PURPOSE:Esophageal leaks in children are associated with significant morbidity. While they are traditionally managed with prolonged fasting and drains, endoluminal vacuum-assisted closure (EVAC) is a minimally invasive alternative. We evaluated outcomes and factors associated with EVAC success. METHODS:Retrospective single-center review of pediatric patients treated with EVAC for esophageal leaks (2019-2025). Leak episodes were analyzed independently. Data included leak characteristics, timing of EVAC initiation, procedural details, and outcomes. The primary outcome was leak resolution without surgery. RESULTS:Thirty-eight children with 40 leak events were included. Median age was 1.5 years (IQR 0.6-2.5). Etiologies included postsurgical (53%), endoscopic (45%), and perforation due to foreign body ingestion (2.5%); 78% were contained leaks. EVAC achieved leak resolution without surgery in 83% of cases (94% endoscopic vs 71% surgical). Median time to closure was 11 days (IQR 6-16). Median number of EVAC exchanges was 2 (IQR 1-3). During EVAC therapy, most patients maintained enteral post-pyloric feeding (65%), and drains were only required in 26%. No EVAC-related adverse events occurred. Strictures requiring surgery developed in 31%. CONCLUSION:EVAC is an effective treatment strategy for pediatric esophageal leaks, with high rates of leak resolution without surgery. Many patients were managed without pleural drainage while maintaining enteral nutrition, supporting EVAC as an active treatment option for selected pediatric esophageal leaks.

INTRODUCTION:Current surgical trainees experience less autonomy in their training than prior generations. Intentionally integrating graduated autonomy into the educational development of fellows would enhance trainee competence while providing the safety net of fellowship programming. The objective of this study was to pilot a competency-based training (CBT) approach for pediatric surgery fellowship programs. METHODS:A CBT approach was developed at a single pediatric surgery fellowship program. Three goals were identified for the development of the CBT structure: 1) demonstrate flexibility for trainees to gain knowledge and skills at individualized paces, 2) readily identify and address knowledge gaps, and 3) facilitate increased autonomy for fellows while in training, in areas where competence has been successfully assessed. The CBT program consisted of five components: operative evaluations, a communication assessment tool (CAT), entrustable professional activities (EPAs), oral exams, and video reviews. Once a fellow completed the minimum requirements of each component, they proceeded to the final review at the clinical competency committee (CCC) meeting. For this pilot, we tracked the changes that were made to the program over the first few years as well as progression of the first six fellows and their participation in the various components. RESULTS:Between 2017 and 2023, six pediatric surgery fellows were evaluated by fourteen pediatric surgery faculty. Three fellows progressed through the pilot program with three procedures (Laparoscopic Appendectomy, Laparoscopic Inguinal Hernia Repair, and Laparoscopic Pyloromyotomy), while the other three fellows progressed through the program with these three initial and two additional procedures (Laparoscopic Gastrostomy Tube Placement and Open Malrotation Repair). The median number of each component completed was: 5 CATs, 101 operative evaluations, 4 oral exams, and 3 video reviews. Fellows achieved competency for 1-4 procedures. From semi-structured interviews, fellows appeared overall satisfied with their experience of the CBT program, stating that these additional sets of tasks and requirements were a helpful thought exercise, provided an extra layer of structure to the curriculum, created a culture of independence and autonomy, and gave added purpose to the first year of training. The principal strength of the program was the structured format leading to graduated autonomy. All fellows reported feeling very prepared to move into a faculty role following graduation from fellowship training. CONCLUSION:Competency-based training may allow for identification of specific gaps in knowledge, skills or abilities and support progressive autonomy among trainees prior to fellowship graduation. Generating further validity evidence and engaging in implementation research are necessary for quality improvement and dissemination of the program.

Objectives: The purpose of this study was to assess the financial literacy level of medical students, evaluate their perceptions about the importance of financial literacy, and determine the optimal timing and delivery for financial literacy education. Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to a convenience sample of first-year (M1) to fourth-year (M4) medical students at the University of Michigan Medical School, with 216 of 680 (32%) students completing the survey. Respondents voluntarily answered 15 multiple choice questions on personal finance and 30 questions on their demographics, current financial situation, and opinions on financial literacy education. Individual financial proficiency was defined as answering 60% of the personal finance questions correctly. Results: Overall, respondents correctly answered 5.64 (38%) of the personal finance questions, with 41 (19%) students achieving financial proficiency. Lower performance on the financial literacy assessment was significantly associated with gender, age, and debt. Overall, 192 (89%) medical students believed that they should receive financial literacy training in medical school. Conclusions: Medical students demonstrate low levels of financial literacy and have a strong desire to improve their financial literacy during their medical education. Medical schools are well positioned to harness this interest for financial literacy education and integrate self-directed learning opportunities.

Background: Children with end-stage lung disease are commonly managed with extracorporeal life support (ECLS) as a bridge to lung transplantation. A pumpless artificial lung (MLung) is a portable alternative to ECLS and it allows for ambulation. Both ECLS and pumpless artificial lungs require systemic anticoagulation which is associated with hemorrhagic complications. We tested the MLung with a novel Nitric Oxide (NO) Surface Anticoagulation (NOSA) system, to provide local anticoagulation for 72 h of support in a pediatric-size ovine model. Methods: Four mini sheep underwent thoracotomy and cannulation of the pulmonary artery (inflow) and left atrium (outflow), recovered and were monitored for 72hr. The circuit tubing and connectors were coated with the combination of an NO donor (diazeniumdiolated dibutylhexanediamine; DBHDN2O2) and argatroban. The animals were connected to the MLung and 100 ppm of NO was added to the sweep gas. Systemic hemodynamics, blood chemistry, blood gases, and methemoglobin were collected. Results: Mean device flow was 836 +/- 121 mL/min. Device outlet saturation was 97 +/- 4%. Pressure drop across the lung was 3.5 +/- 1.5 mmHg and resistance was 4.3 +/- 1.7 mmHg/L/min. Activated clotting time averaged 170 +/- 45s. Methemoglobin was 2.9 +/- 0.8%. Platelets declined from 590 +/- 101 at baseline to 160 +/- 90 at 72 h. NO flux (x10-10 mol/min/cm2) of the NOSA circuit averaged 2.8 +/- 0.6 (before study) and 1.9 +/- 0.1 (72 h) and across the MLung 18 +/- 3 NO flux was delivered. Conclusion: The MLung is a more portable form of ECLS that demonstrates effective gas exchange for 72 h without hemodynamic changes. Additionally, the NOSA system successfully maintained local anticoagulation without evidence of systemic effects. (c) 2023 Elsevier Inc. All rights reserved.

Introduction A radical paradigm shift in the treatment of premature infants failing conventional treatment is to recreate fetal physiology using an extracorporeal Artificial Placenta (AP). The aim of this study is to evaluate the effects of changing fetal hemoglobin percent (HbF%) on physiology and circuit function during AP support in an ovine model. Methods Extremely premature lambs ( n = 5) were delivered by cesarean section at 117-121 d estimated gestational age (EGA) (term = 145d), weighing 2.5 ± 0.35 kg. Lambs were cannulated using 10-14Fr cannulae for drainage via the right jugular vein and reinfusion via the umbilical vein. Lambs were intubated and lungs were filled with perfluorodecalin to a meniscus with a pressure of 5–8 cm H2O. The first option for transfusion was fetal whole blood from twins followed by maternal red blood cells. Arterial blood gases were used to titrate AP support to maintain fetal blood gas values. Results The mean survival time on circuit was 119.6 ± 39.5 h. Hemodynamic parameters and lactate were stable throughout. As more adult blood transfusions were given to maintain hemoglobin at 10 mg/dL, the HbF% declined, reaching 40% by post operative day 7. The HbF% was inversely proportional to flow rates as higher flows were required to maintain adequate oxygen saturation and perfusion. Conclusions Transfusion of adult blood led to decreased fetal hemoglobin concentration during AP support. The HbF% was inversely proportional to flow rates. Future directions include strategies to decrease the priming volume and establishing a fetal blood bank to have blood rich in HbF.

Recent medical advances, such as permissive hypercapnia, inhaled nitric oxide, and the use of oscillatory ventilation, have spared numerous patients from extracorporeal membrane oxygenation (ECMO), yet many children still benefit from this modality. Patients with reversible cardiopulmonary disease who meet criteria should be considered ECMO candidates. As of January 2020, 32,385 neonates (87% survival) and 10,346 paediatric patients (72% survival) have been treated with ECMO for respiratory failure and 8830 neonatal (69% survival) and 12,538 paediatric (72% survival) patients for cardiac failure. ECMO provides an excellent opportunity to provide “rest” to the cardiopulmonary systems, thus avoiding the additional lung or cardiac injury which would otherwise be associated with maintaining life support. This review outlines the indications, contraindications, management approach and complications associated with ECMO, as well as the various bypass configurations and cannulation strategies that may be employed.

Background: Enterostomies provide fecal diversion for numerous conditions, but anatomical complications-prolapse, stricture, and retraction-occur in up to 25%. Given up to 76% of these complications require surgical intervention, effective minimally invasive repair techniques for their management are needed. This article describes a new technique for prolapse repair utilizing image-guided surgery for incisionless repair of ostomy prolapse.Methods: To perform the procedure, the prolapsed bowel is reduced and evaluated for feasibility for ultrasound repair. Under direct ultrasound guidance sutures are used to pexy the bowel loop to the overlying fascia. Sutures are tied with knots and sutures buried below the skin to securely tack the bowel to the abdominal wall.Results: Four patients aged 2-10 years underwent ultrasound-guided enteropexy for repair of major prolapse of an end ileostomy (2 patients), loop colostomy, and end colostomy. All patients remained free of major prolapse for 3-10 months after the procedure, 2 of whom have progressed to ostomy takedown without complications.Conclusions: Ultrasound-guided enteropexy is a noninvasive effective way to manage ostomy prolapse.

Clinical translation of the extracorporeal artificial placenta (AP) is impeded by the high risk for intracranial hemorrhage in extremely premature newborns. The Nitric Oxide Surface Anticoagulation (NOSA) system is a novel non-thrombogenic extracorporeal circuit. This study aims to test the NOSA system in the AP without systemic anticoagulation. Ten extremely premature lambs were delivered and connected to the AP. For the NOSA group, the circuit was coated with DBHD-N2O2/argatroban, 100 ppm nitric oxide was blended into the sweep gas, and no systemic anticoagulation was given. For the Heparin control group, a non-coated circuit was used and systemic anticoagulation was administered. Animals survived 6.8 ± 0.6 days with normal hemodynamics and gas exchange. Neither group had any hemorrhagic or thrombotic complications. ACT (194 ± 53 vs. 261 ± 86 s; p < 0.001) and aPTT (39 ± 7 vs. 69 ± 23 s; p < 0.001) were significantly lower in the NOSA group than the Heparin group. Platelet and leukocyte activation did not differ significantly from baseline in the NOSA group. Methemoglobin was 3.2 ± 1.1% in the NOSA group compared to 1.6 ± 0.6% in the Heparin group (p < 0.001). The AP with the NOSA system successfully supported extremely premature lambs for 7 days without significant bleeding or thrombosis.

Background: Cold storage of hearts is limited to 6 hr prior to transplant. Extending preservation time may impact transplant coordination and potentially increase the organ pool, as marginal organs can be evaluated during ex vivo preservation. This study employs normothermic ex vivo heart perfusion (NEVHP) for the resuscitation and evaluation of hearts after 24 hr of cold static storage followed by transplantation. Methods: Porcine hearts (n=8) were recovered using standard techniques with antegrade hypothermic cardioplegic arrest. A catheter was placed in the LV to assess function. Inflow and outflow catheters were placed into the aorta and PA, respectively. Hearts were then placed in cold static storage in CoStorSol™ solution at 5 degrees Celsius for 24 hr. Following cold storage, hearts were supported by NEVHP for 8 hr with in-parallel hemofiltration. Coronary perfusion was maintained at 1 mL/min/g cardiac tissue. After NEVHP, 3 hearts were transplanted into 3 recipient pigs and 5 hearts were electively terminated. Results: Using NEVHP, all hearts were successfully resuscitated, as defined by resumption of sinus rhythm and preserved LV function. During NEVHP, mean values for LV systolic pressure = 51.2 ± 4.1 mmHg; coronary resistance = 0.49 ± 0.05 mmHg/mL/min; oxygen consumption = 1.1 ± 0.1 mL/min; and serum lactate = 3.08 ± 0.2 mmol/L (Fig 1A-D). No statistical differences were identified at endpoint compared to hour one. Average weight gain was 4.4 ± 1.0 g. Following transplantation, time to full bypass wean after aortic cross clamp removal was 120 ± 14 min. Animals were supported off bypass for 90 min prior to elective euthanasia. Conclusions: Hearts that underwent cold static storage for 24 hr can be routinely resuscitated to viable function using NEVHP. In addition, ex vivo perfusion allows for assessment of organ function prior to transplantation. Successful transplantation of these hearts corroborates adequate resuscitation and confirms viability after NEVHP.

Background: The authors analyzed the distribution of medical student debt and identified demographic features that placed students at high risk for increased debt and financial stress. Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to first-year (M1) to fourth-year (M4) medical students at the University of Michigan to assess financial literacy, debt burden, financial stress, and demographic factors. A total of 216 of 680 (32%) students completed the survey. Respondents voluntarily answered 15 multiple-choice questions on personal finance and 30 questions on their demographics, current financial situation, and debt burden. To quantify debt burden, students estimated anticipated education-related debt in one of four categories: no debt, $1–99,999; $100,000–$199,999; and $200,000 or more. A chi-square test was used to identify associations between categorical variables and logistic regression was used to identify risk factors for debt and worry. Results: Fifty-four respondents (25%) reported $0 in education related debt, while 44 (16%) had $200,000 or more. Race (p=0.006), first-generation college student status (p=0.004), first-generation medical student status (p<0.001), household income (p<0.001), and parental education (p=0.008) were associated with higher levels of debt. Students who were underrepresented in medicine (URiM) had higher odds of higher debt compared to Arab and Asian students (p=0.02). URiM students (p=0.02), first-generation college students (p=0.009), and parental education (p=0.01) were associated with increased financial stress. Additionally, female students had higher odds of increased financial stress (OR=1.85, p=0.045) on logistic regression. Conclusions: URiM and socioeconomically disadvantaged students feel the burden of the high cost of medical school disproportionately more, suggesting that our current systems are not adequately supporting these students. Reducing this burden may serve to further promote diversity in medicine.

The artificial placenta (AP) promotes organ development and reduces organ injury in a lamb model of extreme prematurity. This study evaluates hepatic outcomes after AP support with total parenteral nutrition (TPN) administration. Premature lambs (116-121 days estimated gestational age; term = 145) were cannulated for 7 days of AP support. Lambs received TPN with SMOFlipid (n = 7) or Intralipid (n = 5). Liver function and injury were compared between the two groups biochemically and histologically. Groups were compared by ANOVA with Tukey's multiple comparisons or linear-mixed effects models. From baseline to day 7, total bilirubin (Intralipid 2.6 +/- 2.3 to 7.9 +/- 4.4 mg/dl; SMOFlipid 0.3 +/- 0.1 to 5.5 +/- 2.3 mg/dl), alanine aminotransferase, and gamma-glutamyl transferase increased in both groups (p < 0.001 for all). Direct bilirubin (0.3 +/- 0.2 to 1.8 +/- 1.4 mg/dl; p = 0.006) and AST (27 +/- 5 to 309 +/- 242 mg/dl; p < 0.001) increased in SMOFlipid group (not measured in Intralipid group). On liver histology, Intralipid showed more cholestasis than SMOFlipid; both groups showed more than tissue controls. The Intralipid group alone showed hepatocyte injury and had more congestion than controls. Lambs supported by the AP with TPN administration maintain normal hepatic function and sustain minimal hepatic injury. SMOFlipid is associated with decreased cholestasis and hepatic injury versus Intralipid.

Background: The authors analyzed the distribution of medical student debt and identified demographic features that placed students at high risk for increased debt and financial stress. Methods: From April to May 2019, a cross-sectional, anonymous, web-based survey was administered to first-year (M1) to fourth-year (M4) medical students at the University of Michigan to assess financial literacy, debt burden, financial stress, and demographic factors. A total of 216 of 680 (32%) students completed the survey. Respondents voluntarily answered 15 multiple-choice questions on personal finance and 30 questions on their demographics, current financial situation, and debt burden. To quantify debt burden, students estimated anticipated education-related debt in one of four categories: no debt, $1–99,999; $100,000–$199,999; and $200,000 or more. A chi-square test was used to identify associations between categorical variables and logistic regression was used to identify risk factors for debt and worry. Results: Fifty-four respondents (25%) reported $0 in education related debt, while 44 (16%) had $200,000 or more. Race (p=0.006), first-generation college student status (p=0.004), first-generation medical student status (p<0.001), household income (p<0.001), and parental education (p=0.008) were associated with higher levels of debt. Students who were underrepresented in medicine (URiM) had higher odds of higher debt compared to Arab and Asian students (p=0.02). URiM students (p=0.02), first-generation college students (p=0.009), and parental education (p=0.01) were associated with increased financial stress. Additionally, female students had higher odds of increased financial stress (OR=1.85, p=0.045) on logistic regression. Conclusions: URiM and socioeconomically disadvantaged students feel the burden of the high cost of medical school disproportionately more, suggesting that our current systems are not adequately supporting these students. Reducing this burden may serve to further promote diversity in medicine.

Introduction: A potential solution to increase hearts available for transplantation is to use extended criteria donor hearts that are deemed unacceptable at initial evaluation. This study uses normothermic ex vivo heart perfusion (NEVHP) to resuscitate, recover, and assess performance of hearts after prolonged cold ischemia time. METHODS: Piglet (6 to 10 kg) hearts were procured after delivering antegrade cardioplegia. Catheters were placed in the left ventricle (functional assessment), aorta (inflow), and pulmonary artery (outflow) to support NEVHP, followed by either initiation of NEVHP (“direct group,” n = 5) or cold static storage in CoStorSol solution at 5°C for 12 hours (“12-hour group,” n = 5) or 24 hours (“24-hour group,” n = 5). All hearts were recovered and supported using NEVHP with in-parallel hemofiltration. Coronary perfusion was maintained at 1 mL/min/g. One-way ANOVA was used for statistical analysis. RESULTS: All hearts were resuscitated to normal sinus rhythm and were viable at 8 hours NEVHP. There were no significant differences between the direct, 12-hour, and 24-hour groups in hemodynamic or metabolic performance at the end of NEVHP. Mean heart rate was 95 ± 4, 90 ± 2, and 101 ± 3 beats per minute (p = 0.08); left ventricle pressure was 45 ± 4.7, 51 ± 5.0, and 56.0 ± 3.0 mmHg (p = 0.24); coronary resistance was 0.77 ± 0.29, 0.76 ± 0.18, and 0.48 ± 0.13 mmHg/mL/min (p = 0.08); lactate was 2.6 ± 0.3, 2.84 ± 0.3, and 3.5 ± 0.2 mmol/L (p = 0.10); and oxygen consumption was 0.015 ± 0.001, 0.021 ± 0.004, and 0.015 ± 0.004 mL/min/g (p = 0.24) for the direct, 12-hour, and 24-hour groups, respectively. Conclusion: Use of extended criteria donor hearts would increase organs available for transplantation. NEVHP with hemofiltration offers a solution to successfully recover and assess these hearts while maintaining organ performance.

Background: Artificial lungs have the potential to serve as a bridge to transplantation or recovery for children with end-stage lung disease dependent on extracorporeal life support, but such devices currently require systemic anticoagulation. We describe our experience using the novel Nitric Oxide (NO) Surface Anticoagulation (NOSA) system-an NO-releasing circuit with NO in the sweep gas-with the Pediatric MLung-a low-resistance, pumpless artificial lung. Methods: NO flux testing: MLungs ( n = 4) were tested using veno-venous extracorporeal life support in a sheep under anesthesia with blood flow set to 0.5 and 1 L/min and sweep gas blended with 100 ppm NO at 1, 2, and 4 L/min. NO and NO 2 were measured in the sweep and exhaust gas to calculate NO flux across the MLung membrane. Pumpless implants: Sheep (20-100 kg, n = 3) underwent thoracotomy and cannulation via the pulmonary artery (device inflow) and left atrium (device outflow) using cannulae and circuit components coated with an NO donor (diazeniumdiolated dibutylhexanediamine; DBHD-N 2 O 2 ) and argatroban. Animals were connected to the MLung with 100 ppm NO in the sweep gas under anesthesia for 24 h with no systemic anticoagulation after cannulation. Results: NO flux testing: NO flux averaged 3.4 +/- 1.0 flux units (x10 -10 mol/cm 2 /min) (human vascular endothelium: 0.5-4 flux units). Pumpless implants: 3 sheep survived 24 h with patent circuits. MLung blood flow was 716 +/- 227 mL/min. Outlet oxygen saturation was 98.3 +/- 2.6%. Activated clotting time was 151 +/- 24 s. Platelet count declined from 334,333 +/- 112,225 to 123,667 +/- 7,637 over 24 h. Plasma free hemoglobin and leukocyte and platelet activation did not significantly change. Conclusions: The NOSA system provides NO flux across a gas-exchange membrane of a pumpless artificial lung at a similar rate as native vascular endothelium and achieves effective local anticoagulation of an artificial lung circuit for 24 h.

Percutaneous catheterization is currently utilized for central venous access in adult and adolescent porcine models; however, neonatal models require a cut down to gain venous access. This approach requires general anesthesia and can result in systemic inflammation, which can confound studies investigating other inflammatory triggers. Here we present the first successful series of percutaneous, ultrasound-guided, durable central venous access in newborn piglets weighing 1 kg with a novel method of tunneling the catheter subcutaneously using a needle. Catheters (3–5 Fr, single- or double-lumen) were successfully placed in the right jugular vein of eight piglets weighing 1.3 ± 0.4 kg (mean ± standard deviation) with an average duration of catheter patency of 4.5 ± 2.1 days. There were no adverse events from catheter placement, though one catheter was inadvertently removed. This technique is a safe, minimally invasive method for obtaining secure central venous access in a neonatal porcine model.

The optimal approach for repairing large paraesophageal hernia (PEH) is unclear. Historically, these were initially approached through a transthoracic incision, then shifted to a laparotomy. Now laparoscopy has been the most common approach for at least the past decade, during which time the robotic approach has also increased in utilization. This article reviews the pros and cons of the different approaches, including recurrence rates, morbidity, and mortality. Using this information, we propose a general framework for the utilization of each approach as a reference for surgeons in their clinical decision making and operative planning. Laparoscopic (and/or robotic) approaches are best suited for small PEHs or cases of reflux alone. Robotic technology can aid in crural repair and potentially reduce long-term recurrence compared to traditional laparoscopy, while maintaining the benefits of quicker recovery. A laparotomy should generally be reserved for patients with recurrent PEH and severe intra-abdominal adhesions or urgent situations such as obstruction, gangrene, or conversion from laparoscopy. Due to the high risk of recurrence, patients with larger PEHs (type III or IV) or risk factors for recurrence (obesity, shortened esophagus, chronic cough, or constipation), should be strongly considered for a transthoracic approach. It is unclear if mesh offers benefits long term, but there is a small incidence of catastrophic mesh complications that should also be considered. Non-operative management of PEH, though occasionally utilized for asymptomatic patients, should generally be avoided due to a high risk of PEH-related complications and mortality.

A pumpless artificial lung has the potential to provide a bridge to recovery or transplantation in children with respiratory failure. Pulmonary artery inflow and left atrial outflow are necessary for low-gradient, pumpless systems; however, long-term cannulation of the fragile left atrium remains problematic. In this technique, the left atrium and pulmonary artery were exposed through a left anterior thoracotomy. Inflow to the artificial lung was created using an end-to-side anastomosis with the pulmonary artery. Device outflow was established through the left atrium. A single-stage venous cannula was passed through a free PTFE graft. Using polypropylene with pledgets, two concentric purse-string sutures were placed in the dome of the left atrium. The venous cannula was inserted. The graft was slid down the cannula and circumferentially secured to the adjacent left atrial tissue and pledgets. The other end of the graft was secured to the cannula with silk ties. The procedure was successful in 10 sheep. Initial device blood flow was 969 ± 222 ml/min, which remained stable for up to 7 days with no anastomotic complications. This is an effective method of achieving secure, long-term left atrial cannulation without cardiopulmonary bypass for use in a low-resistance, pumpless artificial lung. And, most importantly, improves the ease and safety of cannula replacement and final decannulation when AL support is no longer required.

Introduction: For children with end-stage lung disease that cannot wean from extracorporeal life support (ECLS), a wearable artificial lung would permit extubation and provide a bridge to recovery or transplan-tation. We evaluate the function of the novel Pediatric MLung-a low-resistance, pumpless artificial lung developed specifically for children-in healthy animal subjects.Methods: Adolescent "mini sheep" weighing 12-20 kg underwent left thoracotomy, cannulation of the main pulmonary artery (PA; inflow) and left atrium (outflow), and connection to the MLung. Results: Thirteen sheep were studied; 6 were supported for 7 days. Mean PA pressure was 23.9 +/- 6.9 mmHg. MLung blood flow was 633 +/- 258 mL/min or 30.0 +/- 16.0% of CO. MLung pressure drop was 4.4 +/- 3.4 mmHg. Resistance was 7.2 +/- 5.2 mmHg/L/min. Device outlet oxygen saturation was 99.0 +/- 3.3% with inlet saturation 53.8 +/- 7.3%. Oxygen delivery was 41.1 +/- 18.4 mL O2/min (maximum 84.9 mL/min) or 2.8 +/- 1.5 mL O2/min/kg. Platelet count significantly decreased; no platelet transfusions were required. Plasma free hemoglobin significantly increased only on day 7, at which point 2 of the animals had plasma free hemoglobin levels above 50 mg/dL. Conclusion: The MLung provides adequate gas exchange at appropriate blood flows for the pediatric pop-ulation in a PA-to-LA configuration. Further work remains to improve the biocompatibility of the device. Level of evidence: N/A (c) 2022 Elsevier Inc. All rights reserved.

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.

Over 50 years ago, visionary researchers began work on an extracorporeal artificial placenta to support premature infants. Despite rudimentary technology and incomplete understanding of fetal physiology, these pioneering scientists laid the foundation for future work. The research was episodic, as medical advances improved outcomes of premature infants and extracorporeal life support (ECLS) was introduced for the treatment of term and near-term infants with respiratory or cardiac failure. Despite ongoing medical advances, extremely premature infants continue to suffer a disproportionate burden of mortality and morbidity due to organ immaturity and unintended iatrogenic consequences of medical treatment. With advancing technology and innovative approaches, there has been a resurgence of interest in developing an artificial placenta to further diminish the mortality and morbidity of prematurity. Two related but distinct platforms have emerged to support premature infants by recreating fetal physiology: a system based on arteriovenous (AV) ECLS and one based on veno-venous (VV) ECLS. The AV-ECLS approach utilizes only the umbilical vessels for cannulation. It requires immediate transition of the infant at the time of birth to a fluid-filled artificial womb to prevent umbilical vessel spasm and avoid gas ventilation. In contradistinction, the VV-ECLS approach utilizes the umbilical vein and the internal jugular vein. It would be applied after birth to infants failing maximal medical therapy or preemptively if risk stratified for high mortality and morbidity. Animal studies are promising, demonstrating prolonged support and ongoing organ development in both systems. The milestones for clinical translation are currently being evaluated.