatum. It effectively controls pain, decreasing postoperative opioid use and hospital length of stay with few short-term complications. Although more long-term studies are needed, early evidence suggests there is reliable return of sensation to the chest wall and long-term neuropathic pain is rare.

Introduction: The minimally invasive repair of pectus excavatum (PE) is a painful procedure that can result in long-term hospitalization and opioid use. To mitigate the length of stay and opioid consumption, many different analgesia strategies have been implemented. The aim of this study is to review the use and patient outcomes of intercostal nerve cryoablation (INC) during PE repair reported in the literature., Methods: An unfunded literature search using PubMed identifying articles discussing INC during PE repair from 1946 to 1 July 2023 was performed. Articles were included if they discussed patient outcomes with INC use during PE repair. Articles were excluded if they were reviews/meta-analyses, editorials, or not available in English. Each article was reviewed for bias by analyzing the study methods, data analysis, patient selection, and patient follow-up. Articles comparing outcomes of INC were considered significant if p -value was <0.05., Results: A total of 34 articles were included in this review that described INC use during pectus repair. Most supported a decreased hospital length of stay and opioid use with INC. Overall, INC was associated with fewer short-term and long-term complications. However, the researchers reported varied results of total hospital costs with the use of INC., Conclusion: The review was limited by a paucity of prospective studies and low number of patients who received INC. Despite this, the present data support INC as a safe and effective analgesic strategy during the repair of PE., Competing Interests: LM is an educational consultant for AtriCure. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Eldredge and McMahon.)

Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure.  To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology.  This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques.  Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation.  Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients., (Copyright © 2023. Published by Elsevier Inc.)

Introduction: Minimally invasive repair of pectus excavatum (MIRPE) and cartilaginous rib excision (CRE) for slipping rib syndrome (SRS) are painful procedures. Intercostal nerve cryoablation (Cryo) controls pain and decreases opioid use in MIRPE. Herein, we describe our experience with cryoablation in CRE., Methods: A retrospective chart review was performed of all patients undergoing CRE between 2018 and 2022. Data on demographics, clinical characteristics, operative details, and hospital course were collected., Results: A total of 98 patients underwent CRE: 68 CRE without cryo, 22 CRE + Cryo, and 8 combined MIRPE + CRE + Cryo. Ninety percent of patients underwent bioabsorbable rib plating. Patients were predominantly female (79%, 73%, 50% respectively) with median ages 17.6, 16.9, and 14.2 years respectively. CRE + Cryo patients used significantly less opioids in hospital (0.6 OME/kg [0.1,1.2]) compared to CRE without cryo (1.0 OME/kg [0.6,2.1]), p < 0.05. The median length of stay (LOS) in CRE + Cryo was 1 day [1,2] compared to 2 days in CRE without cryo [1,2], p = 0.09. MIRPE + CRE + Cryo patients used 0.6 OME/kg [0.2,8.0] with a 2 day [1,5.5] LOS. Ninety-one percent of Cryo patients had cryoablation of T9 and/or T10 intercostal nerves, with no documented abdominal wall laxity at median follow-up of 16 days. Cryo was applied extra-thoracically in CRE + cryo without thoracoscopy or lung isolation, while MIRPE + CRE + Cryo used a combination extra-/intra-thoracic cryoablation in with thoracoscopy., Conclusion: Intercostal nerve cryoablation reduces opioid use and LOS in patients undergoing cartilaginous rib excision for slipping rib syndrome. Cryotherapy to as low as T10 did not result in abdominal wall laxity and can be applied extra-thoracically without the need for thoracoscopy. Ongoing prospective studies are required to assess the long-term outcomes., Level of Evidence: III., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: In adults, the gold standard for surgical repair of an inguinal hernia is a mesh repair, whereas, in children, the standard is high ligation of the hernia sac. However, adolescents represent a "gray zone" between children and adults, and there is no consensus on the most appropriate operation for inguinal hernias in these patients. We aimed to describe the outcomes in adolescents undergoing high ligation for inguinal hernia repair and determine what factors may portend an increased risk of recurrence in this population., Methods: A retrospective cohort study was performed of all children that underwent open high ligation for an inguinal hernia at our tertiary children's hospital from January 2000 to January 2018, who were 12 to 18 years old at the time of surgery. We compared the patient demographic data, medical history, and repair characteristics for the cohort of hernias that developed a recurrence to the cohort that did not., Results: During our study period, 256 adolescent patients underwent repair with 11 of those patients having both sides repaired for a total of 267 hernias repaired. The median age at surgery was 14.7 years, and 83.9% of the hernias were in male patients. There was a 6.0% recurrence rate, and all patients that developed recurrence underwent a reoperation. The median time from surgery to reoperation for recurrence was 3.1 years. Patients with recurrence were more likely to have cardiac (25.0% vs. 5.8%, p = 0.02) and gastrointestinal comorbidities (25% vs. 7.1%, p = 0.01). There were no other significant differences between the two cohorts., Conclusion: High ligation of the hernia sac in adolescents is effective and has an acceptable risk of recurrence while avoiding any additional morbidity that may come from the use of mesh. Patients with cardiac and gastrointestinal comorbidities should be counseled on the higher risk of recurrence., (Copyright © 2020. Published by Elsevier Inc.)

Introduction: Acute respiratory distress syndrome (ARDS) is a complication that affects approximately 40% of burn patients and is associated with high mortality rates. Extracorporeal membrane oxygenation (ECMO) therapy is a management option for severe refractory hypoxemic respiratory failure; however, there is little literature reporting the effectiveness of this therapy in burns. Our study objective was to review patient outcomes in burns following severe ARDS treated with ECMO., Methods: We retrospectively reviewed all patients treated with ECMO for ARDS who received their burn care at a single regional burn center between 9/1/2006 and 8/31/2016. Primary patient outcome examined was discharge disposition., Results: We identified 8 patients who had ARDS secondary to burn who were placed onto ECMO during this 10-year period. The average APACHE score, SOFA score, and P/F ratio were 21±3, 9±2, and 59±8, respectively, at the time of decision for ECMO. No ECMO-related complications were identified. Out of the 8 patients reviewed, 1 died, 4 were discharged to acute rehabilitation or a long-term acute care facility, and 3 were discharged to home., Conclusion: Mortality in burn patients with ARDS who are managed with ECMO is extremely low. Careful selection and timely intervention with ECMO contributed to good clinical outcomes., (Copyright © 2018 Elsevier Ltd and ISBI. All rights reserved.)