CONSORTIUM PUBLICATIONS
Effect of activity restrictions on pectus bar displacement following minimally invasive repair of pectus excavatum - A Western Pediatric Surgery Research Consortium.
Eldredge RS 1, Padilla BE 1, Kahan AM 2, Nicassio L 1, Chao SD 3, Schwab M 3, Diaz-Miron J 4, Ibarra A 4, Pandya S 5, Ryan M 5, Gillory L 5, Lee J 1, Ignacio RC 6, Keller BA 6, Scaife JH 2, Clinker CE 2, McDuffie LA 7, Byrd E 7, Rothstein D 8, Kelley-Quon LI 9, Kim S 10, Ostlie DJ 1, Russell KW 2
Abstract:
Introduction
Activity restrictions following the minimally invasive repair of pectus excavatum (MIRPE) are often given with the intention of reducing pectus bar displacement (PBD). We aimed to assess the effect of activity restrictions on PBD following MIPRE.
Methods
A ten-center retrospective review was conducted among patients <21 years undergoing MIRPE between 7/1/2022-10/31/2023. Postoperative activity restrictions were categorized into two groups: no restrictions versus any activity restrictions. PBD was defined as bar migration requiring reoperation within 90 days of MIRPE. We compared the incidence of PBD and postoperative outcomes between cohorts.
Results
A total of 532 patients were included (mean age - 15.9 ± 2.0 years, male - 86 %, median Haller index - 4.5 [IQR:3.8-5.8]). Postoperatively, 24 % of patients (127/532) were not given activity restrictions. Patients with activity restriction had a higher proportion of pericostal suture use (78 % vs 43 %, p < 0.001) and subpectoral tunneling (58 % vs 36 %, P < 0.001), and a lower proportion of sternal elevation (63 % vs 80 %, p < 0.001) and cryoanalgesia (88 % vs 100 %, p < 0.001) during MIRPE. Overall, PBD occurred in 1.6 % of patients, with no difference in the incidence of PBD between those patients with and without activity restrictions (1.7 % vs 0.8 %, p = 0.468). Additionally, there were no significant differences in other postoperative complications between these groups.
Conclusion
Ad libitum physical activity after MIRPE was not associated with an increased risk of pectus bar displacement. Activity restrictions may be unnecessary, and consideration should be given to their elimination to accelerate recovery.
J Pediatr Surg. 2026 Jan;61(1):162520. doi: 10.1016/j.jpedsurg.2025.162520. Epub 2025 Aug 8. PMID: 40784579.
Pleural drain placement following lung resection in children: A prospective observational study of the Western Pediatric Surgery Research Consortium
Kahan AM, Kelley-Quon LI, Acker SN, Vincent S, Chao SD, Nepomuceno H, Lee JH, Padilla BE, Patwardhan UM, Gollin G, Ignacio RC, Fialkowski EA, Fowler KL, Cairo SB, Munar D, Pandya SR, Russell KW, Fenton SJ, Lee SL, Rothstein DH
Abstract:
J Pediatr Surg. 2026 Jan;61(1):162541. doi: 10.1016/j.jpedsurg.2025.162541. Epub 2025 Aug 9. PMID: 40789464.
Opioid prescriptions practices following the minimally invasive repair of pectus excavatum: A western pediatric surgery research consortium study
Anastasia M. Kahana Sasha.kahan@hsc.utah.edu ∙ R Scott Eldredgeb ∙ Lauren Nicassiob ∙ Stephanie D. Chaoc ∙ Marisa E. Schwabc ∙ Jose Diaz-Mirond ∙ Ana Ibarra Merazd ∙ Samir R. Pandyae ∙ Mark L. Ryane ∙ Lauren A. Gillorye ∙ Justin H. Leeb ∙ Romeo C. Ignaciof ∙ Ben A. Kellerf ∙ Jack H. Scaifea ∙ Christopher E. Clinkera ∙ Raphael C. Sung ∙ Emily Byrdg ∙ David H. Rothsteinh ∙ Rabab M. Barqi ∙ Lorraine I. Kelley-Quoni ∙ Sunghoon Kimj ∙ Daniel J. Ostlieb ∙ Katie W. Russella ∙ Benjamin E. Padillab
Abstract:
Purpose
Minimally invasive repair of pectus excavatum (MIRPE) is among the most painful elective procedures in pediatric patients and is frequently managed with both inpatient and outpatient opioids. However, opioid prescribing practices vary, and evidence-based discharge guidelines are lacking. This study aimed to evaluate outpatient opioid prescribing patterns following MIRPE across multiple institutions.
Methods
A multicenter retrospective review was performed of patients (<21 years) who underwent MIRPE from 2022 to 2023 across 10 hospitals in the Western Pediatric Surgery Research Consortium. Demographic, operative, inpatient, and outpatient opioid data were collected. All opioid doses were converted to oral morphine equivalents (OME) using standardized conversion factors. Associations between inpatient opioid use and discharge prescriptions were assessed with linear regression.
Results
Among 532 patients (85.9 % male; median age 15.5 years [IQR 14.5–17.1]; median Haller index 4.5 [3.8–5.7]), 91 % received intercostal nerve cryoablation. Median hospital length of stay was 1 day [1–2]. Patients were discharged with a median of 10 opioid doses [8–16.5], equivalent to 75 OME [45–120] or 1.32 OME/kg [0.85–2.12]. Discharge prescriptions varied substantially by institution, ranging from 0 [0–10] to 20 [10–20] doses. Discharge OME correlated with inpatient opioid use (β = 0.35, 95%CI 0.26–0.44) and length of stay (β = 20.9, 95%CI 13.4–28.3).
Discussion
Outpatient opioid prescriptions following MIRPE varied widely across hospitals and were positively associated with inpatient opioid use and hospital stay. These findings underscore the need for standardized discharge analgesia guidelines to reduce variability and minimize excess opioid prescribing in pediatric surgical care.
Keywords
J Pediatr Surg. 2025 Dec 16:162878. doi: 10.1016/j.jpedsurg.2025.162878. Epub ahead of print. PMID: 41412427.
Is There a Role for ERCP in the Management of Gallstone Pancreatitis in Children? A Western Pediatric Surgery Research Consortium Study
Utsav M Patwardhan 1, Gretchen Floan Sachs 1, Romeo L Ignacio 1, Benjamin Padilla 2, Justin Lee 2, Shannon N Acker 3, Aaron R Jensen 4, Marisa Schwab 4, Katie W Russell 5, Jonathan Roach 5, Lorraine I Kelley-Quon 6, Adaeze Obinelo 7, Katrine Lofberg 8, Tina H Tran 8, David H Rothstein 9, Lauren N Nicassio 9, Claudia Mueller 10, Stephanie Chao 10, Stephanie E Iantorno 10, Jillian C Jacobson 11, Samir R Pandya 11, Romeo C Ignacio 12; Western Pediatric Surgery Research Consortium
Abstract:
Background: Guidelines for adult gallstone pancreatitis (GP) in adults recommend endoscopic retrograde cholangiopancreatography (ERCP) for ongoing biliary obstruction. Studies in children are limited by small sample sizes. We sought to explore whether factors predictive of choledocholithiasis (CDL) are correlated with ERCP findings of stones in pediatric GP.
Methods: We analyzed a subgroup of GP patients from a retrospective pediatric cohort undergoing cholecystectomy across ten hospitals from 2016 to 2019. Those with incomplete records and cholangitis were excluded. The absence of CDL was defined as ERCP that was either negative or not performed because of the resolution of obstruction. Comparative analyses were made between ERCP and non-ERCP patients.
Results: Among 1601 children undergoing cholecystectomy, 125 with GP were identified of which 30 (24 %) underwent preoperative ERCP. ERCP patients had a greater mean bilirubin (4.1 vs. 2.4, p = 0.02), median CBD diameter (9 vs. 5 mm, p <0 .001), and visualized stone on MRCP (36.7 vs. 4.2 %, p < 0.001). However, among patients with hyperbilirubinemia (≥1.8 mg/dL) or a dilated CBD (≥6 mm), 71 % of patients did not have CDL. In contrast, only 40 % of patients with a visualized stone on MRCP had a negative ERCP. ERCP was not associated with prolonged length of stay (LOS) or readmissions.
Conclusion: In children with GP, hyperbilirubinemia and CBD dilation were not reliable predictors of a positive ERCP, potentially leading to unnecessary radiation and/or anesthesia. MRCP with visualized stone was the best predictor of CDL. Although ERCP did not result in greater LOS or readmissions, the use of MRCP prior to ERCP may reduce unnecessary procedures for children with gallstone pancreatitis.
Keywords: Choledocholithiasis; Cholelithiasis; ERCP; Gallstone pancreatitis; Pediatric.
J Pediatr Surg. 2025 Nov;60(11):162595. doi: 10.1016/j.jpedsurg.2025.162595. Epub 2025 Aug 18. PMID: 40834917.
Comparison of postoperative antibiotic protocols for pediatric complicated appendicitis: A Western Pediatric Surgery research consortium study
Patwardhan UM, Kahan A, Scott Eldredge R, Russell KW, Lee J, Short SS, Padilla B, Cairo SB, Acker SN, Jensen AR, Kelley-Quon LI, Rothstein DH, Fialkowski EA, Chao SD, Gillory L, Pandya S, Diaz-Miron J, Ignacio RC Jr.
Abstract:
J Pediatr Surg. 2025 Jul 17:162461. doi: 10.1016/j.jpedsurg.2025.162461. Epub ahead of print. PMID: 40683345.
Pediatric Cholecystectomy Case Volume and Complexity Following the COVID-19 Pandemic
Olivia A. Keane, Shadassa Ourshalimian, Romeo Ignacio, Shannon Acker, Aaron Jensen, Katrine Lofberg, Claudia Mueller, Benjamin E. Padilla, Samir Pandya, David H. Rothstein, Katie W. Russell, Caitlin Smith, Ma Kayla O’Guinn, Madeleine Ing, Gretchen Floan Sachs, Alexandra Highet, Stephanie E. Iantorno, Lauren R. Templeton, Brielle Ochoa, Utsav M. Patwardhan, Alyssa Peace, Marisa E. Schwab, Tina H. Tran, Lorraine I. Kelley-Quon
Abstract:
BACKGROUND AND OBJECTIVES: Historically, cholecystectomy was infrequently performed in children. Lifestyle changes, delays in health care access, and increases in childhood obesity occurred during the COVID-19 pandemic. The impact of these shifts on need for cholecystectomy are poorly understood. We evaluate trends in cholecystectomy case volume among children during the COVID-19 pandemic.
METHODS: A multi-institutional retrospective cohort study was conducted for children ages 18 years and younger who underwent cholecystectomy from January 1, 2016, to July 31, 2022, at 10 children’s hospitals. Differences in cholecystectomy case mix and volume before and during the pandemic were identified using bivariate comparisons and interrupted time series analysis.
RESULTS: Overall, 4282 children were identified: 2122 before the pandemic and 2160 during the pandemic. Most were female (74.2%) with a median age of 15 years (IQR, 13.0–16.0 years). The proportion of Hispanic (55.0% vs 60.1%; P = .01) patients, body mass index (BMI) (26.0 vs 27.1; P < .001), and obesity (BMI > 30) (30.8% vs 37.4%; P < .001) increased during the pandemic. Predicted monthly case volume increased from 40 to 100 during the pandemic. Patients transferred from an outside hospital increased (21.3% vs 28.5%; P < .001). Significant increases in acute cholecystitis (12.2% vs 17.3%; P < .001), choledocholithiasis (12.8% vs 16.5%; P = .001), gallstone pancreatitis (10.6% vs 12.4%; P = .064), and chronic cholecystitis (1.4% vs 3.2%; P < .001) also occurred. On interrupted time series analysis, change in month-to-month case count significantly increased during the pandemic (Figure 1; P < .001), which persisted after exclusion of transferred patients.
CONCLUSIONS: Pediatric cholecystectomy case volume and complexity increased during the COVID-19 pandemic. These findings may be secondary to changes in childhood health, transfer patterns, and shifts in access, highlighting an increased health care burden on children’s hospitals
Pediatrics. 2025 Feb 21:e2024068065. doi: 10.1542/peds.2024-068065. Epub ahead of print. PMID: 39978405.
Recurrence Following Operative vs. Non-Operative Management of Adhesive Small Bowel Obstruction in Children: A Multi-center Prospective Observational Study
Utsav M Patwardhan 1, Romeo C Ignacio 1 2, Kaci Pickett-Nairne 3, Katie W Russell 4, Justin Lee 5, Ben Padilla 5, Caroline Melhado 6, Lorraine I Kelley-Quon 7 8, David H Rothstein 9, Hariharan Thangarajah 1 2, Ana Ibarra-Meraz 10, Rabab M Barq 7, Kezlyn E Larsen 4, Kathryn L Fowler 11, Zebediah Hunteman 5, Maria Valencia-Bradd 12, Katrine Lofberg 11, Aaron Jensen 6, Samir Pandya 12, Shannon N Acker 10; Western Pediatric Surgery Research Consortium
Abstract:
Objective: Data on the incidence of recurrent adhesive small bowel obstruction (ASBO) following index admission for ASBO in children are limited. We sought to determine if operative management was associated with a lower rate of recurrence compared to non-operative management (NOM).
Methods: We conducted a prospective observational study of children with ASBO admitted to nine hospitals from 10/2020 to 12/2022 who underwent a trial of NOM. Children were followed for a year after admission. The primary outcome was readmission for recurrent ASBO. Adjusted comparisons were made between children successfully managed nonoperatively at the index admission and those who underwent surgery.
Results: Among 136 children, 87 (63.9%) had successful NOM at the index admission. Within 1 year, twenty patients (14.7%; 17/87 NOM group; 3/49 operative group) had recurrent ASBO. On unadjusted analysis, there was a higher risk of recurrent ASBO in the NOM group (19.5 vs. 6.1%, P=0.04). However, after adjusting for age (HR 0.35, CI 0.10-1.23), there was no significant difference. Among patients with recurrent ASBO, 7/20 (35%) underwent an urgent or emergent operation at readmission; this rate was similar between initial management groups.
Conclusion: Although the rate of recurrent ASBO in children is nearly 15% within one year, this rate does not differ based on the initial management strategy. Among children with recurrent ASBO, one-third underwent an urgent or emergent operation at readmission. NOM appears to be as effective in preventing recurrent ASBO as surgery.
Ann Surg. 2025 Feb 10. doi: 10.1097/SLA.0000000000006653. Epub ahead of print. PMID: 39925301.
The Sensitivity of Limited-Sequence MRI in Identifying Pediatric Cervical Spine Injury: A Western Pediatric Surgery Research Consortium Multicenter Retrospective Cohort Study
Caroline Melhado 1, Rachelle Durand 1, Katie W Russell 2, Natalya E Polukoff 2, John Rampton 2, Rajiv R Iyer 2, Shannon N Acker 3, Richele Koehler 3, Connor Prendergast 3, Nicholas Stence 3, Brent O'Neill 3, Benjamin E Padilla 4, Ramin Jamshidi 4, Jennifer A Vaughn 4, Jennifer S Ronecker 4, Leigh Selesner 5, Katrine Lofberg 5, Michael Regner 5, Jaclyn Thiessen 5, Christine Sayama 5, Ryan G Spurrier 6, Erin E Ross 6, Chia-Shang Jason Liu 6, Jason Chu 6, Kathryn McNevin 7, Catherine Beni 7, Bryce R H Robinson 7, Ken Linnau 7, Robert T Buckley 7, Stephanie D Chao 8, Akanksha Sabapaty 8, Elizabeth Tong 8, Laura M Prolo 8, Romeo Ignacio 9, Gretchen Floan Sachs 9, Peter Kruk 9, David Gonda 9, Mark Ryan 10, Samir Pandya 10, Korgun Koral 10, Bruno P Braga 10, Kurtis Auguste, Aaron R Jensen 1; Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group
Abstract:
Introduction: Clinical clearance of a child's cervical spine after trauma is often challenging due to impaired mental status or an unreliable neurologic examination. Magnetic resonance imaging (MRI) is the gold standard for excluding ligamentous injury in children but is constrained by long image acquisition times and frequent need for anesthesia. Limited-sequence MRI (LSMRI) is used in evaluating the evolution of traumatic brain injury and may also be useful for cervical spine clearance while potentially avoiding the need for anesthesia. The purpose of this study was to assess the sensitivity and negative predictive value of LSMRI as compared to gold standard full-sequence MRI as a screening tool to rule out clinically significant ligamentous cervical spine injury.
Methods: We conducted a ten-center, five-year retrospective cohort study (2017-2021) of all children (0-18y) with a cervical spine MRI after blunt trauma. MRI images were re-reviewed by a study pediatric radiologist at each site to determine if the presence of an injury could be identified on limited sequences alone. Unstable cervical spine injury was determined by study neurosurgeon review at each site.
Results: We identified 2,663 children less than 18 years of age who underwent an MRI of the cervical spine with 1,008 injuries detected on full-sequence studies. The sensitivity and negative predictive value of LSMRI were both >99% for detecting any injury and 100% for detecting any unstable injury. Young children (age < 5 years) were more likely to be electively intubated or sedated for cervical spine MRI.
Conclusion: LSMRI is reliably detects clinically significant ligamentous injury in children after blunt trauma. To decrease anesthesia use and minimize MRI time, trauma centers should develop LSMRI screening protocols for children without a reliable neurologic exam.
J Trauma Acute Care Surg. 2024 Mar 25. doi: 10.1097/TA.0000000000004271.
Decision-Making in Pleural Drainage Following Lung Resection in Children: A Western Pediatric Surgery Research Consortium Survey
Jamie K Schnuck 1, Shannon N Acker 2, Lorraine I Kelley-Quon 3, Justin H Lee 4, Stephen B Shew 5, Elizabeth Fialkowski 6, Romeo C Ignacio 7, Caroline Melhado 8, Faisal G Qureshi 9, Katie W Russell 10, David H Rothstein 11; Western Pediatric Surgery Research Consortium
Abstract:
Introduction: Studies of adults undergoing lung resection indicated that selective omission of pleural drains is safe and advantageous. Significant practice variation exists for pleural drainage practices for children undergoing lung resection. We surveyed pediatric surgeons in a 10-hospital research consortium to understand decision-making for placement of pleural drains following lung resection in children.
Methods: Faculty surgeons at the 10 member institutions of the Western Pediatric Surgery Research Consortium completed questionnaires using a REDCap survey platform. Descriptive statistics and bivariate analyses were used to characterize responses regarding indications and management of pleural drains following lung resection in pediatric patients.
Results: We received 96 responses from 109 surgeons (88 %). Most surgeons agreed that use of a pleural drain after lung resection contributes to post-operative pain, increases narcotic use, and prolongs hospitalization. Opinions varied around the immediate use of suction compared to water seal, and half routinely completed a water seal trial prior to drain removal. Surgeons who completed fellowship within the past 10 years left a pleural drain after wedge resection in 45 % of cases versus 78 % in those who completed fellowship more than 10 years ago (p = 0.001). The mean acceptable rate of unplanned post-operative pleural drain placement when pleural drainage was omitted at index operation was 6.3 % (±4.6 %).
Conclusions: Most pediatric surgeons use pleural drainage following lung resection, with recent fellowship graduates more often omitting it. Future studies of pleural drain omission demonstrating low rates of unplanned postoperative pleural drain placement may motivate practice changes for children undergoing lung resection.
J Pediatr Surg. 2024 Jan 17:S0022-3468(24)00009-5. doi: 10.1016/j.jpedsurg.2024.01.006.
Utility of Enteral Contrast Protocols in Pediatric Adhesive Small Bowel Obstruction: A Prospective Multicenter Observational Study
Shannon N Acker 1 2, Romeo Ignacio 3, Katie W Russell 4, Lorraine Kelley-Quon 5 6, Katrine Lofberg 7, Justin Lee 8, Aaron R Jensen 9, Kaci Pickett-Nairne 2, Connor Prendergast 1 2, Stephanie E Iantorno 4, Hari Thangarajah 3, Utsav Patwardhan 3, Caroline Melhado 9, Allen Zhong 5, Ben Padilla 8, David H Rothstein 10, Lauren Nicassio 10, Samir Pandya 11, Maria Valencia 1, Kasper Wang 12, Tom H Inge 13; Western Pediatric Surgery Research Consortium
Abstract
Objective: Our objective was to determine the utility of enteral contrast-based protocols in the diagnosis and management of adhesive small bowel obstruction (ASBO) for children.
Background: Enteral contrast-based protocols for adults with ASBO are associated with decreased need for surgery and shorter hospitalization. Pediatric-specific data are limited.
Methods: We conducted a prospective observational study between October 2020 and December 2022 at nine children's hospitals who are members of the Western Pediatric Surgery Research Consortium. Inclusion criteria were children aged 1-20 years diagnosed with ASBO who underwent a trial of nonoperative management (NOM) at hospital admission. Comparisons were made between those children who received an enteral contrast challenge and those who did not. The primary outcome was need for surgery.
Results: We enrolled 136 children (71% male; median age: 12 y); 84 (62%) received an enteral contrast challenge. There was no difference in rate of operative intervention between the no contrast (34.6%) and contrast groups (36.9%; P=0.93). Eighty-seven (64%) were successfully managed nonoperatively with no difference in median length of stay (P=0.10) or rate of unplanned readmission (P=0.14). Among the 49 children who required an operation, there was no significant difference in time from admission to surgery or rate of small bowel resection based on prior contrast administration.
Conclusions: The addition of enteral contrast-based protocols for management of pediatric ASBO does not decrease the likelihood of surgery or shorten hospitalization. Larger randomized studies may be needed to further define the role of radiologic contrast in the management of ASBO in children.
Ann Surg. 2024 Jan 23. doi: 10.1097/SLA.0000000000006207
“Healthcare-Associated Pressure Injury in Pediatric Trauma Patients with Cervical Spine Immobilization: A Western Pediatric Surgery Research Consortium Multi-Center Retrospective Review” has been accepted as a podium presentation in the Scientific Abstract Session at the 2023 Western Pediatric Trauma Conference
Caroline Melhado MD MS, Katie W. Russell MD, Shannon N. Acker MD, Benjamin E. Padilla MD, Katrine Lofberg MD, Ryan G. Spurrier MD, Bryce Robinson MD MS, Stephanie Chao MD, Romeo C. Ignacio, Jr., MD, MS, MPath, Mark Ryan MD, and Aaron R. Jensen MD MEd MS, on behalf of the Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group.
Negative Predictive Value of a Normal Cervical Spine CT Compared to MRI for Ligamentous Injury After Blunt Trauma in Children: A Western Pediatric Surgery Research Consortium Multi-Center Retrospective Review for consideration at the 2023 National Conference & Exhibition’s Section on Surgery Program.
Caroline Melhado MD MS, Katie W. Russell MD, Shannon N. Acker MD, Benjamin E. Padilla MD, Katrine Lofberg MD, Ryan G. Spurrier MD, Bryce Robinson MD MS, Stephanie Chao MD, Romeo C. Ignacio, Jr., MD, MS, MPath, Mark Ryan MD, and Aaron R. Jensen MD MEd MS, on behalf of the Western Pediatric Surgery Research Consortium Cervical Spine Injury Study Group.
Machine Learning to Predict Pediatric Choledocholithiasis: A Western Pediatric Surgery Research Consortium Retrospective Study
Gretchen Floan Sachs, MD, Shadassa Ourshalimian, MPH, Aaron R. Jensen, MD, MEd, MS, FACS, Lorraine I. Kelley-Quon, MD, MSHS, FACS , Benjamin E. Padilla, MD, FACS, Stephen B. Shew, MD, FACS, Katrine M. Lofberg, MD, FACS, Caitlin A. Smith, MD, FACS, Jonathan P. Roach, MD, FACS , Samir R. Pandya, MD, FACS, Katie W. Russell, MD, FACS, Romeo C. Ignacio Jr., MD, MS, MPath, FACS, Western Pediatric Surgery Research Consortium Choledocholithiasis Investigative Group
Abstract:
Background: The purpose of this study was to accurately predict pediatric choledocholithiasis with clinical data using a computational machine learning algorithm.
Methods: A multicenter retrospective cohort study was performed on children <18 years of age who underwent cholecystectomy between 2016 to 2019 at 10 pediatric institutions. Demographic data, clinical findings, laboratory, and ultrasound results were evaluated by bivariate analyses. An Extra-Trees machine learning algorithm using k-fold cross-validation was used to determine predictive factors for choledocholithiasis. Model performance was assessed using the area under the receiver operating characteristic curve on a validation dataset.
Results: A cohort of 1,597 patients was included, with an average age of 13.9 ± 3.2 years. Choledocholithiasis was confirmed in 301 patients (18.8%). Obesity was the most common comorbidity in all patients. Choledocholithiasis was associated with the finding of a common bile duct stone on ultrasound, increased common bile duct diameter, and higher serum concentrations of aspartate aminotransferase, alanine transaminase, lipase, and direct and peak total bilirubin. Nine features (age, body mass index, common bile duct stone on ultrasound, common bile duct diameter, aspartate aminotransferase, alanine transaminase, lipase, direct bilirubin, and peak total bilirubin) were clinically important and included in the machine learning algorithm. Our 9-feature model deployed on new patients was found to be highly predictive for choledocholithiasis, with an area under the receiver operating characteristic score of 0.935.
Conclusion: This multicenter study uses machine learning for pediatric choledocholithiasis. Nine clinical factors were highly predictive of choledocholithiasis, and a machine learning model trained using medical and laboratory data was able to identify children at the highest risk for choledocholithiasis
J. Surg. 2023 Aug. https://doi.org/10.1016/j.surg.2023.07.008
The Peds Duct Score: A Highly Specific Predictive Model for Pediatric Choledocholithiasis
Ignacio RC Jr, Kelley-Quon LI, Ourshalimian S, Padilla BE, Jensen AR, Shew SB, Lofberg KM, Smith CA, Roach JP, Pandya SR, Russell KW, Wang K; Western Pediatric Surgery Research Consortium Choledocholithiasis Investigative Group
Abstract:
Introduction: To determine whether adult preoperative factors predicting choledocholithiasis (CD) are reliable in children and to create a validated pediatric-specific risk model.
Methods: A multicenter retrospective cohort study was performed including children (<18 yo) who underwent cholecystectomy for gallstone disease at 10 Western Pediatric Surgical Research Consortium children’s hospitals between 2016-2019. Multivariable regression analyses and ROC curves were used to determine predictive factors and optimal cutoff values for CD. The predictive model was tested with a 20% hold-out sample.
Results: The cohort comprised 979 children after cholecystectomy with an average age of 14.1+3.0 years, 75.1% female, 59.2% Hispanic, BMI was 27.7+8.3. Choledocholithiasis was confirmed in 222 patients (22.7%) by MRCP, ERCP, and/or IOC. Multivariable analyses with ROC curves identified three predictive factors for CD 1) a Dilated CBD>6mm, 2) Ultrasound (US) with visualized CBD stone, and 3) Total bilirubin>1.8 mg/dL (Peds DUCT criteria). These criteria demonstrated appropriate accuracies (>76%), specificities (>78%), and negative predictive values (>79%). Other factors commonly used in adults (elevated AST/ALT, pancreatitis, BMI, and age) were not independently predictive of CD in children. When tested on a hold-out sample, higher stratified risk groups demonstrated high accuracy, specificity, and negative predictive values similar to the adult CD literature.
Conclusion: Unique to children, dilated CBD>6mm, US findings of CBD stone, and total bilirubin>1.8 mg/dL are three highly-specific clinical variables predictive of choledocholithiasis. The Peds DUCT score is simple, practical, and validated on a large, multi-institutional pediatric data set and should become standard for choledocholithiasis risk assessment in children.
J Am Coll Surg. 2023 May 1;236(5):961-970. doi: 10.1097/XCS.0000000000000650. Epub 2023 Feb 14. PMID: 36786471.
Standardized Perioperative Care Reduces Colorectal Surgical Site Infection: A Western Pediatric Surgery Research Consortium Multicenter Analysis
Joe Tobias, MD, Ben Padilla, MD, Justin Lee, MD, Stephanie Chen, MD, Kasper Wang, MD, Lorraine Kelley-Quon MD, MSHS, Claudia Mueller, PhD, MD, Steve Shew, MD, Katie Joskowitz, Romeo Ignacio, MD, Lauren Evans, MD, Aaron Jensen, MD MEd MS, Shannon Acker, MD, Andrew Mason, Alicia Johnson, Jessica McConahey, MD, Erik Hansen, MD, Samir Pandya, MD, Scott S. Short, MD, Katie W. Russell, MD, Lauren Nicassio, MD, Caitlin A. Smith, MD, Elizabeth Fialkowski, MD
Abstract:
Purpose: Surgical site infection (SSI) remains a significant source of patient morbidity and resource utilization in children undergoing colorectal surgery. We examined the utility of a protocolized perioperative care bundle in reducing SSI in pediatric patients undergoing colorectal surgery.
Methods: We conducted a prospective cohort study of patients ≤18 years of age undergoing colorectal surgery at ten United States children's hospitals. Using a perioperative care protocol comprising eight elements, or “colon bundle”, we divided patients into low (1-4 elements) or high (5-8 elements) compliance cohorts. Procedures involving colorectal repair or anastomosis with abdominal closure were included. Demographics and clinical outcomes were compared between low and high compliance cohorts. Compliance was compared with a retrospective cohort. The primary outcome was superficial SSI incidence at 30 days.
Results: Three hundred and thirty-six patients were included in our analysis: 138 from the low compliance cohort and 198 from the high compliance cohort. Age and gender were similar between groups. Preoperative diagnosis was similar except for more patients in the high compliance cohort having inflammatory bowel disease (18.2% versus 5.8%, p<0.01). The most common procedure performed was small bowel to colorectal anastomosis. Wound classification and procedure acuity were similar between groups. Superficial SSI at 30 days occurred less frequently among the high compliance compared to the low compliance cohort (4% versus 9.7%, p = 0.036). Median postoperative length of stay and 30-day rates of readmission, reoperation, intra-abdominal abscess and anastomotic leak requiring operation were not significantly different between groups. None of the individual colon bundle elements were independently protective against superficial SSI.
Conclusion: Standardization of perioperative care is associated with a reduction in superficial SSI in pediatric colorectal surgery. Expansion of standardized protocols for children undergoing colorectal surgery may improve outcomes and decrease perioperative morbidity.
J Pediatr Surg. 2022 Sep 26. doi: 10.1016/j.jpedsurg.2022.09.026
Adolescent Vaping-Associated Trauma in the Western United States
Katie W. Russell, Micah G. Katz, Ryan C. Phillips, Lorraine I. Kelley-Quon, Shannon N. Acker, Niti Shahi, Justin H. Lee, Elizabeth A. Fialkowski, Deepthi Nacharaju, Caitlin A. Smith, Aaron R. Jensen, Claudia M. Mueller, Benjamin E. Padilla, Romeo C. Ignacio, Shadassa Ourshalimian, Kasper S. Wang, Daniel J. Ostlie, Stephen J. Fenton , Zachary J. Kastenberg. On behalf of the Western Pediatric Surgery Research Consortium.
Abstract:
Introduction: Electronic cigarettes (e-cigarettes) are handheld, battery-powered vaporizing devices. It is estimated that more than 25% of youth have used these devices recreationally. While vaping-associated lung injury is an increasingly recognized risk, little is known about the risk of traumatic injuries associated with e-cigarette malfunction.
Methods: A multi-institutional retrospective study was performed by querying the electronic health records at nine children's hospitals. Patients who sustained traumatic injuries while vaping from January 2016 through December 2019 were identified. Patient demographics, injury characteristics, and the details of trauma management were reviewed.
Results: 15 children sustained traumatic injuries due to e-cigarette explosion. The median age was 17 y (range 13-18). The median injury severity score was 2 (range 1-5). Three patients reported that their injury coincided with their first vaping experience. Ten patients required hospital admission, three of whom required intensive care unit admission. Admitted patients had a median length of stay of 3 d (range 1-6). The injuries sustained were: facial burns (6), loss of multiple teeth (5), thigh and groin burns (5), hand burns (4), ocular burns (4), a radial nerve injury, a facial laceration, and a mandible fracture. Six children required operative intervention, one of whom required multiple operations for a severe hand injury.
Conclusions: In addition to vaping-associated lung injury, vaping-associated traumatic injuries are an emerging and worrisome injury pattern sustained by adolescents in the United States. This report highlights another means by which e-cigarettes pose an increasing risk to a vulnerable youth population.
Journal of Surgical Research, Volume 276, August 2022,Pages 251-255, ISSN 0022-4804, https://doi.org/10.1016/j.jss.2022.02.026
A Multi-Institutional Quality Improvement Project to Minimize Opioid Prescribing in Children after Appendectomy Using NSQIP-Pediatric
Lorraine I. Kelley-Quon, MD, MSHS, Shadassa Ourshalimian, MPH, Justin Lee, MD, Katie W. Russell, MD, Karen Kling, MD, Stephen Shew, MD, Claudia Mueller, MD, Aaron Jensen, MD, Lan Vu, MD, Benjamin Padilla, MD, Daniel Ostlie, MD, Caitlin Smith, MD, Thomas Inge, MD, Jonathan Roach, MD, Romeo Ignacio, MD, Katrine Lofberg, MD, Stephanie Radu, MCR, Autumn Rohan, Kasper Wang, MD
Abstract:
Background: There is wide variation in opioid prescribing after appendectomy in children and adolescents, with recent increases noted in opioid-related pediatric deaths from prescription and illicit opioids. The goal of this project was to minimize opioid prescribing at the time of discharge for children undergoing appendectomy by using Quality Improvement (QI) methodology.
Study Design: Children (18 years of age or less) who underwent appendectomy were evaluated from January to December 2019 using NSQIP-Pediatric at 10 children’s hospitals within the Western Pediatric Surgery Research Consortium. Before project initiation, 5 hospitals did not routinely prescribe opioids after appendectomy (protocol). At the remaining 5 hospitals, prescribing was not standardized and varied by surgeon (no-protocol). A prospective multi-institutional QI project was used to minimize outpatient opioid prescriptions for children after appendectomy. The proportion of children at each hospital receiving an opioid prescription at discharge was compared for 6 months before and after the intervention using chi-square analysis.
Results: Overall, 1,524 children who underwent appendectomy were evaluated from January to December 2019. After the QI intervention, overall opioid prescribing decreased from 18.2% to 4.0% (p < 0.001), with significant decreases in protocol hospitals (2.7% vs 0.8%, p = 0.038) and no-protocol hospitals (37.9% vs 8.8%, p < 0.001). The proportion of 30-day emergency room visits did not change after the QI intervention (8.9% vs 9.9%, p = 0.54) and mean postintervention pain management satisfaction scores were high.
Conclusion: Opioid prescribing can be minimized in children after appendectomy without increasing emergency room visits or decreasing patient satisfaction. Furthermore, NSQIP-Pediatric can be used as a platform for multi-institutional collaboration for successful implementation of QI projects.
J Am Coll Surg. 2022 Mar 1; 234(3):290-298. doi: 10.1097/XCS.0000000000000056. PMID: 35213491.
The Need for Early Kasai Portoenterostomy: A Western Pediatric Surgery Research Consortium Study
Lorraine I. Kelley-Quon, MD, MSHS, Eveline Shue, MD, Rita V. Burke, PhD, MPH, Caitlin Smith, MD, Karen Kling, MD, Elaa Mahdi, MD, Shadassa Ourshalimian, MPH, Michael Fenlon, MD, Matthew Dellinger, MD, Stephen B. Shew, MD, Justin Lee, MD, Benjamin Padilla, MD, Thomas Inge, MD, Jonathan Roach, MD, Ahmed I. Marwan, MD, Katie W. Russell, MD, Romeo Ignacio, MD, Elizabeth Fialkowski, MD, Amar Nijagal, MD, Cecilia Im, BS, Ken Azarow, MD, Daniel Ostlie, MD, Kasper Wang, MD
Abstract:
Purpose: The purpose of this study was to investigate factors impacting transplant-free survival among infants with biliary atresia.
Methods: A multi-institutional, retrospective cohort study was performed at nine tertiary-level children's hospitals in the United States. Infants who underwent Kasai portoenterostomy (KP) from January 2009 to May 2017 were identified. Clinical characteristics included age at time of KP, steroid use, surgical approach, liver pathology, and surgeon experience. Likelihood of transplant-free survival (TFS) was evaluated using logistic regression, adjusting for patient and surgeon-level factors. Secondary outcomes at 1 year included readmission, cholangitis, reoperation, mortality, and biliary clearance.
Results: Overall, 223 infants underwent KP, and 91 (40.8%) survived with their native liver. Mean age at surgery was 63.9 days (± 24.7 days). At 1 year, 78.5% experienced readmission, 56.9% developed cholangitis, 3.8% had a surgical revision, and 5 died. Biliary clearance at 3 months was achieved in 76.6%. Controlling for patient and surgeon-level factors, each additional day of age toward operation was associated with a 2% decrease in likelihood of TFS (OR 0.98, 95% CI 0.97-0.99).
Conclusion: Earlier surgical intervention by Kasai portoenterostomy at tertiary-level centers significantly increases likelihood for TFS. Policy-level interventions to facilitate early screening and surgical referral for infants with biliary atresia are warranted to improve outcomes.
Keywords: Biliary atresia; Kasai portoenterostomy; Liver transplant; Transplant-free survival.
Pediatr Surg Int. 2022 Feb;38(2):193-199. doi: 10.1007/s00383-021-05047-1. Epub 2021 Dec 2. PMID: 34854975; PMCID: PMC8742784.
Attitudes Affecting Decision-making for Use of Radiologic Enteral Contrast in the Management of Pediatric Adhesive Small Bowel Obstruction: A Survey Study of Pediatric Surgeons
Acker SN, Diaz-Miron J, Ignacio RC, Russell KW, Lofberg K, Shew SB, Peterson PN, Kelley-Quon LI, Jensen AR, Lee J, Padilla B, Smith CA, Kastenberg ZJ, Azarow KS, Ostlie DJ, Wang KS, Inge TH; Western Pediatric Surgery Research Consortium.
Abstract:
Background: Pediatric surgeons are often asked to treat clinical problems for which little high-quality data exist. For adults with adhesive small bowel obstruction (ASBO), water soluble contrast-based protocols are used to guide management. Little is known about their utility in children. We aimed to better understand key factors in clinical decision-making processes and integration of adult based data in pediatric surgeon's approach to ASBO.
Methods: We administered a web-based survey to practicing pediatric surgeons at institutions comprising the Western Pediatric Surgery Research Consortium.
Results: The response rate was 69% (78/113). Over half of respondents reported using contrast protocols to guide ASBO management either routinely or occasionally (n = 47, 60%). Common themes regarding the incorporation of adult-based data into clinical practice included the need to adapt protocols for pediatric patients, the dearth of pediatric specific data, and the quality of the published adult evidence.
Conclusions: Our findings demonstrate that pediatric surgeons use contrast-based protocols for the management of ASBO despite the paucity of pediatric specific data. Furthermore, our survey data help us understand how pediatric surgeons incorporate adult based evidence into their practice.
Keywords: Contrast protocol; Pediatric surgeon survey; Small bowel obstruction.
J Surg Res. 2021 Nov;267:536-543.doi: 10.1016/j.jss.2021.06.004 .Epub 2021 Jul 10.
Child Physical Abuse and COVID-19: Trends from Nine Pediatric Trauma Centers
Katie W. Russell, Shannon N. Acker, Romeo C. Ignacio, Katrine M. Lofberg, Erin M. Garvey, Stephanie D. Chao, David W. Bliss, Caitlin A. Smith, Deepika Nehra, Melissa L. Anderson, Brittney L. Bunnell, Niti Shahi, John M. Perry, Lauren L. Evans, Jacky Z. Kwong, Joseph Tobias, Autumn Rohan, Kaci L. Pickett, Jill L. Kaar, Zachary J. Kastenberga, Antoinette L. Laskey, Eric R. Scaifea, Aaron R. Jensen
Abstract:
Background: Economic, social, and psychologic stressors are associated with an increased risk for abusive injuries in children. Prolonged physical proximity between adults and children under conditions of severe external stress, such as witnessed during the COVID-19 pandemic with "shelter-in-place orders", may be associated with additional increased risk for child physical abuse. We hypothesized that child physical abuse rates and associated severity of injury would increase during the early months of the pandemic as compared to the prior benchmark period.
Methods: We conducted a nine-center retrospective review of suspected child physical abuse admissions across the Western Pediatric Surgery Research Consortium. Cases were identified for the period of April 1-June 30, 2020 (COVID-19) and compared to the identical period in 2019. We collected patient demographics, injury characteristics, and outcome data.
Results: There were no significant differences in child physical abuse cases between the time periods in the consortium as a whole or at individual hospitals. There were no differences between the study periods with regard to patient characteristics, injury types or severity, resource utilization, disposition, or mortality.
Conclusions: Apparent rates of new injuries related to child physical abuse did not increase early in the COVID-19 pandemic. While this may suggest that pediatric physical abuse was not impacted by pandemic restrictions and stresses, it is possible that under-reporting, under-detection, or delays in presentation of abusive injuries increased during the pandemic. Long-term follow-up of subsequent rates and severity of child abuse is needed to assess for unrecognized injuries that may have occurred.
Keywords: COVID-19; Child abuse; Nonaccidental trauma; SARS-CoV-2.
J Pediatr Surg. 2021 Oct 8;S0022-3468(21)00679-5. doi: 10.1016/j.jpedsurg.2021.09.050 .Online ahead of print