Day to Day Advocacy by Pediatric Health Care Providers.

This manuscript highlights the impressive advocacy work that members of the American Academy of Pediatrics have achieved and serves to inspire pediatric health care providers of all specialties to pursue such efforts beyond the acute physical need of the child. This article represents one of the Symposia presented at the 2023 American Academy of Pediatrics Section on Surgery.

A citywide experiment testing the impact of geographically targeted, high-pay-off vaccine lotteries.

Lotteries have been shown to motivate behaviour change in many settings, but their value as a policy tool is relatively untested. We implemented a pre-registered, citywide experiment to test the effects of three high-pay-off, geographically targeted lotteries designed to motivate adult Philadelphians to get their COVID-19 vaccine. In each drawing, the residents of a randomly selected 'treatment' zip code received half the lottery prizes, boosting their chances of winning to 50×-100× those of other Philadelphians. The first treated zip code, which drew considerable media attention, may have experienced a small bump in vaccinations compared with the control zip codes: average weekly vaccinations rose by an estimated 61 per 100,000 people per week (+11%). After pooling the results from all three zip codes treated during our six-week experiment, however, we do not detect evidence of any overall benefits. Furthermore, our 95% confidence interval provides a 9% upper bound on the net benefits of treatment in our study.

Laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents.

BACKGROUND/PURPOSE: Obesity has contributed significantly to morbidity and premature deaths in the adolescent population. Because many patients do not respond to dietary modification, exercise regimens, or pharmacologic treatment, weight reduction surgery has become a viable alternative, although the morbidity of conventional gastric bypass has tempered enthusiasm for this approach. Experience with the laparoscopic approach has not been reported previously. The authors examined the outcome of adolescents undergoing laparoscopic Roux-En-Y gastric bypass (lap RYGB). METHODS: Medical records of patients less than 20 years of age (n = 4; 3 girls, 1 boy) who had undergone lap RYGB for morbid obesity were reviewed. All patients met National Institute of Health criteria for bariatric surgery. Outcome variables examined included weight; body mass index (BMI); hospital length of stay (LOS); comorbid conditions; and tolerance of a regular diet. Mean time to follow-up was 17 months. RESULTS: All procedures were completed laparoscopically. There were no complications. The average LOS was 2 days. Patients with greater than 20-month follow-up lost an average of 87% of their excess body weight and had nearly complete resolution of comorbidities (including hypertriglyceridemia, hypercholesterolemia, asthma, and gastroesophageal reflux disease). CONCLUSION: Laparoscopic gastric bypass is a safe alternative in morbidly obese adolescents who have not responded to medical therapy.

Surgical management of open versus laparoscopic adrenalectomy: outcome analysis.

PURPOSE: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. METHODS: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient's age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. RESULTS: Mean age for an open procedure was 8.9 +/- 0.9 years and 14 +/- 1.1 for laparoscopic (P =.019). Surgical length of stay for open was 5.4 +/-.38 days and 2.7 +/-.62 days for laparoscopic (P =.006). Patient operative charges were $12,941 +/- 676 for laparoscopic and $4,714 +/- 411 for open (P <.001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. CONCLUSIONS: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications.

Long-term follow-up of patients with necrotizing enterocolitis.

BACKGROUND/PURPOSE: Despite the rise in the incidence of necrotizing enterocolitis (NEC), there is a paucity of data regarding long-term patient outcome. The authors examined functional outcome of infants with NEC (n = 103) treated at our institution between 1991 and 1995. METHODS: The authors reviewed the medical records of infants who were treated both operatively and nonoperatively, n = 103. Variables examined included gestational age, birth weight, Bell stage (I through III), operations performed, and mortality rate. Telephone interviews assessed school enrollment, developmental delay, bowel function, and nutritional status. RESULTS: Children treated operatively had a lower gestational age than those in the nonoperative group. Likewise, birth weight in the operative group was significantly lower. Sixty-three percent of patients had stage III, and the remainder had stage II disease. The telephone response rate was 61%. Mean age at follow-up was 7.5 +/- 2.5 years. All children ate by mouth. Nearly all children were toilet trained. All children were less than the 50th percentile for height and weight, and the majority (83%) were enrolled in school full time. CONCLUSION: Infants with stage II and III NEC who are treated operatively or nonoperatively have a favorable long-term outcome.

The surgical management of short bowel syndrome.

Short bowel syndrome is a clinical entity that results from a diverse group of congenital and acquired conditions in the pediatric population. The pathophysiology of this syndrome is characterized by malabsorption, malnutrition, and metabolic disturbances. The vast majority of children with this condition undergo spontaneous adaptation of the intestinal remnant and achieve enteral nutritional autonomy. However, a small portion of pediatric patients develop intestinal failure and require long-term or permanent dependence on total parenteral nutrition. These children may benefit from surgical interventions that facilitate intestinal adaptation. Such adjunctive procedures facilitate nutrient absorption by improving motility, prolonging intestinal transit, and/or increasing mucosal contact time. In selected patients, this may allow them to be weaned from parenteral nutritional support or to have it discontinued. The purpose of this review is to discuss the various surgical techniques for the management of short bowel syndrome in children, along with their indications, complications, and outcomes.