"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.

Moving the needle for laparoscopic common bile duct exploration: defining obstacles for the path forward.

Introduction: Laparoscopic cholecystectomy is performed very commonly but laparoscopic common bile duct exploration (LCBDE) is performed infrequently. We aimed to determine the most significant barriers to performing LCBDE and to identify the highest yield interventions to facilitate adoption.

Methods And Procedures: A national survey was designed by content experts, who regularly perform LCBDE.

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.

INVESTIGATING THE RELATIONSHIP BETWEEN BLEEDING, CLOTTING, AND COAGULOPATHY DURING AUTOMATED PARTIAL REBOA STRATEGIES IN A HIGHLY LETHAL PORCINE HEMORRHAGE MODEL.

Background: Death due to hemorrhagic shock, particularly, noncompressible truncal hemorrhage, remains one of the leading causes of potentially preventable deaths. Automated partial and intermittent resuscitative endovascular balloon occlusion of the aorta (i.e.

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).

MAN VERSUS MACHINE: PROVIDER DIRECTED VERSUS PRECISION AUTOMATED CRITICAL CARE MANAGEMENT IN A PORCINE MODEL OF DISTRIBUTIVE SHOCK.

Background: Critical care management of shock is a labor-intensive process. Precision Automated Critical Care Management (PACC-MAN) is an automated closed-loop system incorporating physiologic and hemodynamic inputs to deliver interventions while avoiding excessive fluid or vasopressor administration. To understand PACC-MAN efficacy, we compared PACC-MAN to provider-directed management (PDM).

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.

Spare the Needle, Discharge the Child: Trending Post-Op Labs After Laparoscopic Common Bile Duct Exploration in Pediatric Patients Is Not Helpful.

Laparoscopic common bile duct exploration (LCBDE) utility in management of choledocholithiasis may decrease length of stay and patient cost, but postoperative management remains widely debated. We examined periprocedural LFTs for patients undergoing LCBDE and endoscopic retrograde cholangiopancreatography (ERCP) speculating for trend existence after successful LCBDE. We hypothesized that postoperative LCBDE LFTs would not downtrend even after successful ductal clearance.

Transcystic Laparoscopic Common Bile Duct Exploration for Pediatric Patients with Choledocholithiasis: A Multi-Center Study.

Background: Patients with choledocholithiasis are often treated with endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). Upfront LC, intraoperative cholangiogram (IOC), and possible transcystic laparoscopic common bile duct exploration (LCBDE) could potentially avoid the need for ERCP. We hypothesized that upfront LC + IOC ± LCBDE will decrease length of stay (LOS) and the total number of interventions for children with suspected choledocholithiasis.

Dynamic Aortic Pressure Augmentation as a Novel Method of Swine Terminal Blood Extraction.

Introduction: Uncontrolled hemorrhage models require sufficient quantities of donor blood products to support resuscitation. To that end, we describe a novel method of whole blood extraction from donor swine using resuscitative endovascular balloon occlusion of the aorta (REBOA) to support hemodynamics during terminal blood extraction and its impact on the quality of banked blood.

Methods: Ten adult Yorkshire-cross swine were anesthetized and instrumented with an REBOA catheter, femoral multistage venous cannula, and proximal/distal blood pressure monitoring.

Investigating the variability in pressure-volume relationships during hemorrhage and aortic occlusion.

Introduction: The pressure-volume (P-V) relationships of the left ventricle are the classical benchmark for studying cardiac mechanics and pumping function. Perturbations in the P-V relationship (or P-V loop) can be informative and guide the management of heart failure, hypovolemia, and aortic occlusion. Traditionally, P-V loop analyses have been limited to a single-beat P-V loop or an average of consecutive P-V loops (e.

Balanced resuscitation with whole blood versus component therapy in critically injured preadolescent children: Getting there faster with fewer exposures.

Purpose: Balanced blood product resuscitation with red blood cells, plasma, and platelets can be achieved using whole blood (WB) or component therapy (CT). However, balanced resuscitation of younger children with severe traumatic hemorrhage may be complicated by delays in delivering all blood components and concerns regarding multiple product exposures. We hypothesized that WB achieves balanced resuscitation faster than CT, with fewer product exposures and improved clinical outcomes.

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.

ERCP findings provide further justification for a "surgery-first" mindset in choledocholithiasis.

Introduction: Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions.

Reclaiming the management of common duct stones in acute care surgery.

Background: Acute care surgery (ACS) is well positioned to manage choledocholithiasis at the time of laparoscopic cholecystectomy, but barriers to laparoscopic common bile duct exploration (LCBDE) include experience and the perceived need for specialized equipment. The technical complexity of this pathway is generally seen as challenging. As such, LCBDE is historically relegated to the "enthusiast.

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).

Precision Automated Critical Care Management: Closed-loop critical care for the treatment of distributive shock in a swine model of ischemia-reperfusion.

Background: Goal-directed blood pressure management in the intensive care unit can improve trauma outcomes but is labor-intensive. Automated critical care systems can deliver scaled interventions to avoid excessive fluid or vasopressor administration. We compared a first-generation automated drug and fluid delivery platform, Precision Automated Critical Care Management (PACC-MAN), to a more refined algorithm, incorporating additional physiologic inputs and therapeutics.

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.

Automated partial resuscitative endovascular balloon occlusion of the aorta reduces blood loss and hypotension in a highly lethal porcine liver injury model.

Background: Partial and intermittent resuscitative endovascular balloon occlusion of the aorta (pREBOA and iREBOA, respectively) are lifesaving techniques designed to extend therapeutic duration, mitigate ischemia, and bridge patients to definitive hemorrhage control. We hypothesized that automated pREBOA balloon titration compared with automated iREBOA would reduce blood loss and hypotensive episodes over a 90-minute intervention phase compared with iREBOA in an uncontrolled liver hemorrhage swine model.

Methods: Twenty-four pigs underwent an uncontrolled hemorrhage by liver transection and were randomized to automated pREBOA (n = 8), iREBOA (n = 8), or control (n = 8).