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

The authors sought better outcomes for uncomplicated gastroschisis through development of clinical practice guidelines. The authors and the American Pediatric Surgical Association Outcomes and Evidenced-based Practice Committee used an iterative process and chose two questions to develop clinical practice guidelines regarding (1) standardized nutrition protocols and (2) postnatal management strategies. An English language search of PubMed, MEDLINE, OVID, SCOPUS, and the Cochrane Library Database identified literature published between January 1, 1970, and December 31, 2019, with snowballing to 2022. The Appraisal of Guideline, Research and Evaluation reporting checklist was followed. Thirty-three studies were included with a Level of Evidence that ranged from 2 to 5 and recommendation Grades B–D. Nine evaluated standardized nutrition protocols and 24 examined postnatal management strategies. The adherence to gastroschisis-specific nutrition protocols promotes intestinal feeding and reduces TPN administration. The implementation of a standardized postnatal clinical management protocol is often significantly associated with shorter hospital stays, less mechanical ventilation use, and fewer infections. There is a lack of comparative studies to guide practice changes that improve uncomplicated gastroschisis outcomes. The implementation of gastroschisis-specific feeding and clinical care protocols is recommended. Feeding protocols often significantly reduce TPN administration, although the length of hospital stay may not consistently decrease.

BACKGROUND:The benefit of targeting high ratio fresh frozen plasma (FFP)/red blood cell (RBC) transfusion in pediatric trauma resuscitation is unclear as existing studies are limited to patients who retrospectively met criteria for massive transfusion. The purpose of this study is to evaluate the use of high ratio FFP/RBC transfusion and the association with outcomes in children presenting in shock. METHODS:A post hoc analysis of a 24-institution prospective observational study (April 2018 to September 2019) of injured children younger than 18 years with elevated age-adjusted shock index was performed. Patients transfused within 24 hours were stratified into cohorts of low (<1:2) or high (≥1:2) ratio FFP/RBC. Nonparametric Kruskal-Wallis and χ 2 were used to compare characteristics and mortality. Competing risks analysis was used to compare extended (≥75th percentile) ventilator, intensive care, and hospital days while accounting for early deaths. RESULTS:Of 135 children with median (interquartile range) age 10 (5-14) years and weight 40 (20-64) kg, 85 (63%) received low ratio transfusion and 50 (37%) high ratio despite similar activation of institutional massive transfusion protocols (low-38%, high-46%, p = 0.34). Most patients sustained blunt injuries (70%). Median injury severity score was greater in high ratio patients (low-25, high-33, p = 0.01); however, hospital mortality was similar (low-24%, high-20%, p = 0.65) as was the risk of extended ventilator, intensive care unit, and hospital days (all p > 0.05). CONCLUSION:Despite increased injury severity, patients who received a high ratio of FFP/RBC had comparable rates of mortality. These data suggest high ratio FFP/RBC resuscitation is not associated with worst outcomes in children who present in shock. Massive transfusion protocol activation was not associated with receipt of high ratio transfusion, suggesting variability in MTP between centers. LEVEL OF EVIDENCE:Therapeutic/Care Management; Level III.

Introduction: Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evi-dence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations. Methods: Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1,1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed. Results: Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recur-rence after VATS can be treated with repeat VATS with intensification of pleural treatment. Conclusions: The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and manage-ment of recurrence after observation, tube thoracostomy, or operative intervention.Level of Evidence: Level 4. Type of study: Systematic Review of Level 1-4 studies.(c) 2023 Elsevier Inc. All rights reserved.

INTRODUCTION:The incidence of ulcerative colitis (UC) is increasing. Roughly 20% of all patients with UC are diagnosed in childhood, and children typically present with more severe disease. Approximately 40% will undergo total colectomy within ten years of diagnosis. The objective of this study is to assess the available evidence regarding the surgical management of pediatric UC as determined by the consensus agreement of the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP). METHODS:Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on surgical decision-making for children with UC. Questions focused on surgical timing, reconstruction, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Risk of Bias was assessed using Methodological Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS:A total of 69 studies were included for analysis. Most manuscripts contain level 3 or 4 evidence from single-center retrospective reports, leading to a grade D recommendation. MINORS assessment revealed a high risk of bias in most studies. J-pouch reconstruction may result in fewer daily stools than straight ileoanal anastomosis. There are no differences in complications based on the type of reconstruction. The timing of surgery should be individualized to patients and does not affect complications. Immunosuppressants do not appear to increase surgical site infection rates. Laparoscopic approaches result in longer operative times but shorter lengths of stay and fewer small bowel obstructions. Overall, complications are not different using an open or minimally invasive approach. CONCLUSIONS:There is currently low-level evidence related to certain aspects of surgical management for UC, including timing, reconstruction type, use of minimally invasive techniques, need for diversion, and risks to fertility and sexual function. Multicenter, prospective studies are recommended to better answer these questions and ensure the best evidence-based care for our patients. LEVEL OF EVIDENCE:Level of evidence III. STUDY TYPE:Systematic review.

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

Purpose Management of undescended testes (UDT) has evolved over the last decade. While urologic societies in the United States and Europe have established some guidelines for care, management by North American pediatric surgeons remains variable. The aim of this systematic review is to evaluate the published evidence regarding the treatment of (UDT) in children. Methods A comprehensive search strategy and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were utilized to identify, review, and report salient articles. Five principal questions were asked regarding imaging standards, medical treatment, surgical technique, timing of operation, and outcomes. A literature search was performed from 2005 to 2020. Results A total of 825 articles were identified in the initial search, and 260 were included in the final review. Conclusions Pre-operative imaging and hormonal therapy are generally not recommended except in specific circumstances. Testicular growth and potential for fertility improves when orchiopexy is performed before one year of age. For a palpable testis, a single incision approach is preferred over a two-incision orchiopexy. Laparoscopic orchiopexy is associated with a slightly lower testicular atrophy rate but a higher rate of long-term testicular retraction. One and two-stage Fowler-Stephens orchiopexy have similar rates of testicular atrophy and retraction. There is a higher relative risk of testicular cancer in UDT which may be lessened by pre-pubertal orchiopexy.

AIMS:The aims of this study were to document the injury pattern in pediatric traumatic craniocervical dissociation (CCD) and identify features of survivors. METHODS:Pediatric traumatic CCDs, diagnosed between January 2004 and July 2016, were reviewed. Survivors and nonsurvivors were compared. Categorical and continuous variables were analyzed with Fisher exact and t tests, respectively. RESULTS:Twenty-seven children were identified; 10 died (37%). The median age was 60 months (ranges, 6-109 months [survivors], 2-98 months [nonsurvivors]). For survivors, the median follow-up was 13.4 months (range, 1-109 months). The median time to mortality was 1.5 days (range, 1-7 days). The injury modality was motor vehicle collision in 18 (67%), pedestrian struck in 8 (30%), and 1 shaken infant (3%). For nonsurvivors, CCD was equally diagnosed by plain radiograph and head/cervical spine computed tomography scan. For survivors, CCD was diagnosed by computed tomography in 7 (41%), magnetic resonance imaging in 10 (59%), and none by radiograph. Seven diagnosed by magnetic resonance imaging (41%) had nondiagnostic initial imaging but persistent neck pain. Magnetic resonance imaging was obtained and was diagnostic of CCD in all 7 (P < 0.01). Survivors required significantly less cardiopulmonary resuscitation (P < 0.01), had lower Injury Severity Scores (P < 0.01), higher Glasgow Coma Scale scores (P < 0.01), and shorter transport times (P < 0.01). Significantly more involved in motor vehicle collisions survived (P = 0.04). Nine (53%) had no disability at follow-up evaluation. CONCLUSIONS:In pediatric CCD, high-velocity mechanism, cardiac arrest, high Injury Severity Score, and low Glasgow Coma Scale score are associated with mortality. If CCD is correctly managed in the absence of cardiac arrest or traumatic brain or spinal cord injury, children may survive intact.

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

Spontaneous splenic rupture is a rare but life-threatening complication of Epstein-Barr virus (EBV)-induced infectious mononucleosis (IM). It occurs in less than 0.5% of cases and is the most frequent cause of death in IM. We report a case of a 13-year old female presenting with hemodynamic instability following diagnosis of EBV-induced IM. Abdominal CT was positive for grade III splenic laceration with active extravasation and exploratory laparotomy with splenectomy was performed. Postoperatively, she recovered appropriately, received vaccinations, and was discharged on postoperative day 5. Follow up has revealed no complications and return to normal activity.

Aim: The aim of this study was to evaluate the effects of a carbon dioxide pneumoperitoneum on cerebral and renal oxygenation and oxygen extraction, in a cohort of infants from the neonatal intensive care unit, undergoing laparoscopic gastrostomy. Methods: After institutional review board approval, between February 2018 and June 2019, infants 0-3 mo corrected age, undergoing laparoscopic gastrostomy tube placement, were included. Strict exclusion criteria created a homogeneous cohort. Cerebral and renal tissue oxygen saturation (rSO(2)) by near-infrared spectroscopy, skin surface oxygen saturation (SpO(2)), by pulse oximetry, andamplitude-integrated electroencephalographyweremeasured. Monitoring was divided into preoperative, intraoperative and postoperative time periods. Cerebral and renal fractional tissue oxygen extraction was calculated using arterial (SpO2) and tissue oxygen saturation (rSO(2)): (SpO(2)-rSO(2)/SpO(2)) X100. Data were averaged into one-minute epochs and significant changes from baseline during the intraoperative and postoperative periods were detected using one-way analysis of variance with repeated measures. Results: This pilot study examined sixteen infants, born at amedian gestational age of 34.2wk (range: 23.0-40.6) with a median corrected age of 42.9 wk (range: 40.0-46.3) at operation. None had seizure activity or altered sleep-wake cycles. No statistically significant variations in cerebral and renal tissue oxygenation and extraction were observed. Pulse oximetry did demonstrate significant variation from baseline on analysis of variance, but post hoc analysis did not identify any one specific time point at which this difference was significant. Conclusions: During a short infant laparoscopic procedure, no significant alteration in cerebral or renal oxygenation or oxygen extraction was observed. No seizure activity or changes in infant sleep-wake cycles occurred. (C) 2020 Elsevier Inc. All rights reserved.

Background: Anorectal malformation (ARM) is a common congenital anomaly. The combination of a utricle cyst and an ARM is rare. The purpose of this video is to describe a multidisciplinary approach to the diagnosis and management of a complex anorectal and urologic anomaly. Materials and Methods: A 38-week gestation male infant had multiple genitourinary anomalies. These included distal hypospadias with the urethral opening situated just below the coronal sulcus, a bifid scrotum, and left renal agenesis. The testes had descended bilaterally and were palpable in the scrotum, which ruled out a disorder of sexual differentiation. He had a high imperforate anus and underwent a divided colostomy on day of life two. At 1 month, he developed a scrotal abscess; MRI demonstrated a pelvic cyst. A mucous fistulogram revealed the rectum terminated 4 cm cranial to an anal marker with a possible fistulous connection between the rectum, seminal vesicles, bladder, and the cystic structure. Retrograde urethrogram demonstrated that the cyst was connected posteriorly to the urethra, consistent with a utricle cyst. The rectum connected to the urethra but filled separately. At 3 months, the infant underwent combined endoscopy and cystoscopy to delineate the connections and attempt transurethral drainage of the utricle cyst. Endoscopy of the mucous fistula with a GIF-XP190N pediatric gastroscope (Olympus America Medical) allowed placement of a 0.035 × 150 cm guidewire (Cook Medical). The wire passed transurethral and allowed isolation of the mucous fistula and the utricle cyst. Because a wire was already in the mucous fistula, during cystoscopy with a 9.5F offset pediatric cystoscope (Richard Wolf Medical), the opening of the utricle cyst could be isolated. Each had a separate opening into the urethra. A 0.035 × 145 cm guidewire (Cook Medical) was placed into the utricle cyst and an 8F feeding tube (Bard Medical) was slid over the wire, to allow for transurethral drainage. The mother was trained to flush the cyst, which promoted resolution of the recurrent infections. Before the anal reconstruction, the transurethral drain dislodged but was not replaced. Instead the mucus fistula was flushed. The infant remained infection free before surgery. Results: After transurethral drainage and flushing, the utricle cyst appeared resolved. The infant underwent repair of his ARM at 7 months of life, 3 months after the initial drainage procedure. There was no evidence of the utricle cyst or previous infections during the pull through procedure. Follow-up: The infant is managed by a multidisciplinary team that includes pediatric urology. At present he is undergoing clinical examination and an ultrasonography once or twice annually and remains asymptomatic. His colostomy was reversed. Owing to his many genitourinary anomalies he is followed by pediatrics urology and will be followed into adulthood. Less than 40% of cysts become symptomatic.1 If intervention is required, most are cured by endoscopic procedures. Conclusion: A multidisciplinary approach allows for delineation and management of complex anorectal and urogenital anomalies with preservation of reconstructive planes. This video was presented at the 28th Annual Congress for Endosurgery in Children, March 22, 2019 in Santiago, Chile. No competing financial interests exist. Runtime of video: 4 mins 43 secs

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

Purpose: Pediatric blunt solid organ injury management based on hemodynamic monitoring rather than grade may safely reduce resource expenditure and improve outcomes. Previously we have reported a retrospectively validated management algorithm for pediatric liver and spleen injuries which monitors hemodynamics without use of routine phlebotomy. We hypothesize that stable blunt pediatric isolated splenic/liver injuries can be managed safely using a protocol reliant on vital signs and not repeat hemoglobin levels. Methods: A prospective multi-institutional study was performed at three pediatric trauma centers. All pediatric patients from 07/2016-12/2017 diagnosed with liver or splenic injuries were identified. If appropriate for the protocol, only a baseline hemoglobin was obtained unless hemodynamic instability as defined in an age-appropriate fashion was determined by treating physician discretion. Descriptive statistics were conducted. Results: One hundred four patients were identified of which 38 were excluded from the protocol. There was a significant difference in abnormal shock index, pediatric age-adjusted (SIPA) values, hematocrit, and percentage of patients with hemoglobin less than 10 between the excluded and induded patients. Of the 66 patients managed on the protocol, four patients had to be removed, two each on day one and day two. Of those four patients, only one required intervention. There were no mortalities. Conclusion: A phlebotomy limiting protocol may be a safe option for stable pediatric splenic and liver injuries cared for in a pediatric trauma center with the resources for rapid intervention should the need arise. The differences in groups highlight the importance of utilizing this protocol in the correct patient population. Reduced phlebotomy offers the potential for reduced resource expenditure without any evidence of increased morbidity or mortality. (C) 2019 Elsevier Inc. All rights reserved.

OBJECTIVES:The aim of this study was to document the process of achieving full enteral feeding in infants with omphalocele and to identify factors that affect feeding success.METHODS:After institutional review board approval (study no. 5100169), 123 infants with omphalocele, born between 1993 and 2011 were reviewed. Mortalities were excluded. All survivors had complete follow-up. Variables suspected to impact enteral feeding in infants with non-giant versus giant omphalocele were compared. Independent t test, Mann-Whitney, and χ test were used. Regression evaluated for variable independence.RESULTS:Of 123 infants with omphalocele, 97 (79%) survived, 62/97 (64%) had non-giant, and 35/97 (36%) giant omphalocele. For survivors, the mean gestational age was 37 ± 4 weeks with median follow-up of 4.4 years (range: 1.4-7.4 years). The median time to full feeds was 4 days (range: 0-85 days) for non-giant versus 8 days (range: 1-96 days) for giant, a significant difference (P < 0.01). Breast milk significantly decreased time to full feeds independent of omphalocele size. Giant omphalocele infants had a significantly higher incidence of respiratory insufficiency at birth (P < 0.01) and sac rupture (P = 0.02), but fewer chromosomal anomalies (P = 0.04). Respiratory insufficiency at birth (P < 0.01) and gastroesophageal reflux disease (P < 0.01) independently delayed feeding in omphalocele infants.CONCLUSIONS:Infants with non-giant omphalocele can achieve full enteral feeds within the first week of life, but giant omphalocele infants require significantly more time. Breast milk independently promotes feeding success whereas gastroesophageal reflux disease and respiratory insufficiency at birth independently delay feeding in infants with omphalocele.

Background/Purpose: To identify factors associated with nonoperative treatment failure in pediatric perforated appendicitis compared to immediate appendectomy. Methods: After IRB approval, between September 2016 and August 2017, prospective data were recorded for children (age: 1-18 years) with completed appendectomies and pathologist-confirmed perforations. Children were treated according to clinician-designated preference. Nonoperative treatment was considered failed if a nonresolving obstruction developed or any return of symptoms before the planned interval The median time from pain onset to treatment initiation was 3 days (range: 1-14). Presentation on days 1 or 2 (early) was compared to day 3 or after(late). The nonoperatives were compared to appendectomies stratified by presentation time. Variables were compared by chi-square, Fisher exact or t-tests. Logistic regression evaluated for independence. Results: Of 201 suspected perforations, 176 were included, 101 (57%) immediate appendectomies and 75 (43%) nonoperatives. Of 75, 24 (32%) failed; 6 (25%) in hospital, 18 (75%) after discharge. In 51 (68%), nonoperative treatment succeeded. Significantly younger children failed nonoperative treatment (p = 0.03). Failure was independently associated with treatment initiation within 2.75 days from pain onset (OR: 0.07, 95% CI: 0.57-0.98) (p = 0.010) and lower WBC at presentation (OR: 0.03, 95% CI: 0.81-0.98) (p = 0.014). When compared to immediate appendectomy, nonoperatives had more morbidity. Conclusion: Younger children fail nonoperative treatment, perforate rapidly and have a significantly lower WBC, but benefit from immediate appendectomy. (C) 2018 Elsevier Inc. All rights reserved.

Pneumatoceles are air-filled cysts within the lung parenchyma that can have a connection to the bronchial tree. These are often seen following severe lung infections mainly with Staphylococcus aureus (S. aureus). Currently there is no consensus on management of these lesions. We present the case of a premature 28 weeks gestational age male infant, born at an outside hospital, requiring intubation shortly after birth for respiratory distress, who during the first week of life developed a S. aureus pneumonia. He was treated with a three-week course of Nafcillin but on day of life (DOL) 13, chest radiographs (CXR) demonstrated the presence of a right upper lobe pneumatocele. Despite treatment of the pneumonia, the pneumatocele persisted. It steadily enlarged and progressed to an acute tension physiology presentation. Despite supportive care with maximal ventilatory support, the clinical condition deteriorated which led to a decision for surgical intervention. Because of the extremely high mortality risk associated with a formal lung resection in this premature infant, a percutaneous drain was placed at the bedside on DOL76. The drain remained in place until DOL106 when complete resolution of the pneumatocele prompted removal of the tube. During the prolonged course that the drain was in place, there were intermittent air leaks as well as pneumatocele expansion episodes that prompted intermittent suction. Based on our limited experience, single percutaneous chest tube drainage is a viable option for treatment of large post-infectious pneumatocele in preterm infants.

The aim was to prospectively document the impact of early versus late appendectomy on intestinal function in pediatric perforated appendicitis. After Institutional Review Board approval, between September 2016 and August 2017, complete data were prospectively collected for children undergoing planned appendectomy for perforated appendicitis. One hundred children with pathologist-confirmed transmural perforations were included. The median time to operation after pain onset was three days. Operation on day 1 or 2 (early) was compared with that on day 3 or after (late) (range, 3-9 days). Emesis, nasogastric tubes, and time to tolerate diet evaluated intestinal function. Categorical and continuous variables were analyzed by chi-square and t tests. Of the 100, there were 45 in the early and 55 in the late group, with 22/55(40%) operated on day 3. Children with early appendectomy were significantly younger, 7.8 (3.5) versus 9.5 (3.8) years (P = 0.02). Pre-appendectomy, more than 80 per cent of each group had emesis (P = 0.84), but the late group had a 10-fold increase in nasogastric tube use (P = 0.02). The early group tolerated regular diet significantly faster, 2.5 (2.1) versus 4.4 (4.1) days (P = 0.01), and had a significantly shorter hospital stay, 3.5 (2.2) versus 5.6 (4.3) days (P = 0.01). When pain onset to appendectomy is less than three days, the time to return of intestinal function is significantly reduced.

Congenital generalized lipodystrophy (CGL) is a rare autosomal recessive disorder that affects adipocyte development. Presentation varies based on type. A 12-year old female with CGL type 4, developed a sigmoid colon perforation in the setting of colonic wall hypertrophy after colonoscopy. She presented to the emergency room (ER) with several days of worsening abdominal pain and fevers. The initial evaluation was concerning for infectious versus inflammatory colitis. She was admitted for gastroenterology (GI) consultation for the complaint of abdominal pain. The patient had an established history of constipation management with laxatives. Full GI evaluation, including infectious panel as well as esophagogastroduodenoscopy (EGD) and colonoscopy, was negative. During the colonoscopy some difficulty with passage of the colonoscope past 25 cm was reported and therefore a gastroscope was used. She met criteria to start a clear liquid diet following the procedure. Two days after the colonoscopy, she had pneumoperitoneum on abdominal radiographs and was taken to the operating room for exploratory laparotomy. At the time of surgery, copious fibrinopurulent exudate was found throughout the abdominal cavity, as well as a thickened sigmoid colon/rectum and perforation with a contained abscess at the rectosigmoid junction. Sigmoid colectomy and end colostomy were performed. Pathologic examination demonstrated diffuse colonic wall thickening, a serosal defect that did not extended to the mucosa and several early diverticula. The pathology report stated that the presence of microscopic perforations could not be ruled out. The patient had an uneventful post-operative recovery. Congenital generalized lipodystrophy type 4 is a rare disease. We suspect an association between the muscular hypertrophy and the clinical presentation of bowel wall thickening and stricture. Given the rare nature of this disorder, clinicians that evaluate patients with CGL type 4 for constipation should have a suspicion for the possibility of colonic strictures. Rarely the condition can advance to perforation.

Objective: The aim was to review the incidence and clinical presentation of neonates with congenital syphilis requiring surgical consultation at a single tertiary neonatal intensive care unit (NICU). Methods: Between 2014 and 2016, all records incorporating congenital syphilis and syphilis during pregnancy were obtained to establish disease incidence. During this time, neonates with congenital syphilis and a pediatric surgery consultation were reviewed. Demographic data, details of surgical consultation, operations and clinical outcomes were recorded. Results: Between 2014 and 2016, cases of maternal syphilis increased from one to five, and congenital syphilis cases ranged from two to ten. In 2016, four (40%) required surgical consultation. Indications for surgical consultation included: (1) obstructive jaundice, (2) abdominal distension with bilious emesis, (3) distension and hematochezia, and (4) possible anorectal malformation. All were diagnosed by rapid plasma reagin test (RPR) and completed a 10-day course of Penicillin G. One neonate with obstructive jaundice underwent surgery to rule out biliary atresia. Three neonates did not require surgical intervention. Conclusion: An understanding of congenital syphilis is imperative for pediatric surgeons. Hepatic and gastrointestinal manifestations may mimic surgical diagnoses in neonates.