Perianal complications are common and morbid in children with Crohn’s disease. In this review, we describe the epidemiology, the presentation and diagnosis, evaluation and management. We focus on ...updates such as the increasing frequency of biologic medications and MRI for evaluation. We also highlight controversies on the timing and approaches to surgical techniques. Finally, perianal disease requires the coordination of multidisciplinary care with nursing, radiology, gastroenterology, and surgery to optimize outcomes – both medical and patient-centered.
The purpose of this review is to explore the effects of the opioid crisis on pediatric patients in the postoperative setting and provide recommendations for well-tolerated opioid prescribing ...practices.
Opioid overdoses have increased among all age groups, predominantly related to overprescribing and accessibility of opioids in the home. Adverse risks of prescribed opioids include respiratory depression, gastrointestinal distress, accidental ingestion, intentional misuse, new chronic use, diversion to another user, and overdose. Well-tolerated opioid prescribing practices include multimodal pain management; prescribing guided by patient need; risk assessment for potential misuse; and comprehensive patient and family education on risks, safe storage, and disposal practices. Evolving state laws will affect varying institutional policies; thus, providers must ensure their prescribing practices are current and compliant.
All age groups have been affected by the opioid crisis, including children and adolescents. When managing postoperative pain, clinicians must balance appropriate pain management with well-tolerated opioid stewardship to minimize harm related to postoperative care.
Necrotizing enterocolitis (NEC) has been a long-recognized complication of prematurity, but there is a paucity of studies on term infants. We sought to characterize the clinical presentation and ...outcomes of full term (FT) infants with NEC and compare these to our experience with preterm (PT) neonates.
We conducted a chart review of infants admitted to the NICU at University of Michigan with a diagnosis of NEC for over a 10-year period with a Modified Bell stage of 2 or greater. We compared the outcomes and comorbidities of PT against those of FT, defined as gestational age at birth below and above 37 weeks, respectively.
Out of 170 infants, 28(17%) were FT. FT neonates were more likely to have undergone cardiac surgery for a congenital defect, excluding PDA ligation (64% vs. 8%)*. When compared to FT infants, PT infants were more likely to require surgical intervention (18% vs. 59%)*, have Bell stage 3 disease (82% vs. 43%)*, require vasopressor support (21% vs. 42%)+, and require ventilatory support (43% vs 75%)*. *p<0.01,+p<0.05.
FT neonates present with different patterns of disease and have different outcomes, suggesting that this may be a different clinical entity than NEC in preterm infants.
Retrospective review
Level III
Perianal fistulas are among the most severe complications of Crohn disease, but limited data regarding their outcomes are available in children. Our objective was to determine predictors of perianal ...fistula healing among pediatric patients newly diagnosed with Crohn disease.
This single-center retrospective study followed patients with perianal fistulas at Crohn disease diagnosis until fistula healing. Time to healing was analyzed using Cox proportional hazard regression models considering relevant covariates including patient demographics, disease characteristics, medical therapies no anti-tumor necrosis factor (TNF)α therapy, anti-TNFα therapy ±therapeutic drug monitoring, and perianal surgical procedures including fistulotomy, fistulectomy, removal of perianal lesions, seton placement, and incision and drainage.
Of 485 patients identified, 107 (22%) had a perianal fistula at Crohn disease diagnosis. Multivariate analysis identified that perianal fistulotomy, fistulectomy, and lesion removal hazard ratio (HR) 0.46; P = 0.028, non-White race (HR 0.30, P < 0.01), and male sex (HR 0.42; P = 0.02) were associated with delayed fistula healing. Faster fistula healing was associated with treatment with anti-TNFα with therapeutic drug monitoring (HR 1.78, P = 0.009). There were no other differences in healing by treatment.
Fistulotomy, fistulectomy, and perianal lesion removal as well as non-White race were associated with delayed fistula healing. Anti-TNFα therapy was associated with faster fistula healing when combined with therapeutic drug monitoring, compared to all other medical treatment groups, including anti-TNFα therapy without therapeutic drug monitoring.
National Institute of Health (NIH) funding is a “gold-standard” of achievement; we examined trends in NIH-funded pediatric surgeons.
NIH Research Portfolio Online Reporting Tools (RePORT) was queried ...for American Pediatric Surgical Association (APSA) members (2012 vs 2022). Demographics and time-to-award (TTA) from fellowship were compared. Number of grants, funding allotment, award classification, administering institutes/centers, research type were studied.
Thirty-eight (4.6%) APSA members were NIH-funded in 2012 compared to 37 (2.9%) in 2022. Of funded surgeons in 2022, 27% were repeat awardees from 2012. TTA was similar (12 vs 14years, p=0.109). At each point, awards were commonly R01 grants (40 vs 52%, p = 0.087) and basic science-related (76 vs 63%, p = 0.179). Awardees were predominantly men (82% in 2012 vs 78% in 2022, p=0.779) and White (82% in 2012 vs 76% in 2022, p=0.586). Median amount per grant increased: $254,980 (2012) to $364,025 (2022); by $96,711 for men and $390,911 for women. Median awards for White surgeons increased by $215,699 (p=0.035), and decreased by $30,074 for non-White surgeons, though not significantly (p=0.368).
The landscape of NIH-funded pediatric surgeons has remained unchanged between time points. With a substantial number of repeat awardees, predominance of R01 grants, and a median TTA over a decade after fellowship graduation, the phenotypes of early career pediatric surgeon-scientists are facing academic endangerment.
•The academic landscape of pediatric surgeon-scientists (PSS) is continually evolving.•National Institute of Health (NIH) funding is historically a gold-standard metric.•Compared to 2012, the proportion of NIH-funded PSSs has decreased.•Gender and ethnic diversity of NIH-funding awardees has remained stagnant.•Repeat awardees and K-award decreases indicate endangerment of early career PSS.
Use of ultrasound-guidance for central venous access in adults is the standard of care. There is, however, less clarity in the role of routine ultrasound use in obtaining venous access in children. ...We sought to evaluate safety and efficiency of the placement of central lines utilizing an ultrasound-guided approach compared to the traditional, landmark approach in pediatric patients.
A single-institution retrospective chart review, using CPT codes, was performed for all tunneled central venous catheters in children between 2005 and 2017 by the same pediatric surgery group. During the study period, a practice change occurred from exclusively landmark-based line placement to ultrasound-guided line placement. Groups were divided into three phases: a traditional/landmark era (Phase 1), transitional period (Phase 2), and the ultrasound era (Phase 3). The primary outcomes analyzed were postoperative chest tube insertions and operative time.
A total of 2010 tunneled central lines were included for analysis: Phase 1 (N = 930), Phase 2 (N = 313) and Phase 3 (N = 767). Venous access for chemotherapy was the most common indication (29%). Phase 1 had a chest tube placement rate of 9.7/1000 procedures, while Phase 2 had a rate of 6.4/1000 procedures, and Phase 3 had no chest tube insertions (p = 0.009). Phase 1 had longer OR times compared to Phase 2 (57 vs. 49, p = 0.0026) and Phase 3 (57 vs. 46 min, p < 0.001).
This study represents the largest analysis of ultrasound-guided access for children. A complete practice transition to the ultrasound-guided approach was feasible within a two-year period. The ultrasound-guided approach had a shorter operative time and less chest tube insertions than the traditional, landmark technique in children.
Level III evidence.
Holistic review (HR) considers applicants’ unique identities and experiences rather than focusing on academic metrics. Though several residency programs have demonstrated increases in women and those ...underrepresented in medicine (URiM), this is the first study to examine HR in pediatric surgery (PS).
Using a retrospective review of applicants, demographic, academic, and non-academic metrics of traditional review (TR) 2015–2017 were compared to HR 2018–2022. HR initiatives include expansion of faculty reviewers, implementation of a pre-screening rubric, and greater prioritization of non-academic factors. Chi-squared/Fisher's exact tests, Wilcoxon rank-sum tests, and two sample z-test for proportions were used where appropriate.
For 635 applicants (TR: 268, HR: 367), the proportion offered interviews in the TR and HR cohorts were similar (31.7 vs 36%, p = 0.30). Candidates selected for interview pre- and post-HR most commonly graduated from residency programs affiliated with PS fellowships (56.5 vs 50%, p = 0.65). After HR implementation, no change in proportion of women interviewees (TR: 52.9 vs HR: 54.5%, p = 0.93) was observed. Though URiM residents applying to PS remained consistently low (TR: 14.6 vs HR: 10.9%, p = 0.21), significantly more received interviews with HR (30.8 vs 42.5%, p = 0.001). The median number of peer-review publications per interviewee increased (17 vs 22, p = 0.02) as did non-academic achievements (leadership, service, athletic awards, etc.) per applicant (1.0 vs 1.5, p = 0.104), though the latter did not reach significance, demonstrating similar qualification of interviewees in HR and TR.
Holistic review of PS fellowship applications increased the proportion of URiM interviewees, despite a persistently low URiM proportion in the applicant pool. Furthermore, implementing HR did not sacrifice the caliber of interviewees, as publications and non-academic achievements increased by over 25% in the HR cohort.
IV.
