The Impact of Pediatric Surgical Specialty Meetings: A 5-year Analysis of Presented Abstracts.

BACKGROUND: Abstracts presented at the American Academy of Pediatrics Section on Surgery (AAP) and American Pediatric Surgical Association (APSA) meetings can be taken as a reasonable representation of academic activity in pediatric surgery. We sought to assess ongoing trends in pediatric surgical research by analyzing the scientific content of each association's yearly meeting. METHODS: Abstracts presented at AAP and APSA between 2009 and 2013 were identified from the final printed programs (n = 910). Video abstracts (n = 34) were excluded. Collected data included title, authors, classification (basic science/clinical), presentation type (podium/poster), and topic. Publication as a journal article was determined using the abstract title/authors in a PubMed search. Journal impact factors were recorded for each journal and a composite impact factor (CIF) was calculated by dividing the sum of impact factors by the published articles per meeting. RESULTS: Number of abstracts presented, percentage published, abstract classifications, and presentation type remained consistent over the study period. The AAP meetings accepted a higher percentage of clinical abstracts: AAP 72.3 ± 3.4% versus APSA 65.9 ± 1.3%. The five most popular topics at both meetings were oncology, congenital diaphragmatic hernia, necrotizing enterocolitis, trauma, and appendicitis. The publication rate for clinical and basic science abstracts did not vary significantly over the study period, whereas CIFs were higher for basic science publications nearly every year. The percentage of podium abstracts published was significantly greater than poster abstracts, but no statistical difference in CIF was seen between podium- and poster-associated publications. CONCLUSIONS: Abstracts accepted and presented at the two major pediatric surgical specialty meetings more commonly involve clinical studies with a trend away from basic science. Despite this, basic science abstracts tended to be published in higher impact journals. This study attempts to quantify the quality of pediatric surgical research and serves as a baseline for future comparison.

An Analysis of Pediatric Scar Progression Over Time.

Objective: The advances in surgical approaches for a pyloromyotomy have all focused on creating smaller incisions from a right upper quadrant now to a laparoscopic umbilical incision. A key assumption is that the final scar retains the size of the original incision as the child matures. Our case reports on a family with several members, now adults, with the same surgery and same surgeon who had the right upper quadrant incision as infants to elucidate the extent of how infantile scars grow over time, significantly exceeding the original incision. Methods: We evaluated the various pyloromyotomy scars of our newborn patient, his maternal grandmother, and his two maternal twin aunts. One aunt (#1) was of normal stature, whereas her twin (#2) never went through a full vertical growth phase due to being stunted by Cornelia de Lange syndrome. For each member, we compared the length of the original incision with the current scar length to determine how much the scar has grown over time. Results: Significant scar growth was seen in the grandmother and aunt 1. In contrast aunt 2's scar did not grow significantly due to her stunted vertical growth from Cornelia de Lange syndrome. Conclusions: This case supports the notion that surgical incisions in infants grow more substantially than realized with age, resulting in larger scars than anticipated. Our findings suggest the reason why the laparoscopic pyloromyotomy has been popularized due to its incisions being so small that they continue to present a cosmetic advantage over time.

The radiation footprint on the pediatric trauma patient.

BACKGROUND: The actual baseline of radiation exposure used in evaluating pediatric trauma is not known and has relied on estimates in the literature that may not reflect clinical reality. Our objectives were to determine the baseline amount of radiation delivered in a pediatric trauma evaluation and correlate radiation exposure with trauma activation status to identify the cohort most at risk. METHODS: We retrospectively evaluated trauma patients (N = 1050) at an independent Level I children's hospital for each level of trauma activation (consults, alerts, stats) from June 2010 to January 2011. Those patients with full dosimetry (N = 215) were analyzed for demographics, mechanism of injury, Injury Severity Score, imaging modalities, and total effective radiation dosages during the full trauma assessment from the time of injury to discharge. RESULTS: Demographics included gender (143 males, 72 females) and average age (5.5 years [range < 1-16]). The most radiation was conferred from CTs and greatest in trauma stats, followed by alerts, then consults (p < 0.001 for stat and alert doses compared to consults). Repeated imaging was common: 35% of stats had 2-3 CTs and 40% had 4-10 CTs (range 0-10 CTs). The average non-accidental trauma consult utilized four times as many CTs as the average consult (p = 0.002). Most outside hospital CTs (66%) delivered more radiation: 50.0% were at least double the standard pediatric dosage. CONCLUSIONS: This study is the first to identify the actual baseline of radiation exposure for one trauma evaluation and correlate radiation exposure with trauma activation status. Factors associated with highest radiation include stat activations, suspected non-accidental traumas (NAT), and outside hospital system imaging.

Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques.

PURPOSE: Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques. METHODS: Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared. RESULTS: Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38 ± 9, compared to 58 ± 20 for LBG and 31 ± 10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy. CONCLUSIONS: EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.

Chest Wall Reconstruction: Evolution Over a Decade and Experience With a Novel Technique for Complex Defects.

BACKGROUND: Chest wall reconstruction (CWR) with biologic matrices has gained popularity over the last decade; however, data on this topic remain sparse. The aim of this study is to review the different methods and materials used for CWR while reviewing and highlighting a novel approach using a biologic inlay and synthetic onlay technique for larger, complex high-risk defects. METHODS: A retrospective review was performed of all patients who underwent full thickness chest wall resection and reconstruction during a 10-year period. Patient characteristics, comorbidities, operative data, as well as postoperative wound complications and outcomes were reviewed. Different reconstructive methods and materials were reviewed and compared. RESULTS: From December 2003 to January 2014, a total of 81 patients underwent CWR. The indications for resection/reconstruction included oncologic in 49 patients (60.5%), desmoids tumors in 10 (12.3%), bronchopleural fistula in 3 (3.7%), infection in 7 (8.6%), and anatomic deformity in 7 (8.6%) patients. Synthetic and/or acellular dermal matrices (ADM) reconstruction was used in 59 patients (10 biologic, 22 synthetic, and 27 biologic ADM inlay/synthetic onlay combination). On average, 2.5, 3.5, and 3.6 ribs were resected in the biologic, synthetic, and combination group, respectively (P = 0.1). A greater number of patients in the combination group had a history of chemotherapy and/or radiation therapy (P = 0.03) than the synthetic or biologic alone groups. Risk analysis demonstrated an association between the number of ribs resected and postoperative chest wall complications. The incidence of chest wall/wound complications in the synthetic, combination, and biologic groups was 31.8%, 22.2%, and 10%, respectively (P = 0.47). CONCLUSIONS: In the largest single institution study comparing the use of different reconstructive materials, including ADM in CWR, the authors demonstrate that a biologic inlay/synthetic onlay may be used effectively for high-risk, large complex defects. Early outcomes with this technique are promising. The authors believe this combination highlights benefits from both materials because the ADM facilitates tissue ingrowth and revascularization, whereas the synthetic component provides structural durability. Additional studies with larger sample sizes are necessary to further explore the benefits of the combination technique to determine if outcomes are better than either material alone when used to reconstruct high-risk wounds after larger resections.

Rising incidence and aggressive nature of cutaneous malignancies after transplantation: An update on epidemiology, risk factors, management and surveillance.

Although immunosuppression has been a key component to the success of solid-organ transplantation, the morbidity associated with long-term immunosuppression remains a substantial burden, particularly as recipients of transplants live longer. Indeed, malignancy is one of the most common reasons for mortality following transplantation and the most common of these cancers are cutaneous in origin. Recently, the incidence of these malignancies has been on the rise, partly due to the fact that recipients of these transplants are living longer as a result of improvements in surgical technique, immunosuppression and perioperative management. Although there have been initiatives to increase awareness of cutaneous malignancies following transplantation, such programs are not standardized and there continues to be gaps in skin cancer education and post-operative surveillance. This review provides an update on the epidemiology, risk factors, clinical management, prevention and surveillance of cutaneous malignancies.

Pediatric surgeons' attitudes toward regionalization of neonatal surgical care.

BACKGROUND/PURPOSE: Research has suggested that high-risk pediatric surgical patients have better outcomes when treated in resource-rich children's environments. Surgical neonates are a particularly high-risk population and some suggest that regionalization might be a strategy to improve clinical outcomes in neonatal surgical patients. We conducted a national survey of pediatric surgeons in the United States to explore their attitudes toward regionalization of neonatal surgical care. METHODS: Members of the American Pediatric Surgical Association were asked to participate in an anonymous online survey to assess both attitudes toward regionalization, as well as perceptions of the importance of various resources in providing optimal care for surgical neonates. RESULTS: Overall, 56.2% of participants favored regionalization. Surgeons whose practice was part of a training program tended to favor regionalization more, as did those from larger group practices and those who practiced at free-standing children's hospital. In addition, surgeons from larger groups and those involved with training programs more strongly favored the premise that a higher level of resource commitment should be available to treat surgical neonates. CONCLUSIONS: The impact of any national strategy to improve neonatal surgical outcomes will be large and multi-faceted. While the majority of pediatric surgeons favor regionalization, our findings demonstrate variation in this view and highlight the necessity for surgeon involvement and education that will be critical in this effort.

Extubation during pediatric extracorporeal membrane oxygenation: a single-center experience.

OBJECTIVES: Describe aspects of one center's experience extubating infants and children during extracorporeal membrane oxygenation. DESIGN: Retrospective review of medical records. SETTING: Seventy-one-bed critical care service (PICU and cardiovascular ICU) in a large urban tertiary children's hospital. PATIENTS: Pediatric and neonatal patients supported on extracorporeal membrane oxygenation between 1996 and 2013 who were either not intubated or extubated greater than 24 hours during their extracorporeal membrane oxygenation course. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixteen of 511 patients on extracorporeal membrane oxygenation were extubated for at least 24 hours during their extracorporeal membrane oxygenation courses. Fourteen had respiratory failure and two had cardiac disease. Five patients died while on extracorporeal membrane oxygenation, but the cause of death was not related to complications associated with extubation. Extubated patients were supported a median of 19.7 days on extracorporeal membrane oxygenation, with a median extubation latency (time between cannulation and first extubation) of 6.2 days and a median extubation duration of 5.5 days. Mean time extubated was 43% of the total time on extracorporeal membrane oxygenation. Two patients were reintubated briefly or had a laryngeal mask airway placed for decannulation (n = 1). The remaining patients were extubated within 5 days of decannulation, weeks afterward (n = 2), transferred to outside facilities (n = 2), or died during extracorporeal membrane oxygenation support (n = 5). We also observed no complications directly attributable to extubation and spontaneous reaeration of consolidated lungs in acute respiratory distress syndrome in extubated patients on extracorporeal membrane oxygenation. CONCLUSION: Extubation and discontinuation of mechanical ventilation appear feasible in patients requiring long-term extracorporeal membrane oxygenation. Emergency procedure planning may need to be modified in extubated patients on extracorporeal membrane oxygenation.

Autologous buccal mucosa graft for repair of recurrent rectovaginal fistula.

Post-operative pediatric rectovaginal fistulas are rare, can be challenging to repair, and often recur. The versatility, ease of accessibility, vascularization, and likeness to native vaginal tissues make autologous buccal mucosal grafts a novel tissue substitute for the repair of a recurrent rectovaginal fistula after the surgical repair of anorectal malformations.

Differential expression of degradome components in cutaneous squamous cell carcinomas.

Although the cure rate for cutaneous squamous cell carcinoma is high, the diverse spectrum of squamous cell carcinoma has made it difficult for early diagnosis, particularly the aggressive tumors that are highly associated with mortality. Therefore, molecular markers are needed as an adjunct to current staging methods for diagnosing high-risk lesions, and stratifying those patients with aggressive tumors. To identify such biomarkers, we have examined a comprehensive set of 200 histologically defined squamous cell carcinoma and normal skin samples by using a combination of microarray, QRT-PCR and immunohistochemistry analyses. A characteristic and distinguishable profile including matrix metalloproteinase (MMP) as well as other degradome components was differentially expressed in squamous cell carcinoma compared with normal skin samples. The expression levels of some of these genes including matrix metallopeptidase 1 (MMP1), matrix metallopeptidase 10 (MMP10), parathyroid hormone-like hormone (PTHLH), cyclin-dependent kinase inhibitor 2A (CDKN2A), A disintegrin and metalloproteinase with thrombospondin motifs 1 (ADAMTS1), FBJ osteosarcoma oncogene (FOS), interleukin 6 (IL6) and reversion-inducing-cysteine-rich protein with kazal motifs (RECK) were significantly differentially expressed (P≤0.02) in squamous cell carcinoma compared with normal skin. Furthermore, based on receiver operating characteristic analyses, the mRNA and protein levels of MMP1 are significantly higher in aggressive tumors compared with non-aggressive tumors. Given that MMPs represent the most prominent family of proteinases associated with tumorigenesis, we believe that they may have an important role in modulating the tumor microenvironment of squamous cell carcinoma.

Single-incision laparoscopic surgery in children: a randomized control trial of acute appendicitis.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery that uses a single incision to minimize all ports to one site. The end result is an incision that can be strategically placed in the umbilicus for a perceived scarless abdomen. The authors rationalized that a randomized controlled trial was important given the rapid popularization of this approach. METHODS: An institutional review board-approved prospective randomized trial compared patients undergoing SILS (SILS-A) and conventional laparoscopic (LAP-A) appendectomy at a free-standing children's hospital during a median follow-up period of 2.2 years. RESULTS: A total of 50 patients (50 % boys and 67 % Hispanics) were randomized equally to SILS-A and LAP-A. The patients ranged in age from 3 to 15 years without a difference between the two groups. Half (50 %) of these patients were younger than 8 years. The technique for SILS-A involved a single supraumbilical curvilinear skin incision with three fascial incisions. Ports were inserted to varying depths to minimize restriction of instrument movement. Coaxial visualization was improved by the use of a 30° scope. To achieve technical comparability with the LAP-A, a stapler device was used, which required upsizing a 5 mm port to a 12 mm port. The mean duration of the operation was 46.8 ± 3.7 min (range, 22-120 min) compared with 34.8 ± 2.5 min (range, 18-77 min) for standard LAP-A (p = 0.010). No conversions occurred, and the two groups did not differ in hospital length of stay. The postoperative complications consisted of one wound seroma in the SILS-A group (nonsignificant difference), and no hernias were seen. No difference in readmissions, diet tolerance, fever, or postoperative pain was noted between the two groups. CONCLUSIONS: The findings show the SILS approach to be feasible in the pediatric population despite the limited abdominal domain in younger children. Although SILS operating room times currently are longer than for LAP-A, they are comparable, and no other outcomes differed appreciably between the two techniques at the time of hospitalization or during the follow-up period.

Ovarian torsion: diagnosis of inclusion mandates earlier intervention.

PURPOSE: The treatment of ovarian torsion (OT) is often delayed because of diagnostic uncertainty and dependence on radiologic confirmation. In contrast, when testicular torsion (TT) is suspected, diagnosis and management are expedited despite lack of certainty, and operative exploration is not delayed by radiologic investigations. We compared the management of torsion in both sexes to define a better clinical pathway for suspected OT. METHODS: A 2.5-year review of the Pediatric Health Information System database was performed to determine the incidence of TT and OT at large children's hospitals. A 10-year retrospective review of children (0-19 years) diagnosed with TT or OT at a single academic center was performed to identify differences in diagnosis and management and determine the impact on gonadal salvage rates. RESULTS: The incidence of TT was comparable with OT in the Pediatric Health Information System database (0.03% vs 0.02%). A total of 158 patients with TT and 90 patients with OT were managed at our center with a median age of 12 years in both groups. Boys presented earlier after the onset of pain (36 vs 72 hours, P < .0001) and were imaged more quickly (0.77 vs 1.86 hours, P < .0001). Time to operating room (OR) was also shorter for TT (2.3 vs 6.3 hours, P < .0001). The salvage rate for TT was 30.3% vs 14.4% for OT (P < .01). CONCLUSIONS: Girls with suspected OT waited 2.5 times as long for diagnostic imaging and 2.7 times as long to be taken to the operating room. In addition, the gonadal salvage rate was significantly worse for girls compared with boys with TT. More urgent intervention for OT, with liberal use of diagnostic laparoscopy and without reliance on a definitive diagnosis by imaging, should be considered in girls with lower abdominal pain.

Costs of congenital diaphragmatic hernia repair in the United States-extracorporeal membrane oxygenation foots the bill.

BACKGROUND: Congenital diaphragmatic hernia (CDH) is the costliest noncardiac congenital defect. Extracorporeal membrane oxygenation (ECMO) is a treatment strategy offered to those babies with CDH who would not otherwise survive on conventional therapy. The primary objective of our study was to identify the leading source of expenditures in CDH care. METHODS: All patients surviving CDH repair were identified in the Kids' Inpatient Database (KID) from 1997 to 2006, with costs converted to 2006 US dollars. Patients were categorized into groups based on severity of disease for comparison including CDH repair only, prolonged ventilator dependence, and ECMO use. Factors associated with greater expenditures in CDH management were analyzed using a regression model. RESULTS: Eight hundred thirty-nine patients from 213 hospitals were studied. Extracorporeal membrane oxygenation use decreased from 18.2% in 1997 to 11.4% in 2006 (P = .002). Congenital diaphragmatic hernia survivors managed with ECMO cost more than 2.4 times as much as CDH survivors requiring only prolonged ventilation postrepair and 3.5 times as much as those with CDH repair only (both P < .001). Age, multiplicity of diagnoses, patient transfer, inhaled nitric oxide use, prolonged ventilation, and ECMO use were all associated with higher costs. Extracorporeal membrane oxygenation use was the single most important factor associated with higher costs, increasing expenditures 2.4-fold (95% confidence interval, 2.1-2.8). Though the CDH repair with ECMO group constituted 12.2% of patients, this group has the highest median costs ($156,499.90/patient) and constitutes 28.5% of national costs based on CDH survivors in the KID. Annual national cost for CDH survivors is $158 million based on the KID, and projected burden for all CDH patients exceeds $250 million/year. CONCLUSIONS: Extracorporeal membrane oxygenation use is the largest contributing factor to the economic burden in CDH. With limited health care resources, judicious resource utilization in CDH care merits further study.

Experience performing 64 consecutive stapled intestinal anastomoses in small children and infants.

BACKGROUND/PURPOSE: Intestinal anastomosis in children has traditionally been performed using hand-sewn techniques. Little data exist evaluating the efficacy of stapled intestinal anastomoses in the infant and pediatric populations. METHODS: A review of a 5-year experience using a mechanical stapler to treat 64 consecutive children requiring intestinal anastomoses was performed. An intestinal stapler was used to complete a side-to-side functional end-to-end anastomosis. Postoperative outcomes and modifications made to the technique were identified. RESULTS: Since 2004, 64 children (median age, 3 months; range, newborn to 24 months) underwent procedures requiring intestinal anastomosis. Twenty-six children (41%) were 1 week or less in age. Twenty-seven children (42%) underwent a stoma closure using a stapler. Thirty-seven children (58%) underwent bowel resection and stapled anastomosis in treating a variety of surgical disorders. Complications included wound infection (n = 2) and anastomotic stricture (n = 1). No issues suggesting anastomotic dilatation and subsequent stasis/overgrowth were identified. CONCLUSIONS: These results suggest that stapled bowel anastomosis is an effective approach applicable to a variety of surgical diseases in newborns and infants.

Molecular markers in cutaneous squamous cell carcinoma.

Nonmelanoma skin carcinoma (NMSC) is the most frequent cancer in the USA with over 1.3 million new diagnoses a year; however due to an underappreciation of its associated mortality and growing incidence and its ability to be highly aggressive, the molecular mechanism is not well delineated. Whereas the molecular profiles of melanoma have been well characterized, those for cutaneous squamous cell carcinoma (cSCC) have trailed behind. This importance of the new staging paradigm is linked to the ability currently to better clinically cluster similar biologic behavior in order to risk-stratify lesions and patients. In this paper we discuss the trends in NMSC and the etiologies for the subset of NMSC with the most mortality, cutaneous SCC, as well as where the field stands in the discovery of a molecular profile. The molecular markers are highlighted to demonstrate the recent advances in cSCC.

Pediatric ovarian malignancies: how efficacious are current staging practices?

PURPOSE: Conventional staging is not routinely practiced because of a lack of preoperative indicators for pediatric ovarian malignancy. Children's Oncology Group (COG) developed guidelines for germ cell tumors to revise staging to correlate with primary pediatric ovarian pathology. Are COG guidelines being used, and are they applicable to all pediatric ovarian malignancies? METHODS: A 15(1/2)-year retrospective review of operative ovarian masses from a single academic center was performed. RESULTS: There were 424 patients identified, with 46 malignancies (11%). Most were stage I (73%). Complete COG staging was performed in 24%. Each staging component performed was as follows: oophorectomy (91%), examination with or without biopsy of omentum (72%), peritoneum (67%), retroperitoneum (63%), contralateral ovary (56%), and washings (46%). Advanced stages had visible findings at exploration to guide biopsies. Of site-directed biopsies, 40.5% were positive, whereas all random biopsies (n = 38) were negative. Two recurrences and all mortalities (n = 4) had complete initial COG operative staging. Mean duration of follow-up was 3.62 +/- 0.365 years. CONCLUSION: The COG staging is not consistently followed. All cases of advanced disease were visibly obvious and confirmed with site-directed biopsies. Random samplings were all negative and did not impact stage. Negative outcomes reflected inherent tumor biology not deviation from COG staging. The COG guidelines appear to be sufficient for all pediatric ovarian malignancies.

Single-incision laparoscopic surgery: feasibility for pediatric appendectomies.

INTRODUCTION: Single-incision laparoscopic surgery (SILS) is a novel area of minimally invasive surgery using a single incision. The end result is a lone incision at the umbilicus for a perceived scarless abdomen. We report our early experience using the SILS technique for appendectomies in the pediatric population. METHODS: A retrospective chart review was performed on our first patients to undergo SILS appendectomy (SILS-A) or laparoscopic appendectomy (LAP-A) during the same period at a freestanding children's hospital. RESULTS: Thirty-nine patients were reviewed. Nineteen patients underwent SILS-A (8.7 +/- 0.76 [SEM] years old), and 20 patients underwent LAP-A (10.5 +/- 0.87 years old, 2-17). Ages were 19 months to 14 years in the SILS-A group, with 21% (4 patients) not older than 6 years. Median weight for SILS-A was 32 kg (14.5-80.3). Twelve patients had acute nonperforated appendicitis (62%). Mean duration of operation was 58 +/- 5.6 (30-135) minutes vs 43 +/- 3.6 (30-85) minutes for standard LAP-A. Two patients were converted to a transumbilical appendectomy, one for inability to maintain a pneumoperitoneum and one for extensive adhesions. Postoperative complications consisted of one wound seroma. No wound infections, hernias, readmissions, or difference in length of stay were noted. CONCLUSION: The SILS approach for acute appendicitis is feasible in the pediatric population even in patients as young as 19 months. Operating room times are somewhat longer than with LAP-A, but should decrease with improved instrumentation and experience. Larger studies and further technical refinements are needed before its widespread implementation.