Shifting the pediatric choledocholithiasis paradigm: Development of a surgery-first clinical practice guideline at a tertiary children's hospital.

Background: Pediatric choledocholithiasis has traditionally been managed with a two-stage endoscopy-first (EF) approach involving ERCP followed by cholecystectomy. This strategy increases hospital length of stay (LOS), procedural complexity, and exposure to anesthesia. A growing body of evidence supports a surgery-first (SF) paradigm.

Endoscopic Retrograde Cholangiopancreatography (ERCP) Findings in Pediatric Patients With Choledocholithiasis Justify a Surgery-First Approach: A Multi-Center Study.

Background: Pediatric choledocholithiasis is traditionally managed with an endoscopy-first approach, where Endoscopic Retrograde Cholangiopancreatography (ERCP) is performed before laparoscopic cholecystectomy (LC). However, ERCP carries risks such as pancreatitis, bleeding, infection, and perforation, and may even be an unnecessary procedure should stones pass spontaneously. An alternative surgery-first approach, utilizing intraoperative cholangiogram (IOC), laparoscopic common bile duct exploration (LCBDE), power flushing, and glucagon, may offer a more efficient treatment pathway.

"Surgery First" vs. "Endoscopy First" for Pediatric Choledocholithiasis Presenting at the End of the Week - A CARES Working Group Study.

Background: Choledocholithiasis in children is commonly managed with an "endoscopy-first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC)). Because ERCP availability is often limited at the end of the week (EoW), we hypothesized that a "surgery-first" (SF) approach (LC with intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile exploration (LCBDE)) would decrease length of stay (LOS) and time to definitive intervention (TTDI).

Methods: A multicenter, retrospective cohort study was conducted on pediatric patients from 2018 to 2023 with suspected choledocholithiasis.

Multi-Institutional Analysis of Choledocholithiasis in Pediatric vs Adult Patients.

Background: In adults, upfront intraoperative cholangiogram with laparoscopic common bile duct exploration (LCBDE) is well accepted for management of choledocholithiasis. Despite recent evidence supporting LCBDE utility in children, there has been hesitation to adopt this surgery first (SF) approach over ERCP first (EF) due to perceived technical challenges. We compared rates of successful stone clearance during LCBDE between adult and pediatric patients to evaluate if pediatric surgeons could anticipate similar rates of successful clearance.

Reducing MRCP Utilization Through a "Surgery First" Approach for Pediatric Choledocholithiasis: A CARES Working Group Retrospective Study.

Background: Choledocholithiasis in children is rising and frequently managed with an endoscopy-first (EF) approach that utilizes endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Magnetic resonance cholangiopancreatography (MRCP) is a resource intensive modality that often precedes ERCP to gain further assurance of choledocholithiasis prior to intervention. MRCP can lead to a longer length of stay (LOS) and strain healthcare resources.

Patient Safety and Radiation Exposure in Transcystic Laparoscopic Common Bile Duct Exploration: A CARES Working Group Multicenter Study.

Background: Treatment of choledocholithiasis with laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC) ± transcystic laparoscopic common bile duct exploration (LCBDE) is associated with fewer procedures and shorter length of stay (LOS) compared to preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by LC. Fluoroscopy is required for both LCBDE and ERCP but fluoroscopic time (FT) and radiation dose (RD) in LCBDE has not been studied.

Methods: The Choledocholithiasis Alliance for Research, Education, and Surgery (CARES) Working Group conducted this retrospective study on pediatric patients with suspected choledocholithiasis who received IOC.

A Novel Taxonomy of Intraoperative Cholangiograms in Suspected Choledocholithiasis: A Tool for Advancing Laparoscopic Common Bile Duct Exploration Outcomes Research.

Background: Cholangiography for visualization of the biliary tree during laparoscopic cholecystectomy is an important diagnostic roadmap in the context of suspected choledocholithiasis (CDL). The renewed interest in transcystic laparoscopic common bile duct exploration (LCBDE) necessitates a general description of the range of CDL presentations. Our aim was to establish a novel classification system of intraoperative cholangiograms (IOCs) to advance research efforts in this field.

Photoacoustic imaging for non-invasive assessment of biomarkers of intestinal injury in experimental necrotizing enterocolitis.

Background: Necrotizing enterocolitis (NEC) is an often-lethal disease of the premature infant intestinal tract, exacerbated by significant diagnostic difficulties. In NEC, the intestine exhibits hypoperfusion and dysmotility, contributing to disease pathogenesis. However, these features cannot be accurately and quantitively assessed with current imaging modalities.

Does the Timing of Surgical Intervention Impact Outcomes in Necrotizing Enterocolitis?

Objectives: The optimal time for intervention in surgical necrotizing enterocolitis (sNEC) remains to be elucidated. Surgical management varies between peritoneal drain (PD), laparotomy (LAP), and PD with subsequent LAP (PD + LAP). We propose that some infants with surgical NEC benefit from late (>48 h) operative intervention to allow for resuscitation.

A Comparative Analysis of "Surgery First" vs. "Endoscopy First" for Pediatric Choledocholithiasis Presenting at the End of the Week.

Background: Choledocholithiasis in children is commonly managed with an "endoscopy first" (EF) strategy (endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) under a separate anesthetic). Endoscopic Retrograde Cholangiopancreatography is limited at the end of the week (EoW). We hypothesize that a "surgery first" (SF) approach with LC, intraoperative cholangiogram (IOC), and possible laparoscopic common bile duct exploration (LCBDE) can decrease length of stay (LOS) and time to definitive intervention (TTDI).

The Effect of 4-Factor Prothrombin Complex Concentrate to Reverse Factor Xa Inhibitors in Patients With Traumatic Intracranial Hemorrhage.

The utility of 4-factor prothrombin complex concentrate (4F-PCC) for reversal in patients on factor Xa inhibitors (XaI) is unclear, specifically in mild traumatic brain injury (mTBI). This is a retrospective review over 6 years at a level 1 trauma center of patients presenting with mTBI on XaI comparing outcomes for those that received 4F-PCC to those that did not. 140 patients were included, 103 (74%) of these patients received 4F-PCC while 37 (26%) did not.

Contemporary management and outcomes of blunt traumatic American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries in children: A Trauma Quality Improvement Program analysis.

Background: The Trauma Quality Improvement Program (TQIP) database has delineated management strategies and outcomes for adults with American Association for the Surgery of Trauma Organ Injury Scale grades III and IV pancreatic injuries and suggests that nonoperative management (NOM) is a viable option for these injuries. However, management strategies vary for children following significant pancreatic injuries and outcomes for these intermediate/high-grade injuries have not been sufficiently studied. Our aim was to describe the management and outcomes for grades III and IV pancreatic injuries using TQIP.

Clinical Correlates of Cholestasis in Preterm Infants with Surgical Necrotizing Enterocolitis.

Background: We sought to investigate the clinical determinants and outcomes of cholestasis in preterm infants with surgical necrotizing enterocolitis (sNEC).

Methods: Retrospective comparison of clinical information in preterm infants who developed cholestasis vs those who did not.

Results: Sixty-two (62/91, 68.

Photoacoustic Imaging for Non-Invasive Assessment of Physiological Biomarkers of Intestinal Injury in Experimental Necrotizing Enterocolitis.

Background: Necrotizing enterocolitis (NEC) is an often-lethal disease of the premature infants' intestinal tract that is exacerbated by significant difficulties in early and accurate diagnosis. In NEC disease, the intestine often exhibits hypoperfusion and dysmotility, which contributes to advanced disease pathogenesis. However, these physiological features cannot be accurately and quantitively assessed within the current constraints of imaging modalities frequently used in the clinic (plain film X-ray and ultrasound).

Photoacoustic Imaging as a Novel Non-invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats.

Background: Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health.

Neonatal complicated intraabdominal infection.

Purpose Of Review: The purpose of this review is to summarize the treatment of complicated intraabdominal infections (cIAIs) in premature infants.

Recent Findings: Recent work has continued to define the complex nature of cIAIs and necrotizing enterocolitis (NEC). This includes new findings on the microbiome, breast milk and risk factors associated with NEC.

Photoacoustic Imaging as a Novel Non-Invasive Biomarker to Assess Intestinal Tissue Oxygenation and Motility in Neonatal Rats.

Background: Within the premature infant intestine, oxygenation and motility play key physiological roles in healthy development and disease such as necrotizing enterocolitis. To date, there are limited techniques to reliably assess these physiological functions that are also clinically feasible for critically ill infants. To address this clinical need, we hypothesized that photoacoustic imaging (PAI) can provide non-invasive assessment of intestinal tissue oxygenation and motility to characterize intestinal physiology and health.

Raising the Bar: Multimodal Analgesia with Transdermal Lidocaine for Nuss Repair of Pectus Excavatum Decreases Length of Stay and Opioid Use.

Intro: Pain management for minimally invasive (Nuss) repair of pectus excavatum (PE) is challenging, particularly as the judicious use of opioids has become a patient safety priority. Multi-modal pain management protocols are increasingly used, but there is limited experience using transdermal lidocaine patches (TLP) in this patient population.

Methods: Pediatric anesthesiologists and surgeons in a children's hospital within a hospital designed a multi-modal perioperative pain management protocol for patients undergoing Nuss repair of PE (IRB00068901).

Storage Practices, Devices, and Presence of Children Among Owners of Firearms: Informing Pediatric Firearm Safety.

Background: Firearm injury is the leading cause of death in children and prevention is the most effective method to reduce severe morbidity and mortality. Injury prevention programs have used community firearm lock giveaway events to promote safe firearm storage practices. The locks are generally simple and inexpensive devices suitable for mass distribution but may not possess the owner-desired attributes for use in the home.

Oral 'Board Style' Examination for Surgery Clerkship.

Evaluating medical students during surgical clerkships relies on multifactorial methods of evaluation. Clinical evaluations, combined with standardized multiple-choice exams, are often the foundation of evaluation highlighting the challenge of combining subjective and objective measurements. Oral board exams are standard amongst medical certification and employ an additional element to evaluate students more holistically.

Spontaneous rupture of omental pseudoaneurysm in a patient on systemic anticoagulation.

A ruptured omental pseudoaneurysm is a rare cause of intra-abdominal hemorrhage. Herein, we present a case of bleeding ruptured omental pseudoaneurysm in a patient on systemic anticoagulation and successful treatment with surgery. A 72-year-old female on warfarin for atrial fibrillation presented with worsening abdominal pain.

Making common duct exploration common-balloon sphincteroplasty as an adjunct to transcystic laparoscopic common bile duct exploration for pediatric patients.

Background: Laparoscopic common bile duct exploration (LCBDE) at the time of cholecystectomy has well-established benefits for managing pediatric choledocholithiasis. However, providers increasingly favor ERCP pre-or-post laparoscopic cholecystectomy (ERCP+LC) due to perceived complexity of LCBDE. We refined a stepwise method employing wire-ready balloon dilation of the Sphincter of Oddi.

Ionizing Radiation Exposure in Pediatric Patients With Intestinal Failure.

Background: Children with intestinal failure (IF) are frequently exposed to imaging studies using ionizing radiation. Due to many advancements in care of pediatric patients with IF, the number of patients living with this condition is growing. This burden of disease as pertains to pediatric IF patients has not been previously described.