Pediatric Surgery

A Moving Problem: Magnetically Generated Peristalsis in an Artificial Intestinal Graft for the Treatment of Short Bowel Syndrome in Children Cody Tragesser, MD, Daniel J Scheese, MD, Mariana Smith, BEng, Adam C May, BS, Carla Lopez, MD, Maame Efua Sampah, MD, PhD, Axel Krieger, PhD, Chhinder Sodhi, PhD, David J Hackam, MD, PhD, FACS Johns Hopkins University School of Medicine, Baltimore, MD Introduction: Short bowel syndrome (SBS) refers to intestinal length insufficient for nutritional requirements, and is a major cause of long-term morbidity in NEC patients. One novel approach to restoration of enteral autonomy for patients with SBS is the implantation of an artificial intestine. We have previously implanted synthetic intestinal grafts possessing absorptive capacity, but lacking peristalsis. We now demonstrate proof-of-concept for magnetically-driven peristalsis in a simple synthetic intestinal graft derived from small intestinal submucosa (SIS). Methods: In preliminary experiments, tubular grafts were implanted into mice and piglets in continuity with native ileum. Then, a tubular graft (length 5.5 cm, internal diameter 5 mm) was generated by tubularizing a sheet of CorMatrix® SIS-ECM (CorMatrix Cardiovascular, Inc.) with running 8-0 nylon suture. Rare earth magnets of alternating polarity were secured to the graft in opposing configurations. The graft was suspended within a pressurized chamber approximating peritoneal pressure. Alternating external magnetic fields were applied, resulting in magnet movement in two waves with offset peaks and generating alternating coordinated peristaltic waves. Propulsion of intraluminal contents was achieved (Figure 1).Figure 1Results: In prior studies, implantation of grafts was performed in mice and piglets with minimal morbidity. Propulsion of polystyrene microparticles was achieved with minimal intraluminal distending pressure. Successful peristalsis was quantified by the percentage reduction in cross-sectional area when magnetically deformed, approximating 50% of non-deformed bowel. Conclusion: We demonstrate magnetically-driven peristalsis of viscous intraluminal contents in a simple tubular graft, providing proof-of-concept for implementation into more complex bio-printed models of intestine for the treatment of SBS. A Roadmap to a Greener Pediatric Operating Room: A Quality Improvement Initiative Emilie K Landry, MD, Caroline P Lemoine, MD Division of Pediatric Surgery, CHU Sainte-Justine, Montreal, QC, Canada Introduction: While most pediatric surgeons support integrating environmental actions in the operating room (OR), a recent survey reported that only 15.9% are involved in such initiatives. Existing strategies to a greener OR can appear less tangible for pediatric surgeons wishing to implement change. We present the first step of a quality improvement project for a greener OR in a pediatric academic hospital from a surgeon’s perspective. Methods: A literature review was performed to assess existing green initiatives. Actions were prioritized according to our institution’s resources and feasibility in a public healthcare system. Interdisciplinary meetings were held with surgeons, OR staff, sustainable care representatives, medical suppliers, and hospital administrators. Results: Our institution is a 550-bed tertiary mother-child hospital. Approximately 13,000 surgeries are performed yearly across 11 pediatric subspecialties. Paper, cardboard, and plastic recycling in the OR was implemented in 2010 and is performed during every case. Reusable gowns were used until 2015 but were abandoned because of challenges with the sterilization process. Other green initiatives were prioritized according to a feasibility scoring system (Table 1). Initiatives with a lower score received greater priority since they require less implementation resources. Surgeon report cards optimization and proper waste segregation/management were identified as the first actionable initiatives. Table 1. - Green Initiative Priority Assessment Initiatives (Points/16) Human Resources (Points/4) Financial Resources (Points/4) Material Resources (Points/4) Organizational Resources (Points/4) Priority #1: Surgeon Report Cards Optimization (4/16) Pediatric surgeons (1) None (1) None (1) <3 months (1) Priority #2: Proper Waste Segregation and Management (8/16) OR staff (2) <5,000$CAD (2) Current material or alternative purchase options (2) 3 to < 6 months (2) Priority #3: Surgical Trays Reformulation (9/16) OR staff (2) <5,000$CAD (2) Current material or alternative purchase options (2) 6 to < 12 months (3) Priority #4: Lean Intraoperative Use of Supply (10/16) OR staff (2) 5,000 - 50,000$CAD (3) Current material or alternative purchase options (2) 6 to < 12 months (3) Priority #5: Reprocessing Program (11/16) Local administrators (3) 5,000 - 50,000$CAD (3) Current material or alternative purchase options (2) 6 to < 12 months (3) Priority #6: Reusable Surgical Gowns (16/16) Government administrators (4) >50,000$CAD (4) Infrastructure modification (4) ≥12 months (4) Conclusion: Assessing green initiatives applicable to a pediatric OR according to feasibility and resources availability is the first step in creating a sustainable eco-friendly program. This initiative can serve as a roadmap for other pediatric surgery teams considering changes that could be made in their own practice. Addressing Health Inequities: Understanding the Relationship Between Social Determinants of Health and Necrotizing Enterocolitis Kailah Young, Kristen Kaiser, MD, Troy A Markel, MD, FACS Indiana University, Indianapolis, IN Introduction: Necrotizing enterocolitis (NEC) is a severe illness with high mortality. Traditional known risk factors within the infant are prematurity, stress, and dysbiosis. Maternal risk factors have also been postulated but are often overlooked. We aimed to define parental, patient, and social factors associated with NEC and their impact on outcomes on a national level. Methods: Patients 0-1 yo diagnosed with NEC were identified via the Pediatric Health Information System database between 2012-2022, excluding those with complex cardiac conditions. The cohort was analyzed based on demographics and mortality. Childhood Opportunity Index (COI) was used as a representation of each family’s household educational, environmental, and socioeconomic conditions. Results: Overall, 11,643 patients of median admission age of 2 days (IQR 0-14 days), median gestational age of 26 weeks (IQR 23-32) and median birthweight of 980 g (IQR 640-1,830 g) met inclusion criteria. Our cohort was majority male (58%), and White (47%), and overall, had a mortality rate of 17.6%. Demographic factors significant for increased mortality are highlighted in Table 1. On adjusted regression analysis using age, gender, birthweight, race, primary payor, country region, mechanical ventilation, and operating room charge, high COI remained a significant factor associated with decreased odds of mortality (OR 0.97, CI 0.95-0.99, p = 0.004) when compared to those with lower COI. Table 1. - **Characteristic** All NEC Patients N = 11,643 Alive at Discharge N = 9,563 Discharge Mortality N = 2,080 P-Value Gender, Male 6,718 (58%) 5,525 (58%) 1,193 (57%) 0.3 Race, White 5,309 (46%) 4,502 (47%) 807 (39%) <0.001 Black 3,296 (28%) 2,686 (28%) 610 (29%) Other/Multi-racial 2,194 (18.8%) 1,821(19%) 373 (17.9%) Primary Payor, Commercial 3,818 (33%) 3,187 (33%) 631 (30%) <0.001 Medicare/Medicaid/Government 7,433 (64%) 6,084 (64%) 1,349 (65%) Self-Pay/Other/Unknown 392 (3.4%) 292 (3.1%) 100 (4.8%) Child Opportunity Index, Low 6,232 (54%) 5,042 (53%) 1,190 (57%) <0.001 Middle 2,188 (19%) 1,799 (19%) 389 (19%) High 3,138 (27%) 2,654 (28%) 484 (23%) Conclusion: NEC is an incredibly severe and morbid disease that disproportionately affects socially disadvantaged infants. The mortality rates of NEC are linked to parental social determinants of health, highlighting to for risk and resources. in a of Intestinal MD, MD, C MD, MD, BS, BS, MD, PhD, FACS Introduction: patients with bowel syndrome are at risk of intestinal disease and a from and models have the and of an We that in a of Methods: mice received and g or for were with or on days received or on were and in The primary was of were Results: mice had and In with of and compared to for and (Figure mice with had lower compared to (Figure of in mice (Figure and compared to in a of and on and is in a in patients with of Index with for in Pediatric Patients BS, J MD, MD, MD, MD, MD, MD, MD, A FACS University of University of University of University of Introduction: This the of with the risk of for disease in pediatric patients and Methods: A cohort of pediatric patients 12 to with disease at pediatric from to was was at Patients were with medical and or or and for A was used to of Results: patients were of age and White and male was and were were of patients to patients more One of patients had or excluding for A significant was between and treatment < patients had the of compared to medical and patients (23%) Conclusion: is associated with rates of for disease in patients. can be used to Between Social Determinants of Health and for Children for Caroline MD, MD, A PhD, MD MD, MD, MD, MD, MD, MD, MD, FACS University of University of University of University of Health at University in Introduction: Social Determinants of Health are associated with to care for with We that increased social also be associated with increased Methods: between Index Index and Child Opportunity Index and outcomes were in a cohort of from hospital or and hospital length of analysis for age, hospital and hospital Results: (27%) had age was were and were in of with the majority in the increased of hospital was associated with in more disadvantaged for were associated with or hospital Conclusion: rates of with from disadvantaged are more to for or hospital The of to is to for with also the primary factors to care in - for the Between and - p Child Opportunity Index - <0.001 Index - <0.001 Social Index - - p Child Opportunity Index - Index - Social Index - each OR is in for an OR of an in odds for every in and an OR of a in odds for every in Child Opportunity Index is to with the other social determinants of the Understanding on MD, MD, MD, MD, MD, Daniel MD, FACS Johns Hopkins University, Baltimore, MD Introduction: disease across and in the most in Our the between disease treatment and outcomes in pediatric patients. 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= = OR Male <0.001 for Syndrome in BS, BS, MD, J MD, MD, PhD, MD, David P MD, N MD, FACS University School of Medicine, Introduction: syndrome for long-term are challenges for in the first between and We aimed to the of and during first Methods: A institution analysis was of patients from Patients were by of enteral during first or and regression were Results: patients were = and = 2 for age or at in first (Figure were more in the p = A significant was for in the first < and at and (Figure were 2 patients during 5 5 - 2 and 2 weeks of was = = Conclusion: during the first of at with and Other of for and to in of Necrotizing Enterocolitis MD, MD, MD, MD, PhD, BS, C BS, Troy A Markel, MD, FACS Indiana University, Indianapolis, IN Introduction: Necrotizing enterocolitis (NEC) is a the of and often to in intestinal and in a NEC We that long-term with Methods: a NEC were and to were with were = and weeks of age, the to assess by a with a The was to assess (Figure 1Results: with NEC increased < and less < of by a to first < when compared to with NEC with decreased < and increased < by 3 compared to mice with NEC the was with NEC more and less compared to and Conclusion: with NEC and were by treatment during the NEC This the first in enterocolitis and as a Use for in Children of A MD, MD, MD, A MD, A FACS University, University of University of University, Introduction: The of at the of hospital a of most treatment to support their This aimed to is associated with morbidity in with Methods: We the Surgical Quality Improvement for for from and had or The impact of on outcomes was analyzed using Results: A of with met and were Patients were according to the age = = and = increased with age and p = for was associated with morbidity in age was associated with rates of in Conclusion: Children with of at or appear to have significant in rates of or of that can be to a Table - of Use Discharge on Use Use Use Discharge Discharge for from to and in the of A MD, MD, BS, BS, A MD, of Introduction: to have long-term morbidity and in to are factors that to The of is to of in the of Methods: of a using an and were were and and of the for analysis using of was by the Results: analysis demonstrate in compared to was in the of = was increased in the of = was increased in the of compared to = and analysis increased an primary Conclusion: in and are in the that in prior to to as a and a for to outcomes in in Children with Bowel BS, MD, MD Introduction: is performed in patients with bowel disease with or with pediatric patients. Methods: A cohort of patients from was was using with the of and Results: = had a and = had a were performed age at was (IQR age at first was (IQR 5 with of patients and of patients had and had The of surgery was greater in the cohort < = of patients and were = of and = of patients with significant in rate = a for of patients and of patients with significant between Conclusion: rate between of in with and is to rates in rates of outcomes on but on In of via for Treatment of MD, PhD, BS, J MD, MD The of Introduction: is a by is by a in the first of the and be used to the We to assess the of of to in a Methods: to the and were into and to a of via or at gestational or from the and were and for of via via and via and Results: is in of = The most was in the of at via = in p = (Figure 1). was significant in in the in or compared to of and A MD, MD, P MD, PhD, MD University in Introduction: to of for the treatment of This to and at Methods: were with = or = on and were using were into high and at and compared to = Results: at were and for the high = and = only mice had compared to (Figure All mice have of based on in (Figure only mice had compared to (Figure increased of in a in and We that the increased of in high be by to are to a high in a MD, MD, BS, MD, PhD, MD, PhD, FACS Introduction: is a used in on intestinal and the risk of enterocolitis been Our was to assess the of on intestinal as by of with was used to the of Methods: piglets days were with for was used as to and were were to received of from to = received was or prior to of in 2 = and 3 = were analyzed by Results: increased = (Figure This in with was with of (Figure was associated with was significant in or of across = to with a for in process. are to be associated with Intraoperative or in Pediatric MD, BS, MD, MD, FACS University of Introduction: is an but pediatric literature on We to pediatric patients and Methods: pediatric patients or at institution from were The primary was outcomes care with for and at were regression between the primary and Results: patients received 6 and patients had lower patients and p = patients were with = and had lower and compared to significant = and p = was in for or at between the two significant of were on regression Conclusion: was associated with at and a lower and and are but by small and of of and the of in pediatric the of Social on in Kristen Kaiser, MD, MD, MD, PhD, FACS Indiana University, Indianapolis, IN Introduction: is a disease that can in and mortality. is social and environmental factors of the hospital impact to social determinants of factor into outcomes for patients with Methods: the Pediatric Health Information were associated with for at from The Child Opportunity Index (COI) of and and social and factors into for a to healthcare and in their COI was into and compared across admission and outcomes using or Results: with were associated with high with and with COI. between and high age and were but Black and primary as Medicare/Medicaid/Government were < during during and mortality at when COI (Table 1). Table 1. - for with The Child Opportunity Index High COI = COI = Low COI = P-Value of in 5 6 6 <0.001 <0.001 Surgical Mortality at Discharge Conclusion: mortality is increased for patients with a COI. a for to in outcomes and mortality rates in patients with of Pediatric in Opportunity for MD, MD, BS, MD, BS, MD, MD, PhD, MD, FACS The University, Introduction: of pediatric complex resulting from medical report MD rates in pediatric but MD tertiary care Our were to the MD rate in with complex and associated Methods: Children for complex between at a academic hospital were using an quality improvement MD was as for to within days prior to regression and were used to associated Results: had MD from care care primary care compared to our MD was most in care in patients with and (Figure 1). for significant MD was associated with age and primary MD was associated with rates of p < length of p < and p = Conclusion: MD of complex in care is more in and and is associated with the for and in care and in MD, PhD, J PhD, PhD, MD, PhD, PhD, MD, FACS University, Introduction: from of We that and in We that with can Methods: and were performed on (2) in of mice were with (2) to mice were or were with the of to of treatment were compared using Results: treatment significant length in compared to or treatment treatment and the most compared to other mice were of with and decreased for with compared to those with = in Conclusion: can and in We for the first that could be in and be an approach for in the in the of and to Treatment MD, PhD, MD, A PhD, MD, P MD, FACS University of University Introduction: of the intestinal is a of of on but patients have increased to and are quality is in the intestinal during and to a in We that and to and are Methods: We mice the to the to for was in via of on from was mice were to and disease were a known was to Results: was increased in the in mice compared to and were increased in the from mice to of A to mice disease and Conclusion: and are in to of by A for the treatment of and Use of in Pediatric Patients with MD, MD, MD of Introduction: The the of with in a that the of This for of and outcomes of patients with We that the in patients with and in a rate of but also to of to Methods: The and were excluding patients Patients were in they had a that was and they had a or were and outcomes were compared between Results: were in or between and patients. patients had more p < less p = more p < and in or length of Conclusion: patients had more and but had rates of into the approach and of with during the and Social for Children MD, BS, MD, MD, FACS Health University, High High OR Introduction: This to the between socioeconomic and pediatric in our area using and area Methods: The of two pediatric were from Children with a or and those diagnosed with were were to the and to and The impact of and on demographics and outcomes was Results: a = = within the Demographic in more disadvantaged p = p = and that with at had socioeconomic those p < p < In the of and were from = and p = were in length of hospital hospital and mortality between and Conclusion: In our in and and and outcomes when at our pediatric at risk for for for of and on Demographic and - < median < < median patients = 0.004) = = = = = = hospital Mortality by via of MD, PhD, PhD, BS, BS, PhD, A MD, FACS University of at Introduction: is the most primary pediatric Children with have a and to a of in the in are of involved in those in the is a novel that We that the to decreased in Methods: We were with for was performed to was using chamber identified of were reported in of the with p Results: Treatment with in a The 50% of in was identified an in a known to decreased of and with treatment Treatment with a decreased of a known of the that of as a a

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