BackgroundThe prenatal "double bubble" (DB) sign is a marker of duodenal obstruction. When accompanied by distal bowel fluid on prenatal imaging, concern may arise for malrotation with volvulus. This study evaluated whether distal bowel fluid in fetuses with a prenatal DB sign is associated with malrotation or volvulus.MethodsWe performed an 11-year retrospective review (Jan 2015-Dec 2025) of fetuses with a prenatal DB sign evaluated at a single tertiary care center. Prenatal ultrasound and fetal MRI findings, operative diagnoses, and neonatal outcomes were reviewed, with specific attention to distal bowel fluid on fetal MRI.ResultsTwenty-nine fetuses were identified. Median gestational age at birth was 37.5 weeks (IQR 34.5-38.0), and polyhydramnios was present in 62.1%. Fetal MRI was performed in 10 cases, demonstrating distal bowel fluid in 5. No prenatal imaging suggested volvulus. Among 27 neonates undergoing surgery, duodenal obstruction was confirmed in 25 (93.8%). Asymptomatic malrotation was identified in 5 infants, and no cases of prenatal or postnatal midgut volvulus occurred. One-year survival was 100%.ConclusionsPrenatal DB is a highly sensitive marker of duodenal obstruction. Distal bowel fluid on fetal MRI was not associated with malrotation with volvulus, supporting reassurance during prenatal counseling.

Background: Pressure readings used in extracorporeal membrane oxygenation (ECMO) guide a variety of clinical interventions. However, several factors affect the accuracy of these measurements. We aimed to determine a model to mathematically predict expected pressure readings for different pediatric ECMO cannulae. Methods: We assembled an in-vitro circuit simulating those used clinically. Flow (mL/min) was adjusted and corresponding pressure drop (mm Hg) across the cannula was documented for various Medtronic Bio-medicus® and Life Support® cannulae. We utilized both water and blood product mixtures of differing hematocrit (Hct) levels – analogous to differing viscosities. Experimentally derived mathematical models were then applied to clinical data. Results: The relationship between flow and pressure drops across different cannulae and at different Hct levels was graphed and analyzed. At the same flow, larger cannula size corresponded to smaller drops in pressure and increased viscosity corresponded to larger drops in pressure. Using regression models of the experimental data, we estimated five exponential equations, which include Hct and flow, to predict expected pressure drop for different pediatric ECMO cannulae. There was high variability in data among patients with significant differences between clinically observed and expected pressures. Conclusion: Our models derived from in-vitro experimentation are the first steps towards defining the pressure-flow relationship and validating drainage pressure as a surrogate measure of intravascular volume for critically ill patients on ECMO. Further studies are still needed to refine these models and validate their clinical applicability.

INTRODUCTION:The last 40 years have seen an increase in fetal diagnosis and therapy centers and the emergence of professional societies such as IFMSS, NAFTNet, iFetus, Eurofetus, and ISPD. Despite the progress and cross-collaboration, it is still unclear what resources are needed for the creation of new fetal diagnosis and treatment centers (FDTCs). Our study aimed to ascertain the key resources essential for effective FDTC implementation. METHODS:A cross-sectional study using a questionnaire was distributed to providers at North American FDTCs. The questionnaire ranked the importance of providers, facilities, interventions, and resources. Data analysis used descriptive statistics and series cross-tabulations for significance. RESULTS:Overall, 40.2% completed the questionnaire. Maternal-fetal medicine (MFM) specialists and pediatric surgeons (92%) predominated. Most centers were >10 years old. Critical resources included MFM providers, a dedicated nurse coordinator, high-resolution US capabilities, needle-based interventions, and patient access to an FDTC close to their home. Although specialty-based differences were not significant between newer and long-established centers, centers older than 10 years ranked additional surgical specialties and a mandatory reporting system as more important. CONCLUSION:Our findings offer valuable insights into the perspectives of fetal therapy providers, informing the strategic allocation of resources for establishing new FDTCs.

INTRODUCTION:Management of pediatric primary spontaneous pneumothorax (PSP) has practice variations and different risk factors for recurrence. Management of pediatric PSP is not standardized. The risk of recurrence may vary based on initial treatment strategy. METHODS:A multicenter retrospective review of patients (≤21 y) presented with PSP between 2011 and 2022. Initial management was categorized as observation, tube thoracostomy, or operation during the index admission. Chi-square, Fisher's exact, and Kruskal-Wallis tests were used to examine associations between patient characteristics at first PSP presentation and recurrence. Kaplan-Meier curves and multivariate Cox regression estimated the risk of ipsilateral PSP recurrence up to 5 y after primary hospitalization. RESULTS:Of the 357 patients with PSP, most were male (88%) and White (75%). Median initial pneumothorax size was 4.5 cm. Management included observation in 72 (25.5%) patients, tube thoracostomy in 113 (40.1%) patients, and operative management in 91 (34.4%) patients. A total of 115 (32%) patients experienced ipsilateral recurrence at a median of 71 d (interquartile range: 20, 241) and 80% within 12 mo. Ipsilateral recurrence differed depending on initial management strategy, with 32% patients recurring after observation, 53% after tube thoracostomy, and 17% after operative management (P < 0.001). When compared to chest tube alone, observation of PSP was associated with decreased risk of recurrence (hazard ratio: 0.54; 95% confidence interval: 0.34-0.87, P = 0.011) and even further with surgery (hazard ratio: 0.22; 95% confidence interval: 0.12-0.39, P < 0.001). CONCLUSIONS:Both observation and surgery have significantly lower recurrence rates than chest tube alone in managing pediatric PSP. The authors recommend against using chest tubes as the definitive management of PSP.

OBJECTIVES:The objective of this meta-analysis is to determine the effect of intraoperative tranexamic acid, aminocaproic acid, and aprotinin on bleeding in pediatric surgery. STUDY DESIGN:A literature search was performed for the meta-analysis and systematic review in the following databases from inception until April 2023: Ovid MEDLINE, Ovid EMBASE, and The Cochrane Library. Studies included patients under 18 years of age, non-cardiac surgery, and administration of antifibrinolytics. Forest plots were used for statistical analysis. Primary outcomes were intraoperative blood loss and intraoperative blood transfusions. RESULTS:One hundred thirty articles met inclusion. Tranexamic acid compared to control resulted in an estimated blood loss of -410.0 mL p-value = < 0.001 for scoliosis surgery, -14.0 mL/kg p-value = < 0.001 for craniofacial surgery, and -21.0 mL p-value < 0.001 for tonsillectomy/adenoidectomy surgery. Aminocaproic acid compared to control resulted in an estimated blood loss of -464.0 mL p-value < 0.001 for scoliosis surgery. Tranexamic acid compared to aminocaproic acid resulted in an estimated blood loss of -391.0 mL p-value < 0.001 for scoliosis surgery. For blood transfusion during craniosynostosis surgery, tranexamic acid compared to control resulted in a mean decrease of -7 mL/kg p-value = 0.010 and aprotinin compared to control resulted in a mean decrease of -20.0 mL/kg p-value < 0.001. The analysis for VRO/VDRO and hip reconstruction did not reach statistical significance. CONCLUSIONS:In craniofacial, scoliosis, and tonsillectomy/adenoidectomy surgery, prophylactic administration of tranexamic acid results in lower estimated blood loss. Tranexamic acid and aprotinin are effective for reducing transfusion in craniofacial surgery. For scoliosis surgery, tranexamic acid is more efficacious than aminocaproic acid. More literature is needed to assess the efficacy of tranexamic acid in VRDO/VRO and hip reconstruction surgery and the efficacy of different dosing regimens.

Myelomeningocele is a neural tube defect associated with high rates of morbidity and mortality. This review traces the evolution of its management, beginning with the Sheffield protocol in the mid-20th century, which promoted early postnatal surgical intervention. Ethical, logistical, and surgical challenges at the time sparked debate among clinicians regarding which patients might truly benefit from surgery. While postnatal intervention did improve survival for some, morbidity and mortality rates remained significant, with many patients facing severe physical and cognitive disabilities. Advances in our understanding of myelomeningocele physiology, surgical techniques, and management of multiorgan complications have shaped modern treatment. Preclinical studies underscored the detrimental impact of open neural tube defects exposed to the amniotic environment, giving rationale to prenatal intervention. Several animal studies and select pilot cases of human patients with prenatal intervention led to the pivotal Management of Myelomeningocele Study (MOMS), which confirmed the advantages of in utero repair over postnatal surgery. While the MOMS trial marked a shift in the standard of care, its implementation remained limited by disparities in access and the strict eligibility criteria of the trial. Ongoing studies have aimed to validate the generalizability of MOMS findings, with hopes of enabling more widespread prenatal intervention.

PURPOSE:To assess the association between social determinants of health (SDoH) and both mortality and pulmonary outcomes in infants with congenital diaphragmatic hernia (CDH). METHODS:We conducted a retrospective observational cohort study of all patients with CDH at our institution from January 2004 to July 2023. Child opportunity index (COI) and area deprivation index (ADI) were determined from reported addresses at birth. Baseline demographics and details from initial hospitalization were described by COI quintiles. Outcomes of mortality and CDH-associated pulmonary outcomes were compared between COI quintiles. RESULTS:Among the 281 patients, there were unequal distributions of race (p < 0.001) and ethnicity (p = 0.006) among the COI quintiles, with Black patients comprising a quarter of the very low COI quintile. In-hospital mortality, supplemental oxygen at discharge, reactive airway disease (RAD)/asthma, and differed significantly among the COI quintiles (p = 0.02, p = 0.024, p = 0.04). Multivariable regression analyses of composite outcomes (mortality or pulmonary comorbidities) demonstrated those in the very high vs. very low COI quintile had 20-31 % lower odds of requiring oxygen (O2) support and having pulmonary hypertension (PH) at discharge (p = 0.006, p = 0.029) and at 6 months (p = 0.01, p = 0.003), respectively. ADI similarly correlated with need for O2 support and PH in CDH infants at 6 months, AOR 1.03 (95 % CI 1.01-1.04), p = 0.001 and 1.02 (95 % CI 1-1.03), p = 0.029, respectively. CONCLUSION:Children of very low COI and higher ADI with CDH may be at increased risk of mortality or pulmonary morbidities. Further studies are needed to better characterize this vulnerable population and to improve these SDoH-related disparities in CDH outcomes.

Background: Extrathoracic congenital lung lesions (CLLs) are a rare anomaly of lung development. Management and surgical approach are variable. We present our institutional experience with extrathoracic CLLs for the past 18 years. Methods: We retrospectively reviewed all patients younger than 18 years diagnosed with a CLL from January 2005 to June 2023. Only patients with suspected extrathoracic CLLs on prenatal imaging were included. Results: A CLL was identified in 381 patients and was extrathoracic in 25 patients (6.6%). Six patients (24%) with other congenital anomalies were excluded, and 3 were lost to follow-up. The prenatal course and delivery of the 16 study patients were unremarkable and all were asymptomatic. Larger lesions, both prenatally and postnatally, were more likely to undergo surgical resection (11.8 ± 8.2 cm3 versus 3.9 ± 3.3 cm3, P = .05; 6.1 ± 5.1 cm3 versus 2.5 ± 2.5 cm3, P = .10, respectively). Seven patients (7/16; 44%) underwent resection-5 thoracoscopic and 2 laparoscopic. Thoracoscopic transdiaphragmatic approach was favored for lesions extending >50% above the diaphragm. Five lesions were intradiaphragmatic, one infradiaphragmatic, and one intrathoracic. Four lesions (4/7; 57%) were hybrid lesions on pathology. No malignancy was identified. Nine patients (9/16; 56%) underwent surveillance. Imaging modality for surveillance varied. Duration of follow-up ranged from 0.5 to 83 months. Conclusions: We provide the largest case series to date describing both operative and nonoperative management of extrathoracic CLLs. Surveillance appears to be appropriate for small lesions. If surgical excision is pursued, the thoracoscopic approach is safe and preferred if diaphragmatic involvement is suspected.

Pediatric surgeons often obtain intraoperative liver wedge biopsies during Kasai portoenterostomy for biliary atresia despite an existing preoperative core needle biopsy. We conducted a single-institution retrospective review analyzing preoperative factors, Batts-Ludwig fibrosis stage (preoperative percutaneous core needle and intraoperative wedge biopsies), and survival with native liver from 2004 to 2023. Of 116 patients, 87 underwent both preoperative and intraoperative biopsies, with discordant results observed in 30/87 (34.5 ​%) patients. Of the discordant samples, intraoperative wedge biopsies upstaged the Batts-Ludwig scoring system in 97 ​% of biopsies. Neither the core needle (p ​= ​0.80) nor wedge (p ​= ​0.18) fibrosis stage correlated with native liver survival at one year. Age at surgery (58 vs. 63 days, p ​= ​0.04), aspartate transferase (145 vs. 195 U/L, p ​= ​0.05), and alanine transferase (108 vs. 143 U/L, p ​= ​0.03) demonstrated associations with native liver survival at one year. Our data suggests that routine intraoperative wedge biopsies may not be necessary after preoperative core biopsies.

OBJECTIVE:Prenatal repair of myelomeningocele (MMC) improves fetal outcomes; however, open uterine surgery has associated morbidities. We report our institutional outcomes following laparotomy-assisted fetoscopic MMC repair. METHODS:A prospective observational study, including a 1-year follow-up period, was conducted from April 2018 to March 2024. Similar study considerations from the 2011 Management of Myelomeningocele Study (MOMS) and 2019 MOMS Plus study were applied. Laparotomy-assisted repair utilized an extended Pfannenstiel incision and vertical midline fascial incision to exteriorize the uterus for trocar placement. Primary outcomes were ventriculoperitoneal (VP) shunt at 12 months or perinatal death. Secondary outcomes included select maternal and neonatal outcomes. RESULTS:Of 39 qualifying patients, 10 underwent repair at a median GA of 25w4d (IQR 25w0d-26w6d). All pregnancies resulted in live births in a median GA of 36w1d (IQR 32w2d-37w0d). Preterm premature rupture of membranes was observed (PPROM) in five patients. Four patients delivered vaginally without complications. All trocar sites were noted to be intact at the time of cesarean deliveries. Two neonates required revision of MMC closure after birth. One patient required a VP shunt placement at 4 months of age. CONCLUSION:Early results at our center demonstrate that laparotomy-assisted fetoscopic MMC repair is a safe option for qualified patients.

Background: Institutions lack consensus on the management of patients with congenital diaphragmatic hernia (CDH) who are repaired on extracorporeal membrane oxygenation (ECMO). Our study aimed to evaluate risk factors associated with bleeding complications in patients with CDH repaired on ECMO. Methods: A single-institution retrospective review evaluated all patients with CDH who underwent on-ECMO repair between January 2005 and December 2023. A significant bleeding complication post-repair was defined as bleeding necessitating re-operation. The association between preoperative factors and bleeding complications was evaluated. Results: Forty-six patients were included. Bleeding complications developed in 11/46 (24%) patients. Birthweight (2.5 vs. 3.2 kg, p = 0.02), platelet count <100/mm(3) (64% vs. 29%, p = 0.04), elevated blood urea nitrogen (BUN; 24.5 vs. 17.5 mg/dL, p = 0.05), and older age at repair (8 vs. 5 days, p = 0.04) were associated with bleeding. In univariate analysis, patients with platelets under 100/mm(3) were more likely to develop a bleeding complication (OR = 4.4, p = 0.04). Patients who experienced a significant bleeding event experienced increased ECMO days (12 vs. 7 days, p < 0.01), ventilator days (31 vs. 18 days, p < 0.05), and lower survival to discharge (36% vs. 74%, p = 0.03). Conclusion: Among CDH patients undergoing repair on ECMO, those with lower birth weight, platelet counts under 100/mm(3), elevated BUN, and older age at repair had an increased risk of a significant bleeding complication, resulting in more ECMO and ventilator days and higher mortality. Patients undergoing on-ECMO repair should have platelet count transfused to greater than 100/mm(3). Patients at high risk for bleeding may benefit from early repair on ECMO.

OBJECTIVE:Fetal head and neck masses can result in critical airway obstruction. Our study aimed to evaluate prenatal factors associated with the decision for a definitive airway, including ex-utero intrapartum treatment (EXIT), at birth among at-risk fetuses. METHODS:A single-institution retrospective review evaluated all fetal head and neck masses prenatally diagnosed from 2005 to 2023. The primary outcome was the decision for a definitive airway at birth, including intubation, tracheostomy, or EXIT. RESULTS:Thirty four patients were included, with 23 deliveries occurring at our institution. 8/23 (35%) patients received a definitive airway at birth, six underwent an EXIT procedure, and two required intubation only. Patients who received a definitive airway had higher rates of polyhydramnios (50% vs. 7%, p = 0.03), tracheal narrowing on ultrasound (US) (50% vs. 0%, p = 0.01), tracheal displacement on US (63% vs. 0%, p < 0.01), abnormal fetal breathing on US (50% vs. 0%, p = 0.01), tracheal narrowing or displacement on magnetic resonance imaging (MRI) (75% vs. 7%, p < 0.01), and larger mass maximum diameter (7.9 vs. 4.3 cm, p = 0.02). In our series, 100% of patients with polyhydramnios, tracheal narrowing or displacement on either US or MRI, and abnormal fetal breathing on US received a definitive airway at birth. CONCLUSION:Prenatal findings of tracheal narrowing or displacement, polyhydramnios, and abnormal fetal breathing are strongly associated with the decision for a definitive airway at birth and warrant mobilization of appropriate resources.

Objective The aim of this article was to evaluate high-frequency positive pressure ventilation (HFPPV) compared with high-frequency oscillatory ventilation (HFOV) as a rescue ventilation strategy for patients with congenital diaphragmatic hernia (CDH). HFPPV is a pressure-controlled conventional ventilation method utilizing high respiratory rate and low positive end-expiratory pressure. Study Design Seventy-seven patients diagnosed with CDH from January 2005 to September 2019 who were treated with stepwise progression from HFPPV to HFOV versus only HFOV were included. Fisher's exact test and the Kruskal–Wallis test were used to compare outcomes. Results Patients treated with HFPPV + HFOV had higher survival to discharge (80 vs. 50%, p = 0.007) and to surgical intervention (95.6 vs. 68.8%, p = 0.003), with average age at repair 2 days earlier (p = 0.004). Need for extracorporeal membrane oxygenation (p = 0.490), inhaled nitric oxide (p = 0.585), supplemental oxygen (p = 0.341), and pulmonary hypertension medications (p = 0.381) were similar. Conclusion In CDH patients who fail respiratory support with conventional ventilation, HFPPV may be used as an intermediary mode of rescue ventilation prior to HFOV without adverse effects. Key Points

Congenital diaphragmatic hernia (CDH) is a severe congenital anomaly often accompanied by other structural anomalies and/or neurobehavioral manifestations. Rare de novo protein-coding variants and copy-number variations contribute to CDH in the population. However, most individuals with CDH remain genetically undiagnosed. Here, we perform integrated de novo and common-variant analyses using 1,469 CDH individuals, including 1,064 child-parent trios and 6,133 ancestry-matched, unaffected controls for the genome-wide association study. We identify candidate CDH variants in 15 genes, including eight novel genes, through deleterious de novo variants. We further identify two genomic loci contributing to CDH risk through common variants with similar effect sizes among Europeans and Latinx. Both loci are in putative transcriptional regulatory regions of developmental patterning genes. Estimated heritability in common variants is ∼19%. Strikingly, there is no significant difference in estimated polygenic risk scores between isolated and complex CDH or between individuals harboring deleterious de novo variants and individuals without these variants. The data support a polygenic model as part of the CDH genetic architecture.

Schertz Hickey, Katherine1; Smith, Morgan2; Karam, Oliver3; Faraoni, David4; Demetres, Michelle5; Duron, Vincent6; Sanz Wu, Yeu7; Nellis, Marianne8 Author Information

Smith, Morgan1; Schertz Hickey, Katherine2; Karam, Oliver3; Faraoni, David4; Demetres, Michelle5; Duron, Vincent6; Sanz Wu, Yeu7; Nellis, Marianne8 Author Information

Background: Small bowel obstruction (SBO) is a known complication following congenital diaphragmatic hernia (CDH) repair, resulting in significant morbidity and potential mortality. Our study aims to evaluate the incidence and risk factors for SBO following CDH repair. Methods: A single-institution retrospective review evaluated all CDH births between January 2010 and September 2022 (n = 120). Risk factors for SBO were analyzed, including operative approach, type of repair, need for extracorporeal membrane oxygenation (ECMO), and additional abdominal surgeries (gastrostomy tube and fundoplication). Results: 120 patients were included. 16 (13%) patients developed an SBO, of which 94% were due to adhesive bands. The median time to SBO was 7.5 months. 15/16 (94%) patients required operative intervention. Need for ECMO (P < 0.01), prior gastrostomy tube (P < 0.01), and prior fundoplication (P < 0.01) were associated with an increased risk of SBO, as were longer time to initial CDH repair (6 days vs 3 days; P < 0.01) and longer length of initial hospitalization (63 days vs 29 days; P = 0.01). Discussion: Neonates with increased acuity of illness (ie, those requiring ECMO, additional abdominal operations, longer time to repair, and longer initial hospitalizations) appear to have an increased risk of developing adhesive SBO after CDH repair. More than 90% of patients who developed SBO required surgery.

OBJECTIVE: Injury and surgery both represent well-defined starting points of a predictable inflammatory response, but the consequent response to IV fluids has not been studied. We aimed to review and compare our single-center fluid management strategies in these two populations. DESIGN: Retrospective cohort study from January 2020 to July 2022. The primary outcome was total IV fluid volume administered. Net fluid balances and select clinical outcomes were also evaluated. SETTING: Single tertiary academic center and level 1 pediatric trauma center in New York. PATIENTS: A dataset of critically ill trauma and surgical patients aged 0–18 years who were admitted to the PICU, 2020–2022. Trauma patients had at least moderate traumatic injuries (Injury Severity Score ≥ 9) and surgical patients had at least a 1-hour operation time. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 25 trauma and 115 surgical patients. During the first 5 days of hospitalization, we did not identify an association between grouping and total IV fluids administered and fluid balance in the prehospital, emergency department, and operating room (p = 0.90 and p = 0.79), even when adjusted for weight (p = 0.96). Time trend graphs of net fluid balance and IV fluid administered illustrated analogous fluid requirement and response with the transition from net positive to net negative fluid balance between 48 and 72 hours. There was an association between total IV fluid and ventilator requirement (p = 0.003). CONCLUSIONS: Critically ill pediatric trauma and postoperative patients seem to have similar fluid management and balance after injury or surgery. In our opinion, these two critically ill populations could be combined in large prospective studies on optimal fluid therapy in critically ill children.

Background: Bronchogenic cysts result from a congenital anomalous budding of the tracheobronchial tree. Resection is usually recommended to avoid complications. Mediastinal bronchogenic cysts present a unique challenge due to their proximity to vital structures. The purpose of this study is to review our experience with mediastinal bronchogenic cysts. Methods: A single-institution retrospective review evaluated all mediastinal bronchogenic cyst excisions between January 2012 and November 2022. Patient demographics were assessed, including age at diagnosis, presenting symptoms, imaging workup, and cyst characteristics. Operative approach, complications, and surgical pathology were reported. Results: Five patients were identified. Age at diagnosis ranged from 18 to 27 months. No patient was diagnosed prenatally. All patients had symptoms at the time of diagnosis, including cough, wheezing, and respiratory distress. Three cysts were paratracheal, and two were paraesophageal. Age at surgery ranged from 26 to 30 months. All bronchogenic cysts were successfully resected thoracoscopically. Individual technical challenges included narrowing of the mainstem bronchus preventing lung isolation, significant mediastinal inflammation, the necessity for cyst evacuation to delineate the extent of the cyst, adherence of cyst wall to bronchus or trachea requiring cold dissection, and a stalk of tissue with an intimate connection to the carina that was amputated. No intraoperative or postoperative complication occurred. Surgical pathology was consistent with a bronchogenic cyst in all cases. Median length of hospital stay was two days. Conclusion: Thoracoscopy is a safe and effective procedure for mediastinal bronchogenic cyst excision in children. Certain technical maneuvers are highlighted, which may facilitate resection.

Background: Bronchogenic cysts result from a congenital anomalous budding of the tracheobronchial tree. They should be excised, regardless of symptoms, due to the risk of infection, mass effect on adjacent structures, and malignant transformation. Mediastinal bronchogenic cysts present a unique challenge due to their proximity to vital structures. We present a video of two cases of technically challenging mediastinal bronchogenic cysts successfully excised thoracoscopically. Methods: Two patients who underwent mediastinal bronchogenic cyst excision in 2022 were identified. Patient demographics were assessed, including age at diagnosis, presenting symptoms, imaging workup, and cyst characteristics. Operative approach, complications, and surgical pathology were reported. Intraoperative thoracoscopic videos were reviewed, highlighting unique challenges and technical maneuvers that were utilized. Results: Case 1 is a previously healthy 37-month-old female with a mediastinal cystic mass initially diagnosed on screening echocardiogram due to a parental history of connective tissue disorder. CT confirms a 2.4-cm lobulated mediastinal mass with compression of the left main stem bronchus and abutment of the aorta, pulmonary artery, and esophagus. The mass is initially believed to be a lymphatic malformation, so the patient undergoes sclerotherapy. Follow-up MRI demonstrates a persistent subcarinal mass that appears more consistent with a bronchogenic cyst. Case 2 is a 30-month-old female with recurrent pneumonia and upper respiratory tract infections. CT demonstrates a 3.9 cm posterior mediastinal cystic mass resulting in deviation of adjacent mediastinal structures and compression of the left main stem bronchus consistent with a bronchogenic cyst vs foregut duplication cyst. Both patients undergo thoracoscopic resection. Excision was technically challenging in both cases due to the location of the cyst deep within the mediastinum. Case 1 was particularly challenging given its adherence to the right pulmonary artery and proximity to the aorta, azygous vein, and trachea. Case 2 demonstrated signs of chronic inflammation. The accompanying video illustrates right and left thoracoscopic resection of a central adherent bronchogenic cyst, including port placement, energy device use, and exposure strategy. Techniques specifically highlighted include retraction of surrounding vital structures without grasping, working within different windows inferior and posterior to the bronchus, and cyst aspiration for optimal visualization of the cyst wall. Both cases were successfully managed thoracoscopically with complete cyst wall excision and no observed complications. Both patients were discharged on postoperative day 1. Conclusion: Thoracoscopy is a safe and effective procedure for mediastinal bronchogenic cyst excision in children. Certain technical maneuvers are highlighted that may facilitate resection. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure. No competing financial interests exist. Runtime of video: 4 mins 33 secs