Midwest Pediatric Surgery Consortium

Current Studies

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​​​​1. Esophageal Atresia/Tracheoesophageal Fistula

Esophageal Atresia/Tracheoesophageal Fistula (EA/TEF) occurs in approximately 1/3500 live births. The MWPSC Centers identified variability in surgical techniques and management of infants with EA/TEF due to the lack of evidence-based guidelines. This was the first disease studied with the consortium. In 2016, Lal et al. published the largest multi-institutional retrospective analysis of 396 patients to define and understand current management practices. Their findings included an overall postoperative complication rate of 62%, anastomotic stricture rate of 42% and substantial practice variability amongst the participating centers.

In 2017, Lal et al. expanded on the previous study and examined specific peri-operative management features in patients with type-c defects, searching for modifiable factors associated with the high complication rates found in their previous study. It was shocking to the authors that the overall complication rates for patients with EA/TEF had not improved in decades, despite advances in technology and surgical technique. The authors reported the use of trans-anastomotic tubes in the post-operative setting were associated with increased rates of anastomotic stricture (OR 2.2, p=0.01), interposing prosthetic material between the trachea and esophageal suture line was associated with higher anastomotic leak rates (OR 4.7, p<0.001). Furthermore, common practices such as the use of prophylactic antibiotics greater than 24 hours or
empiric acid suppression did not prevent complications. Lastly, obtaining post-operative esophagrams on day 5 instead of the traditional day 7, was safe and resulted in earlier initiation of feedings.

The identified risk factors in the 2017 paper, led to the creation of evidence-based clinical practice guidelines to standardize management amongst institutions within the consortium. The outcomes from this intervention were published in a 2020 paper by Bence et al. A standard management bundle was applied to 102 infants with type c-defects and compared to a historical control of 68 infants. The key components of the management bundle were no prosthetic material between esophageal and tracheal sutures, no routine trans-anastomotic tube, no prophylactic antibiotics past 24 hours, and performing esophagrams within 5 postoperative days. The authors demonstrated no increase in complications keeping prophylactic antibiotics to only 24 hours and performing an esophogram at day 5 instead of day 7 from surgery.
Additionally, when compliance to the no prosthetic material and no trans-anastomotic tube was >80% there was a reduction in anastomotic strictures.

Two other special populations of EA/TEF have been studied through the MWPSC: patients with right-sided aortic arch (RAA), and those with type E (H-type) TEF. Lal et al. reported findings from one of the largest studies on neonates with EA and RAA. When compared to infants with EA and a left aortic arch, infants with EA and a RAA were more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. They found that EA repair in infants with RAA can be safely repaired through a right or left thoracotomy. However, there was a trend to higher anastomotic strictures in RAA patients who underwent EA repair via a right thoracotomy. From the initial study on
perioperative outcomes in EA patients, a high rate of vocal cord paralysis/paresis (5-28%) was identified and varied by EA/TEF type. This data led to a subsequent MWPSC proof of concept study by Wright et al. in which intraoperative nerve monitoring was used to identify, stimulate and preserve the recurrent laryngeal nerve during fistula ligation in infants with Type E (H-type) TEF. EA/TEF remains an active area of research amongst the consortium. The goal is to improve the care and outcomes of infants undergoing EA/TEF repair through evidence-based practices and standardization of care.

[1] Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Perioperative management and outcomes of esophageal atresia and
tracheoesophageal fistula. Journal of Pediatric Surgery 2017;52:1245–51. https://doi.org/10.1016/j.jpedsurg.2016.11.046.
[2] Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, et al. Challenging surgical dogma in the management of proximal esophageal
atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium. Journal of Pediatric Surgery 2018;53:1267–72.
[3]Bence CM, Rymeski B, Gadepalli S, Sato TT, Minneci PC, Downard C, et al. Clinical outcomes following implementation of a management bundle for
esophageal atresia with distal tracheoesophageal fistula. Journal of Pediatric Surgery 2021;56:47–54. https://doi.org/10.1016/j.jpedsurg.2020.09.049.
[4]Lal DR, Gadepalli SK, Downard CD, Minneci PC, Knezevich M, Chelius TH, et al. Infants with esophageal atresia and right aortic arch: Characteristics and
outcomes from the Midwest Pediatric Surgery Consortium. Journal of Pediatric Surgery 2019;54:688–92.
[5]Wright TN, Grant C, Hirschl RB, Lal DR, Minneci PC, Fallat ME. Neural monitoring during H-type tracheoesophageal fistula division: A way to decrease
recurrent laryngeal nerve injury? Journal of Pediatric Surgery 2019;54:1711–4. https://doi.org/10.1016/j.jpedsurg.2018.10.059.

2. Management of Spontaneous Pneumothorax

Primary Spontaneous Pneumothorax (PSP) occurs in up to 1 in 6000 males and 1 in 16,000 females. The etiology is thought to be from rupture of thin-walled blebs or bubbles in the lungs and presents with sharp pain on the affected side. Depending on size and symptoms, there are many ways of managing this but traditionally, it has been done with a chest tube to suction out the air and let the lung re-expand. There have been several adult studies that have shown the majority of these resolved without intervention if the pneumothorax did not expand under a period of observation. The MWPSC sought to examine whether simple aspiration or removing the air once was predictive of resolution or need for surgery. In 2019, Leys et al. created a prospective protocol to test aspiration through a pigtail catheter followed by a 6-hour observation period with the tube clamped. 33 patients were managed on this protocol. The aspiration test was successful in 48% of patients and they were able to go home after the observation period. PSP did recur in 44% of the patients who passed the initial test. Of the patients that failed the initial test, 30% went directly to surgical intervention and 70% were managed with admission and a chest tube.

Of the patients admitted and managed with a chest tube, 83% had a recurrence of PSP and went on to surgical intervention. This study showed that initial aspiration as management is safe and if successful, has about 50% recurrence. If the initial aspiration test fails, it is predictive of needing surgical intervention.

[1] Leys CM, Hirschl RB, Kohler JE, Cherney-Stafford L, Marka N, Fallat ME, et al. Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation. Journal of Pediatric Surgery 2020;55:169–75. https://doi.org/10.1016/j.jpedsurg.2019.09.043.

3. Nonoperative Management of Uncomplicated Appendicitis

Appendicitis remains the most common pediatric surgical emergency, and treatment with an appendectomy in children has been largely unchallenged. Recently there have been several studies showing the safety and efficacy of non-operative management with antibiotics alone, however, prospective large multi-institutional studies in children were lacking. In 2019 Minneci et al. published their study design and in 2020 they published their findings comparing operative vs. non-operative management of pediatric uncomplicated appendicitis. Across the participating centers, 1068 patients were enrolled in the study. Of those, 65% of patients and families chose surgery and 35% chose antibiotics alone. Of patients that chose not to have surgery, 63% were successful at 1 year of follow-up, and they had significantly fewer disability days (6.6 vs. 10.9) with similar quality of life and satisfaction scores. This showed the safety and efficacy of nonoperative
management, challenging the traditional dogma, and has given providers and patients the information required to have informed discussions on the treatment approach.
The follow-up from this study is ongoing with active research and grant funding to continue studying the management of acute appendicitis within our consortium. We have been fortunate to partner with the Patient-Centered Outcomes Research Institute for project funding.

[1]Minneci PC, Hade EM, Lawrence AE, Saito JM, Mak GZ, Hirschl RB, et al. Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale. Contemporary Clinical Trials 2019;83:10–7. https://doi.org/10.1016/j.cct.2019.06.013.
[2]Minneci PC, Hade EM, Lawrence AE, Sebastião YV, Saito JM, Mak GZ, et al. Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis. JAMA 2020;324:581. https://doi.org/10.1001/jama.2020.10888.
[3]Minneci PC, Hade EM, Metzger GA, Saito JM, Mak GZ, Deans KJ, et al. Association of Initial Treatment With Antibiotics vs Surgery With Treatment Success and Disability in Subgroups of Children With Uncomplicated Appendicitis. JAMA 2021;325:2502–4. https://doi.org/10.1001/jama.2021.6710.

4. Congenital Lung Malformations

Congenital Lung Malformations (CLM) may occur in up to 1 in 2000 live births and include several sub-types such as Congenital Pulmonary Airway Malformations (CPAM), Bronchopulmonary Sequestration (BPS), Congenital Lobar Emphysema (CLE), and Bronchogenic Cysts. They have a range of clinical presentations from lesions that may go undiagnosed until chest imaging is done for other purposes, to recurrent infections, to life-threatening respiratory distress after birth. These malformations have traditionally been managed with surgical resection both to prevent future complications and concern of progression into a race cancer called Pleuropulmonary Blastoma (PPB), however, outcomes from resection and other features of surgical management have not had large patient studies and the MWPSC chose to investigate this.

In 2018 Kunisaki et al. utilized the MWPSC to create a multi-institutional registry of children who underwent surgery for all types of CLM. They were able to study 506 children and studied all aspects of the disease from fetal diagnosis and treatment through post-operative care and follow-up. They were able to describe that 90% of resections occur outside of the neonatal period and were mostly elective. Surgical resections had an all-complication rate of approximately 18% with residual pneumothorax requiring chest tube as the most common occurring in 8% of cases. Complication rates were highest in the neonatal period. This registry also served as a dataset for future studies. In 2019 Kunisaki et al. focused on the operative management of CLE specifically due to the severity of its peri-natal presentation. Using the registry, they were able to find 53 patients with CLE, the largest study of this pathologic sub-type. They found that compared to other congenital lung malformations, prenatal diagnosis was less common for CLE and that ultrasound was not specific for
CLE. Neonates with CLE were three times as likely to have respiratory symptoms at birth and to have neonatal resection compared to other CLM lesions. Data on operative management also identified variability in the approach between open and thoracoscopic resections. This led to a study by Weller et al. that looked at outcomes between the two approaches. They found that thoracoscopic approaches were becoming more common and that while they had longer operative times, they required less epidural anesthesia and had no increase in post-operative complications. This has led to an increase in minimally invasive approaches for these children.

Prenatal screening and management of CLM are variables based on institution. Kunisaki et al. focused on this aspect of management in a 2020 study aimed at risk stratification. They were able to show that Congenital Pulmonary Airway Malformation Volume Ratio (CVR) was
predictive of postnatal course although CVR measurements were only available for half of the patients identified.
The authors found that a cutoff CVR of greater than 2.25 had a 100% sensitivity for detecting fetal hydrops whereas a CVR of below 1.36 had almost a 100% prediction for not developing fetal hydrops. The initial and maximum CVR was found to be associated with respiratory symptoms at birth, need for supplemental oxygen, preoperative neonatal ventilator use, and neonatal lung resection, although the ideal CVR cutoff is different for each outcome. The authors were able to use this data to generate a decision tree to help patients and providers with prenatal counseling and to decide on a delivery facility.

Lastly, one of the major drivers for elective resection is a concern for PPB, however, its exact risk and prevalence were unknown. Kunisaki et al. looked at the pathology of 521 lung lesions. PPB was identified in 8.7 % of postnatally diagnosed CLM. They found that if CT imaging is suggestive of malignancy, then the lung lesion was likely malignant, however, CT imaging was not sensitive. The higher-than-expected malignancy rate for postnatally diagnosed CLM has led providers to consider operative management for more of these patients. CLM remains an active area of study with ongoing analysis and publications of our registry.

[1]Kunisaki SM, Saito JM, Fallat ME, St. Peter SD, Lal DR, Johnson KN, et al. Development of a multi-institutional registry for children with operative congenital lung malformations. Journal of Pediatric Surgery 2020;55:1313–8. https://doi.org/10.1016/j.jpedsurg.2019.01.058.
[2]Kunisaki SM, Saito JM, Fallat ME, St. Peter SD, Kim AG, Johnson KN, et al. Current operative management of congenital lobar emphysema in children: A report from the Midwest Pediatric Surgery Consortium. Journal of Pediatric Surgery 2019;54:1138–42. https://doi.org/10.1016/j.jpedsurg.2019.02.043.
[3]Weller JH, Peter SDSt, Fallat ME, Saito JM, Burns CR, Deans KJ, et al. Thoracoscopic versus open lobectomy in infants with congenital lung malformations: A multi-institutional propensity score analysis. Journal of Pediatric Surgery

2021:S0022346821003237. https://doi.org/10.1016/j.jpedsurg.2021.04.013.
[4]Kunisaki SM, Saito JM, Fallat ME, St. Peter SD, Lal DR, Karmakar M, et al. Fetal Risk Stratification and Outcomes in Children with Prenatally Diagnosed Lung Malformations: Results from a Multi-Institutional Research Collaborative. Annals of Surgery 2020; Publish Ahead of Print. https://doi.org/10.1097/SLA.0000000000004566.
[5]Kunisaki SM, Lal DR, Saito JM, Fallat ME, St. Peter SD, Fox ZD, et al. Pleuropulmonary Blastoma in Pediatric Lung Lesions. Pediatrics 2021;147:e2020028357. https://doi.org/10.1542/peds.2020-028357.

5. Natural History of Patent Processus Vaginalis (PPV) in Infants

The processus vaginalis is the canal that travels along the inguinal ligament (groin crease). In males, it is the path in which the testicle descends during development, and in females, it contains a structure called the round ligament. This path is supposed to close during development, but occasionally it does not, and it is the source of groin hernias or fluid collections called hydroceles. Sometimes a patent processus vaginalis is asymptomatic and found incidentally during other abdominal surgery. The natural course of these incidental ones is not well understood, and the frequency with which they become symptomatic or problematic is not known. St. Peter et al. have designed a prospective observational study currently enrolling patients who undergo laparoscopy for pyloric stenosis to inspect the inguinal ring for a patent processus vaginalis. This study will inform surgeons whether these are safe to observe or should be surgically repaired.

6. Gastroschisis

Gastroschisis is a defect in the abdominal wall where the baby is born with their intestines outside of the body in the amniotic fluid. Its prevalence appears to be increasing and can be found in up to 1 in 2000 live births. Traditionally management included either primary or staged reduction and closure of the abdominal wall with sutures. This paradigm changed in 2004 when centers began publishing sutureless closure typically covering the defect with the umbilical cord and letting it heal by itself. These centers had good results with this, however, like other pediatric surgical conditions, patient studies with large numbers were difficult. The MWPSC decided to study and compare outcomes between sutured and sutureless closures to better study the differences. In 2019 Fraser et al. studied 315, patients, of which 79% had the
sutured closure and 21 % underwent sutureless closure. Of the patients that underwent sutured closure, the majority (85%) had delayed closure after silo placement and the inability to reduce the abdominal organs initially, and only 36 patients (15% of sutured closure) were closed this way at the initial operation. In the sutureless group, 55% were done delayed after silo, with 45% done at the initial operation. In the groups closed at the initial operation without silo, the sutureless closure had less ventilator and anesthetic use, but had more time on TPN. In patients closed after a silo, the sutureless closure had less ventilator and anesthetic use, less antibiotic use, and no difference on TPN. This study showed that with large numbers of patients, sutureless closure was safe, effective and may have fewer complications than the suture closure.

One of the biggest challenges in postnatal management of gastroschisis for providers and families is the timing of enteral feeds. The MWPSC wanted to know if a standardized feeding protocol could improve outcomes in gastroschisis patients. In 2020 Dekonenko et al. compared patients who were fed by a protocol to those who were not. 315 patients with uncomplicated gastroschisis were identified and 65% of them were fed on an institution-specific feeding protocol. They found fewer surgical site infections in patients fed on a feeding protocol, but were unsure if this was a direct result or not. There were no other significant differences between groups. One challenge with this study was the differences in feeding protocols between centers which made it difficult to draw definitive conclusions.

Given the variability in patient presentation, it is difficult to counsel families about the expected course after delivery. In 2020 Dekonenko et al. looked to estimate outcomes and compare differences between simple and complex gastroschisis. They studied 394 patients, of which, 20% were complex gastroschisis defined as having additional intestinal anomalies. They found that complex gastroschisis patients had more associated cardiac and pulmonary disease, increased ventilator use, longer ventilator days, and overall length of stay and other complications including mortality. This has provided information for providers to help counsel parents of gastroschisis patients, particularly if they are complex.
The MWPSC has been grateful to partner with the Avery’s Angels Foundation who helps provide funding for ongoing gastroschisis research focused on patient and family long-term outcomes. Gastroschisis remains an active area of research for the consortium.

[1]Fraser JD, Deans KJ, Fallat ME, Helmrath MA, Kabre R, Leys CM, et al. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium. Journal of Pediatric Surgery 2020;55:2284–8. https://doi.org/10.1016/j.jpedsurg.2020.02.017.
[2]Dekonenko C, Fraser JD, Deans K, Fallat ME, Helmrath M, Kabre R, et al. Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium. Eur J Pediatr Surg 2020:s-0040-1721074. https://doi.org/10.1055/s-0040-1721074.
[3]Dekonenko C, Fraser JD, Deans KJ, Fallat ME, Helmrath M, Kabre R, et al. Outcomes in gastroschisis: expectations in the postnatal period for simple vs complex gastroschisis. J Perinatol 2021;41:1755–9. https://doi.org/10.1038/s41372-021-01093-8.

7. Ovarian Masses

Pediatric ovarian tumors are rare, occurring in up to 1 in 40,000 girls per year with about 20% being malignant. Ovarian masses can cause pain, torsion or twisting of the ovary and can harbor cancer making. Preoperative risk stratification and surgical treatment must balance the risk of malignancy with risks of future infertility. Given their rarity, the MWPSC decided to study various features of ovarian masses. In 2018 Lawrence et al. looked broadly at current management practices regarding ovarian tumors. They were able to identify 819 girls undergoing surgery.
Malignant lesions were found in 11% of cases, and oophorectomy (removal of the entire affected ovary) was done in 33% of benign cases. Factors associated with malignancy were younger age, abdominal bloating, enlarged lymph nodes, and increased size of the mass. Features associated with oophorectomy in benign cases were solid components on imaging, larger size, and initial suspicion for malignancy.

To help with this differentiation between malignant and benign lesions, Lawrence et al. also utilized the MWPSC to study the value of tumor markers in 2019. They used a population of 401 patients with at least one concerning feature for malignancy of which 22% had a confirmed malignancy on pathology. The results from their study found that the different tumor markers each contributed together as a panel to help with diagnosis. The markers that were most specific were AFP, Inhibin A and Inhibin B (98%, 97%, 92% respectively).
The markers with the highest sensitivity were LDH and beta-hCG (95%, 44% respectively). This data helps providers understand the utility of various tumor markers for ovarian masses and supports the use of a panel that combines tumor markers to help differentiate benign and malignant masses.

Another concern for ovarian masses is the risk of malignancy in patients that present with torsion. In 2021, Lawrence et al. used the consortium data to study ovarian torsion along with the associated risk factors and the risk of malignancy. They identified 814 girls with an ovarian mass, of which, 22% had an episode of torsion. Size greater than 5cm carried twice the risk of torsion. Other associated factors with torsion were younger age, abdominal pain, and vomiting. They also found that imaging had low reliability at detecting or ruling out ovarian torsion. Of the patients that had torsion from a mass, 48% had an oophorectomy as their operation. The authors saw a decreased risk of malignancy in torsed masses than in masses without torsion and have been able to provide evidence in favor of ovarian preservation during intervention for torsion.
The retrospective studies published have provided the foundation for prospective analysis on the management of ovarian masses using a standardized preoperative algorithm. This work is ongoing, we have completed enrollment in this study and are completing follow-up for this study. We have been fortunate to partner with Thrasher Research Fund for grant funding on this topic.

[1]Lawrence AE, Gonzalez DO, Fallat ME, Aldrink JH, Hewitt GD, Hertweck SP, et al. Factors Associated With Management of Pediatric Ovarian
Neoplasms. Pediatrics 2019;144:e20182537. https://doi.org/10.1542/peds.2018-2537.
[2]Lawrence AE, Fallat ME, Hewitt G, Hertweck P, Onwuka A, Afrazi A, et al. Understanding the Value of Tumor Markers in Pediatric Ovarian Neoplasms.
Journal of Pediatric Surgery 2020;55:122–5. https://doi.org/10.1016/j.jpedsurg.2019.09.062.
[3]Lawrence AE, Fallat ME, Hewitt G, Hertweck P, Onwuka A, Afrazi A, et al. Factors Associated with Torsion in Pediatric Patients with Ovarian Masses.
Journal of Surgical Research 2021;263:110–5. https://doi.org/10.1016/j.jss.2020.12.058.

8. Venous Thromboembolism in Pediatric Trauma Patients

Venous Thromboembolism (VTE) includes a spectrum of clotting diseases from deep vein thrombosis (blood clots in the legs/arms) to Pulmonary Embolism (blood clots in the lungs) that can be life-threatening. It is well known that the trauma population is at high risk for VTE, particularly if they suffered a major brain or bone injury and if they have limited mobility. Interventions such as pharmacologic prophylaxis with a blood-thinning medication as well as early mobility and mechanical compression devices have greatly reduced the incidence of VTE in the adult trauma population. Pediatric trauma patients have a lower risk than adults for developing VTE, however, they are at higher risk than other
hospitalized pediatric patients. The timing of VTE prophylaxis, the population who would benefit the most, as well as the type, is not very well understood and it is difficult for trauma providers to predict which children would benefit from these interventions. Ehrlich et al. is evaluating a prospective cohort of pediatric trauma patients and evaluating both what the current management practices are, as well as their risk factors and incidence of VTE to provide evidence-based guidelines on this topic. This study is currently enrolling patients.

9. Pediatric and Adolescent Breast Masses

Pediatric and adolescent breast masses are rare compared to adults, with the majority being benign. However, management is variable and multi-institutional studies on management and outcomes are lacking. Grabowski and Minneci et al. have designed a retrospective review across the MWPSC, designed to characterize and describe current management practice. This will guide the standardization and further analyses of outcomes.

10. Pediatric Surgeon Burnout and Wellness

Surgeon Burnout has become a critical focus at the national level of medical organizations. This is thought to negatively affect the entire healthcare system from patient outcomes to surgeon shortage as well as mental health and suicide rates. Pediatric Surgeons are at high risk for burnout given the stressors of training, academic expectations, high-risk operations on children, management of pediatric trauma and abuse, and effects of the job on the surgeon’s own family. Fraser et al. are surveying and reaching out to surgeons through the MWPSC to study contributing factors associated with burnout, as well as identifying ways in which this can be mitigated and hopefully prevented.

11. Pilonidal Disease

Pilonidal Disease occurs in approximately 1 in 4000 teenagers and young adults. It is a disease where hair collects in the gluteal cleft and creates epithelialized sinus tracts. These tracts can cause abscesses and infections as well as pain and discomfort. Traditional management has been wide excision of the tracts with either the healing of an open wound over time or flap coverage. Recently less invasive procedures commonly called the “Gips procedure” have shown good outcomes with faster recovery and less pain causing a paradigm shift in management. Even with this shift medical and surgical management is widely variable among providers. Through the MWPSC, Rymeski et al. have designed a multi-institutional prospective cohort study studying outcomes from various medical and surgical management. We have
been fortunate to partner with American Pediatric Surgical Association for grant funding to support this research. The study is ongoing and actively enrolling.

12. Small Bowel Obstruction

Bowel obstruction is one of the most common post-surgical complications thought to be caused by adhesions or scar tissue on the inside of the abdomen. Management with contrast challenge has been well studied in adults to reduce the length of stay, help with resolution and identify patients who may need surgical intervention earlier. However, large multi-institutional studies showing safety and efficacy in children are lacking. Speck et al. have designed a prospective multi-institutional study through the MWPSC to examine this practice in children. This study is currently being approved at participating centers with a plan to roll out the protocol and enroll patients in Fall 2021.

13. Biliary Atresia

Biliary Atresia (BA) is a rare progressive inflammatory disease of the bile ducts leading to liver fibrosis and cirrhosis. The diagnosis of BA remains a challenge, as other causes of neonatal cholestasis present in a similar fashion. Early diagnosis and prompt surgical intervention with Kasai portoenterostomy (KPE), the preferred surgical treatment, is critical for favorable outcomes. Delayed KPE significantly increases the proportion of patients who fail this surgery and ultimately require liver transplantation to survive. Mullapudi et al. have developed a retrospective cohort study through the MWPSC to characterize components of diagnosis and management. They will review how evaluation and management of infants with jaundice occurred, compare times from diagnosis to surgical intervention and the relative benefits of different diagnostic pathways. This study is in active data collection and is designed to provide the foundation for a prospective study to determine if a blood test measuring matrix metalloproteinase-7 can help with the diagnosis of BA compared to what was previously done.

14. Effect of COVID-19 on Pediatric Trauma

The COVID-19 Pandemic has affected both the distribution, injury pattern, and severity of trauma cases. The effect of this on trauma epidemiology has been published in adult populations but multi-institutional data on children is not available. Flynn O’Brien et al. are actively studying what effect this pandemic has had on pediatric trauma, to better inform health systems, emergency and surgery providers on how to better anticipate and care for these patients. This data may also help with community outreach and injury prevention.

15. Pectus Excavatum

Pectus Excavatum is a congenital deformity of the chest wall that results in a depression of the sternum and ribs. In addition to cosmesis, the deformity can compress the heart and lungs and affect other skeletal development. Surgical Management involves either placing a bar across the chest or removing the cartilage parts of the ribs and straightening out the sternum. These procedures are effective but can be painful and have a long recovery. Enhanced Recovery After Surgery (ERAS) pathways have been well studied in other surgical disciplines as ways to standardize care, improve

outcomes and patient satisfaction. They are comprehensive protocols including pre-operative optimization, and
standardized peri-operative management, focusing on multi-modal pain control and early mobilization among other aspects. The advent of cryotherapy for thoracic surgery has greatly reduced pain, narcotic requirement, and length of stay and makes ERAS protocols more feasible in pectus patients. Speck et al. have designed a retrospective study of MWPSC centers to characterize current management practices for pectus. This will provide the foundation to build a prospective ERAS protocol amongst centers to improve pectus outcomes. The study is approved and in the data collection phase.

16. Thyroid Disease

Both benign and malignant thyroid disease occurs in the pediatric population. As with many other pediatric diseases, the incidence is rare and difficult to study in a single institution. Therefore, most recommendations and guidelines on medical and surgical management of pediatric thyroid disease are founded on adult-based evidence. Through the MWPSC, Bruch et al. are studying all aspects of pediatric thyroid disease. The initial workup and evaluation, imaging, surgical intervention and complications, adjuvant radioactive iodine, and follow-up are being studied from patients across the consortium. This will provide the first multi-institutional evidence-based guidelines that are pediatric-specific. They also plan to continue this prospectively as the largest known pediatric thyroid registry.