Pediatric Surgery

The Department of Pediatric Surgery at Nationwide Children's is one of the largest centers of its kind in the United States, with 16 surgeons performing more than 5,000 cases each year. Our team cares for infants, children and adolescents with congenital and acquired conditions, including major congenital anomalies, traumatic and thermal injuries and tumors.

Our surgeons have the experience and expertise to provide the best care for each patient — from the smallest infant to the most complex cases. When minimally invasive surgery is possible, our surgeons provide advanced laparoscopic, endoscopic and thoracoscopic options, as well as robot-assisted alternatives. Our Robot-Assisted Surgery Program is one of the most advanced in the nation, and offers extensive training to fellows and other surgeons in robot-assisted techniques.

We are doing amazing things for our patients and for patients everywhere. As a result of our research programs, our four fellowship programs and numerous collaborative programs with subspecialties throughout the institution, we are taking pediatric surgery to a whole new level.
Gail E. Besner, MD
Chief of Pediatric Surgery

Through our educational programs — Pediatric Surgery Residency, Pediatric Minimally Invasive Surgery Fellowship, Pediatric Colorectal Surgery Fellowship, Surgical Critical Care and Adolescent Bariatric Surgery Fellowship — we are training the surgeon-scientists of the future. Our Pediatric Surgery Residency is one of the oldest and most established residencies of its kind. Our Pediatric Minimally Invasive Surgery Fellowship is one of only a few pediatric minimally invasive surgery fellowships in the United States.

Our trainees are given opportunities to conduct research alongside mentors who are leaders in the field. In 2015, Nationwide Children's ranked sixth nationally in National Institutes of Health-funding among pediatric hospitals. From tissue engineering research to treating appendicitis without surgery; from reversing liver fibrosis to solving the puzzle of intestinal diseases including necrotizing enterocolitis and short bowel syndrome, our work is changing outcomes for patients and their families.

Collaboration and providing comprehensive, coordinated care are cornerstones of our work in pediatric surgery at Nationwide Children’s. For our most complex patients that require care from multiple subspecialties, we team up with experts from across the hospital. Our programs and centers include: adolescent bariatric surgery, Burn Program, chest wall deformities, Center for Colorectal and Pelvic Reconstruction, inflammatory bowel disease, Level 1 Pediatric Trauma Center, neonatal surgery and surgical oncology.

8,021 Clinic visits in 2015
4,292 Surgical cases in 2015
7 Fellowship/residency programs
16 Number of surgical faculty
Giving Aria’s Family a Choice

It wasn't the pizza and the Christmas cookies she had eaten, but 9-year-old Aria had thought so when she began feeling sharp pain her abdomen. That evening, the pain became so severe that she couldn't walk.

Her parents carried her to the car and took her to the hospital.

An ultrasound revealed she had appendicitis. Because Aria's appendix swelled but had not burst, doctors at Nationwide Children's offered an alternative to removing her appendix in surgery: she could participate in an ongoing study using antibiotics to treat mild appendicitis for patients who have experienced abdominal pain 48 hours or less. After receiving the antibiotics, if Aria's appendix remained infected, her family could then have her appendix removed through surgery.

“I felt like it was a risk-free option for us,” says Aria's mother, Aubrey. “I thought: Let's try this and of course if it doesn’t work, we'll be right here to do what we need to do.”

With surgery, Aria would have to be hospitalized one to two days, then restricted from strenuous exercise for about a month. She would have to undergo anesthesia, and as with any surgery, there is the risk of complications.

A couple of other considerations influenced the family's choice to try antibiotics: In four days, Aria was to perform the lead role in a play, and weeks later, the family planned to travel to Disney World.

Aria received intravenous antibiotics in the hospital one day. When she returned home, she began taking an oral antibiotic daily for nine more days. Within a couple of days after of leaving the hospital, she danced and sang on stage for her school's Christmas play, and the family flew to Disney World later that month.

That was four years ago. Today, Aria has not had a recurrence of appendicitis and she still has her appendix.

Shared Decision Making and a New Paradigm for Appendicitis Care

At Nationwide Children's, we believe that parents, patients and physicians should make treatment decisions together whenever possible. We also believe in challenging the status quo and looking for better solutions.

A landmark study led by Peter C. Minneci, MD, and Katherine J. Deans, MD, principal investigators in the Center for Innovation in Pediatric Practice and co-directors of the Center for Surgical Outcomes Research, highlights our commitment to both.

First, Drs. Minneci and Deans developed a study to challenge the conventional practice of always treating appendicitis with antibiotics followed by surgery.

“We noticed that after being on antibiotics overnight, many children with acute appendicitis were feeling better by the time they could be taken in to surgery,” explains Dr. Minneci. “Parents began to question whether or not these kids really needed surgery, so we decided to find the answer.”

The answer they found is compelling. In the study, of the families who chose to be treated with antibiotics alone, three out of four patients managed nonoperatively did not have appendicitis again and have not undergone surgery one year after discharge.

Second, the study involved an unprecedented level of shared decision making.

For shared decision making, both the clinician and family must be comfortable with the level of certainty, and the process varies with each family, explains Dr. Minneci. In Aria's case, the family saw the benefits to treating her appendicitis with antibiotics, and they were confident in knowing that surgery was still an option if needed later on.

Drs. Minneci and Deans are now expanding this research. They have an ongoing study investigating shared decision making in pediatric appendicitis that is supported by a $1.6 million Patient-Centered Outcomes Research Institute (PCORI) award. In addition, they are beginning a multi-center study upon receiving a new $2.9 million award from PCORI. The expanded study will measure the amount of time missed from everyday activities, quality of life after treatment, satisfaction with care, burden on the caregiver and the success of nonoperative management at one year.

As for Aria's family, they are happy to have had a choice in her care.

“I think it's an amazing advance,” says Aubrey. “She didn’t have to go under anesthesia. They didn’t have to cut her. We just didn’t have to worry about that.”

Regenerative Medicine: Tissue Engineering

Translational research applies discoveries from bench science to the bedside. And applies what is learned at the bedside back to the bench.

At Nationwide Children’s, we’ve been doing just that.

“We are going full circle to advance the science, which ultimately advances the patient care by leaps and bounds,” says Christopher Breuer, MD, pediatric surgeon and co-director of the Tissue Engineering Program at Nationwide Children’s. “We understand that the process of discovery, clinical implementation and success is a two-way street. Our definitions of success are refined by our discoveries, which in turn change clinical implementation.”

The first decade of Dr. Breuer's research in tissue engineering was largely empiric.

“We built a scaffold and a product, and it worked,” he says. “It had growth capacity, which is very good for application in pediatrics.”

When they moved to the clinic, Dr. Breuer and colleague Toshiharu Shinoka, MD, PhD, co-director of the Tissue Engineering Program, saw narrowing and stenosis as a complication in some patients, but they could not identify why or predict who would develop stenosis.

“We took a step back to the bench to do basic science research,” says Dr. Breuer. “We’ve spent the last 10 years discovering and learning the cellular and molecular mechanisms of stenosis.”

And that research has been prolific. Breuer's lab has published 18 journal articles in 2015 alone. Among their discoveries, possible interventions to prevent stenosis have emerged.

One such intervention, the inhibition of TGF-β receptor 1 (TGF-βR1), was published in May 2016 in FASEB Journal. Previously Breuer and his team demonstrated that host monocyte infiltration and activation within the graft drives stenosis. Additionally, TGF-β receptor 1 inhibition can prevent stenosis in the context of tissue-engineered vascular grafts. Now, he suggests the TGF-β signaling pathway contributes to stenosis by inducing classic activation of host monocytes. Furthermore, blocking monocyte activation by TGF-βR1 inhibition provides a viable strategy for preventing stenosis while maintaining the formation of tissue regeneration in the graft.

The team’s next step will be to bring this and other learnings to the clinic in a clinical trial.

“Currently, we have vascular graft implants in three patients. We’ve used what we’ve learned with those patients to inform the bench work. Now we’re ready to bring some interventions for stenosis back to the bedside,” says Dr. Breuer.

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