Childhood obesity is an increasing health problem for U.S. children. Along with obesity, these children can have early onset of chronic and progressive obesity related conditions. Obesity in childhood predicts increased morbidity and mortality as an adult. A review of relevant recent articles was carried out. National trends and demographics are reviewed. American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee and the American Academy of Pediatrics (AAP) have published recommendations and guidelines for pediatric metabolic and bariatric surgery (MBS). Referral for metabolic and bariatric surgery evaluation should occur early as soon as child is recognized to suffer from severe obesity disease. Efforts should be made to be as inclusive as possible in making this important treatment available to children with clinical obesity. A strict multidisciplinary team approach is crucial to providing all the facets of MBS care that can help to set these patients up for success. Pediatric patients with obesity can benefit from MBS. Laparoscopic sleeve gastrectomy (LSG) has been successful in long-term excess body weight loss, and also resolution of co-morbidities associated with pediatric obesity. Factors have been identified which help to identify patients who are more or less likely to successfully progress through an MBS program.
To analyze the diagnosis and treatment of infection following internal fixation for long bone fractures in children. From January 2022 to 2024, 6 children with chronic infection following internal fixation for long bone fractures were admitted to the Department of Trauma. All the cases showed chronic infection with nonunion of the fracture, including 4 males and 2 females, 4 cases of falling from height, 1 case of traffic accident and 1 case of falling injury. The patients were treated with repeated debridement, antibiotic calcium sulfate filling, bone grafting, and intravenous antibioticsstable. The patients were followed up for at least 3 months after discharge, the symptoms, signs, and imaging changes were observed, and the Paley Fracture Healing Score.1 was recorded at the last follow-up. All patients on admission showed different degrees of fracture nonunion or thinning of the fracture on X-rays, but the internal fixation was stable and the infection site was covered by soft tissue. All patients retained their implants and were treated 2-5 vacuum sealing drainage (VSD), antibiotic calcium sulfate combined with bone graft local anti-infection treatment. Secondly, Linezolid was the main antibiotic used in the perioperative and postoperative period, and Rifampicin (RFP) was added to 3 cases. Bacterial culture showed that 3 cases were Gram-positive bacteria (G+), 1 case was Serratia marcescens, and Sulperazon were added, Pseudomonas aeruginosa and Klebsiella variicola (Gram-negative bacteria, G-) were isolated from the 2 cases, and Meropenem and Imipenem (IPM) were added to increase the antimicrobial spectrum, respectively. All patients were followed up for 4-14 months, with an average of 7.8 months and achieved clinical healing without recurrence of infection. According to the Paley Fracture Healing Score1, the results were excellent in 5 patients and good in 1 patient. In 6 children with chronic infection after internal fixation of fracture, imaging showed nonunion of fracture. In order to avoid secondary internal fixation of fracture or later orthopedic surgery, careful retention of internal fixation, thorough debridement, local antibiotic filling and release of anti-infection, combined with systemic antibiotic treatment for a sufficient period, and constant monitoring of inflammatory indicators were performed. Infection control and fracture healing can be achieved clinically.
Malignant ovarian tumors are exceedingly rare in children. The overwhelming majority of ovarian masses in the pediatric population are benign. Distinguishing benign from malignant ovarian pathology can be challenging. Avoidance of oophorectomy for benign ovarian disease and potential fertility sparing surgery for ovarian malignancy are crucial preoperative risk stratification steps for the healthcare team. The presentation of malignant ovarian tumors in girls is often non-specific, and may include abdominal pain and distention, palpable abdominal or pelvic mass, hirsutism or virilization. When evaluating young girls presenting with ovarian masses, it is important to consider their clinical characteristics, as ovarian masses in young, pre-pubescent girls are more likely to be malignant. Imaging should include abdominal-pelvic US, and axial imaging (CT or MRI). Serum tumor markers are essential elements of the work up includingCA-125, β-hCG, AFP, estradiol, testosterone, inhibin, LDH, and FSH. Germline mutations and cancer predisposition syndromes are associated with malignant ovarian tumors. Malignant ovarian masses are categorized into epithelial and non-epithelial subtypes. Epithelial tumors are the most common type of ovarian tumor in adult women. Non-epithelial tumors are most frequent in children. Non-epithelial tumors include the germ cell tumors (most frequent malignant tumor in children), and sex-cord stromal cord tumors. The Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) staging classification is used for staging epithelial tumors and sex-cord stromal tumors and the Children's Oncology Group (COG) staging is used for staging of germ cell tumors. The goal of treatment for all malignant ovarian tumors is complete resection and adjuvant platinum-based chemotherapy may be necessary for advanced stages. In the pediatric population, fertility sparing surgery should always be included in preoperative decision-making and family counseling.
Pediatric surgical conditions contribute substantially to the global burden of disease, yet children in low- and middle-income countries (LMICs) continue to face profound barriers in access to safe and timely surgical care. In disaster and conflict settings, these gaps are often magnified. Military humanitarian missions provide a unique, but understudied platform for delivering pediatric surgical care while supporting host-nation surgical capacity. In this narrative review, we summarize the current landscape of pediatric global surgery and examine the role of military surgical teams in humanitarian assistance and disaster response. We review models of military engagement, the development of telehealth capabilities to extend pediatric surgical expertise, and the ethical challenges that arise when providing care in politically complex, resource-limited environments. We further explore considerations in surgical decision making in LMICs, including disease severity, nutritional compromise, and limited rehabilitation resources. Finally, we highlight the importance of coordinated partnerships between military teams, local providers, and non-governmental organizations (NGOs) to promote sustainable, context-appropriate pediatric surgical care. Lessons from military pediatric disaster response have broad implications for global surgery, underscoring the need to prioritize children in emergency preparedness, invest in ethical and operational frameworks, and leverage telehealth and collaboration to strengthen local health systems.
Organoids are three-dimensional structures derived from a single stem cell. They self-organize in vitro and mature to recreate microarchitecture and characteristics of their tissues of origin. Since the first culture of mouse intestinal epithelial organoids and the translation to human, this technology has shown vast potential. Applications include developmental biology, disease modelling, drug testing and regenerative medicine making it increasingly relevant to clinical practice. Organoids can now be generated from tissues such as lung, intestine, kidney and brain using adult and fetal stem cells, pluripotent stem cells and cancer samples. Whether to study fetal development, disease physiopathology, regenerative medicine or to develop new therapies in a faster, more ethical and cost-effective way than animal models, organoids represent a powerful new tool. First described in 1999, personalised medicine aims to fine-tune diagnostic, prognosis and treatment to each patient. Nowadays, personalised medicine is spreading to most areas of clinical management, becoming the gold standard for the adoption of new interventions. More recently, these concepts have been applied to fetal medicine for prevention and therapy with initial reports appearing in literature in 2020. By recapitulating patient-specific disease mechanisms, prenatal organoids represent a unique bridge between in vitro-based approaches and personalised fetal medicine. This review presents fetal diseases for which organoids were explored, focusing on the implications of their derivation from prenatal sources such as the amniotic fluid, and discusses their advantages, challenges, and perspectives for prenatal counselling, prognosis or diagnosis, regenerative therapy, in utero surgery, disease modelling and prenatal drug testing.
Pancreatic trauma in the pediatric population is an uncommon but highly morbid injury. Its management remains controversial, with treatment strategies ranging from non-operative management (NOM) to upfront operative management (OM), primarily guided by the patient's hemodynamic stability and the integrity of the main pancreatic duct. This systematic review and meta-analysis aim to elucidate the comparative effectiveness and safety of NOM versus OM for pediatric pancreatic trauma. Following PRISMA guidelines, a systematic search was conducted in seven major databases (including PubMed/MEDLINE, EMBASE, and Scopus) up to September 10, 2025. From 320 identified records, 17 observational studies met the eligibility criteria, comprising 1147 patients. A random-effects meta-analysis was performed to calculate pooled Odds Ratios (OR) with 95% Confidence Intervals (CI) for key outcomes, including mortality, overall complications, pancreatic pseudocyst, and fistula. Bayesian analysis was used for corroboration, and the certainty of evidence was assessed using the GRADE framework. The analysis found no significant difference between NOM and OM for mortality (OR 0.89; 95% CI 0.48-1.66; I²=0%) or overall complications (OR 0.75; 95% CI 0.41-1.38; I²≈41%). However, a significant clinical trade-off emerged for specific complications. NOM was associated with a significantly higher risk of pancreatic pseudocyst (OR 2.56; 95% CI 1.55-4.23; I²=0%). Conversely, NOM was associated with a substantially lower risk of pancreatic fistula compared to OM (OR 0.27; 95% CI 0.11-0.69; I²=0%). Evidence for other secondary outcomes was largely inconclusive due to statistical imprecision. The certainty of evidence for all outcomes was rated as very low. Non-operative management is a viable and safe primary strategy in selected pediatric patients with pancreatic trauma and does not appear to increase mortality. The therapeutic decision hinges on a crucial trade-off: NOM increases the risk of pseudocyst formation, while OM increases the risk of iatrogenic fistula. Despite the very low certainty of the available evidence-an inherent limitation of trauma research-these findings provide a critical framework for facilitating shared decision-making. Prospective, multi-center registry studies are urgently needed to establish more definitive guidelines.
Enhanced recovery after surgery (ERAS) is a multidisciplinary, evidence-based protocol designed to standardize perioperative care, minimize complications, and optimize recovery. While ERAS has demonstrated significant benefits in adult populations, widespread adoption in pediatric surgery remains in progress. One of its central goals is reducing postoperative infections, particularly surgical site infections (SSIs), which represent a common source of morbidity in children. Core ERAS elements-including perioperative nutrition, glycemic control, fluid and temperature management, antibiotic prophylaxis, wound care, device removal, and early mobilization-directly or indirectly influence infection risk. Although pediatric-specific data remain limited, growing evidence supports that ERAS protocols are safe and may reduce SSI incidence. This narrative review outlines how individual ERAS components target SSI prevention, highlights current pediatric evidence, and identifies knowledge gaps where further research is needed to optimize infection prevention strategies for children undergoing surgery.
Children with congenital foregut malformations including tracheal pathology or long-gap esophageal atresia have limited treatment options. Severe malformations have suboptimal replacement options for both congenital and acquired anomalies despite maximal surgical intervention. Tissue engineering offers a potential solution to address this unmet need. For esophageal reconstruction, the combination of decellularized extracellular matrix scaffolds, myogenic progenitor cells, and bioreactor pre-conditioning has shown the most promising preclinical results. For tracheal replacement, there have been initial reports in pediatric patients, but no strategy has yet demonstrated consistent preclinical success, and the optimal approach remains to be defined. The two fields are at markedly different stages of translational readiness. Tracheal tissue engineering has not yet achieved consistent safety or durability in orthotopic large-animal models, and clinical use has been confined to a small number of compassionate-use cases with mixed outcomes partly related to inconsistent use of scaffold materials and cell replacement strategies. Esophageal reconstruction is closer to clinical translation, with a clinical trial of segmental replacement in adults underway and full-thickness circumferential replacement with evidence of secondary peristalsis demonstrated in a growing large-animal model. Pediatric patients impose unique constraints for tissue engineering but also offer advantages, including enhanced tissue remodeling capacity. Bridging the gap between current preclinical progress and safe clinical application will demand robust animal model validation, transparent documentation of setbacks, and sustained interdisciplinary engagement. This review summarizes current strategies for tracheal and esophageal reconstruction using tissue-engineered approaches, evaluating preclinical and clinical evidence across scaffold design, cell sourcing, and vascularization.
Appendicitis serves as a model for pathway-driven quality improvement (QI) in pediatric surgical care. The high case volume, predictable clinical trajectory, and measurable outcomes associated with acute appendicitis care facilitate identification of unwarranted practice variation and allow standardization to be feasible at scale. Starting in the mid-2010s, several QI initiatives transformed appendicitis management in children. This review highlights four QI efforts in pediatric appendicitis management including the shift of diagnostic imaging from routine computed tomography to ultrasound-first strategies, improved opioid stewardship, de-implementation of low-value practices such as routine total parenteral nutrition utilization, and generation of severity-guided clinical practice guidelines that decreased postoperative antibiotic durations. Across these domains, improvement followed a consistent progression through phases of documented variation, evidence consolidation, structured local implementation, guideline alignment, and eventually sustained monitoring of guideline-based practices. Continued progress will require ongoing development of pediatric-specific evidence, dissemination of evidence-based practices into broader practice settings, and focused efforts to ensure equitable implementation across populations. QI efforts for appendicitis serve as a transferable blueprint for value-based and safety-focused pediatric care, demonstrating that unwarranted variation can be reduced when evidence-based practices are embedded into structured clinical guidelines, process metrics and outcomes are measured transparently, and principles are reinforced through coordinated dissemination.
Surgical site infection (SSI) is one of the most common nosocomial infections that occur in pediatric patients in the United States, with colorectal procedures consistently demonstrating the highest rates of SSI. Strategies to reduce SSI in colorectal surgery include standardized perioperative colorectal care bundles, which commonly incorporate preoperative bowel preparation. Robust adult literature exists supporting the use of mechanical bowel preparation in combination with oral antibiotics to mitigate SSI; however, pediatric evidence remains less definitive. Current pediatric literature shows heterogeneity of bowel preparation use amongst surgeons, with existing literature consisting primarily of small retrospective studies. A well-designed pediatric randomized controlled trial comparing the four available bowel preparation strategies would provide much needed evidence to define best practice for preoperative colorectal surgery care amid current variations in clinical practice.
Antimicrobial stewardship is essential to safe, effective pediatric surgical care, yet surgical antimicrobial prophylaxis (SAP) remains highly variable and frequently overused across children's hospitals. This review provides a high-level synthesis of the public health rationale for stewardship, the current landscape of SAP practice, and the growing body of pediatric-specific evidence informing appropriate prophylaxis use. We integrate national guideline recommendations with contemporary outcomes data and describe how benchmarking initiatives such as ACS NSQIP-Pediatric and Children's Surgery Verification programs promote accountability and standardization in perioperative antibiotic use. The review also highlights the critical role of antimicrobial stewardship programs in guiding institutional practice and supporting the development of evidence-based local protocols. Finally, we outline the broad categories of evidence-based tools and strategies that facilitate high-quality stewardship for prophylaxis use. Together, these components establish a contemporary roadmap for optimizing prophylaxis use while minimizing unnecessary antibiotic exposure in children undergoing elective surgical procedures.
Surgical site infections (SSIs) remain a significant source of morbidity in pediatric surgery, prolonging hospital stays, increasing readmissions, and driving up healthcare costs. Manual chart reviews and static risk models limit traditional SSI prediction and detection. The rise of artificial intelligence (AI), including machine learning (ML), natural language processing (NLP), and large language models (LLMs), offers a transformative opportunity to enhance prediction and surveillance. This review synthesizes current literature on AI applications in pediatric SSI, emphasizing predictive models built on NSQIP-P data and detection strategies leveraging EHRs and wearable technologies. Despite encouraging retrospective results, real-world adoption remains constrained by poor validation, limited generalizability, and workflow misalignment. Ethical and regulatory concerns, including bias, transparency, and pediatric-specific data limitations, must be addressed to ensure safe, equitable implementation. Thoughtfully developed and deployed, AI-driven tools can transform pediatric surgical care by enabling earlier intervention and improving outcomes.
Pivotal advancements in diagnostics have greatly improved early detection of disease in the fetus. Rapid diagnosis of prenatal disease, including many aneuploidies and single-gene disorders, is now possible. These capabilities present an opportunity for earlier interventions and involvement of multidisciplinary care for infants discovered to have genetic disorders. While advancements continue to be made surgically addressing anatomic pathologies, more recently, the scope of fetal medicine has expanded to include the treatment of genetic disease. This unique and growing group of conditions with potential prenatal therapeutic targets spans broadly to include inborn errors of metabolism, neurodegenerative disorders, hematologic conditions, and errors in hormone biosynthesis. Because many of these hereditary conditions begin exerting deleterious effects before birth, prenatal therapies are critical to minimize or potentially avoid postnatal consequences. Fetal treatments can leverage the benefits of early human development such as a selectively permissive blood-brain barrier and a naive immune system. These factors, along with a favorable vector-to-tissue mass ratio in the fetus, create ideal treatment conditions that are not present after birth. Together, improved prenatal diagnostics and safe minimally invasive approaches for the delivery of therapies in utero have opened a window to what was previously an inaccessible population: the fetal patient. This review summarizes current clinical strategies and emerging investigational approaches, including enzyme replacement, protein therapy, stem cell transplantation, and gene-targeted interventions.
Extracellular vesicles (EVs) are lipid bilayer-delimited nanoparticles released by cells to act as mediators of intercellular communication during organ development, injury, and repair. EVs carry cargo (bioactive proteins, lipids, and nucleic acids) that reflects the status of the parent cell and is transferred to recipient cells to regulate biological processes, such as inflammation, immune responses, and tissue regeneration. These properties have made EVs promising tools for investigating disease pathogenesis, improving diagnostic and prognostic accuracy, and developing cell-free regenerative therapies for conditions characterized by dysregulation of multiple biological pathways. EVs are particularly relevant in diseases that affect the pediatric population where pathogenesis often remains poorly understood, access to affected tissues is limited, and treatment options are frequently inadequate. This review summarizes current evidence on EV applications in fetal and neonatal disorders, including necrotizing enterocolitis, congenital diaphragmatic hernia, and bronchopulmonary dysplasia, and highlights emerging data in biliary atresia, spina bifida, short bowel syndrome, and Hirschsprung's disease. In this age group, human milk and amniotic fluid represent particularly attractive biologically accessible sources of EVs, combining therapeutic potential with feasibility of clinical application. Building on robust preclinical evidence, the field is now advancing toward clinical translation, but several aspects still need to be addressed such as cargo heterogeneity, scalability of production, dosing, biodistribution, safety, and regulatory standardization. Herein, we discuss the translational challenges and future directions that will shape the clinical application of EVs in perinatal conditions.
Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) remains a common, complex congenital anomaly with high survival but significant postoperative morbidity. Despite advances in surgical technique and neonatal care, one of the main contributors to postoperative morbidity is infection with anastomotic leakage occurring in up to 25 % of cases. Leakage of the esophageal anastomosis is associated with mediastinal and thoracic infection, prolonged hospitalization, and long-term sequelae. Prompt recognition and management can minimize short- and long-term complications for these patients. Here we present a narrative review of contemporary literature incorporating retrospective cohort studies, multicenter analyses, and guideline statements to summarize the clinical presentation and management strategies of anastomotic leaks following surgical intervention for EA. We highlight the symptoms specific to infections following EA repair and diagnostic modalities such as contrast esophagram. Treatment requires an individualized approach based on clinical status ranging from conservative management utilizing chest drainage, antibiotics, and parenteral nutrition, to large or uncontained leaks that necessitate endoscopic interventions or surgical re-exploration. Endoscopic stenting and vacuum therapy are increasingly employed modalities that may reduce the need for invasive revisional surgery, although pediatric data remain limited. Long-term follow-up demonstrates children who experience anastomotic leaks are more likely to develop late complications including esophageal strictures, dysmotility, reflux, and chronic respiratory issues. Vigilant surveillance and multidisciplinary care are therefore essential to optimize outcomes and preserve esophageal function.
Pediatric infections in low- and middle-income countries (LMICs) represent a substantial proportion of the pediatric surgical burden. Overall in-hospital mortality for surgically treated infections is 12.5 %. The incidence, morbidity, and mortality associated with pediatric infections are all higher in LMICs due to delayed presentation, lack of access to primary care, and a greater incidence of communicable diseases. Over 1.7 billion children and adolescents do not have access to safe, timely, and affordable surgical care, and a disproportionate number of these children reside in LMICs making them a vulnerable population. Within this context, pediatric surgeons are frequently required to make diagnostic and therapeutic decisions in the setting of limited supportive infrastructure. This review examines common infectious conditions encountered in pediatric surgical practice in LMICs through the lens of resource-adapted decision-making, highlighting how constraints in diagnostics, operative capacity, anesthesia, and postoperative support shape management strategies and outcomes.
Despite major advances in neonatal and perioperative care, surgical site infections remain a persistent source of morbidity in neonatal surgery. Compared to older pediatric patients, neonates possess unique physiological vulnerabilities, including immature immune function, underdeveloped skin barriers, and frequent exposure to invasive devices, that heighten infection risk. Reported surgical site infection (SSI) rates range from 2.6% to 12.6%, with the highest incidence observed following abdominal wall defect repair, necrotizing enterocolitis surgery, and colorectal procedures. Staphylococcus is the predominant pathogen, although Gram-negative enteric organisms are frequent in gastrointestinal cases. Evidence guiding prophylaxis is limited; available data suggest that prolonged antibiotic use does not reduce SSI risk and may increase adverse outcomes such as fungal infection or necrotizing enterocolitis. Similarly, standard adult-derived wound classifications and prophylactic frameworks often fail to account for neonatal-specific factors. Prevention strategies must therefore be tailored to the neonatal population, emphasizing appropriate antibiotic stewardship, optimized skin preparation, temperature regulation, and neonatal intensive care unit (NICU) infection control. Future research should focus on defining procedure-specific prophylaxis, neonatal SSI definitions, and multicenter quality improvement efforts to standardize care and reduce infection-related morbidity.
Pediatric choledocholithiasis is a rare but increasingly recognized disease process that is predominantly managed with either an "endoscopy-first" or "surgery-first" approach. In the endoscopy-first approach, a preoperative endoscopic retrograde cholangiopancreatography is performed with subsequent cholecystectomy. In contrast, the surgery-first approach is a single-stage procedure that includes a laparoscopic cholecystectomy and intraoperative cholangiogram, followed by a laparoscopic common bile duct exploration when indicated. Recent studies have highlighted the potential advantages of the SF approach. However, no standardized treatment algorithm exists, and institutional capabilities and practicing patterns heavily influence management decisions. This point-counterpoint review explores both approaches, analyzing their effects on clinical outcomes and healthcare resources. Continued research and a multidisciplinary approach are needed to develop consensus-driven treatment algorithms.
Following the closure of the Paediatric Hepatic International Tumour Trial (PHITT), interim guidance is required to support surgical decision-making in hepatoblastoma. Current PRETEXT/POST-TEXT staging does not fully reflect contemporary imaging capabilities and evolving surgical strategies. The SIOPEL radiology and surgery committees developed the first-ever consensus-based recommendations integrating expert opinion, institutional experience, and available evidence to refine radio-surgical decision-making. Current evidence is reviewed and we provide updated criteria to guide upfront, early, standard, and complex resections, and to support decision-making between organ-preserving surgery and liver transplantation. Key domains addressed include vascular involvement, multifocal disease, surgical margins, extrahepatic extension, lymph node disease, and metastatic spread. We highlight limitations of the current PRETEXT system and advocate for more detailed, surgically relevant radiologic reporting, including refined descriptors of vascular contact, tumour thrombus, and future liver remnant considerations. This review and consensus framework aims to bridge the gap between existing staging systems and modern radiological as well as surgical practice, standardize multidisciplinary communication, and optimize curative-intent treatment strategies in children with hepatoblastoma.
Retained esophageal button batteries (BBs) cause significant morbidity in children. Current guidelines recommend oral honey administration in children over 1 year and esophageal irrigation with 0.25 % acetic acid (ACA) after BB removal, but supporting evidence is limited. We aimed to develop a dynamic in vitro esophageal model to evaluate these interventions. Our novel model consisted of fresh porcine oesophagi suspended in an environment simulating body temperature, peristalsis, and saline perfusion. BBs or sham BBs were placed in the oesophagus. Honey was administered at specific intervals after BB insertion. After BB removal, the lesions were washed with ACA or buffer solution. Paraffin slides were stained with hematoxylin and eosin (HE) to quantify the ulceration. The mean pH was significantly lower in samples exposed to honey (p≤0.0001) and the voltage discharge was reduced with honey as well (p≤0.0001). Application of honey resulted in macroscopically smaller ulcers than in untreated oesophagi. HE staining confirmed the macroscopic results with significantly reduced ulcers with honey application (p < 0.009). Irrigation with ACA had no effect. We developed a dynamic in vitro model of oesophageal button battery ingestion by including peristalsis, body temperature, an upright lumen and saline perfusion. Our data supports the recommendations that oral honey application before endoscopic battery removal protects the mucosa after oesophageal BB retention, whereas ACA irrigation at the time of BB removal showed no effect in this study.