Abstract Anastomotic strictures and leaks are severe complications following esophageal atresia (EA) repair. We hypothesized that esophageal injections of botulinum toxin type A (BTX-A) could mitigate these complications through muscle relaxation. This randomized, controlled, blinded animal trial evaluated the feasibility and safety of a long- and short-gap porcine EA model. Furthermore, the effect of BTX-A as a surgical adjunct on anastomotic outcomes were exploratory assessed. Twenty-four animals received BTX-A or saline pre- or intraoperative to a three- or one-centimeter esophageal resection and primary anastomosis. The primary feasibility endpoint was animal completion rate at postoperative day 14, while stricture severity was the primary exploratory outcome. Secondary exploratory outcomes were anastomotic leakage frequency, and biomechanical and histological characteristics. Animal completion rate was 62.5% (15/24). There was no difference in stricture severity between the intervention and control groups (Esophageal Anastomotic Stricture Index 0.41 [IQR 0.26–0.55] versus 0.35 [IQR 0.27–0.58]; p = 0.73). One animal in the control group suffered an anastomotic leak. Biomechanical properties and anastomotic healing did not differ. While the procedure was technically feasible, refinement is necessary to reduce attrition rate and establish a safe model for long-term evaluation. More studies are needed to determine whether BTX-A can provide a reduction in anastomotic complications.

The pathogenesis of appendicitis is not fully understood. This study aimed to evaluate the associations between serum IgA and pediatric appendicitis. A prospective cohort study in which children ≤ 15 years with suspected appendicitis were enrolled at the Pediatric Emergency Department during 2017–2021. Blood samples were analyzed for serum IgA concentrations. Primary outcomes were appendicitis and complicated appendicitis. Associations were evaluated using univariate and multivariable logistic regression. Primary exposure was serum IgA concentrations, both in absolute concentrations as well as categorized as either normal, high or low in relation to age-dependent reference intervals. Independent variables were age, sex, symptom duration and/or presence of appendicolith. 177 children were included. Median age was 10 (IQR 8–12) years and 102 (58%) were boys. 137 (77%) had appendicitis, of which 58 (42%) were complicated. Median serum IgA among the children with appendicitis was 1.10 (IQR 0.68–1.52) g/L, compared to 1.11 (IQR 0.78–1.61) g/L in the non-appendicitis group, p = 0.44. Among the children with uncomplicated appendicitis, median IgA was 1.18 (0.80–1.58) g/L, compared to 0.92 (0.59–1.48) g/L among the children with complicated appendicitis, p = 0.07). Serum IgA was neither significantly associated with appendicitis (cOR 0.72 [95% CI 0.45–1.16], p = 0.18; aOR 0.70 [95% CI 0.41–1.20], p = 0.20) nor complicated appendicitis (cOR 0.71 [95% CI 0.41–1.21], p = 0.20); aOR 0.79 [95% CI 0.42–1.50], p = 0.47). Analyses of high and low serum IgA according to age-dependent reference intervals did not show any significant associations to appendicitis or complicated appendicitis, neither in the univariate nor the multivariable analyses. There were no significant associations between serum IgA and odds of appendicitis or complicated appendicitis in children. This does not rule out associations between appendicitis and secretory IgA found in the appendix mucosa or lumen. This should be the target for future studies on IgA and appendicitis.

PurposeGenital malformations are increasingly recognized when a VACTERL is present, but remain insufficiently described in children with esophageal atresia (EA). This study aimed to determine the prevalence and spectrum of genital and urinary tract malformations in children with EA, and to describe associated morbidity, need for additional surgery, and association with Gross classification.MethodsRetrospective cohort study including all children undergoing surgery for EA at a tertiary center of pediatric surgery between 2012-2023. Children deceased within five days of birth were excluded. Data were collected from medical records and analyzed using Chi2 and Fisher's exact tests.ResultsNinety-three children were included. Genital and urinary tract malformations occurred in 12 (12.9%) and 18 (19.4%) children. In children with a VACTERL association, the prevalence was 29% (9/31) and 51.6% (16/31), respectively. Urinary tract infections, neurogenic bladder, and intermittent catheterization were more common in children with a genital or urinary tract malformation. Additional urogenital surgery was required in 50% of affected children. There was no significant association with Gross classification.ConclusionGenital and urinary tract malformations are common in EA, contributing to morbidity and need for additional surgery. Screening for genital malformations should be considered, especially when a VACTERL association is present.

This article analyzes the immediate and long-term effects of medical humanities teaching at a Swedish medical degree program. The objectives, format, and core pedagogical ideas and practices of an elective course in medical humanities are presented, situating the learning experience in the wider context of medical humanities in the Nordics. We conducted a qualitative, thematic analysis of course evaluations amassed over 15 years and of open-ended responses in an alumni survey sent out in 2023. Using these two sources, we compare the students' immediate perception of medical humanities' contribution to their education with what they discern when looking back. The students report that medical humanities teaching advances an understanding and responsiveness to narratives and furthers an ability to balance the rational, bio-medical perspective with a more holistic empathetic view of patients and illness, providing a deeper and broader toolkit to work from in clinical practice. The students perceive that they have acquired a specific expertise, obtained training in perspective taking, and yielded personal growth and agency. The interpretative sensitivities and competencies reverberated in the alumni survey and were reported to influence subsequent clinical work. Our study suggests that the impact of medical humanities teaching is transferred to both occupational practice and personal life, and that the impact is long term.

Leucine rich alpha-2 glycoprotein 1 (LRG1) has emerged as a promising biomarker for appendicitis, especially in pediatric patients. However, the currently available data are sparse, and the biomarker must be validated in more settings and compared to standard inflammatory markers. We aimed to evaluate the diagnostic and discriminative utility of serum and urine LRG1 in children with other causes of abdominal pain (no appendicitis) versus appendicitis, and uncomplicated versus complicated appendicitis. The study design was prospective including children ≤ 15 years with suspected appendicitis. Blood and urine samples were collected at the time of clinical evaluation at the Pediatric Emergency Department and analyzed for concentrations of LRG1. Appendicitis diagnosis and severity were determined through histopathological examination and intraoperative findings. Group comparisons were carried out using Kruskal–Wallis test with post hoc Dunn–Bonferroni tests for pairwise comparisons. Associations between LRG1 and other laboratory and clinical variables and the odds of appendicitis and complicated appendicitis were assessed by univariate and multivariable logistic regression analyses. Diagnostic (no appendicitis versus appendicitis) and discriminative (uncomplicated versus complicated appendicitis) performance were evaluated through Receiver Operating Characteristic (ROC) curves with analyses of Areas Under the Curve (AUC). Optimal cutoffs were generated using Youden’s index, and diagnostic and predictive values were calculated and compared. 172 children were included. 132 (77

Childhood constipation is increasingly common, yet its prevalence is uncertain. This study examines comprehensive national data for trends in medically treated childhood constipation over a period of 18 years. Included were all Swedish children, 0–14 years, 2006–2023, and all prescriptions for constipation, using the national Swedish Prescribed Drug register. The primary outcome was the number of unique patients prescribed, presented by age, gender, year, county, and ATC-code. Univariate and multivariable linear regression with ecological data were assessed for associations with age, gender, and year of prescription. The study population increased from 1.54 to 1.84 million children 0–14 years, while constipation increased more than sixfold, from 1.2

Leucine rich alpha-2 glycoprotein 1 (LRG1) has emerged as a promising biomarker for appendicitis, especially in pediatric patients. However, the currently available data are sparse. We aimed to compare serum and urine leucine rich alpha-2 glycoprotein 1 (LRG1) concentrations in children with no appendicitis (NA), uncomplicated appendicitis (UA) and complicated appendicitis (CA). A prospective study including children <15 years with suspected appendicitis (pain in the right lower quadrant). Blood and urine samples were collected during clinical evaluation at the Pediatric ED and analyzed for LRG1 concentrations. Group comparisons were made using Kruskal-Wallis test with post hoc Dunn-Bonferroni tests for pairwise comparisons. Appendicitis diagnosis and severity were determined through histopathological examination. The study was approved by the regional ethics committee (Regionala Etikprövningsmyndigheten, Lund, Sweden, DNR 2013/614). 173 children were included. 133 (77%) had appendicitis and 57 (43%) of these had complicated appendicitis. The median age was 10 (IQR 8-12) years and 99 (57%) were boys. The groups differed in distribution of sex, age and symptom duration. Median serum LRG1 for patients with NA, UA, and CA were 27.6 (19.7-36.6) μg/mL, 24.8 (18.7-30.1) μg/mL, and 23.5 (18.9-31.5) μg/mL, respectively (p=0.16). Median urine LRG1 were 0.33 (0.10-0.72) μg/mL, 0.1 (0.02-0.29) μg/mL, and 0.3 (0.12-1.07) μg/mL, respectively (p<0.001, significant when comparing NA with UA, and UA with CA). There were no differences in serum LRG1 in our groups. Children with UA had lower urine LRG1 compared to children with NA and CA. These analyses, however, do not take into consideration potential confounding.

Cesarean section (CS) is a life-saving procedure when performed for the right indication but carries substantial risks, specifically during subsequent pregnancies. The aim of this study was to evaluate obstetric outcomes for women 5 years after a CS performed by medical doctors and associate clinicians. This was a prospective multi-center observational study of women who had a CS at any of nine hospitals in Sierra Leone. Women and their offspring were followed up with three home visits for 5 years after surgery. Outcomes of interest included long-term complications, mode and place of delivery, and maternal and pediatric outcomes of subsequent pregnancies. Of the 1274 women included in the study, 140 (11.0%) were lost to follow-up. Within 5 years after the index CS, 27.0% of the women became pregnant and 2.5% had a second pregnancy. Women with perinatal death at the index CS had 5.25 higher odds of becoming pregnant within 1 year. Of the 259 women who delivered, 31 (12.0%) had a planned CS and 228 (88.0%) attempted a trial of labor after CS, resulting in either a successful vaginal birth (n = 138; 60.5%) or an emergency CS (n = 90; 39.5%). Peripartum and long-term complications did not significantly differ between those that were operated on by medical doctors and associate clinicians. Within 5 years after CS, one in four women became pregnant again and more than half had a vaginal delivery. Significant differences in place and mode of birth between wealth quintiles illustrate inequities.

The pathogenesis of appendicitis is not understood fully, and the diagnosis can be challenging. Previous research has suggested an association between a T helper (Th) 1-dependent immune response and complicated appendicitis. This prospective cohort study aimed to evaluate the association between serum concentrations of the Th1-associated cytokines interleukin (IL)-1α, IL-1β, IL-2, IL-6, IL-10, IL-17A and tumor necrosis factor beta (TNF-β) and the risk of complicated appendicitis in children. Appendicitis severity was determined through histopathological examination. A total of 137 children < 15 years with appendicitis were included with a median age of 10 years (IQR 8–12); 86 (63%) were boys, and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of serum IL-6 and IL-10, and lower of TNF-β. After adjustment for age, symptom duration, and presence of appendicolith in a multivariable logistic regression, a higher concentration of IL-6 remained associated with an increased risk of complicated appendicitis (aOR 1.001 [95% CI 1.000–1.002], p = 0.02). Serum concentrations of IL-1α, IL-1β, IL-2, IL-10, IL-17A and TNF-β were not significantly associated with the risk of complicated appendicitis. In conclusion, our results suggests that the systemic inflammatory response in complicated appendicitis is complex and not solely Th1-dependent.

Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC. Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded. In total, 109 neonates were included. Median gestational age was 25 weeks (22–38), and median birth weight was 771 g (269–3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%. Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

BackgroundA multitude of operative trauma courses exist, most of which are designed for and conducted in high-resource settings. There are numerous barriers to adapting such courses to low- and low-middle-income countries (LMICs), including resource constraints and contextual variations in trauma care. Approaches to implementing operative trauma courses in LMICs have not been evaluated in a structured manner.MethodsWe conducted a scoping review of the literature including databases (e.g., PubMed, Web of Science, EMBASE), grey literature repositories, and structured queries of publicly available course materials to identify records that described operative trauma courses offered since 2000.ResultsThe search identified 3,518 non-duplicative records, of which 48 relevant reports were included in analysis. These reports represented 23 named and 11 unnamed operative trauma courses offered in 12 countries. Variability existed in course format and resource requirements, ranging from USD 40 to 3,000 per participant. Courses incorporated didactic and laboratory components, which utilized simulations, cadavers, or live animals. Course content overlapped significantly but was not standardized. Data were lacking on course implementation and promulgation, credentialing of instructors, and standardized evaluation metrics.ConclusionsWhile many operative trauma courses have been described, most are not directly relatable to LMICs. Barriers include cost-prohibitive fees, lack of resources, limited data collection, and contextual variability that renders certain surgical care inappropriate in LMICs. Gaps exist in standardization of course content as well as transparency of credentialing and course implementation strategies. These issues can be addressed through developing an open-access operative trauma course for low-resource settings.

BACKGROUND:Children with suspected ureteropelvic junction obstruction (UPJO) may present with a paradoxical ipsilateral supranormal differential renal function (snDRF) on 99mTechnetium mercaptoacetyltriglycine scintigraphy (MAG3 scan). OBJECTIVE:The aim was to investigate the prevalence of snDRF, the risk of pyeloplasty among children with UPJO and snDRF, and to explore the experience of snDRF among international pediatric urologists. METHODS:A retrospective cohort study of children with suspected unilateral UPJO who underwent MAG3 scan at four hospitals in Sweden between 2005 and 2020. SnDRF was defined as DRF ≥55%. Normal DRF was defined as DRF 45-54%. Primary outcome was risk of pyeloplasty. Indications for pyeloplasty were loss of >10%-points of differential renal function (DRF), ipsilateral DRF <40%, or symptomatic UPJO. Logistic and cox regressions were performed in univariate and multivariable analyses, adjusting for age, gender, year, laterality, antenatal hydronephrosis, anterior-posterior diameter (APD), and kidney size. An international questionnaire regarding the management of snDRF was developed and distributed to pediatric urologists. RESULTS:The prevalence of snDRF was 19%. SnDRF was more common in boys, children with antenatal hydronephrosis, children undergoing their first MAG3 scan at a younger age, and in the left kidney. After further exclusion of 70 children with DRF <45%, a total of 264 were included for longitudinal follow-up of median 6.6 (IQR 2.5-11.5) years. SnDRF was not associated with increased risk of pyeloplasty (adjusted OR 0.98 (95% CI 0.41-2.33), p = 0.96, and adjusted HR 1.00 (95% CI 0.53-1.91), p = 0.99) or time to pyeloplasty (1.1 years vs. 1.6 years, p = 0.40). Among the 79 surveyed pediatric urologists, a majority would not change clinical UPJO-management based on the presence or absence of ipsilateral snDRF. DISCUSSION:There are only a few studies considering the need of pyeloplasty based on the presence of snDRF and this is the first survey among pediatric urologists on its management. With more included patients than previous studies, this study showed a snDRF prevalence of 19%, congruent with the findings of others. The underlying cause of snDRF is debated, but it cannot solely be explained as an artifact of hydronephrotic kidneys. Further studies on the clinical implications of snDRF are warranted, since DRF influences the decision to operate. CONCLUSION:A fifth of all children with suspected UPJO presented with ipsilateral snDRF on initial MAG3 scan, and snDRF was not associated with a greater risk of pyeloplasty. Supported by a large group of international pediatric urology colleagues, this study concludes that the same clinical follow-up and management apply, regardless of presence of snDRF.

"Why is it that there's such rank injustice in fortune itself?"1 Dyoma was a thoughtful child with cancer in Aleksandr Solzhenitsyn's Cancer Ward, with a lower extremity tumour requiring amputation despite radiation and injections. Medical oncology can claim remarkable advancements for many generations, but to most people in the world cancer surgery remains in fiction. Among the millions of people diagnosed with cancer every year, 80% will need a surgical procedure at some point in their treatment and three of four will find such surgery prohibitively expensive and dangerous, or unavailable.

BACKGROUND:The shortage of trained surgeons, anesthesiologists, and obstetricians is a major contributor to the unmet need for surgical care in low- and middle-income countries, and the shortage is aggravated by migration to higher-income countries.METHODS:We performed a cross-sectional observational study, combining individual-level data of 43,621 physicians from the Health Professions Council of South Africa with data from the registers of 14 high-income countries, and international statistics on surgical workforce, in order to quantify migration to and from South Africa in both absolute and relative terms.RESULTS:Of 6670 surgeons, anesthesiologists, and obstetricians in South Africa, a total of 713 (11%) were foreign medical graduates, and 396 (6%) were from a low- or middle-income country. South Africa was an important destination primarily for physicians originating from low-income countries; 2% of all surgeons, anesthesiologists, and obstetricians from low- and middle-income countries were registered in South Africa, and 6% in the other 14 recipient countries. A total of 1295 (16%) South African surgeons, anesthesiologists, and obstetricians worked in any of the 14 studied high-income countries.CONCLUSION:South Africa is an important regional hub for surgical migration and training. A notable proportion of surgical specialists in South Africa were medical graduates from other low- or middle-income countries, whereas migration out of South Africa to high-income countries was even larger.

Aim: Necrotising enterocolitis (NEC) is the dominating surgical emergency in preterm neonates. The aims were to investigate indications, surgical management and mortality for surgically treated neonates with NEC.Methods: Data were retrieved from the Swedish Neonatal Quality Register for Swedish neonates with surgically treated NEC from 1 January 2017 to 31 December 2021. Diagnosis was validated by surgical records and histopathology. Neonates with isolated spontaneous intestinal perforation were excluded.Results: In total, 109 neonates were included. Median gestational age was 25 weeks (22-38), and median birth weight was 771 g (269-3920). Preoperative pneumoperitoneum was found in 32%, portal venous gas in 25% and clinical deterioration on conservative treatment in 26% of the neonates. Among the 97 neonates presenting with small bowel necrosis, single-focal NEC occurred in 38 (39%), multifocal NEC in 35 (36%) and panintestinal NEC in 24 (25%). A primary anastomosis was performed in 10/87 (11%) of the neonates with bowel resection at primary surgery. Clip-and-drop technique was applied in 24/87 (28%).Mortality rate was 37%.Conclusion: Mortality was well comparable with earlier reports considering exclusion of spontaneous intestinal perforation (SIP) and the low gestational age of the study population. Resection of necrotic bowel with stoma formation was the dominating surgical method.

BackgroundThe pathogenesis of appendicitis is not understood completely and establishing a correct diagnosis can be clinically challenging. Previous investigations have shown an association between a T helper cell (Th)2-mediated inflammatory response, for example immunoglobulin E (IgE)-mediated allergy, and a decreased risk of complicated appendicitis. The present study aimed to evaluate differences in serum concentrations of IgE and Th2-associated interleukins (IL) in children with uncomplicated and complicated appendicitis.MethodA prospective study including children <15 years with appendicitis. Blood samples were collected preoperatively at the time of clinical assessment at the Pediatric Emergency Department and analyzed for concentrations of serum total IgE and IL-4, IL-9, and IL-13. Associations with complicated appendicitis were evaluated through logistic regression adjusting for age, appendicolith, and symptom duration.Results138 children with confirmed appendicitis were included. The median age was 10 (IQR 8–12) years, 87 (63%) were boys and 58 (42%) had complicated appendicitis. Children with complicated appendicitis had significantly higher concentrations of IL-9 and IL-13 compared to children with uncomplicated appendicitis. In the univariate logistic regression, high concentrations of IL-13 were associated with an increased risk of complicated appendicitis [OR 1.02 (95% CI 1.01–1.04) p = 0.005], which remained in the multivariate analysis [aOR 1.02 (95% CI 1.01–1.04), p = 0.01]. Serum concentrations of IgE, IL-4, and IL-9 did not significantly affect the risk of complicated appendicitis.ConclusionHigh levels of IL-13 seem to be associated with an increased risk of complicated appendicitis. This is incongruent with the hypothesis of an Th1/Th17-driven inflammation in this type of appendicitis.

Background The shortage of surgeons, anaesthesiologists and obstetricians in low-income and middle-income countries (LMICs) is occasionally bridged by foreign surgical teams from high-income countries on short-term visits. To advise on ethical guidelines for such activities, the aim of this study was to present LMIC stakeholders’ perceptions of visiting surgical teams from high-income countries. Method We performed a systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in November 2021, using standardised search terms in PubMed/Medline (National Library of Medicine), EMBASE (Elsevier), Global Health Database (EBSCO) and Global Index Medicus, and complementary hand searches in African Journals Online and Google Scholar. Included studies were analysed thematically using a meta-ethnographic approach. Results Out of 3867 identified studies, 30 articles from 15 countries were included for analysis. Advantages of visiting surgical teams included alleviating clinical care needs, skills improvement, system-level strengthening, academic and career benefits and broader collaboration opportunities. Disadvantages of visiting surgical teams involved poor quality of care and lack of follow-up, insufficient knowledge transfers, dilemmas of ethics and equity, competition, administrative and financial issues and language barriers. Conclusion Surgical short-term visits from high-income countries are insufficiently described from the perspective of stakeholders in LMICs, yet such perspectives are essential for quality of care, ethics and equity, skills and knowledge transfer and sustainable health system strengthening. More in-depth studies, particularly of LMIC perceptions, are required to inform further development of ethical guidelines for global surgery and support ethical and sustainable strengthening of LMIC surgical systems.

The purpose of this study was to describe the epidemiology of patients presenting with acute burns and undergoing admission at Hospital Nacional Guido Valadares (HNGV) in Dili, Timor-Leste in the period 2013 to 2019. HNGV is the only tertiary referral hospital in Timor-Leste. This was a retrospective study involving all acute burn patients admitted to the surgical wards of HNGV from 2013 to 2019. The data was collected from patient charts and hospital medical archives. Data were reviewed and analyzed statistically in terms of age, gender, residence, cause, total body surface area (TBSA), burns depth, length of stay (LOS), and mortality. The outcomes were analyzed using logistic regression. Over the 7-year period, there were 288 acute burn patients admitted to the surgical wards of HNGV. Most patients were children (55%), male (65%) and from the capital city of Dili or surrounding areas (59%). The most common cause of burns in children was scalds and the most common cause among adults was flames. Of the admitted patients 59% had burns affecting >10% of the TBSA and 41% had full thickness burns. The median LOS was 17 days (1-143) and the average mortality for admitted burn patients in HNGV was 5.6% (annual mortality 0-17%). The odds ratio for extended LOS was 1.9 (95% confidence interval 1.1-3.2) in female compared with male patients. The odds ratio for mortality was 14.6 (95% confidence interval 2.7-80.6) in the older adults when compared with younger adults. Higher TBSA, full thickness burns, and flame burns were also significantly associated with longer LOS and higher mortality. Children and male patients were disproportionately overrepresented among patients admitted to HNGV, while female patients had longer LOS and older adults had more severe injury and a higher risk of mortality. Establishment of a national program for the prevention of burns is essential.

Background: Undernutrition contributes to nearly 50% of all child deaths in the world, yet there is conflicting evidence regarding the association between nutritional status and postoperative complications. The aim was to describe the preoperative nutritional status among pediatric surgery patients in Zimbabwe, and to assess if nutritional status was a risk factor for adverse postoperative outcome of mortality, surgical site infection, reoperation, readmission, and longer length of stay. Methods: This prospective observational cohort study included 136 children undergoing surgery at a tertiary pediatric hospital in Zimbabwe. Nutritional status was standardized using Z-scores for BMI, length, weight, and middle upper arm circumference. Primary outcomes after 30 days included mortality, surgical site infection, reoperation, and readmission. Secondary outcome was length of stay. Univariate and multivariable analyses with logistic regression were performed. Results: Of the 136 patients, 31% were undernourished. Postoperative adverse outcome occurred in 20%; the mortality rate was 6%, the surgical site infection rate was 17%, the reoperation rate was 3.5%, and readmission rate was 2.5%. Nutritional status, higher ASA classification, major surgical procedures, and lower preoperative hemoglobin levels were associated with adverse outcome. Univariate logistic regression identified a seven-fold increased risk of postoperative complications among undernourished children (OR 7.3 [2.3-22.8], p = 0.001), and there was a fourto six-fold increased adjusted risk after adjustment for ASA, major surgery, and preoperative hemoglobin. Conclusion: A third of all pediatric surgery patients were undernourished, and undernourished children had a considerably higher risk of adverse outcome. With a positive correlation identified between undernourishment and increased postoperative complications, future aims would include assessing if preoperative nutritional treatment could be especially beneficial for undernourished children. (C) 2020 Elsevier Inc. All rights reserved.