Faculty Bibliography

BACKGROUND:The delivery of pediatric surgical care to newborns varies based on neonatal intensive care unit (NICU) coverage. We aimed to describe the current national coverage landscape and assess pediatric surgeons' perspectives on the optimal management of infants at outlying NICUs. METHODS:The AAP Delivery of Surgical Care Committee administered a web-based survey to pediatric surgery division chiefs at Children's Hospital Association practices. Responses were analyzed using appropriate nonparametric and categorical statistical tests, with significance set at p<0.05. RESULTS:Fifty-two division chiefs responded (28.9%); 26 (50% reporting covering one or more outlying NICUs. Of these outlying NICUS, 76% were Level III. Just over half (51%) had no affiliation with the surgeons' primary hospital. Case volumes were low, with only 5 NICUs (15%) performing more than 25 operations annually. Factors influencing decisions to operate at outlying NICUs included rapport with neonatologists, NICU level designation, transfer capability, and availability of pediatric anesthesiology. The capacity of outlying NICUs to care for infants with index surgical diagnoses varied based on specific diagnosis. Over half of respondents endorsed transfer to the primary center as the optimal location for care for all procedures except gastrostomy tube placement and central venous access. CONCLUSION/CONCLUSIONS:Half of surveyed pediatric surgery groups provide coverage to one or more outlying NICUs despite low reported case volumes. A clear disconnect exists between pediatric surgeons' views on location for optimal care and sites of current care provision. These findings underscore the need for regionalized strategies to optimize surgical care of these infants.

INTRODUCTION/BACKGROUND:Subway-related trauma is an understudied category of urban injury. Prior work has focused on high-acuity train-contact events, with less attention to more common mechanisms and the roles of psychiatric illness and substance use. We analyzed a large contemporary cohort to define epidemiology, injury patterns, and outcome predictors across the full spectrum of subway trauma. METHODS:We performed a retrospective cohort study of adults presenting with subway-related injury to a Level I trauma center (2018-2024). Registry data and manual chart review captured demographics, mechanisms, comorbidities, intoxication, injury severity, and outcomes. Injuries were categorized using validated natural language processing. Multivariable logistic regression identified predictors of train-contact mechanism, major trauma (ISS ≥ 15), TBI, and assault. RESULTS:Among 809 patients, median age was 50 years and 81.2% were male. Falls were most common (57.2%), followed by train contact (16.8%) and assault (16.7%). Median ISS was 9, with 25.0% sustaining major trauma. TBI occurred in 40.5% and did not differ by mechanism. Train contact was the most severe mechanism and the only independent predictor of major trauma (aOR 5.08). Psychiatric diagnosis (aOR 1.59) and acute intoxication (aOR 1.69) independently predicted train contact, while intoxication predicted TBI (aOR 1.66). Psychiatric illness and substance use disorder were associated with longer hospitalization independent of injury severity. Assault exposure varied by race/ethnicity. CONCLUSION/CONCLUSIONS:Most subway injuries result from falls rather than intentional mechanisms. Train contact drives severity, while intoxication increases TBI risk. Psychiatric and substance use comorbidities prolong hospitalization, supporting routine behavioral health screening and targeted prevention strategies.

BACKGROUND:This review summarizes considerations within the existing recent literature that guide the practice of interval appendectomy (IA) after initial non-operative management (NOM) of complicated appendicitis (CA) in children. METHODS:A systematic review of English language articles published from 2000 to 2025 was conducted in Medline, Embase, and Cochrane Central Register of Controlled Trials to address four elements which could impact the decision for IA after NOM of CA: (1) the incidence of recurrent appendicitis; (2) the time period in which recurrence occurs; (3) the patient or disease-related risk factors which increase recurrence; and (4) the incidence of appendiceal neoplasms identified by IA. RESULTS:Of the 3,022 articles initially reviewed, 46 met inclusion criteria. Recurrence was reported in 2–50% of patients. When IA is pursued, the optimal timing remains undefined, although evidence suggests most recurrences occur within three to six months, so there may be potential benefit to performing IA within three months after the initial presentation. Risk factors for recurrent appendicitis are not well characterized, though the presence of an appendicolith may increase recurrence risk. Across studies, the incidence of appendiceal neoplasms was rare, with most studies not documenting any cases; all reported neoplasms were neuroendocrine tumors. CONCLUSION:Current evidence does not favor any single approach to IA, including routine IA, selective IA, or indefinite NOM; rather a shared-decision ought to be made between the surgeon and patient’s caregivers. Utilization and timing of IA must balance surgical risks with the risk of recurrent disease; however, the risk of neoplasm should not primarily drive management. LEVEL OF EVIDENCE:I−IIV. SUPPLEMENTARY INFORMATION:The online version contains supplementary material available at 10.1007/s00383-026-06445-z.

BACKGROUND:Perinatal ovarian cysts may spontaneously resolve or cause ovarian torsion. Cyst size and appearance often guide surgical decision making. The natural history of these cysts and impact of perinatal interventions on ovarian outcomes remain unclear. We investigated the association of various clinical parameters with operative intervention and ovarian loss. METHODS:Infants with ovarian cysts meeting our definition of perinatal (diagnosed between 15 weeks gestational age and 1 year) from November 2006-January 2022 were identified. Cysts were characterized by size, morphology, laterality, and evolution. Outcome measures included resolution, ovarian loss, and operative intervention. Mann-Whitney U and Fisher exact tests were used. Optimal maximal size cutoffs were obtained using ROC curves. RESULTS:Sixty-two female patients with perinatal ovarian cysts were identified. Spontaneous resolution occurred in 35, prenatally and postnatally, with follow-up length averaging 186 days. Of 18 undergoing cystectomies, 9 revealed non-viable ovaries. Overall ovarian loss rate was 29%. Loss occurred more frequently with large, complex, and right-sided cysts (P < 0.05) but some complex cysts also resolved spontaneously. Operative intervention occurred more frequently with larger cysts (P=<0.001) and was associated with ovarian salvage when performed earlier (P = 0.008) on larger cysts (P = 0.02). Maximal cyst diameter > 4.05 cm predicted ovarian loss with 78% sensitivity, 64% specificity (AUC = 0.67,95%CI = 0.54-0.81, P = 0.04). Maximal cyst diameter > 4.55 cm predicted surgery with 83% sensitivity, 82% specificity (AUC = 0.86,95%CI = 0.77-0.96, P < 0.001). CONCLUSIONS:29% of perinatal ovarian cysts resulted in ovarian loss. 56% resolved spontaneously (prenatal and postnatal resolution) including some complex cysts. Cysts that were postnatally complex and maximally > 4 cm had higher rates of ovarian loss and operative intervention. Earlier postnatal operative intervention was associated with ovarian preservation. Standardized imaging (such as the IOTA terminology) and management protocols are needed to better understand behavior and improve treatment of these cysts.

OBJECTIVES/OBJECTIVE:To evaluate ECMO-related morbidity and mortality between Early-term (ET) and Full-term (FT) infants. METHODS:weeks were classified as FT. Primary outcomes were ECMO survival and survival to discharge. Secondary outcomes were complications while on ECMO. Data were analyzed using Mann-Whitney U and Fisher's Exact testing. Logistic regression was performed to assess odds of ECMO survival for factors noted to be significantly different between groups. RESULTS:Of 2,551 infants who met inclusion criteria based on gestational age, we identified 805 (32 %) ET and 1,746 (68 %) FT infants. ET infants had significantly lower ECMO survival (90 vs. 94 %, p<0.01) and survival to discharge (80 vs. 88 %, p<0.01), more neurologic complications on ECMO (15 vs. 12 %, p=0.024), and increased need for hemofiltration (33 vs. 29 %, p=0.033). There were no statistically significant differences between groups in mechanical, hemorrhagic, infectious, metabolic, renal, pulmonary, limb, or cardiovascular complications while on ECMO. Multiple logistic regression showed that ET gestational age, development of neurologic complications on ECMO, and need for hemofiltration are independent negative predictors of ECMO survival. CONCLUSIONS:ET gestational age is an independent risk factor for worse ECMO outcomes and survival in comparison to FT infants, highlighting the vulnerability of this population.

BACKGROUND:Body contouring surgery (BCS) is a common postoperative trajectory for adults following bariatric surgery, yet research on its application to adolescents is lacking. This scoping review aimed to map the available literature on quality of life (QoL) and potential for BCS in adolescents after bariatric surgery. METHODS:This review followed the Joanna Briggs Institute (JBI) guidance for scoping reviews and is reported in accordance with the PRISMA extension for Scoping Reviews (PRISMA-ScR). Three electronic databases were queried for studies regarding QoL and BCS in adolescents following bariatric surgery within the last 20 years. A descriptive and thematic analysis was conducted. RESULTS:Twenty-three studies met inclusion criteria. A total of 19 (82.6%) evaluated QoL and 4 (17.4%) explored the role of BCS in adolescents following bariatric surgery. The most common method of data collection was prospective study (65.2%). Two themes were described: QoL after bariatric surgery, which expressed improvement in several domains within 6 months, and role for BCS, which showed high interest in addressing residual excess skin and appearance. Gaps in the literature were identified, including a need for studies exploring mediators of QoL, predictors of compliance, and outcomes of BCS. CONCLUSIONS:Studies describing residual symptoms and BCS in adolescents following bariatric surgery are lacking. BCS may complement bariatric surgery, but further research must be conducted to assess its safety in adolescents. By addressing the research gaps described in this review, physicians may have a better understanding of the needs of this population and how to counsel them. LEVEL OF EVIDENCE AND TYPE OF STUDY/UNASSIGNED:Level IV; Systematic Scoping Review.

BACKGROUND:Management of infant perianal disease, including perianal abscess and fistula-in- ano (FIA), remains controversial. There is lack of consensus regarding the risks and benefits of operative and non-operative approaches. METHODS:The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee created a priori consensus-based questions regarding the various approaches to management of perianal abscess and FIA in infants. A comprehensive search strategy was created, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to identify and review relevant articles and answer the established questions. RESULTS:Over 2460 titles and abstracts were screened to identify 31 manuscripts describing the expected course of perianal disease when managed with nonoperative management (NOM) strategies (such as hygiene, sitz baths, and systemic antibiotics), operative intervention for abscess only (incision and drainage (I&D)) or direct surgical management of the FIA (e.g. upfront fistulotomy). Initial failure of NOM is approximately 37.5 %. Recurrence rate after initial success with NOM or I&D is approximately 21 % and 24 %, respectively. The rate of FIA development is approximately 21 % after NOM and 20 % after I&D. Recurrence after operative management of FIA, regardless of approach, is 7 %. Time to complete resolution varies widely and does not appear to differ based on treatment strategy. CONCLUSIONS:Both operative and non-operative approaches can be safely used in the management of perianal abscess and FIA but recurrence is common regardless of approach. Risks and benefits of each approach should be considered on a case-by-case basis. TYPE OF STUDY/METHODS:Systematic Review of level 3-4 studies. LEVEL OF EVIDENCE/METHODS:Level 4.

BACKGROUND:Despite evidence supporting selective use of non-operative management (NOM) for children with uncomplicated, acute appendicitis, no consensus exists regarding its clinical application. This study characterizes surgeons' contemporary perceptions and utilization of NOM. STUDY DESIGN/METHODS:A survey addressing NOM was distributed to attending pediatric surgeons through the American Pediatric Surgical Association, the American Academy of Pediatrics Section on Surgery, and the Pediatric Surgery Research Collaborative between 12/2023-6/2024. RESULTS:The survey achieved a response rate of 41.0% (433/1,056). 42.0% reported regularly discussing NOM, but only half of those who discussed NOM did so in a balanced fashion. Fewer regularly offered NOM to eligible patients (27.9%). Common reasons for not offering NOM included the belief that recovery is faster after appendectomy (52.0%) and concern for high recurrence rates (51.5%). Common reasons for offering NOM included the belief that patients appreciate having options (49.2%) and the potential to avoid surgery (48.5%). 71.2% of surgeons considered absence of an appendicolith essential for attempting NOM, while fewer used symptom duration (50.8%), age (36.0%), or WBC (33.3%) when determining NOM eligibility. Therefore, many respondents did not apply the inclusion criteria used in early clinical trials, and when applied, some deviated from them, especially with increased present-day willingness to use NOM in younger patients. CONCLUSIONS:NOM is infrequently discussed with or offered to eligible patients due to limited surgeon buy-in and different valuations of its risks and benefits. However, many surgeons who do offer NOM are comfortable applying it to a broader patient population than initially studied. LEVEL OF EVIDENCE/METHODS:IV.

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/CONCLUSIONS: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.