INTRODUCTION:Rectal adenocarcinoma is exceptionally rare in children and is now recognized as a distinct entity from colon cancer, thereby requiring different treatment approaches. Differences between the pediatric and adult populations have not been previously explored. This study aims to characterize tumor biology, disease presentation, treatment, and survival outcomes in pediatric and adolescent rectal cancer with the goal of improving care in this population. METHODS:A retrospective analysis was conducted using the National Cancer Database (NCDB) for patients aged 0-90 years old diagnosed with rectal adenocarcinoma between 2004 and 2019. Patients were stratified into three age cohorts: pediatric and adolescents (PEDS) (≤21 years old), young adults (YAs) (22-49 years old), and older adults (OAs) (≥50 years old). Chi-squared, multivariate regression, Kaplan-Meier analysis, and Cox regression were performed. RESULTS:A total of 181,246 patients (127 PEDS, 34,552 YAs, and 146,567 OAs) were included. A greater proportion of PEDS presented with poorly differentiated or undifferentiated tumors. PEDS more commonly presented with Stage III or IV disease. PEDS had equivocal overall survival (OS) compared to OA in all stages and YA in Stage IV disease. PEDS had worse OS compared to YA in Stage I (hazard ratio [HR]: 3.33, confidence interval [CI]: 1.49-7.42, p = 0.003), Stage II (HR: 3.01, CI: 1.62-5.60, p < 0.001), and Stage III (HR: 2.41, CI: 1.69-3.44, p < 0.001) disease. CONCLUSION:PEDS with rectal adenocarcinoma present with more aggressive, advanced disease and often worse survival compared to younger adults. The findings suggest distinct biological behavior of pediatric and adolescent rectal cancer, emphasizing the need for further research in this population.

Since its founding in 1930, the American Academy of Pediatrics (AAP) has recognized that comprehensive child health requires not only primary care but also specialized procedural expertise. Beginning with the establishment of the Section on Surgery in 1948, pediatric surgical and procedural disciplines progressively organized within the academy to ensure that children's unique operative, anesthetic, radiologic, and dental needs were represented in policy, education, and advocacy. Over subsequent decades, sections devoted to anesthesiology and pain medicine, urology, orthopedics, otolaryngology-head and neck surgery, radiology, ophthalmology, plastic surgery, neurological surgery, and oral health were formed, each emerging from sustained advocacy by leaders who understood that children require standards distinct from adult-based models of care. Although subspecialty certification through American Board of Medical Specialties member boards strengthened professional identity in several disciplines, section status within the AAP provided a critical platform for multidisciplinary collaboration, guideline development, and national advocacy. The creation of the Surgical Advisory Panel in 1998 unified these sections and strengthened representation on the AAP Board of Directors. In 2023, organizational restructuring led to the formation of the Pediatric Surgical Specialties Alliance, which aligned 10 sections within a coordinated framework. Together, these specialists now represent more than 2000 members and shape national standards in trauma systems, perioperative safety, imaging, sedation, congenital anomaly management, injury prevention, and oral health, affirming that optimal pediatric care depends on integrated partnerships between general pediatricians and procedural experts.

PURPOSE:This study characterizes the geographic distribution of pediatric surgical practices in the U.S. relative to the pediatric population (ages 0-17 years). Prior analyses estimated that over 10 million children (14.8%) live more than 60 miles from a pediatric surgeon, overlooking outreach clinics that extend access and reduce travel distances. Our goal was to generate a more accurate assessment of travel burden using data that includes all practice locations. METHODS:The APSA membership directory was used to identify pediatric surgery practices. Practices were contacted for information on faculty and the number and location of hospitals and clinics as of July 31, 2025. Practice locations were compared to population demographics from the US 2020 Census data calculating straight-line driving distances both across and within state lines. RESULTS:A total of 248 unique primary hospital and clinic sites were identified. An additional 684 hospital locations and 512 clinic locations were also identified. The average travel distance to the practice's primary location (hospital or clinic) for children traveling across state lines (ASL) was 55.0 miles, and within states travel (WSL) was 63.4 miles, with 13.2% of children living >60 miles from care (n = 9,662,011). Including all 932 hospitals served by these practices, average distances decreased slightly to 50.3 miles ASL and 58.2 miles WSL, with 11.1% >60 miles (n = 8,125,546). For the 248 primary clinics; distances to care were similar to those from the primary hospitals. Considering all clinics (n = 760), distances decreased to 41.5 miles ASL and 48.1 miles WSL, with only 6.7% of children >60 miles away (n = 4,928,417). CONCLUSIONS:Pediatric surgical care is unevenly distributed in the United States. Both outreach hospitals and clinics can positively impact travel distances for patients. This impact is even greater when children are allowed to cross state lines for pediatric surgical care. These findings support workforce planning and resource allocation to ensure pediatric surgeons are available where children need them most.

PURPOSE:Pediatric general surgeons provide essential specialized care for children, yet the structure, geographic distribution, and access implications of U.S. pediatric surgery practices remain incompletely characterized. This study presents a national assessment of the pediatric surgery workforce, examining practice composition, resources, and the complementary roles of fellowship-associated (FA) and non-fellowship-associated (NFA) practices in delivering care. METHODS:Individual pediatric surgical practices were identified through multiple sources, including the American Pediatric Surgical Association membership directory. Practices were contacted to obtain data on surgeon composition, advanced practice provider (APP) utilization, locum tenens (LT) use, and the number of hospitals, clinics, consultation sites, and operating locations covered as of July 31, 2025. Practice locations were geocoded by zip code. Workforce distribution was compared with 2020 U.S. Census data on the pediatric population to calculate children-per-surgeon ratios by state. Travel distance modeling assessed access to care with FA practices alone and with NFA practices added. Data are presented as medians [interquartile range]. RESULTS:A total of 248 practices employing 1191 pediatric surgeons were identified across all states and the District of Columbia. Practice size varied widely (median 3.5 [2.0-6.0] surgeons). APPs were employed in 79% of practices, while 24% relied on LT coverage. State-level child-to-surgeon ratios showed substantial variability, with nearly half of the states having ratios that were either lower or higher than expected. Fifty-two practices (21%) were FA, and 196 (79%) were NFA. FA practices had significantly more surgeons, greater APP support, and broader institutional coverage across hospitals, clinics, and operating sites (all p < 0.0001). NFA practices, however, were more widely distributed geographically. Access modeling showed that including NFA practices reduced median travel distances for families by more than 50% and cut the share of children living more than 60 miles from surgical care from 43% to 13%, affecting approximately 32 million versus 5 million children. CONCLUSION:The U.S. pediatric surgery workforce comprises diverse practice models with distinct but complementary strengths. FA practices provide infrastructure-intensive care, while NFA practices substantially expand geographic access. Together, they form an interdependent national network critical to equitable pediatric surgical care. These findings provide essential data to inform workforce planning, policy initiatives, and strategies to preserve timely access to surgery for children.

Children living in remote and Indigenous communities in Canada often face significant barriers to timely surgical care due to geographic isolation, limited local resources, and financial pressures within a publicly funded healthcare system. These challenges frequently create ethical dilemmas for clinicians and families, who must choose between delaying care for transfer to a tertiary center or proceeding locally with limited expertise. This paper explores three illustrative cases including emergent neonatal volvulus with no possibility of transfer, pyloric stenosis with family-declined transfer, and elective hernia repair with family-requested transfer. The purpose is to examine the ethical tensions that arise when access to specialized pediatric surgery is constrained. Applying the principles of beneficence, non-maleficence, justice, and respect for autonomy, each scenario highlights the complex interplay between individual patient needs, professional responsibility, systemic equity, and fiscal stewardship. Through these cases, we argue that ethical decision-making under constraint demands not only clinical judgment but also an understanding of the healthcare system and a nuanced approach. Solutions such as enhanced rural surgical training, telemedicine support, culturally informed care, and robust infrastructure investment are essential to ensure that no child is left behind due to geography or resource scarcity.

BACKGROUND:Pediatric and Adolescent Gynecology (PAG) emerged to bridge gaps between pediatrics and adult gynecology, while pediatric surgeons currently provide most operative gynecologic care for young patients. The goal of this survey was to understand pediatric surgical subspecialty perspectives on access to PAG services, perceived management patterns for common gynecologic conditions, and to assess opportunities for collaborative clinical and surgical care with PAG providers METHODS: A voluntary, anonymous, eight-question descriptive survey was distributed to members of the American Academy of Pediatrics Section on Surgery (SOSu) and Section on Urology (SOU). Survey questions assessed perceived PAG access, consultation patterns, coverage, and condition-specific management by subspecialty. Quantitative data were summarized descriptively, and qualitative free-text responses were analyzed thematically. RESULTS:Of 701 AAP SOSu and SOU members surveyed, 136 responded (19.4%). 63% reported access to PAG. PAG was perceived as primarily providing consultations (96%) and multidisciplinary support (58%). Pediatric surgeons self identified as the primary managers of most acute and congenital conditions. PAG was associated with endometriosis, ectopic pregnancy, and miscarriage management. Care for fertility preservation and Tuboovarian abscess/pelvic inflammatory disease(TOA/PID) were mixed. Free-text responses emphasized PAG's focused expertise and multidisciplinary value, with concerns regarding limited availability. CONCLUSIONS:This survey describes pediatric surgical subspecialty perspectives on pediatric and adult gynecologic care and access to PAG services. While pediatric surgeons manage many common gynecologic conditions, PAG providers serve as consultants, participate in multidisciplinary clinics, and offer specialized reproductive tract expertise. These findings highlight the importance of pediatric surgery while underscoring the value of expanding PAG within a collaborative model to meet evolving patient needs.

OBJECTIVE:Access to specialized pediatric surgical care is crucial for optimal child health outcomes; however, geographic barriers may limit timely access. This study examines national variations in distance to pediatric general surgeons across the United States. METHODS:We performed a cross-sectional analysis using 2020 American Pediatric Surgical Association membership data to identify board-certified pediatric surgeons, linked with population demographics from the 2020 U S. Census. Straight-line distances from each ZIP code to the nearest pediatric surgeon were calculated, both allowing and restricting crossing of state lines. Distances were compared across demographic, geographic, and socioeconomic factors. State-level surgeon-to-child ratios were standardized and analyzed. RESULTS:Among 73,103,902 children and 1527 pediatric surgeons (47,874 children per surgeon), 89.2 % of children lived within 60 miles of a pediatric surgeon, while 10.8 % lived farther away. Median travel distance differed by race, with Native American children traveling the farthest (86.4 miles), followed by White (28.7), Black (16.9), and Asian (11.8) children. Rural and economically distressed areas were disproportionately affected, with 45.4 % and 18.8 %, respectively, living more than 60 miles from care. Restricting travel within state lines increased the proportion of children living more than 60 miles from a surgeon to 13.8 % and to 54.1 % in rural areas. State-level distances varied from 9.1 miles in Rhode Island to 360.7 miles in Alaska. Nineteen states had more pediatric surgeons than expected based on population, while 31 had fewer. CONCLUSIONS:Despite increased availability of pediatric surgeons, significant geographic and demographic disparities persist, highlighting the need for targeted policies to promote equitable pediatric surgical care nationwide.

Background: Wait times for children's hospital-based surgical services are at unprecedented levels. Opportunities to increase most children's hospital-based service capacity are sparse, and communitybased services are a potential patient-centered alternative. The aim of this study was to understand the current state of pediatric surgical outreach in Canada as an option to address these challenges. Methods: An electronic survey was sent to all (n 1/4 18) Canadian children's hospital surgical leaders inquiring about "outreach services" defined as inpatient/outpatient services provided by pediatric surgeons outside of children's hospitals. Descriptive analysis of outreach included facility type/location (by postal code), nature and frequency of service, and participation of other specialties. Results: 18 survey respondents (100 %) reported that pediatric surgical outreach services were available in 7 out of 10 provinces, but only 8/18 (44 %) of Canadian children's hospitals. Services include: i) inpatient coverage at 2 sites in 2 provinces; ii) outpatient surgery at 6 sites in 3 provinces (median distance 69 km, range 6-1881 km from home children's hospital); and iii) outpatient ambulatory clinics at 19 sites in 4 provinces (median distance 18 km, range 4-1448 km from home children's hospital). Median frequencies of outreach surgical slates and clinics were 1 per week and 1 per month, respectively. Conclusion: Less than half of Canadian children's hospitals have developed outreach programs as a strategy to increase capacity for children's surgical services. To promote improved surgical care for all Canadian children, efforts targeting expansion of outreach capacity could increase access for geographically remote children. Type of Study: Cross sectional Retrospective Survey. Level of Evidence: Level IV. (c) 2025 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Introduction Ergonomic injuries pose significant risks to surgeons, affecting health, productivity, care access, and retirement age. Despite unique challenges in pediatric surgery, including varied patient sizes and operations, little is known about pediatric surgeons' ergonomics. This study aimed to assess ergonomic practices and associated injuries among pediatric surgeons. Methods A cross-sectional survey was distributed to the American Pediatric Surgical Association regular members and fellows. Data collected included demographics, physical health, surgical practices, operating habits, discomfort, injuries, interventions, and outcomes. Associations with injury were analyzed using Fisher's exact test, Pearson's Chi-squared test, and Wilcoxon rank-sum tests. Results One hundred seventeen (11%) surgeons responded, 53% were male with a median of 15 y in practice (interquartile range: 6-25). Regarding operating habits, 76% did not take regular breaks, 48% double-gloved, and 51% used loupes regularly. Notably, 90% experienced discomfort or pain, and 30% sustained injuries from operating, primarily affecting the neck and cervical spine (53%). White-identifying pediatric surgeons (80%) reported significantly more ergonomic injuries than other races (P < 0.01). Only 18% of respondents received ergonomic training. Ergonomics training and operating with a resident or co-surgeon were associated with less injury (P < 0.05). Among those experiencing discomfort or injury, 13% underwent a procedure, 63% experienced sleep disturbance, 74% reported contribution to burnout, and 88% used pain medications. Conclusions Ergonomic-related discomfort and injuries occurred in nearly 90% of pediatric surgeons who responded. Few had ergonomic training and most reported an impact on well-being. Modifiable ergonomic factors for pediatric surgeons, along with targeted interventions to reduce injuries, can improve surgeon well-being.

Surgeons of all specialties are impacted by health policies, primarily written and executed by nonmedical parties. The sequelae of policy change may limit the patient-physician relationship across numerous surgical disciplines, including general and acute care surgery, OB/GYN surgery, pediatric and fetal surgery, and others. The discordance between a surgeon's imperative to provide excellent patient care and legislative limitations that hinder patient care can impact surgeon wellness, career longevity, and attrition as well as reduce access and outcomes for patients, across specialties. Limited literature addresses this presage to physician wellness and patient outcomes. Combatting moral distress requires a framework that considers a multifactorial approach including open communication and respect among colleagues, free discussion of challenges related to health policy, resources for coaching and therapeutic counseling, and organizational actions promoting surgeon wellness. In this article, we present strategies, curated and executed by our subspecialty advocacy group, for navigating moral challenges secondary to health policy. This framework may be implemented across specialties to promote discussion of controversial or difficult topics in the professional setting and help prevent distress and attrition.

Introduction We sought to understand the impact of locum tenens surgeons on pediatric surgical care delivery. Methods We conducted a cross-sectional survey of Children’s Hospital Association pediatric surgical practices. Anonymous electronic surveys were used to investigate locum tenens utilization, primary reason for use, limitations on clinical activities, and variations in practice standards or quality. Bivariate analysis and multivariable logistic regression were performed to evaluate for associations between practice characteristics and locum tenens use. Results Of 172 practices, 71% (n = 122) completed the survey. Median hospital size was 203 beds (interquartile range = 130-350). Median number of surgeons per practice was 5 (interquartile range = 3-8). Thirty-seven practices (30%) employed locum tenens at primary (n = 27) or satellite (n = 12) sites. Locum tenens utilization was higher in suburban (odds ratio [OR] = 3.78, P = 0.006) and rural (OR = 4.96, P = 0.041) locations and lower at sites with a level 4 neonatal intensive care unit (OR = 0.35, P = 0.035). Most (51%) used locum tenens ≥ 1 time monthly but < 1 time weekly and for ongoing or interim coverage (87%). In total, 14% of practices reported clinical restrictions for locum tenens surgeons, including limitations on extracorporeal membrane oxygenation, neonatal index cases, and operative trauma. Most (76%) practices using locum tenens reported variations in practice standards or quality; all were perceived as negative (57%) or neutral (43%). Conclusions Locum tenens providers are utilized most commonly in suburban and rural sites and hospitals without the highest level of neonatal intensive care. While locum tenens surgeons may help maintain access to pediatric surgical care where gaps exist, there may be a need to improve the quality and reliability of care rendered.

BACKGROUND:Specialized pediatric surgical referral programs (PSPs) for complex conditions are increasing across the United States, resulting in care rendered geographically distant from patients' homes. We explored care coordination gaps across differing stakeholder perspectives to identify opportunities to optimize post-discharge practices in this evolving landscape. METHODS:We reviewed published literature for guidelines and consensus statements on ideal care coordination practices. Qualitative interviews were conducted with three PSPs examining themes and gaps in their care coordination workflows. Surveys were distributed to an established family support network to assess patient/family perspectives on post-discharge care. To explore communication bias across practice settings, surveys were provided to American Pediatric Surgical Association (APSA) members. RESULTS:Eight thematic domains for an ideal care coordination framework were identified. Effective PSP practices included identifying local physician contacts, providing thorough pre-discharge patient/family education, and ensuring reliable post-discharge PSP access. PSPs reported challenges in ensuring patient access to medication/devices, variability in discharge documentation, and lack of closed-loop feedback. Fifty-two family support network surveys (13 % response) revealed PSPs frequently fulfilled medication/device safety, but demonstrated gaps in medication/device receipt confirmation, insurance coverage for medications/devices, and assessment of discharge readiness. In 239 APSA responses (17 % response), local surgeons perceived bias against non-academic practice environments as a barrier to effective post-discharge PSP care coordination. CONCLUSION:PSPs implement care coordination practices that inconsistently address the core domains of a standardized framework. These findings provide guidance for improved alignment between PSPs, families, and local surgeons to optimize pediatric surgical post-discharge care coordination independent of geography.

Hazardous consumer products are a leading cause of preventable injuries among children, despite oversight by the U.S. Consumer Product Safety Commission (CPSC). With their unique clinical insights, pediatric surgeons can play a critical role in advocating for improved product safety standards. This paper explores strategies for reducing injuries linked to products like all-terrain vehicles, button batteries, and magnets, emphasizing using injury data, collaboration with policymakers and manufacturers, and engagement with professional organizations. It also underscores the need for advocacy training in surgical education to prepare surgeons to lead these efforts. Importantly, it highlights the crucial role of public awareness campaigns in engaging the community and fostering a safety culture. By aligning clinical expertise with public health initiatives, pediatric surgeons can support the CPSC's mission and foster safer environments for children.

BackgroundThe clinical scope of Pediatric Adolescent Gynecology (PAG) is extensive and overlaps with other providers who participate in female reproductive health including Pediatric General Surgery and Pediatric Urology. PAG took decades to differentiate from their adult counterparts into a now organized subspecialty. We sought to understand the perception of PAG provider availability as well as case coverage given the field's expansion.MethodsA national 8-question survey was sent out to the American Academy of Pediatrics (AAP) Section on Surgery (SOSu) and Urology (SOU) members with questions focused on practice patterns and inquiry on the availability of PAG specialists in their hospitals. The survey was sent to members twice over a period of 3 months to maximize response. Qualitative data was collected.ResultsOf the total of 701 members surveyed, there were 136 responses (19.4%). Of the responders, 63% indicated that PAG providers were currently available in their hospital. PAG providers offered consultations (96%), multidisciplinary team participation (58%), interdisciplinary education (38.5%) and participated in research (30%). Half of respondents viewed PAG as accessible, with 24/7 call coverage, and a majority reported perceived availability as an ambulatory consultant. Respondents could select one or more subspecialty for each response and reported that pediatric surgeons were primarily managing ovarian torsion, GU trauma, adnexal masses, and Mullerian anomalies. PAG was perceived as being primarily responsible for cases of endometriosis, ectopic pregnancies, and miscarriages. There was equipoise regarding care for patients with fertility preservation and TOA/PID. Free text comments regarding the value PAG adds to the care team were categorized as positive vs negative leaning. Positive themes included value in dedicated field of focus, aid in multidisciplinary teams, and longitudinal follow up. Negative themes centered around limited availability and perceived lack of value as a separate practice.ConclusionsThe survey shows the current opinions for which gynecologic disease entities are being cared for by specific services. While pediatric surgeons provide care for many of these patients, PAG providers interact with pediatric care teams as consultants, participate in multidisciplinary clinics, and provide expertise in the surgical management of the reproductive tract. Enthusiasm for increased interdisciplinary collaboration among AAP SOSu members may be based on PAG provider availability and could be aided by the expansion of PAG providers.

BACKGROUND: To review race and ethnic group enrollment and outcomes for Wilms tumor (WT) across all 4 risk-assigned therapeutic trials from the current era Children’s Oncology Group Renal Tumor Biology and Risk Stratification Protocol, AREN03B2. STUDY DESIGN: For patients with WT enrolled in AREN03B2 (2006 to 2019), disease and biologic features, therapeutic study-specific enrollment, and event-free (EFS) and overall (OS) 4-year survival were compared between institutionally reported race and ethnic groups. RESULTS: Among 5,146 patients with WT, no statistically significant differences were detected between race and ethnic groups regarding subsequent risk-assigned therapeutic study enrollment, disease stage, histology, biologic factors, or overall EFS or OS, except the following variables: Black children were older and had larger tumors at enrollment, whereas Hispanic children had lower rates of diffuse anaplasia WT and loss of heterozygosity at 1p. The only significant difference in EFS or OS between race and ethnic groups was observed among the few children treated for diffuse anaplasia WT with regimen UH-1 and -2 on high-risk protocol, AREN0321. On this therapeutic arm only, Black children showed worse EFS (hazard ratio = 3.18) and OS (hazard ratio = 3.42). However, this finding was not replicated for patients treated with regimen UH-1 and -2 under AREN03B2 but not on AREN0321. CONCLUSIONS: Race and ethnic group enrollment appeared constant across AREN03B2 risk-assigned therapeutic trials. EFS and OS on these therapeutic trials when analyzed together were comparable regarding race and ethnicity. Black children may have experienced worse stage-specific survival when treated with regimen UH-1 and -2 on AREN0321, but this survival gap was not confirmed when analyzing additional high-risk AREN03B2 patients.

The Section on Surgery of the American Academy of Pediatrics celebrates its 75th anniversary in 2023. To continue the tradition begun 25 years ago with analyses of the first two 25 years timespans of the organization, this examination focuses on the most recent quarter century. To frame this review, we begin with the seminal beginnings with the work of the section’s founder, Herbert E Coe and reflect upon the twenty charter members of the organization. Then we explore the important accomplishments and challenges of the organization to the current time. Finally, we conclude with a glimpse of what the future holds for the first home of pediatric surgeons.Type of StudyReview.Level of EvidenceV.

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.