Eastern Pediatric Surgery Network

Started 2020: The surgical management of long-gap esophageal atresia remains controversial and has traditionally been based on surgeon learned experience rather than on evidence-based guidelines. Current options for surgical repair include delayed primary repair, the Foker procedure and other traction techniques, and esophageal replacement. Based on a 2023 EPSN retrospective cohort study published in J Ped Surg Open, we have recently launched a prospective data registry aimed at defining outcomes and best practices for infants born with long-gap esophageal atresia. 

Study Lead: Dr. Christine Finck, Connecticut Children's

Strated 2020: Appendicitis is responsible for the greatest burden of surgical site infections and antibiotic utilization in pediatric surgery. This unique EPSN study uses the NSQIP-P database combined with electronic medical record data to analyze antibiotic use and postoperative management of perforated and non-perforated appendicitis. Thus far, we have published several studies in high-impact journals that address controversial practices in appendicitis management such as antibiotic re-dosing prior to incision, postoperative antibiotics in gangrenous/suppurative/exudative appendicitis, and use of white blood cell count data in clinical decision-making. 

Study Lead: Dr. Shawn Rangel, Boston Children's

Started 2020: The most common method for evaluating the preoperative severity of pectus excavatum is by cross-sectional imaging with computed tomography. A clinic-based measurement with chest calipers, known as the Modified Percent Depth (MPD), represents a low-cost, alternative approach for assessing disease severity while avoiding ionizing radiation. This prospective study seeks to establish the MPD as a valid and reliable measurement of pectus severity across multiple EPSN centers. The ultimate goal is to use the MPD to supplant mandatory cross-sectional imaging as dictated by many insurance carriers.

Study Lead: Dr. Nicole Chandler, Johns Hopkins All Children's

Started 2020: A significant risk of long-term parenteral nutrition is the development of a central line-associated bloodstream infections (CLABSI), a potentially life-threatening infection that can lead to septic shock, multi-system organ failure, and death. Children with suspected CLABSI are admitted, treated empirically with intravenous antibiotics, and monitored until blood culture results become available. However, these practices are not data-driven and are associated with unnecessary time in the hospital and added costs for the hospital and families. This EPSN prospective observational study investigates the effectiveness and cost reductions associated with a 24-hr hospital admission to safely rule out CLABSI and seeks to identify subpopulations that may require longer hospitalization. 

Study Lead: Dr. Mark Puder, Boston Children's

Started 2021: Even prior to the COVID pandemic, telemedicine represents a cost-effective way to enhance patient access and to reduce healthcare resources, Current barriers to its widespread use in the post-COVID era include regulatory and technical support, inadequate reimbursement, and lack of insurance for liability coverage. This EPSN study aims to ascertain physician and patient experience and satisfaction with the use of telemedicine across multiple institutions, types of centers, and types of visits. It will evaluate the benefits as well as barriers in its current form, in order to have targeted goals to optimize its use in pediatric surgery.  

Study Lead: Dr. Christina Feng, Children's National Medical Center

Started 2021: The incidence of pediatric and adolescent thyroid cancer is increasing nationwide and represents a diagnostic and treatment dilemma for many pediatric providers. Adolescents are more likely to have extra thyroidal extension, lymph node involvement, and metastases than adults. Early diagnosis and appropriate surgical treatment is therefore imperative. Our multi-center thyroid nodule study is a cohort validation study of the 2017 Bethesda Classification System with three primary aims: to create a multi-institution database of pediatric and adolescent patients undergoing thyroid surgery and/or thyroid nodule biopsy, to characterize rates of pediatric thyroid malignancy in this sample, and to describe variations in practice patterns.

Study Lead: Dr. Cornelia Griggs, Massachusetts General Hospital

Started 2021: Current guidelines from the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend Nissen fundoplication for gastrointestinal reflux refractory to medical treatment. However, these guidelines note a lack of evidence in the literature to support transpyloric or jejunal feeding. We have developed a retrospective EPSN database of over 1200+ infants and toddlers who underwent surgical management of GERD. Our aim is to understand institutional variation in GERD practices and its impact on unanticipated health care utilization and other outcome metrics.

Study Lead: Dr. Jen DeFazio, Columbia University

Started 2021: In the adult surgical population, the standard of care for elective colon and rectal operative procedures has been to perform a preoperative bowel preparation in attempt to decrease the risk of post-operative complications. There is a paucity of data in young children; thus, the best practices for the application of pre-operative bowel preparation in children have not been established. In this multi-phase project, we have recently completed our EPSN surgeon survey study of current bowel prep practices to inform a retrospective EPSN cohort study on the impact of bowel preparation on complications after elective colostomy closure in infants and young children. 

Study Leads: Dr. Sean McLean, University of North Carolina, and Dr. Aaron Lipskar, Cohen Children's

Started 2022: Esophageal atresia patients are at long-term risk for GERD, strictures, cancer, and other complications. Our multi-phase study aims to better understand current practice and preferences in esophageal atresia surveillance while ultimately developing evidence-based practice guidelines to steer future practice.  We recently published a survey of EPSN institutions to understand current surveillance practice as well as perspectives of pediatric surgeons and gastroenterologists. These data have subsequently informed multi-institutional retrospective and prospective databases of current practice and esophageal pathology in this patient population. Our long-term goal is to create a multi-disciplinary practice protocol to standardize care across all hospitals managing these patients.

Study Lead: Dr. Leslie Knod, University of Connecticut

Started 2023: Laparoscopic techniques for pediatric inguinal hernia repair are becoming increasingly popular in infants, but the recurrence rate compared to the open procedure remains controversial. In this EPSN study, we have sought to understand current surgeon preferences for laparoscopic versus open inguinal hernia repair in small ex-preterm infants. We have also developed a retrospective EPSN database of over 2000 patients to evaluate the incidence of recurrent hernia and metachronous contralateral hernia after inguinal hernia repair in infants.

Study Lead: Dr. Matthew Hornick, Yale University

Started 2023: The optimal timing of operative repair in newly diagnosed Hirschsprung's disease has been debated. The primary objective of this EPSN study is to evaluate the role of timing of pull through procedures in neonates and infants with rectosigmoid Hirschsprung disease. The major outcome measures will include rate of postoperative Hirschsprung-associated enterocolitis, anastomotic complications (leak, stricture), and resource utilization.

Study Lead: Prathima Nandivada, Boston Children's Hospital

Started 2024: There continue to be many controversial areas in the diagnosis and management of biliary atresia. A major objective of this study is to understand the diversity of practice patterns in biliary atresia management across the various EPSN sites, especially with regards to imaging, biomarkers, biopsy, steroids, and antibiotic use. A 5-year retrospective study is currently underway with the eventual goal of contributing to a national prospective registry in collaboration with other interested investigators. Another major goal of this project is to evaluate the role of institutional volume in biliary atresia in order to understand how to optimize center-specific resources to improve outcomes.

Study Leads: Dr. Mark Slidell & Dr. Sam Alaish, Johns Hopkins Baltimore