BACKGROUND:The incidence and patterns of cervical spine injury (CSI) have not been well described in children who present after suspected child physical abuse (CPA). The purpose of this study was to describe the pattern of CSI in patients evaluated for suspected CPA in a large, prospectively collected dataset. METHODS:This is a secondary analysis of a prospectively collected, multicenter, pediatric CSI dataset which included 72 trauma centers across the United States. All children with suspected CPA were included, with concerns for CPA determined by each participating center. All children had cervical spine imaging within 24 hours of injury. RESULTS:Among 19,995 pediatric blunt trauma patients, 1,251 children with suspected CPA were identified. Median age was 6 months (IQR 2-12), 42% female, 19% presented with a GCS less than 14, and 11% required intubation. Concomitant traumatic brain injury (TBI) was present in 61% of patients. Overall, 75 children (6%) were diagnosed with CSI. Ligamentous injury was most common (68%), followed by spinal cord injury (19%). No patient underwent operative cervical spine stabilization. Unstable ligamentous injury occurred in seven patients. Four were identified on CT, three were detected on MRI. One patient had a normal initial XR prior to MRI diagnosis with a presenting GCS of 10. On multivariable regression, GCS 3-13 (OR 3.29, 95% CI 1.61-6.47), and intubation (OR 3.07, 95% CI 1.57-6.27) were associated with CSI. CONCLUSION:In this large prospective multicenter cohort, CSI occurred in 6% of children evaluated for suspected CPA and consisted primarily of ligamentous injuries. Low GCS and intubation were strongly associated with CSI. Unstable injuries were rare, CT identified all injuries in which it was performed, and no missed unstable injuries were observed in neurologically intact children with normal screening radiographs. These findings suggest that CT may be a useful adjunct for CSI evaluation in obtunded patients with suspected CPA (GCS < 14) and support a low threshold for advanced imaging in this population. In children with suspected physical abuse who undergo CT imaging, our findings support that a normal CT may be sufficient to allow removal of cervical immobilization regardless of mental status.
INTRODUCTION:The optimal timing of inguinal hernia repair (IHR) in premature infants remains unclear. Our study aims to compare recurrence rates between IHRs performed before and at/after 55 weeks postmenstrual age (PMA). METHODS:A multicenter retrospective cohort study was conducted of premature infants who underwent IHR at ≤1 year of age between 1/2017-12/2019. The primary outcome was inguinal hernia recurrence, defined as recurrence requiring surgical re-repair. Demographic, clinical, perioperative and postoperative variables were analyzed. Multivariable logistic regression was performed to identify factors associated with recurrence. RESULTS:A total of 2,412 premature infants underwent 3,808 IHRs: 3,292 (86.4%) hernias were repaired early (before 55 weeks PMA), and 516 (13.6%) were repaired late (after 55 weeks PMA). Incarceration rates were similar between the groups (9.4% vs. 8.2%, p=0.422), as were the proportion of repairs performed laparoscopically (30.0% vs. 31.2%, p=0.594). Patients undergoing early repair were more frequently admitted postoperatively (81.2% vs. 27.2%, p<0.001). There were no significant differences in hernia recurrence (1.2% vs. 0.8%, p=0.358) or time to recurrence (3 months [IQR 2.0, 9.0] vs. 9 months [IQR 4.3, 11.5], p=0.218) between early and late repair groups. On multivariable regression, laparoscopic repair (OR 1.910 [95% CI 1.018, 3.581], p=0.044) and concurrent procedure (OR 2.046 [95% CI 1.034, 4.047], p=0.040) were independently associated with a higher risk of recurrence, while late repair was not (OR 0.749 [95% CI 0.259, 2.165], p=0.593). CONCLUSION:Time of repair was not an independent predictor of hernia recurrence. Therefore, recurrence risk alone should not drive the decision for early repair; rather timing should be individualized based on patient physiology, anesthetic considerations, and reliability of follow-up.
BACKGROUND:Guidelines endorse metabolic and bariatric surgery (MBS) for eligible adolescents with severe obesity. We described trends in MBS among eligible adolescents and characterized demographic and clinical features, postoperative healthcare utilization, and complications. METHODS:Using Epic Cosmos, we conducted a retrospective, population-based study of US adolescents aged 12-19 years from 2016 through 2025. The primary outcome, annual MBS utilization among eligible adolescents, was modeled by negative binomial regression. Secondary outcomes (patient characteristics, healthcare utilization, complications) were assessed with t-tests, chi-square, weighted least-squares, and logistic regression. RESULTS:Overall, 5,430 adolescents underwent MBS, with utilization rising 7.7-fold from 31 to 239 per 100,000 eligible (p<0.001); at peak, only 0.24% of those eligible underwent MBS. Sleeve gastrectomy (SG) predominated (89.1%). Utilization was steeply graded by obesity severity: by 2025, adolescents with a BMI ≥50 kg/m2 underwent SG roughly nine times as often as those at the lowest eligible BMI class (605 vs 69 per 100,000). Mean length of stay declined from 2.0 to 1.6 days (p<0.001). Serious early complications were uncommon: within 30 days, surgical and infectious complications each affected ≤0.6% of patients, and cardiovascular and thromboembolic events ≤0.3%. The most common diagnoses were gastrointestinal and biliary: nausea and vomiting (12.5%) by one year and cholecystectomy (7.5%) by three years. Reoperation, conversion to gastric bypass, and death were rare (each <0.4%). CONCLUSIONS:Despite increasing use, only a small fraction of eligible adolescents undergo MBS. Given low complication rates, these data highlight a need to expand more equitable access and implementation within clinical workflows.
BACKGROUND:Surgical reconstruction has traditionally been considered the standard of care for imperforate anus with recto-perineal fistula. However, increasing recognition of the role of functional anatomy raises the possibility that selected patients may be managed without surgery. METHODS:We conducted a single-center retrospective cohort study of children with imperforate anus and perineal fistula managed either non-operatively or surgically. Patients were selected for non-operative management based on clinical assessment of fistula caliber, perineal body, and sphincter muscle coverage. Long-term bowel function was evaluated using a standardized ARM-Net-based questionnaire derived from the Rintala score. Clinical outcomes and need for delayed surgical intervention were recorded. RESULTS:A total of 97 patients with recto-perineal fistula were included, of whom 62 (63.9%) were managed non-operatively. At a mean follow-up age of 7.0 ± 3.0 years, most non-operatively managed patients achieved normal bowel function (73.3%), with low rates of constipation and minimal need for bowel management. No patients required delayed surgical reconstruction. Compared to a contemporaneous surgical cohort (n = 35), non-operatively managed patients demonstrated superior functional outcomes; however, these findings reflected baseline differences in anatomical characteristics, including greater sphincter muscle coverage. On univariable analysis, favorable anatomical features and non-operative management were associated with normal bowel function. CONCLUSIONS:In carefully selected patients with imperforate anus and recto-perineal fistula, non-operative management is associated with excellent long-term bowel function and may obviate the need for surgical reconstruction. These findings support a more individualized, anatomy-based approach to management.
Aim To identify and describe health literacy (HL) profiles and possible associations with sociodemographic and clinical characteristics among parents of children with congenital colorectal conditions. Methods Parents (n=269) of children with Hirschsprung disease (HD) or anorectal malformation (ARM) completed the Health Literacy Questionnaire-parent version (HLQ-p) and the General Self-Efficacy Scale. Demographic and clinical data were collected. Ward’s hierarchical clustering was used to identify clusters across the nine HLQ-p domains. Ethical approval was obtained. Results Four parental HL profiles were identified. Cluster 1 (n=75, 28%) showed consistently low HL across all domains, with particular difficulties in information appraisal and social support. This cluster had the lowest self-efficacy, lower educational attainment, nearly half were non-native speakers, and half were not living with the child’s other parent. Cluster 2 (n=57, 21%) demonstrated moderate HL, but distinct challenges in information appraisal. Many had high education, cohabitated, and were native-speaking households. This group had the highest prevalence of child comorbidity. Cluster 3 (n=109, 41%) exhibited generally high HL and strong engagement with healthcare providers, but struggled with information appraisal. Self-efficacy was high, and most parents lived with the child’s other parent. Cluster 4 (n=28, 10%) had the highest HL and self-efficacy, a high proportion of parents with high education and universal cohabitation. Conclusion Nearly half of the parents exhibit low HL, including many with traditionally advantageous sociodemographic characteristics. Language diversity and child comorbidity amplified HL challenges, and difficulties in evaluating and applying health information were common across all parent groups.
BACKGROUND:Congenital lung malformations (CLMs) are often diagnosed prenatally, with high-risk cases potentially benefiting from perinatal intervention. We report outcomes following perinatal intervention for CLMs across a national multicenter cohort. METHODS:Retrospective analysis of prenatally diagnosed CLMs (2016-2024) from a 17-center consortium was performed. Prenatal characteristics, procedural details, and outcomes were analyzed for patients undergoing ex utero intrapartum treatment (EXIT), cesarean section-to-immediate resection (STR), or emergent resection within 24 hours of birth (ER). RESULTS:Of 1756 CLM patients, 25 (1.4%) underwent perinatal intervention: 15 EXIT (0.9%), 4 STR (0.2%), and 6 ER (0.3%). Among EXIT cases, 11 (73%) underwent EXIT-to-resection and 4 (27%) EXIT-to-airway. Most lesions were large, with a median congenital pulmonary airway malformation volume ratio (CVR) at delivery of 2.3 (IQR 1.57-2.70). Mediastinal shift was universal (100%), while hydrops was present in 33%. Congenital pulmonary airway malformation (CPAM) was the most common pathology-based diagnosis among EXIT patients (87%). Procedural survival was 15/15 (100%) for EXIT, 4/4 (100%) for STR, and 5/6 (83%) for ER. Thirty-day survival was 13/15 (87%) for EXIT, 4/4 for STR, and 3/6 for ER. ECMO was used in 2/15 EXIT, 1/4 STR, and 1/6 ER neonates. Median NICU length of stay for survivors was 30 days (EXIT), 24 days (STR), and 25 days (ER). CONCLUSION:Perinatal intervention for CLM remains rare. These findings provide contemporary multicenter data on EXIT, STR, and ER and may help inform prenatal counseling and delivery planning. Further study is warranted to refine patient selection for perinatal intervention and delivery modification.
BACKGROUND:Acute appendicitis in leukopenic pediatric cancer patients is a clinical challenge. While the perceived risks of surgery in this population may delay immediate appendectomy, we sought to identify the consequences of delaying surgery based on the severity of leukopenia at diagnosis. We hypothesized that leukopenic cancer patients are more likely to experience delayed appendectomy and that delay would be associated with worsened outcomes. METHODS:Using ACS NSQIP-P data from 2016-2023, we identified pediatric oncology patients who underwent appendectomy for acute appendicitis. Leukopenic patients (< 4,000 WBC/μL) were stratified by preoperative WBC count as: < 1,000, 1,000-<2,500, and 2,500-<4,000 WBC/μL. Delayed appendectomy was defined as surgery 24 hours or more from admission. The primary outcome was the prevalence of complicated appendicitis. Bivariate comparisons were made using chi-square and nonparametric tests, with p<0.05 considered significant. RESULTS:Of 310 pediatric cancer patients, 84 (27.1%) experienced delayed appendectomy. Median time to operation was significantly longer for leukopenic patients (22.7 hours vs. 11.8 hours, p<0.001). Patients with leukopenia with delayed appendectomy were more likely to have complicated appendicitis (29.2% vs. 2.0%, p<0.001); this association was not observed in non-leukopenic patients. Within each stratum of leukopenic patients, delayed appendectomy was associated with significantly longer length of stay. CONCLUSION:Leukopenic pediatric oncology patients experienced longer delays to appendectomy for acute appendicitis than non-leukopenic patients. Among leukopenic patients, delaying appendectomy by over 24 hours was associated with an increased proportion of complicated appendicitis and prolonged hospitalization, supporting early operative management regardless of leukopenia severity.
PURPOSE:Survivorship, optimization of physical, mental, and emotional health, and quality of life after injury, is critical. We developed the first ever Pediatric Trauma Quality of Life (pTQOL) Clinic, focused on pediatric firearm injury. Our goal was to review the first-year experience of this clinic. METHODS:Patient demographic and injury characteristics were captured for the first year of the clinic from the institutional trauma registry. Additional data were obtained from chart review about index hospitalizations and clinic visits. Reflections on pTQOL experiences were elicited from team members, patients, and families. RESULTS:A total of 126 pTQOL encounters were scheduled for 86 patients. Among those, 57 were completed by 49 patients. The median age at injury was 16.39 years, ranging from 3.07 to 17.98 years. Most patients were male firearm injured youth. Services seen during clinic visits included General Surgery, Psychology, Physical Therapy, Social Work, Hospital-Based Violence Intervention Programs, and Orthopedic Surgery. pTQOL visits led to 56 new referrals for 29 patients in a variety of specialties with bullet excisions scheduled for 4 patients. pTQOL team members, patients, and families reported high levels of satisfaction with the clinic. CONCLUSION:The first ever pTQOL Clinic was successful in its first year. pTQOL provided an opportunity for patients to engage with multiple services in one appointment, including Social Work and Psychology, which are often limited in the post discharge setting, and led to numerous new referrals. Additional process improvements are underway in response to variable appointment completion rates and identified challenges.
PURPOSE:This study characterizes the geographic distribution of pediatric surgical practices in the U.S. relative to the pediatric population (ages 0-17 years). Prior analyses estimated that over 10 million children (14.8%) live more than 60 miles from a pediatric surgeon, overlooking outreach clinics that extend access and reduce travel distances. Our goal was to generate a more accurate assessment of travel burden using data that includes all practice locations. METHODS:The APSA membership directory was used to identify pediatric surgery practices. Practices were contacted for information on faculty and the number and location of hospitals and clinics as of July 31, 2025. Practice locations were compared to population demographics from the US 2020 Census data calculating straight-line driving distances both across and within state lines. RESULTS:A total of 248 unique primary hospital and clinic sites were identified. An additional 684 hospital locations and 512 clinic locations were also identified. The average travel distance to the practice's primary location (hospital or clinic) for children traveling across state lines (ASL) was 55.0 miles, and within states travel (WSL) was 63.4 miles, with 13.2% of children living >60 miles from care (n = 9,662,011). Including all 932 hospitals served by these practices, average distances decreased slightly to 50.3 miles ASL and 58.2 miles WSL, with 11.1% >60 miles (n = 8,125,546). For the 248 primary clinics; distances to care were similar to those from the primary hospitals. Considering all clinics (n = 760), distances decreased to 41.5 miles ASL and 48.1 miles WSL, with only 6.7% of children >60 miles away (n = 4,928,417). CONCLUSIONS:Pediatric surgical care is unevenly distributed in the United States. Both outreach hospitals and clinics can positively impact travel distances for patients. This impact is even greater when children are allowed to cross state lines for pediatric surgical care. These findings support workforce planning and resource allocation to ensure pediatric surgeons are available where children need them most.
BACKGROUND:Tracheobronchial remnant (TBR)-type congenital esophageal stenosis (CES) is a rare infantile anomaly characterized by ectopic tracheobronchial cartilage within the esophageal wall. Magnetic compression devices are effective for soft-tissue approximation, but their ability to transect cartilage remains unproven. This study assessed magnetic compression-mediated transection of rabbit xiphoid cartilage. METHODS:Eighteen rabbits were divided into control, sham-operated, and experimental groups (n = 6 each). Experimental rabbits received magnetic compression devices to compress the xiphoid cartilage; sham-operated rabbits underwent surgery without device placement. Radiography monitored angular changes and time to transection. After transection in the experimental group, cartilage specimens were collected from both experimental and sham groups for histopathology, transmission electron microscopy (TEM), immunohistochemistry, qPCR, and ELISA (measuring serum IL-1β, TNF-α, and BMP-2). RESULTS:All experimental rabbits achieved cartilage transection (mean, 11.83 ± 0.41 days). No significant inflammation or fibrosis was observed. TEM revealed severe chondrocyte damage and disorganized collagen fibers in the experimental group, whereas the sham group showed near-normal ultrastructure. MMP-1 protein and mRNA were significantly elevated in the experimental group versus the sham group (P < 0.05), whereas TIMP-1 showed no differences. TNF-α was higher in the experimental group on day 11 (vs. control, P < 0.001; vs. sham, P < 0.01) and remained elevated versus controls at 2 weeks (P < 0.01). IL-1β showed no intergroup differences. BMP-2 was significantly higher in the experimental group than in both the control and sham groups at 4 and 8 weeks (P < 0.001 and P < 0.01, respectively), but showed no difference versus the sham group at other timepoints. CONCLUSION:Sustained magnetic compression effectively transects rabbit xiphoid cartilage, providing key proof-of-concept evidence for cartilage transectability and establishing a foundational biomechanical rationale for future in vivo animal models mimicking TBR-type CES. CLINICAL TRIAL NUMBER:not applicable.
BACKGROUND:The necessity of routine peritoneal dissection during pediatric laparoscopic inguinal hernia repair remains uncertain. This study evaluated whether omitting peritoneal dissection affects recurrence, postoperative complications, or operative time after laparoscopic intracorporeal inguinal hernia repair in children. METHODS:In this multicenter retrospective cohort study, children younger than 8 years who underwent elective laparoscopic inguinal hernia repair at six tertiary centers in South Korea (January 2023-December 2024) were grouped according to whether peritoneal dissection was performed. Distal sac removal was analyzed as a subgroup procedure within the dissection group. All patients had 1-year follow-up, and propensity score matching was used to reduce baseline imbalance. RESULTS:Of 628 patients, 238 underwent repair without dissection and 390 with dissection. Operative time, recurrence, and overall complications did not differ significantly between groups (33 vs 32 minutes; 0.8% vs 0.5%; 2.1% vs 5.4%; all p>0.05), with similar results after matching. Distal sac removal was associated with longer operative time (75 vs 30 minutes, p<0.001) but not with higher complication or recurrence rates. CONCLUSION:Laparoscopic intracorporeal inguinal hernia repair without routine peritoneal dissection was not associated with worse outcomes. Distal sac removal prolonged operative time and should be reserved for selected cases. Prospective studies incorporating standardized anatomical measurements are warranted.
PURPOSE:This study evaluates a 27-year single-center experience with continent catheterisable channels (CCC) to identify factors influencing long-term outcomes. METHODS:Retrospective review (1998-2025) conducted on patients undergoing CCC placement. Data points analyzed included primary diagnosis, surgical indication, conduit type, stoma location, and postoperative complications. RESULTS:The study included 175 children (99 males) with a total of 178 CCC procedures performed. Primary diagnoses included neuropathic bladder (53%), exstrophy-epispadias complex (21%), complex uropathy (12%), cloacal malformations (7%), and posterior urethral valves (7%). Median age at surgery was 11.3 years (IQR 7.8-14.7). Indications for CCC were concomitant bladder-outlet or reconstructive surgery (46%), difficult urethral catheterization (27%), desire for improved autonomy (21%), and redo surgery (3%). Conduits utilised were appendix (78%), ileum-Casale (9.6%), ileum-Monti (8.4%), and other - sigmoid, vesical flap, ureter (4%). Stoma sites included the right iliac fossa (51%), umbilicus (42%), and other locations (7%). At a median follow-up of 9 years (IQR 4-12), 97% of children maintained channel utility. Complications occurred in 28% of children (n=48), totalling 70 events: superficial stenosis (9%), suprafascial obstruction (10.7%), subfascial obstruction (7.3%), stomal incontinence (6.2%), and complete channel loss (6.2%). The use of the appendix was associated with lower complication rates (p=0.03). Stoma location did not significantly impact complication rates. CONCLUSIONS:Continent catheterisable channels provides durable long-term benefits with high patient utilisation rates. Use of the appendix as a conduit is associated with superior outcomes and fewer complications. Stoma location does not significantly impact complication rates; therefore, site selection should be individualized.
INTRODUCTION:Classic bladder exstrophy (BE) is a rare and complex congenital anomaly requiring highly specialized multidisciplinary care. Although corrective surgery represents the central component of treatment, the national care structure for patients with BE in Germany has yet not been comprehensively evaluated. METHODS:Nationwide hospital discharge data (Diagnosis-Related Group statistics) from 2016 to 2024 were analyzed to identify patients with BE at (1) birth hospitalization and (2) hospitalization for corrective surgery. Patient characteristics, associated anomalies, treatment patterns, hospital caseload, and perioperative outcomes were assessed. RESULTS:Between 2016 and 2024, 177 newborns with BE were treated across 120 hospitals at the time of birth. At least one additional congenital anomaly was documented in 34.5% of patients, and 4.0% had a birthweight below 1500 g. During the same period, 221 corrective procedures were performed in 34 hospitals, with a median annual caseload of one case per institution. Hospitals were stratified into caseload terciles with median annual volumes of 1, 3, and 8 procedures in the low-, medium-, and high-volume groups, respectively. Delayed primary closure beyond 28 days of life was performed more frequently in high-volume centers compared with medium- and low-volume hospitals (85.1% vs. 40.7% vs. 39.3%). Institutional caseloads were insufficient to support a statistically robust volume-outcome analysis regarding early postoperative complications. CONCLUSIONS:Care for patients with BE in Germany is highly decentralized. Differences in treatment strategies between higher- and lower-volume centers suggest potential variability in care delivery. Centralization of corrective BE surgery may support greater standardization of treatment.
Background Segmental dilatation of the intestine (SDI) is a rare congenital disorder with unclear pathogenesis. The role of interstitial cells of Cajal (ICC) in preterm infants remains insufficiently defined. We aimed to characterise the histopathological phenotype of SDI, determine its birth prevalence, and explore associations between clinical and histological features and postoperative complications. Methods This retrospective single-centre study included preterm infants with clinically suspected SDI who underwent surgery. Resected SDI segments were compared with macroscopically normal resection margins. Histopathological assessment focused on ICC, enteric ganglion cells, and muscular layer alterations. Birth prevalence was calculated for very low birth weight infants below 1500 g. Postoperative complications were defined as mechanical ileus, necrotising enterocolitis, intestinal perforation, or death after resection. Results Thirty-five infants with SDI were included. Enteric ganglion cells were preserved in all specimens. ICC were absent or markedly reduced in all SDI segments and preserved in all margins. Muscle layer atrophy was present in the majority of SDI segments. The centre-specific birth prevalence was 17.2 per 1,000 very low birth weight infants. Pneumoperitoneum on X-ray, lower birth weight, and submucosal inflammation contributed most in exploratory modelling. Conclusions SDI in preterm infants shows a consistent segment-restricted neuromuscular pattern with depletion of ICC, preserved enteric ganglion cells, and muscular layer atrophy. These findings are compatible with a segment-restricted developmental disturbance of the intestinal wall, but the causal role of ICC depletion remains uncertain and requires further investigation in relation to antenatal factors, including placental insufficiency.
PURPOSE:Patients with short bowel syndrome (SBS) and intestinal failure (IF) are highly susceptible to micronutrient deficiencies and recurrent infections. Vitamin D plays an important role in immune modulation and has been linked to infection outcomes in other high-risk populations, yet its relevance in SBS/IF remains unclear. This study evaluated the effectiveness of vitamin D supplementation and the association between serum 25-hydroxyvitamin D [25(OH)D] levels and infection risk in SBS/IF patients. METHOD:In this single-center retrospective cohort study, 23 SBS/IF patients (8 pediatric, 34.8%) followed between November 2022 and November 2025 were included. Baseline 25(OH)D levels showed universal insufficiency, with 78.3% classified as deficient (<20 ng/mL). Changes in 25(OH)D levels at 6-12 months were compared between patients with and without supplementation using ANCOVA. The association between serial 25(OH)D levels and recurrent infection events was analyzed using a time-dependent Cox model with person-mean centering. RESULTS:Vitamin D supplementation resulted in significantly greater increases in serum 25(OH)D compared with non-supplementation (mean change +15.61 vs. -0.40 ng/mL; ANCOVA F = 18.33, p = 0.001). During follow-up, 26 infection events occurred. Higher within-individual 25(OH)D levels were associated with a reduced hazard of infection (HR 0.92 per 1 ng/mL increase; 95% CI 0.869-0.976; p = 0.005). CONCLUSION:Vitamin D supplementation effectively improves vitamin D levels in SBS/IF patients. Higher 25(OH)D levels were associated with lower infection hazard, suggesting vitamin D status may represent a modifiable factor related to infection risk in this population.
