Protein-losing enteropathy (PLE) is caused by protein loss through the gastrointestinal tract which results in hypoalbuminemia. The most common causes of PLE in children include cow milk protein allergy, celiac disease, inflammatory bowel disease, hypertrophic gastritis, intestinal lymphangiectasia, and right-sided heart dysfunction. We present a case of a 12-year-old male with bilateral lower extremity edema, hypoalbuminemia, elevated stool alpha-1-antitrypsin, and microcytic anemia. He was found to have a trichobezoar in the stomach extending to the jejunum, an unusual cause of PLE. The patient underwent an open laparotomy and gastrostomy to remove the bezoar. Follow-up confirmed resolution of hypoalbuminemia.

The Children's Surgery Verification Program of the American College of Surgeons began in 2016 based on the standards created by the Task Force for Children's Surgery. This program seeks to improve the surgical care of children by assuring the appropriate resources and robust performance improvement programs at participating centers. Three levels of centers with defined scopes of practice and matching resources are defined. Since its inception more than 50 center have been verified. A specialty hospital program was launched in 2019. The standards for all hospitals were revised in 2021 based on lessons learned. In this article the leaders of the program discuss the development, areas of greatest impact and future directions of the program.

OBJECTIVES:Disparities in pediatric health outcomes are widespread. It is unclear whether rurality negatively impacts outcomes of infants with surgical congenital diseases. This study compared outcomes of rural versus urban infants requiring complex surgical care at children's hospitals in the United States.METHODS:Rural and urban infants (aged <1 year) receiving surgical care at children's hospitals from 2016 to 2019 for esophageal atresia, gastroschisis, Hirschsprung's disease, anorectal malformation, and congenital diaphragmatic hernia were compared over a 1-year postoperative period using the Pediatric Health Information System. Generalized linear mixed effects models compared outcomes of rural and urban infants.RESULTS:Among 5732 infants, 20.2% lived in rural areas. Rural infants were more frequently white, lived farther from the hospital, and lived in areas with lower median household income compared with urban infants (all P < .001). Rural infants with anorectal malformation and gastroschisis had lower adjusted hospital days over 1 year; rural infants with esophageal atresia had higher adjusted odds of 30-day hospital readmission. Adjusted mortality, hospital days, and readmissions were otherwise similar between the 2 groups. Outcomes remained similar when comparing urban infants to rural infant subgroups with the longest hospital travel distance (≥60 miles) and lowest median household income (<$35 000).CONCLUSIONS:Despite longer travel distances and lower financial resources, rural infants with congenital anomalies have similar postoperative outcomes to urban infants when treated at children's hospitals. Future work is needed to examine outcomes for infants treated outside children's hospitals and to determine whether efforts are necessary to increase access to children's hospitals.

More than two thirds of the global population lack access to safe, affordable surgical and anesthesia care. This inequity disproportionately affects children in low- and middle-income countries (LMIC). In 2016, a group of pediatric surgical care providers founded the Global Initiative for Children’s Surgery (GICS). Their goal was to assemble a multidisciplinary team of specialists and advocates to improve surgical care for children, with a particular emphasis on those in low-resource settings. This review details the history of GICS, the process of its inception, the values guiding its work, its past achievements, and its current initiatives. The experience of GICS may serve as an effective model for global collaboration on other areas of public and global health.

On behalf of the American College of Surgeons (Chicago, Illinois) Children’s Surgery Verification program, we wish to clarify some of the statements in the article by McManus and França1 entitled “Availability of Inpatient Pediatric Surgery in the United States,” and the accompanying editorial by Ambardekar and Schwartz.2 Though we completely agree that there has been consolidation of pediatric surgery toward high-capability pediatric centers, we disagree with the statement that “the American College of Surgeons launched its Children’s Surgery Verification Quality Improvement program to promote regionalization.” Regionalization is defined as the “integrated organization of a healthcare system, wherein regional structures are responsible for providing and administrating health services in a specific region.”3 This was never the intent of the American College of Surgeons Children’s Surgery Verification program. In contrast, the program strives to provide care in appropriate settings without the need for consolidation by developing standards not only for Level 1 but also for Level 2 and 3 centers and defining optimal pediatric surgical care within the scope of practice of the institution and providers. The clearly articulated vision of the American College of Surgeons Children’s Surgery Verification is that “every child in need of surgical care in North America today will receive this care in an environment with resources optimal for his/her individual need.” While there is some intrinsic correlation between patient volume and available resources, the American College of Surgeons Children’s Surgery Verification program has focused on defining optimal resources and assuring that the right resources are available at the bedside at the time of a child’s need. One of the lessons learned from the early years of the program has been that even premiere dedicated children’s institutions have required change in order to meet the 24/7/365 expectation of having the right resources for infants and children at all times.An essential component of a Level 1 American College of Surgeons Children’s Surgery Verification–verified center is the engagement with all acute care facilities, designated centers, and nonspecialty hospitals within the referral area in the performance improvement process.4 As part of the verification process, Level 1 centers must show that they provide leadership in education, research, and system planning and the provision of technical assistance and education to regional hospitals and providers for the purpose of improving system performance. As a part of this, investigators have recently begun the process of defining low-risk pediatric surgical procedures to determine when surgery can be safely provided closer to home or by adult practitioners. This is illustrated by a recent study from Lawrence et al. demonstrating better outcomes after pediatric laparoscopic cholecystectomy with higher hospital or surgeon laparoscopic cholecystectomy volume rather than surgeon pediatric subspecialization.5We agree with the concern that “overconsolidation of services could produce access barriers and other unintended consequences,” especially in rural areas of the country. We contend that the best way to optimize children’s surgical care is to provide a team approach that emphasizes system building by forging alliances with other surgical specialties (including anesthesiology), pediatrician and family practice colleagues, and administrative entities that can provide the essential infrastructure in rural hospitals that care for children.6 System building is a relatively new concept, different from regionalization, that has the potential to optimize pediatric surgical care even in the face of uncontrolled consolidation.Dr. Oldham is the Chair and Drs. Houck, Barnhart, Deshpande, and Fallat are members of the American College of Surgeons Children’s Surgery Verification Committee, Chicago, Illinois.

Fortunately, breast cancer in young women is rare. Fewer than 2% of all breast cancers occur in women under 30 years of age. Several important aspects of diagnosis, management, and prognosis are different for young women when compared with older women. This chapter focuses on these differences. Special considerations such as pregnancy, familial disease, and childhood breast cancer are also reviewed. Epidemiologic studies have related a number of factors, such as family history and reproductive status, to the risk of development of breast cancer. In general, these risk factors do not appear to be different in young women, although several observations relative to ovarian function and pregnancy are age-related. Childhood breast cancer usually presents clinically as a unilateral sub-areolar nodule. Early diagnosis of cancer remains the primary objective of any physician who cares for women with breast disease. Breast cancer during pregnancy or lactation is not common but is invariably a cause of great concern.

Intestinal atresia is a common cause of neonatal bowel obstruction and can occur anywhere along the gastrointestinal tract. Regardless of the location, initial management includes gastric decompression, intravenous fluid resuscitation, hemodynamic stabilization, radiographic evaluation, and work-up of any associated anomalies. Due to advancements in perioperative care and nutrition over the last several decades, most children can have successful establishment of gastrointestinal continuity as a primary procedure in contemporary practice. However, children with coexisting abnormalities, particularly congenital heart disease and short-gut syndrome, can have considerably higher rates of morbidity and mortality.

PURPOSE:With the emergence of the coronavirus disease-2019 (COVID-19) pandemic, institutions were tasked with developing individualized pre-procedural testing strategies that allowed for re-initiation of elective procedures within national and state guidelines. This report describes the experience of a single US children's hospital (Children's Wisconsin, CW) in developing a universal pre-procedural COVID-19 testing protocol and reports early outcomes.METHODS:The CW pre-procedural COVID-19 response began with the creation of a multi-disciplinary taskforce that sought to develop a strategy for universal pre-procedural COVID-19 testing which (1) maximized patient safety, (2) prevented in-hospital viral transmission, (3) conserved resources, and (4) allowed for resumption of procedural care within institutional capacity.RESULTS:Of 11,209 general anesthetics performed at CW from March 16, 2020 to October 31, 2020, 11,150 patients (99.5%) underwent pre-procedural COVID-19 testing. Overall, 1.4% of pre-procedural patients tested positive for COVID-19. By June 2020, CW was operating at near-normal procedural volume and there were no documented cases of in-hospital viral transmission. Only 0.5% of procedures were performed under augmented COVID-19 precautions (negative pressure environment and highest-level personal protective equipment).CONCLUSION:CW successfully developed a multi-disciplinary pre-procedural COVID-19 testing protocol that enabled resumption of near-normal procedural volume within three months while limiting in-hospital viral transmission and resource use.

Background: The purpose of this study was to quantify disparities in the utilization of outpatient pediatric surgical care and to examine the extent to which neighborhood-level socioeconomic disadvantage is associated with access to care among children. Methods: Clinic "no-shows" were examined among children scheduled from 2017 to 2019 at seven pediatric surgery clinics associated with a tertiary care children's hospital. The association between Area Deprivation Index, a neighborhood-level measure of socioeconomic disadvantage, and other patient factors with clinic no-shows was examined using multivariable logistic regression models. Difficulties in accessing postoperative care in particular were explored in a subgroup analysis of postoperative (within 90 days) clinic visits after appendectomy or inguinal/umbilical hernia repairs. Results: Among 10,162 patients, 16% had at least 1 no-show for a clinic appointment. Area Deprivation Index (most deprived decile adjusted odds ratio 3.17, 95% confidence interval 2.20-4.58, P < .001), Black race (adjusted odds ratio 3.30, 95% confidence interval 2.70-4.00, P < .001), and public insurance (adjusted odds ratio 2.75, 95% confidence interval 2.38-3.31, P < .001) were associated with having at least 1 no-show. Similar associations were identified among 2,399 children scheduled for postoperative clinic visits after undergoing appendectomy or inguinal/umbilical hernia repair, among whom 20% were a no-show. Conclusion: Race, insurance type, and neighborhood-level socioeconomic disadvantage are associated with disparities in utilization of outpatient pediatric surgical care. Challenges accessing routine outpatient care among disadvantaged children may be one mechanism through which disparate outcomes result among children requiring surgical care. (C) 2021 Elsevier Inc. All rights reserved.

Children with physical disabilities and children with special health care needs (CSHCN) benefit from a cooperative relationship between parents, medical providers, and pediatric surgeons in managing their surgical needs. This benefit is manifested by simplification of the care provided to children by parents, in order to improve quality of life, development of trust and relationships between parents and caregivers to guide thoughtful decisions about surgical interventions, forging an understanding of the complexities of surgical care by all concerned, and the selection of appropriate surgical candidates and expeditious evaluation of perioperative problems. This chapter focuses on the general principles of family-centered care and common perioperative considerations for CSHCN patients and serves to educate the pediatric surgeon about the importance of comprehensive care and special considerations for children with common conditions that encompass the patient with a physical disability. Pediatric surgical CSHCN patients typically have either a genetic malformation syndrome (i.e., Trisomy 21), cerebral palsy or neurologic impairment, complex congenital heart disease, or a spectrum of comorbid conditions as the result of a congenital malformation. Albeit by no means exhaustive, this chapter will serve to highlight some of the common challenges that must be addressed by the pediatric surgeon caring for this complex group of patients.

Congenital lung malformations are uncommon but extraordinarily diverse in their presentation. Potential consequences may be life-threatening; therefore, an understanding of the diagnosis and treatment of these anomalies is important to all physicians and surgeons who care for infants and children. These lesions vary from asymptomatic to immediately life-threatening in nature and may present antenatally or well into adulthood. Lung development and anatomy are important fundamentals in the discussion of these malformations and aide in understanding the pathophysiology which occurs. The most common congenital malformations include congenital pulmonary airway malformations, pulmonary sequestrations, lobar emphysema, and bronchogenic cysts.

Background Health systems for surgical care for children in low- and middle-income countries remain poorly understood. Our goal was to characterize the delivery of surgical care for children across Brazil and to identify associations between surgical resources and childhood mortality. Methods We performed a cross-sectional, ecological study to analyze surgical care for children in the public health system (Sistema Único de Saúde) across Brazil from 2010 to 2015. We collected data from several national databases, and used geospatial analysis (two-step floating catchment, Getis-Ord-Gi analysis, and geographically weighted regression) to explore relationships between infrastructure, workforce, access, procedure rate, under-5 mortality rate (U5MR), and perioperative mortality rate (POMR). Results A total of 246,769 surgical procedures were performed in 6,007 first level/ district hospitals and 491 referral hospitals across Brazil over the study period. The surgical workforce is distributed unevenly across the country, with 0.13–0.26 pediatric surgeons per 100,000 children in the poorer North, Northeast and Midwest regions, and 0.6–0.68 pediatric surgeons per 100,000 children in the wealthier South and Southeast regions. Hospital infrastructure, procedure rate, and access to care is also unequally distributed across the country, with increased resources in the South and Southeast compared to the Northeast, North, and Midwest. The U5MR varies widely across the country, although procedure-specific POMR is consistent across regions. Increased access to care is associated with lower U5MR across Brazil, and access to surgical care differs by geographic region independent of socioeconomic status. Conclusions There are wide disparities in surgical care for children across Brazil, with infrastructure, manpower, and resources distributed unevenly across the country. Access to surgical care is associated with improved U5MR independent of socioeconomic status. To address these disparities, policy should direct the allocation of surgical resources commensurate with local population needs.

Background The provision of health care in low-income and middle-income countries (LMICs) is recognized as a significant contributor to economic growth and also impacts individual families at a microeconomic level. The primary goal of our study was to examine the relationship between surgical conditions in children and the poverty trajectories of either falling into or coming out of poverty of families across Somaliland. Methods This work used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a validated household, cross-sectional survey designed to determine the burden of surgical conditions within a community. We collected information on household demographic characteristics, including financial information, and surgical condition history on children younger than 16 years of age. To assess poverty trajectories over time, we measured household assets using the Stages of Progress framework. Results We found there were substantial fluxes in poverty across Somaliland over the study period. We confirmed our study hypothesis and found that the presence of a surgical condition in a child itself, regardless of whether surgical care was provided, either reduced the chances of moving out of poverty or increased the chances of moving towards poverty. Conclusion Our study shows that the presence of a surgical condition in a child is a strong singular predictor of poverty descent rather than upward mobility, suggesting that this stressor can limit the capacity of a family to improve its economic status. Our findings further support many existing macroeconomic and microeconomic analyses that surgical care in LMICs offers financial risk protection against impoverishment.

IMPORTANCE Although surgical conditions are increasingly recognized as causing a significant health care burden among adults in low- and middle-income countries (LMICs), the burden of surgical conditions among children in LMICs remains poorly defined. OBJECTIVE To estimate the prevalence of pediatric surgical conditions across Somaliland using a nationwide community-based household survey. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional study was conducted through a national community-based sampling survey from August through December 2017 in Somaliland. Participants were 1503 children surveyed using the Surgeons OverSeas Assessment of Surgical Need (SOSAS). MAIN OUTCOMES AND MEASURES The SOSAS survey contains 2 components, including a section on household demographics, deaths, and financial information and sections querying children's history of surgical conditions. RESULTS In this cross-sectional study that included 1503 children (55.6% male; mean [SE] age, 6.4 [0.1] years), 221 surgical conditions were identified among 196 children, yielding a mean (SE) prevalence of pediatric surgical conditions of 12.2%(1.5%). Only 53 of these 221 surgical conditions (23.7%) had been surgically corrected at the time of the survey. The most common conditions encountered were congenital anomalies (33.8%) and wound-related injuries (24.6%). Nationally, an estimated 256 745 children have surgical conditions, with an estimated 88 345 to 199 639 children having unmet surgical needs. CONCLUSIONS AND RELEVANCE Using national sampling, this study found that children have a high burden of surgical conditions in Somaliland. These data highlight the need for a scale-up of pediatric surgical infrastructure and resources to provide the needed surgical care for children in LMICs.

BACKGROUND/PURPOSE:Surgical management of appendicitis accounts for ~30% of total expenditure in the practice of pediatric surgery and is associated with high cost variation. We hypothesize that incorporating single-incision laparoscopy (SILS) and the resultant by-product dual-incision laparoscopy (DILS) into a historically three-incision laparoscopic (TILS) appendectomy practice affords equal outcomes at lower cost. METHODS:Appendectomies performed at a large-volume tertiary care children's hospital from 1/2015-12/2017 were retrospectively reviewed. Appendectomy technique and appendicitis severity were stratified against operative and admission direct variable (DV) costs. Secondary outcomes included perioperative time course and 30-day postoperative outcomes. RESULTS:A total of 970 appendectomies were analyzed during the study period (61% acute, 39% complex appendicitis). SILS and DILS had significantly lower mean DV costs and OR times compared to TILS for both acute and complex appendicitis while maintaining equivalent outcomes. CONCLUSIONS:SILS and DILS appendectomy techniques can be incorporated into pediatric surgical practice at lower cost than TILS appendectomy while maintaining equivalent outcomes. Further, the introduction of a tiered approach to laparoscopic appendectomy, in which all cases are started as SILS with additional incisions added based on operative difficulty, is estimated to save $74,580 annually in operative DV costs at a pediatric surgical center averaging 314 laparoscopic appendectomies per year. TYPE OF STUDY:Treatment Study. LEVEL OF EVIDENCE:Level III.

Background: There is a movement to ensure that pediatric patients are treated in appropriately resourced hospitals through the ACS Children's Surgery Verification (CSV) program. The objective of this study was to assess the potential difference in care provision, health outcomes and healthcare and societal costs after implementation of the CSV program. Methods: All 2011 inpatient admissions for selected complex pediatric patients warranting treatment at a hospital with Level I resources were evaluated across 6 states. Multivariate regressions were used to analyze differences in healthcare outcomes (postoperative complications including death, length of stay, readmissions and ED visitswithin 30 days) and costs by CSV level. Recycled predictions were used to estimate differences between the base case scenario, where children actually received care, and the optimized scenario, where all children were theoretically treated at Level I centers. Results: 8,006 children (mean age 3.06 years, SD4.49) met inclusion criteria, with 45% treated at Level I hospitals, 30% at Level II and 25% at Level III. No statistically significant differences were observed in healthcare outcomes. Readmissions within 30 days were higher at Level II compared to Level I centers (adjusted IRR 1.61; 95% CI 1.11, 2.34), with an estimated 24 avoidable readmissions per 1000 children if treatment were shifted from Level II to Level I centers. Overall, costs per child were not significantly different between the base case and the optimized scenario. Conclusion: Many complex surgical procedures are being performed at Level II/III centers. This study found no statistically significant increase in healthcare or societal costs if thesewere performed instead at Level I centers under the optimized scenario. Ongoing evaluation of efforts tomatch institutional resources with individual patient needs is needed to optimize children's surgical care in the United States. (c) 2018 Elsevier Inc. All rights reserved.

The December 2017 issue of the Journal or Pediatric Surgery featured two important special communications regarding the appropriateness of global pediatric surgical electives during fellowship training. Emil et al. contextualize our subspecialty within the growing field of global surgery and articulate many of the concerns expressed by both the Association of Pediatric Surgery Training Program Directors (APSTPD) and the Pediatric Surgery Board (PSB) of the American Board of Surgery (ABS) [ [1] Emil S. O'Neill J. Poenaru D. Let our fellows go: a plea for allowing global surgery electives during pediatric surgical training. J Pediatr Surg. 2017; 52: 2088-2090 Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar ]. Their responses to these concerns are reasoned and evidence-based, and they elegantly express the moral argument in favor of exposing trainees to the complexities of providing health care in low- and middle-income environments.

OBJECTIVE:This prospective observational study was designed to assess Pediatric Quality of Life (PedsQL) after surgical treatment for congenital diaphragmatic hernia (CDH), esophageal atresia/tracheoesophageal fistula (EA/TEF), Hirschsprung disease (HD), gastroschisis (GAS), omphalocele (OMP), and necrotizing enterocolitis (NEC).SUMMARY OF BACKGROUND DATA:Improvements in neonatal and surgical care have led to increased survival for many newborn conditions. Quality of life in these patients is seldom explored in a longitudinal manner. We hypothesized that age-adjusted physical and psychosocial scores would improve over time, but with diagnosis-dependent variation.METHODS:Data were collected from 241 patients (CDH = 52; EA/TEF = 62; HD = 46; GAS = 32; OMP = 26; NEC = 23) in an institutional Clinical Outcomes Registry (COR) from 2012 to 2017. Aggregate physical, psychosocial, and overall PedsQL scores were determined for each diagnosis. Spline regression models were created to model scores as a function of age.RESULTS:Physical scores trended up for all diagnoses except CDH and NEC beyond age 10. Psychosocial scores trended up for all diagnoses except NEC and EA/TEF beyond age 10. Beyond age 12, CDH, GAS, and HD patients had overall scores within the normal range, while NEC, OMP, and EA/TEF patients had scores similar to children with chronic medical illness.CONCLUSION:Variation exists in long-term PedsQL scores after neonatal surgery for selected, complex disease. Beyond age 12, quality of life is significantly impaired in NEC, moderately impaired in OMP and EA/TEF, and within normal range for CDH, HD, and GAS patients at the population level. These data are relevant to prenatal and perioperative discussions with patients and families.