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Three Landmark Papers in Pediatric Surgery

July 11, 2023

Commentary From the AAP Section on Surgery

The American Academy of Pediatrics (AAP) Section on Surgery (SOSu) began in 1948 through the efforts of Herbert E. Coe. Since its onset, the mission of the SOSu has been to:

  • Provide a forum for the initiation, discussion, and development of ideas and problems related to the surgery of infants and children.
  • Stimulate the study and teaching of the surgery of infants and children.
  • Disseminate the principle of providing better surgery for children everywhere.
  • Bring into the AAP those surgeons whose work was entirely, or no less than 90%, devoted to infants and children.

Over the last three-quarters of a century, surgeons have collaborated on important papers. Since Drs. Robert Gross and Alexander Bill Jr published an article entitled, “Concealed Diverticulum of the Male Urethra as a Cause of Urinary Obstruction,” in the first edition of Pediatrics, singling out 3 papers among the long list was daunting. A search was nonetheless used to identify all surgical papers published in the journal, and each paper was weighted based on its significance and impact on the care of children over the years.

Three Landmark Papers in Pediatric Surgery

Kenneth Gow, MD, MHA, FAAP1, Reto Baertschiger, MD, FAAP2

Affiliations: 1Seattle Children’s Hospital and the University of Washington, 4800 Sand Point Way NE, Seattle, WA; 2Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH

Highlighted Articles From Pediatrics

Our first highlighted article authored by Holder et al in 1964 describes an important initiative during the first formative years when pediatric surgeons were establishing pediatric surgery as a standalone specialty. To assist in this effort, pediatric surgeons united to compile a section-wide experience on rare diseases. This landmark article summarizes findings from a survey sent to 131 members from the AAP SOSu and describes techniques used and outcomes of patients with esophageal atresia and tracheoesophageal fistula (EA-TEF) between 1958 and 1962. The study included more than 1,000 patients treated in North America in academic, freestanding children’s hospitals and private practice settings. The described results reflect the practice of the late 1950s and early 1960s. Some of the practices remain as elements of modern care. The distribution of the anatomical types of EA-TEF described in this paper holds true today. Almost 50% of patients had associated congenital anomalies. Outcomes were assessed as a function of age at diagnosis, associated congenital anomalies, gestational age, and birth weight. Surgical approaches were detailed as well; the majority of patients who underwent a transpleural repair had a lower survival rate (66%) compared to the 76% survival rate among the 144 patients who underwent repair using an extrapleural approach. The survey further analyzed complications, including anastomotic leaks and pulmonary and infectious complications. The authors described a 16.7% incidence of anastomotic leaks and noted an association with higher mortality. The authors also recognized the contributions of best practices and recommendations for the care of complex pediatric surgical problems, including well-trained nursing staff, dedicated pediatric surgical services, and well-trained and supervised house staff. The authors’ comments seem very contemporary and are still valid today for most of our practice taking care of congenital anomalies. Their descriptions and comments were visionary and anticipated the evolution of our current research consortia that engages many surgeons across North America who care for pediatric surgical patients. This article, published nearly 60 years ago, remains as essential reading today for our current pediatric surgical trainees and practicing surgeons both as a historic document as well as a window into how we can continue to improve care for our patients.

The second highlighted article by Starzl et al at the University of Colorado documents the early milestones of liver transplantation as a life-changing procedure for children. This pioneering publication describes the first 74 patients who underwent transplantation between 1963 and 1978, at a time when most of the current AAP SOSu membership was starting or not even in medical school, and the current junior faculty barely born. Most of the children in their series were patients who were born with biliary atresia and who had developed end-stage liver failure. Prior to Starzl’s innovative approach, these children died. The study provides a comprehensive description of the patient cohort thoroughly, the surgical techniques, and challenges unique to small children that necessitated use of microsurgery technique for some anastomoses. The authors also describe and discuss early complications, including biliary complications and organ rejection. Of note, their comments that progress in immunosuppression was necessary to improve patient outcomes were visionary. We need to remember that cyclosporine and more modern immunosuppressive medications were introduced in 1980 and later, after Starzl had moved to Pittsburgh. The overall survival rate of 39% (62% for the latter portion of their cohort) are lower than the current 80%-85% 1-year survival rates. The described distribution of patients requiring transplantation, the description of techniques and challenges, and the recognition of a need for a more specific immunosuppressive regimen with fewer side effects establish Starzl’s article as a groundbreaking effort that has led to dramatic changes in care and outcomes.

The third highlighted paper is a policy statement published in Pediatrics in 2016 and is a model for collaboration between multiple different sections and committees to define current best practices and standards in the management of pediatric trauma in a multidisciplinary fashion. The authors remind us that trauma is the main cause of mortality in children after 1 year of age, a fact that persists today, because penetrating trauma is the leading cause of death among US children between 1 and 18 years of age. This article clearly defines the different levels of comprehensive trauma care, including trauma systems, based on local, regional, and wider geographical boundaries; prehospital care; and participation in quality and performance improvement programs. The article recommends standards of care and how to implement these for pediatric patients. Injury prevention and disaster preparedness are also part of comprehensive trauma care and are well described in this policy statement. The authors define 16 recommendations on how to implement best practices in pediatric trauma care, recommendations that allow pediatric surgeons and all other specialists who advocate for our injured children to improve care and advocate for resources at local, regional, state, and national levels. These recommendations, which were published 6 years ago and are of great importance today, should be shared with all stakeholders who are involved in decision-making that affects the care of our patients.

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