Navigating the Impact of the Dobbs Decision: Perspectives from Pediatric Surgeons on Reproductive Health Care.

SUMMARY: Nationwide abortion restrictions resulting from the Dobbs v. Jackson Women's Health Organization (2022) decision have generated confusion and uncertainty among healthcare professionals, with concerns for liability impacting clinical decision-making and outcomes. The impact on pediatric surgery can be seen in prenatal counseling for fetal anomaly cases, counseling for fetal intervention, and recommendations for pregnant children and adolescents who seek termination. It is essential that all physicians and healthcare team members understand the legal implications on their clinical practices, engage with resources and organizations which can help navigate these circumstances, and consider advocating for patients and themselves. Pediatric surgeons must consider the impact of these changing laws on their ability to provide comprehensive and ethical care and counseling to all patients.

Prevalence and Outcomes of High versus Low Ratio Plasma to Red Blood Cell Resuscitation in a Multi-Institutional Cohort of Severely Injured Children.

BACKGROUND: The benefit of targeting high ratio fresh frozen plasma (FFP):red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP:RBC transfusion and the association with outcomes in children presenting in shock. METHODS: A post-hoc analysis of a 24-institution prospective observational study (4/2018-9/2019) of injured children <18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (>1:2) ratio FFP:RBC. Nonparametric Kruskal-Wallis and chi-square were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS: Of 135 children with median (IQR) age 10 (5,14) years and weight 40 (20,64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (MTP; low-38%, high-46%, p = .34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = .01); however, hospital mortality was similar (low-24%, high-20%, p = .65) as was the risk of extended ventilator, ICU, and hospital days (all p > .05). CONCLUSION: Despite increased injury severity, patients who received a high ratio of FFP:RBC had comparable rates of mortality. These data suggest high ratio FFP:RBC resuscitation is not associated with worst outcomes in children who present in shock. MTP activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE: Prospective cohort study, Level II.

Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee.

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

Crystalloid volume is associated with short-term morbidity in children with severe traumatic brain injury: An Eastern Association for the Surgery of Trauma multicenter trial post hoc analysis.

OBJECTIVE: This study examined differences in clinical and resuscitation characteristics between injured children with and without severe traumatic brain injury (sTBI) and aimed to identify resuscitation characteristics associated with improved outcomes following sTBI. METHODS: This is a post hoc analysis of a prospective observational study of injured children younger than 18 years (2018-2019) transported from the scene, with elevated shock index pediatric-adjusted on arrival and head Abbreviated Injury Scale score of ≥3. Timing and volume of resuscitation products were assessed using χ 2t test, Fisher's exact t test, Kruskal-Wallis, and multivariable logistic regression analyses. RESULTS: There were 142 patients with sTBI and 547 with non-sTBI injuries. Severe traumatic brain injury patients had lower initial hemoglobin (11.3 vs. 12.4, p < 0.001), greater initial international normalized ratio (1.4 vs. 1.1, p < 0.001), greater Injury Severity Score (25 vs. 5, p < 0.001), greater rates of ventilator (59% vs. 11%, p < 0.001) and intensive care unit (ICU) requirement (79% vs. 27%, p < 0.001), and more inpatient complications (18% vs. 3.3%, p < 0.001). Severe traumatic brain injury patients received more prehospital crystalloid (25% vs. 15%, p = 0.008), ≥1 crystalloid boluses (52% vs. 24%, p < 0.001), and blood transfusion (44% vs. 12%, p < 0.001) than non-sTBI patients. Among sTBI patients, receipt of ≥1 crystalloid bolus (n = 75) was associated with greater ICU need (92% vs. 64%, p < 0.001), longer median ICU (6 vs. 4 days, p = 0.027) and hospital stay (9 vs. 4 days, p < 0.001), and more in-hospital complications (31% vs. 7.5%, p = 0.003) than those who received <1 bolus (n = 67). These findings persisted after adjustment for Injury Severity Score (odds ratio, 3.4-4.4; all p < 0.010). CONCLUSION: Pediatric trauma patients with sTBI received more crystalloid than those without sTBI despite having a greater international normalized ratio at presentation and more frequently requiring blood products. Excessive crystalloid may be associated with worsened outcomes, including in-hospital mortality, seen among pediatric sTBI patients who received ≥1 crystalloid bolus. Further attention to a crystalloid sparing, early transfusion approach to resuscitation of children with sTBI is needed. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Timing and volume of crystalloid and blood products in pediatric trauma: An Eastern Association for the Surgery of Trauma multicenter prospective observational study.

BACKGROUND: The purpose of this study was to determine the relationship between timing and volume of crystalloid before blood products and mortality, hypothesizing that earlier transfusion and decreased crystalloid before transfusion would be associated with improved outcomes. METHODS: A multi-institutional prospective observational study of pediatric trauma patients younger than 18 years, transported from the scene of injury with elevated age-adjusted shock index on arrival, was performed from April 2018 to September 2019. Volume and timing of prehospital, emergency department, and initial admission resuscitation were assessed including calculation of 20 ± 10 mL/kg crystalloid boluses overall and before transfusion. Multivariable Cox proportional hazards and logistic regression models identified factors associated with mortality and extended intensive care, ventilator, and hospital days. RESULTS: In 712 children at 24 trauma centers, mean age was 7.6 years, median (interquartile range) Injury Severity Score was 9 (2-20), and in-hospital mortality was 5.3% (n = 38). There were 311 patients(43.7%) who received at least one crystalloid bolus and 149 (20.9%) who received blood including 65 (9.6%) with massive transfusion activation. Half (53.3%) of patients who received greater than one crystalloid bolus required transfusion. Patients who received blood first (n = 41) had shorter median time to transfusion (19.8 vs. 78.0 minutes, p = 0.005) and less total fluid volume (50.4 vs. 86.6 mL/kg, p = 0.033) than those who received crystalloid first despite similar Injury Severity Score (median, 22 vs. 27, p = 0.40). On multivariable analysis, there was no association with mortality (p = 0.51); however, each crystalloid bolus after the first was incrementally associated with increased odds of extended ventilator, intensive care unit, and hospital days (all p < 0.05). Longer time to transfusion was associated with extended ventilator duration (odds ratio, 1.11; p = 0.04). CONCLUSION: Resuscitation with greater than one crystalloid bolus was associated with increased need for transfusion and worse outcomes including extended duration of mechanical ventilation and hospitalization in this prospective study. These data support a crystalloid-sparing, early transfusion approach for resuscitation of injured children. LEVEL OF EVIDENCE: Therapeutic, level IV.

Long term complications and outcomes in omphalocele.

After a diagnosis of omphalocele during pregnancy, questions regarding long-term prognosis are of primary importance for parents. It is imperative that their questions are answered with substantiated data to promote confident decisions for their children. They frequently express concerns regarding long-term survival, quality of life, need for more operations, feeding issues, motor and cognitive development, cosmesis, and the unique difficulties of giant omphaloceles. The available outcome studies that address these questions are discussed.

The use of ECMO for gastroschisis and omphalocele: Two decades of experience.

PURPOSE: The aim was to review the respiratory failure causes and outcomes of infants with omphalocele or gastroschisis receiving ECMO and reported to the Extracorporeal Life Support Organization (ELSO). METHODS: Gastroschisis and omphalocele infants supported with ECMO and reported to the ELSO Registry between 1992 and 2015 were retrospectively reviewed. Clinical variables, diagnosis of respiratory failure (pulmonary hypertension (PHN), congenital heart defects (CHD), congenital diaphragmatic hernia (CDH), and sepsis), and outcomes were recorded. Univariate analysis was performed using Student's t-test for continuous or Fisher's exact test for categorical variables. RESULTS: Fifty-two infants with gastroschisis (41) (79%) or omphalocele (11) (21%) were identified. The survival to discharge rate of 51% for gastroschisis remained stable and was significantly higher (P=0.05). The overall mortality rate for omphalocele was 82%. Omphalocele had significantly more PHN (P<0.01), CDH (P<0.01), and multiple anomalies (P=0.04) had significantly more sepsis (P=0.02), and none had a CDH. CONCLUSION: Infants with gastroschisis requiring ECMO support have significantly better survival than omphaloceles, and respiratory failure is significantly associated with sepsis. The majority of omphalocele infants die despite ECMO, and respiratory failure is associated PHN and CDH. The association of omphalocele, PHN, and CDH merits further investigation. STUDY TYPE AND EVIDENCE LEVEL: Retrospective comparative study of Registry Database, Level 3.

A Multi-Institutional Review of Thoracoscopic Congenital Diaphragmatic Hernia Repair.

INTRODUCTION: Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in the neonate is controversial due to reports of increased hernia recurrence. A multicenter review on thoracoscopic CDH repair was conducted to evaluate outcomes and to identify factors that are associated with recurrence. METHODS: A multicenter retrospective review was conducted from 2009 to 2015 in neonates who were treated for CDH with thoracoscopic repair. Demographics, preoperative, intraoperative, including repair techniques, and postoperative variables were analyzed by using descriptive statistics. Comparative analysis was performed between those patients who were repaired entirely thoracoscopically with hernia recurrence and those without. RESULTS: One hundred nine infants, of whom 57% were male with an average gestational age at time of surgery of 39.6 ± 4.6 weeks and a weight of 3.4 ± 1.1 kg, were included. The median age at repair was 5 days (range: 3-9), 61% patients required vasopressor support, and 1.8% patients required extracorporeal membrane oxygenation (ECMO) cannulation before repair. Forty-five percent were repaired on high-frequency oscillatory ventilation (HFOV). Repair was completed thoracoscopically in 83 patients (76%), 68 (82%) were repaired primarily, 15 (18%) were repaired with a patch, and 50 (60%) had extracorporeal/rib fixation sutures. Recurrence occurred in 7 (8.4%) of those completed thoracoscopically. Factors found to be significant for recurrence included: vasopressor therapy (P = .02), repair on HFOV (P = .04), and the presence of the spleen in the chest (P = .04). There was no significant difference identified between technical variations in repair. CONCLUSIONS: These data suggest that thoracoscopic repair of CDH is feasible in carefully selected patients. However, there is currently no evidence to support a standardized surgical approach to thoracoscopic repair.

Laparoscopic adrenalectomy in children: a multicenter experience.

INTRODUCTION: Laparoscopic adrenalectomy is now being recognized as the standard approach for adrenalectomy for benign lesions in adults. The published experience in children and adolescents has been limited to sporadic small case series. Therefore, we conducted a large multicenter review of children who have undergone laparoscopic adrenalectomy. METHODS: After Institutional Review Board's approval, a retrospective review was conducted on all patients who have undergone laparoscopic adrenalectomy at 12 institutions over the past 10 years. Operative times included unilateral adrenalectomy without concomitant procedures. RESULTS: About 140 patients were identified (70 males [50%]). Laterality included 76 (54.3%) left-sided lesions, 59 (42.1%) right, and 5 (3.6%) bilateral. Mean operative time was 130.2 ± 63.5 minutes (range 43-406 minutes). The most common pathology was neuroblastoma in 39 cases (27.9%), of which 23 (59.0%) had undergone preoperative chemotherapy. Other common pathology included 30 pheochromocytomas (21.4%), 22 ganglioneuromas (15.7%), and 20 adenomas (14.3%). There were 13 conversions to an open operation (9.9%). Most conversions were because of tumor adherence to surrounding organs, and tumor size was not different in converted cases (P=.97). A blood transfusion was required in 2 cases. The only postoperative complication was renal infarction after resection of a large neuroblastoma that required skeletonization of the renal vessels. At a median follow-up of 18 months, there was only one local recurrence, which was in a patient with a pheochromocytoma. CONCLUSIONS: The laparoscopic approach can be applied for adrenalectomy in children for a wide variety of conditions regardless of age with a 90% chance of completing the operation without conversion. The risk for significant blood loss or complications is low, and it should be considered the preferred approach for the majority of adrenal lesions in children.

Peritoneal drainage as definitive management of intestinal perforation in extremely low-birth-weight infants.

BACKGROUND/PURPOSE: The optimal management of extremely low-birth-weight (ELBW) infants with intestinal perforation remains unclear. The authors evaluated ELBW neonates with intestinal perforation in whom peritoneal drainage (PD) was intended as definitive therapy. METHODS: The records of 29 consecutive ELBW infants with intestinal perforation were reviewed. All underwent PD. Survival, the need for other abdominal procedures, the transition to enteral feeding, and the incidence of cholestasis and infectious complications were noted. Variables associated with nonsurvival were assessed. RESULTS: Overall survival rate was 66%. In 24% of cases, a second abdominal procedure was required. Full feedings were achieved at a mean of 69 days. Extraabdominal infectious complications occurred in 63% of survivors, and direct bilirubin was greater than 2.0 mg/dL in 57% at 2 months. Thrombocytopenia and vasopressor requirements at the time of perforation were associated with nonsurvival. CONCLUSIONS: In this consecutive series of ELBW infants in whom PD was intended as definitive treatment for intestinal perforation survival was comparable with that found in series in which immediate laparotomy and resection were used. Few secondary abdominal procedures were required. The interval between PD and full enteral nutrition, however, was long, and the incidence of nonabdominal infectious complications and cholestasis was substantial.