Neonatal Surgical Centre Research Articles

Abdominal Ultrasound Scanning for NEC in Babies at the Threshold of Viability: A Single Centre Experience

AimNeonatal units are caring for increasing numbers of babies born <24 weeks gestation. These babies are vulnerable to developing necrotising enterocolitis (NEC). Their presentation is often atypical, both clinically and radiologically. Optimal diagnostic strategies are not yet known. We report our experience of abdominal ultrasound scanning (AUSS) to clarify its role. MethodsAll babies in a single neonatal surgical centre born <24 weeks gestation undergoing AUSS for suspected NEC from January 2015 to January 2023 were included. We compared abdominal ultrasound findings with plain radiographs and correlated these to intraoperative findings. ResultsThirty-nine babies born <24 weeks gestation were diagnosed with NEC during the study period, and of these seventeen had an AUSS and formed the study cohort. Twelve underwent laparotomy at which NEC was confirmed, and the remaining five were managed non-operatively.Abdominal radiograph findings were: Paucity of gas (12), gaseous dilatation (2), paucity of gas with proximal dilatation (1), pneumatosis (1), and lucencies over the liver (1). In twelve cases who underwent surgery, AUSS findings were (more than one possible): Complex ascites (6), inflamed bowel (4), aperistaltic bowel (3), mass/collection (4), pneumatosis (1). All had NEC confirmed at laparotomy. In five cases who did not progress to surgery, findings were: Simple free fluid (2), pneumatosis (2), inflamed bowel (1), aperistaltic bowel (1). None of these cases subsequently underwent surgery or died of complications of NEC. ConclusionAUSS is a useful imaging modality for NEC in babies born <24 weeks gestation. It can reliably identify babies who would benefit from surgery. Level of Evidence4. Type of StudyRetrospective cohort study.

Exploring Growth Failure in Neonates With Enterostomy

Aim of the studyNeonatal enterostomy is a known risk for growth failure. We hypothesized that episodes of inflammation may drive a catabolic state, exploring this by assessing serum biochemistry alongside growth trajectory in enterostomy patients. MethodsA retrospective analysis of infants with histologically confirmed NEC from 01/2012–07/2021 in a tertiary neonatal surgical centre was performed. Change in weight-for-age Z-score (ΔZ) between stoma formation and closure was calculated. Serum CRP (C-reactive protein), urea, and creatinine levels were recorded and duration of elevated levels calculated as Area Under Curve (AUC). We examined for trends of serum levels rising together using intersecting moving averages. Spearman's correlation analysis was performed, while multivariable linear regression examined factors associated with ΔZ. Results79 neonates were included. At stoma formation, median Z-score was −1.42 [range −4.73, +1.3]. Sixty-two patients (78 %) had a fall in Z-score during their time with a stoma, 16 (20 %) had a ΔZ less than −2. Urea AUC was significantly univariably correlated with ΔZ and remained statistically significant in a multivariable model (Exp(B) x 100 = −0.57[−1, −0.09]; p = 0.022). The number of biomarker peaks correlated significantly with ΔZ for urea (r = −0.25; p = 0.025) and CRP (r = −0.35; p = 0.0017) but not Creatinine (r = −0.21; p = 0.066). Analysing the number of peaks of any combination of variables coinciding was consistently significantly correlated negatively with ΔZ (r = −0.29 to −0.27; p ≤ 0.016 for all). ConclusionOur data shows that infants who were more severely affected by growth failure had more frequent and severe uremia while they had a stoma (suggesting a catabolic state). Disturbances in urea were commonly associated with CRP, suggesting that inflammation is a significant factor in growth failure in these infants. These findings promote aggressive management of sepsis in these infants, as well as suggesting an earlier closure of stoma to minimise their “at-risk”’ period.

Developing a method to capture parental experience in a neonatal surgical centre in the context of COVID-19: a qualitative study

IntroductionImproved parental experience is related to improved mental and physical health outcomes for the infant. The COVID-19 pandemic abruptly impacted on healthcare delivery and services need information to shape how...

Prevalence of Acute Kidney Injury in Neonates with Congenital Diaphragmatic Hernia

Background: Congenital diaphragmatic hernia (CDH) often presents with severe cardio-respiratory impairment in the neonatal period. Affected infants may be exposed to multiple nephrotoxic insults, predisposing them to acute kidney injury (AKI). The prevalence of AKI in a CDH cohort has not previously been described. Objectives: The primary aim of this study was to quantify the prevalence of AKI in patients with CDH treated in a single national centre. Secondarily, we investigated the association between AKI, select neonatal outcomes, and recognised AKI risk factors. Methods: This was a retrospective analysis of all patients with CDH treated at our regional neonatal surgical centre between September 2011 and December 2017. Data was collected on demographics, CDH Study Group stage (size), laboratory and physiological parameters, medications, mortality, and duration of hospitalisation. AKI severity was stratified using the modified paediatric RIFLE criteria, determined by comparing the percentage increase in serum creatinine from baseline. Statistical analysis was performed using Fisher’s exact and Pearson’s χ² tests for parametric analysis and Mann-Whitney U testing for non-parametric analysis. Results: Fifty-four CDH patients met the inclusion criteria, 37% of whom developed AKI. The development of AKI was significantly associated with larger CDH defect (type C/D; p = 0.014), extracorporeal membranous oxygenation support (p = 0.003), patch repair (p = 0.004), and exposure to vancomycin, corticosteroids and diuretics (p = 0.004, p = 0.007, and p ≤ 0.001, respectively). There was no statistical association between AKI and gentamicin administration, umbilical arterial catheter insertion, or significant infection. Prolonged hospitalisation and patient mortality were significantly associated with AKI (p = 0.01 and p = 0.001, respectively). Conclusions: AKI is common in CDH cases treated in our centre and is associated with adverse outcomes. Potentially modifiable risk factors include nephrotoxic medication exposure. Prevention and early recognition of contributory factors for AKI may improve outcomes in CDH.

Epidemiology and risk factors for gastroschisis – a 20‐year experience in a regional neonatal surgical centre

Epidemiology and risk factors for gastroschisis – a 20‐year experience in a regional neonatal surgical centre

Tidal Volume Delivery during the Anesthetic Management of Neonates Is Variable

To describe expiratory tidal volume (VT) during routine anesthetic management of neonates at a single tertiary neonatal surgical center, as well as the proportion of VT values within the range of 4.0-8.0 mL/kg. A total of 26 neonates needing surgery under general anesthesia were studied, of whom 18 were intubated postoperatively. VT was measured continuously during normal clinical care using a dedicated neonatal respiratory function monitor (RFM), with clinicians blinded to values. VT, pressure, and cardiorespiratory variables were recorded regularly while intubated intraoperatively, during postoperative transport, and for 15 minutes after returning to the neonatal intensive care unit (NICU). In addition, paired VT values from the anesthetic machine were documented intraoperatively. A total of 2597 VT measures were recorded from 26 neonates. Intraoperative and postoperative transport expiratory VT values were highly variable compared with the NICU VT (P < .0001, Kruskal-Wallis test), with 51% of inflations outside the 4.0-8.0 mL/kg range (35% and 38% of VT >8.0 mL/kg, respectively), compared with 29% in the NICU (P < .001, χ2 test). The use of a flow-inflating bag resulted in a median (range) VT of 8.5 mL/kg (range, 5.3-11.4 mL/kg) vs 5.6 ml/kg (range, 4.3-7.9 mL/kg) using a Neopuff T-piece system (P < .0001, Mann-Whitney U test). The mean anesthetic machine expiratory VT was 3.2 mL/kg (95% CI, -4.5 to 10.8 mL/kg) above RFM. VT is highly variable during the anesthetic care of neonates, and potentially injurious VT is frequently delivered; thus, we suggest close VT monitoring using a dedicated neonatal RFM.

The burden of excluding malrotation in term neonates with bile stained vomiting.

To determine the number of term infants with bilious vomiting (BV) referred to a neonatal surgical centre for exclusion of malrotation by upper gastrointestinal contrast (UGI) examination. Retrospective review of term (>37/40) neonates <28 days of age undergoing UGI for exclusion of malrotation between Jan 2010 and Dec 2014 in a neonatal network with 30,000 term deliveries annually. Only infants with BV in the absence of alternative clinical/radiological diagnosis were included. One hundred and sixty-six infants met the inclusion criteria. Fourteen (9 %) infants had malrotation diagnosed by UGI and confirmed at laparotomy. Only 1 of 110 infants referred at 0-2 days of age had positive UGI compared to 13 of 56 infants referred after this age (p < 0.01). An increase in referrals followed the death of an infant from midgut volvulus and as a result one in 500 term infants are currently being referred. Increasing awareness of the potential consequences of bilious vomiting appears to have resulted in increased referrals with no increase in detection of malrotation. Prospective studies are required to determine whether investigation of all infants with unexplained bilious vomiting is required and if it is possible to select cases for surgical referral.

PS-296 Hirschsprung’s Disease Presenting In The Neonatal Period: A Regional Centre Experience

Background Hirschsprung Disease (HD) is characterised by the absence of ganglion cells in the distal bowel commonly presents in neonatal period with a suggestive history. However a rectal biopsy (RB) is required to confirm the diagnosis. The reported incidence in the UK is 1:5000. Aim To describe the clinical characteristics of neonates with HD presenting to a regional neonatal surgical centre. Methods Retrospective review of clinical records over a 2 year period (2012–2013). Results 15/51 infants evaluated had a positive rectal biopsy (RB) 4 infants were inborn (Inborn Incidence 1/3000), 11 were referred from 7 other London hospitals. Initial presenting complaint in the HD (non HD) groups was: Abdominal distention 93% (95%) Delayed passage of meconium 78.5%,(69.5%) Bilious vomiting 57% (82%), Poor feeding 7% (35%). Gestation age (mean,(range)) was 39 (37–41). Infants were referred on d 3 (1–10) RB was performed on day 9 (2–37), 85% were initially managed with rectal washouts and discharged home. 2 infants required an operation in the neonatal period. The remainder underwent surgical procedure on day 159(61–521). Conclusion HD needs to be considered and a RB performed in infants with consistent history and examination Especially abdominal distention or history of delayed passage of meconium. The incidence of HD may be higher in some populations and this should be evaluated further.

Serial hemodynamic assessment using Doppler echocardiography in a fetus with left ventricular aneurysm presented as fetal hydrops

A 22-week fetus presented with a large left ventricular aneurysm, 24 × 21 × 18 mm in size, detected by abnormal four-chamber view, and severe fetal hydrops with pericardial effusion, ascites and skin edema. The aneurysm was thin-walled, hypokinetic, and had enlarged with gestational age, causing compression of the lung. Although the left ventricular function had progressively impaired as expressed by increase in Tei index, hydrops had resolved by 32 weeks of gestation, probably because of maternal digoxin therapy and successful compensation by the right ventricle, as represented by retrograde blood flow in the distal aortic arch via the patent arterial duct. Because of the significant risk of severe cardiorespiratory failure, we transported the mother to a neonatal cardiac surgical center at 38 weeks of gestation. Indeed, the baby showed severe cardiopulmonary failure after birth, showing 100% of cardiothoracic ratio on the chest X-ray film, but was saved by the successful Dor procedure, including surgical resection of the aneurysm at 10 h of life. In this case, serial echocardiographic evaluation can allow us to monitor the hemodynamics and lead to successful postnatal management.

Gastroschisis: the cost of an epidemic

Background The rising incidence of gastroschisis has been highlighted by the Department of Health as a growing concern. As well as the health implications for the increasing number of affected infants, this increase in incidence will have an impact of the costs of health care. This study was undertaken to estimate the financial cost of treating this condition in one tertiary neonatal surgical center. Methods A retrospective analysis was performed of all patients admitted to a tertiary neonatal surgical center with gastroschisis from January 1996 to December 2005. The main outcome measures were incidence, length of hospital stay, and total cost for all patients each year. Results The incidence of gastroschisis has risen 3-fold in 10 years. The median cost per patient is relatively constant. A few patients with severe intestinal dysmotility require prolonged hospital stay. As the condition becomes more common, there are an increasing number of complex patients and thus an increase in annual costs, which is disproportionate to the increase in numbers of cases. We estimate that the annual cost to the National Health Service (NHS) of this condition in England and Wales has risen from £3.6 million in 1996 to in excess of £15 million in 2005. Conclusions Urgent research is required into the etiology of gastroschisis and into the severe intestinal dysmotility that occurs in some complex patients.

Neonatal Bilateral Testicular Torsion: A Plea for Emergency Exploration

Bilateral testicular torsion is a rare condition. Most authors present single case reports. Therefore, the clinical and surgical aspects of bilateral torsion in a neonate have not been subjected to detailed analysis. We performed a retrospective analysis of our experience in the management of bilateral perinatal torsion as well as a collective review of the medical literature. All cases of neonatal testicular torsion managed at our neonatal surgical center during the last 2 decades (1986 to 2005) were reviewed, and 3 cases of bilateral torsion were identified. In addition, 45 neonatal cases of bilateral torsion were found through the literature search. In all cases data regarding clinical presentation, imaging studies, surgical management, intraoperative and pathological findings, and final outcome were analyzed. Synchronous torsion occurred in 32 of 48 newborns (67%), while asynchronous pathology was reported in 16 (33%), including the 3 presented in this report. All except 1 patient were full-term newborns with normal or above average birth weight. Difficult delivery was noted in 33% of the cases. Despite prompt surgical intervention in 46 infants, the salvage rate was low, with arterial flow confirmed postoperatively in only 3 gonads (3.1%). Four gonads in 3 additional patients were reported to be of normal size on followup. Asynchronous torsion is not as rare an event as previously reported, and it may pose a diagnostic challenge. In the majority of these cases torsion of the left testis seems to occur later than torsion of the right testis. The role of imaging studies in newborns with bilateral torsion seems to be limited, especially in cases of asynchronous pathology. Urgent bilateral exploration is strongly advised in all newborns presenting with either unilateral or bilateral torsion. Such policy carries diagnostic, potential therapeutic and prognostic implications.

Effects of residential distance to hospitals with neonatal surgery care on prenatal management and outcome of pregnancies with severe fetal malformations

To examine the effect of maternal origin and distance between maternal residence and the nearest maternity ward with a neonatal surgical center in the same hospital, on prenatal diagnosis, elective termination of pregnancy, delivery in an adequate place and neonatal mortality for pregnancies with severe malformations requiring neonatal surgery, and to examine the effect of the place of delivery on neonatal mortality. This was a retrospective study, through the France Central-East malformation registry, of 706 fetuses with omphalocele (n = 123), gastroschisis (n = 99), diaphragmatic hernia (n = 222), or spina bifida (n = 262), but without chromosomal anomalies. Maternal origin was classified as Western European and non-Western European. Adequate place for delivery was defined as birth in a Level-III maternity ward with a neonatal surgical center in the same hospital. The prenatal diagnosis rate was 67.7% in 1990-1995 and 80.2% in 1996-2001 (odds ratio (OR), 2.07 (95% CI, 1.24-3.45)). On multivariate analysis, the rate was significantly lower for women living 11-50 km (adjusted OR, 0.49 (95% CI, 0.25-0.94)), or > 50 km (adjusted OR, 0.39 (0.20-0.74)) from the closest adequate place of delivery, compared with those living < 11 km from it, but there was no difference for maternal origin. Non-Western European women had fewer elective terminations of pregnancy (adjusted OR, 0.34 (95% CI, 0.14-0.81)) and fewer deliveries in an adequate place (adjusted OR, 0.40 (95% CI, 0.18-0.89)). Neonatal mortality was lower in the case of delivery in an adequate place (adjusted OR, 0.22 (95% CI, 0.07-0.72)) and was not associated with maternal origin and distance from nearest maternity ward with a neonatal surgical center. Rate of prenatal diagnosis decreases with increasing distance between parental residence and referral center. Non-Western European women are diagnosed prenatally as often as are Western Europeans, but terminate their pregnancy less often, perhaps for cultural reasons. Non-Western European women with malformed fetuses deliver in adequate centers less often, probably because of the way the perinatal care system is run.

Neonatal surgery. By P. P. Rickham, M.D., M.S., F.R.C.S., D.C.H., Senior Surgeon, Liverpool Regional Neonatal Surgical Centre, Alder Hey Children's Hospital, and J. H. Johnston, M.B., F.R.C.S., F.R.C.S.I., Urological Surgeon, Alder Hey Children's Hospital, Liverpool. 9½ × 6 in. Pp. 633 + xiv, with 341 illustrations. 1969. London: Butterworth &amp; Co. (Publishers) Ltd. £8 10s

Neonatal surgery. By P. P. Rickham, M.D., M.S., F.R.C.S., D.C.H., Senior Surgeon, Liverpool Regional Neonatal Surgical Centre, Alder Hey Children's Hospital, and J. H. Johnston, M.B., F.R.C.S., F.R.C.S.I., Urological Surgeon, Alder Hey Children's Hospital, Liverpool. 9½ × 6 in. Pp. 633 + xiv, with 341 illustrations. 1969. London: Butterworth &amp; Co. (Publishers) Ltd. £8 10s

Effect of maternal place and origin on prenatal management and neonatal mortality for pregnancies with severe malformations required neonatal surgery

NEONATAL MORTALITY FOR PREGNANCIES WITH SEVERE MALFORMATIONS REQUIRED NEONATAL SURGERY JEAN-CHARLES PASQUIER, MAGALI MORELLE, STEPHANIE MORET, ZHONG-CHENG LUO, STEPHANE BAGOUET, MURIEL RABILLOUD, ELISABETH ROBERT, Universite de Sherbrooke, Obstetrics/Gynecology, Sherbrooke, Quebec, Canada, Centre Leon Berard, Lyon, France, Hospices civils de Lyon, Lyon, France, Universite de Montreal, Montreal, Quebec, Canada, Universite deLyon, Lyon, France, Institut Europeen desGenomutations, Lyon, France, Lyon, France OBJECTIVE: To examine the effect of maternal origin and distance between parental residence to the nearest maternity ward with neonatal surgical centre in the same hospital, on the prenatal diagnosis, elective termination of pregnancy, delivery in adequate place and neonatal mortality for pregnancies with severe malformations requiring neonatal surgery, and to investigate the impact of place of delivery on neonatal mortality. STUDY DESIGN: Through the France Central-East Malformation Registry, 706 fetuses with omphalocele (n=123), gastroschisis (n=99), diaphragmatic hernia (n=222), or spina bifida (n=262), excluding chromosomal anomalies, were included in the study. Maternal origin was classified as European or nonEuropean. Adequate place for delivery was defined as birth in a level-3 maternity ward with a neonatal surgical centre. Data were analyzed by univariate and multivariable logistic regression analysis. RESULTS: The prenatal diagnosis rate was 67.7% in 1990-1995, 80.2% in 1996-2001 (OR 2.07, 95%CI 1.24-3.45). With multivariate analysis, the rate was significantly lower for women living 11-50 km (adjOR 0.49, 95%IC:0.250.94) orO50 km (adjOR 0.39, 95%IC 0.20-0.74) to the closest adequate site of delivery, but no differences was observed for maternal origin. Non-European women had fewer elective terminations of pregnancy (adjOR 0.34 95%IC:0.140.81) and fewer deliveries in adequate sites [adjOR 0.40 (0.18-0.89)]. Neonatal mortality was lower in case of delivery in an adequate site (adjOR 0.31 95%IC:0.13-0.7) and was not associated with maternal origin and distance. CONCLUSION: The rate of prenatal diagnosis decreases with increasing distance between parental residence and reference centre. Non-European women have prenatal diagnosis as often as European, but terminate their pregnancy less often, perhaps for cultural reasons. Non-European women with malformed babies deliver less often in adequate centres, probably because of difficulties in the perinatal care system. Minority ethnic groups should be studied to understand and improve pregnancy outcomes.

Congenital Diaphragmatic Hernia in the Newborn

A ten year review (1980-1989) of 59 neonates presenting with congenital diaphragmatic hernia (CDH) to Our Lady's Hospital for Sick Children, the main referral centre for neonatal surgery in Ireland, is presented to determine the outcome and make suggestions for improvements. CDH was more common in males (34M, 25F). The hernia was present on the left side in 47 cases and 11 cases were right sided. Overall mortality was 35.6%, with increased mortality for right-sided hernia (54.5%). Mean gestation period for survivors was 39 weeks and for non-survivors was 36 weeks. Fifty-two (88.1%) patients presented with symptoms within first six hours after birth. Nineteen of 59 patients (32%) did not have their airways secured with an endotracheal tube at the time of arrival in the hospital. Recurrent chest infections and gastro-oesophageal reflux were the most common long term complications. The prognosis was better for late presenters. A period of prolonged ventilatory stabilisation with appropriate inotropic support to help correct acidosis before surgery improved results. Surgery should be postponed until ventilatory stabilisation is established. A protocol for safe transport of patients to the referral centre is recommended. It is advisable that all patients with congenital diaphragmatic hernia be intubated as soon as the diagnosis is made and that a doctor accustomed to airway management accompanies the patient to the neonatal surgical centre.

Diagnosis, transport, and outcome in fetuses with left ventricular outflow tract obstruction

Between March 1986 and April 1990, 22 consecutive fetuses (at gestational ages of 21 to 38 weeks) with a suspected diagnosis of critical (ductus-dependent) left ventricular outflow tract obstruction on fetal echocardiogram were referred to our center for delivery and surgical treatment. Diagnoses were hypoplastic left heart syndrome (n = 16), valvular aortic stenosis (n = 2), common atrioventricular canal with subaortic stenosis (n = 3), and single ventricle with subaortic stenosis (n = 1). Postnatal echocardiography revealed that fetal echocardiography was correct in predicting left ventricular outflow tract obstruction to be critical in all but one patient, for a positive predictive value of 96%. Of the 21 patients with true, critical left ventricular outflow tract obstruction, 17 patients underwent cardiac surgery as neonates (birth to 6 days of age, median 2 days); 13 (or 77%) survived and were discharged from the hospital. In addition, one patient underwent successful balloon aortic valvotomy for critical valvular aortic stenosis but later died of sepsis. Lethal chromosomal and congenital abnormalities should be sought and are contraindications for this approach. In utero transport of fetuses with suspected critical left ventricular outflow tract obstruction to a neonatal cardiac surgical center can result in improved neonatal condition and may improve overall survival.

Anterior abdominal wall defects.

A total of 48 infants with abdominal wall defects referred to the South West Regional Neonatal Surgical Centre over a period of six years were reviewed. There were 27 (56%) infants with gastroschisis and 21 (44%) infants with exomphalos. At the regional centre, four pregnancies with gastroschisis were terminated following a prenatal diagnosis, one child was stillborn, and one with exomphalos and trisomy 13 died soon after birth. Of the remaining 42 live births, the one year survival for babies born with a gastroschisis was 95% (21/22) and with an exomphalos was 81% (17/20). All deaths, except one, were due to factors other than the abdominal defect. The effect on outcome of prenatal diagnosis, parental counselling, in utero transfer, mode of delivery, and methods of surgical closure was reviewed.

Neonatal Surgery

Peter Rickham was one of the first to recognize the advantages of centralized care for newborn infants with birth defects. A founder of the Liverpool Neonatal Surgical Center, he is currently surgeon in chief at the Zurich, Switzerland, Children's Hospital. The second edition of<i>Neonatal Surgery</i>summarizes his experiences as well as those of a number of other surgeons who work in these two centers. The nursing care, physiology, and general principles of surgical management of newborn infants are well discussed. The text is organized by regional anatomy, ie, the head and neck, chest and abdomen, rather than along "problem-oriented" lines, which seems to be a more effective teaching method. Each birth defect is discussed with reference to historical aspects, embryology, pathology, diagnosis, treatment, and results. The text is well illustrated with photographs and x-ray films, but line drawings illustrating operative technique are sparse and poorly done. In fact, there

Milk-Curd Bowel Obstruction in the Newborn Infant

IN 1969, Cook and Rickham1first reported a syndrome of neonatal intestinal obstruction due to inspissated milk curds. This new entity had not been seen before in more than 600 cases of bowel obstruction in newborn infants admitted to the Liverpool Neonatal Surgical Center and had not been previously described in the literature. They found that the obstruction occurred primarily in premature infants in whom high-caloric feedings were begun shortly after birth. In all eight cases, the babies were well at birth, passed normal meconium stools, and began receiving feedings of either reconstituted powdered milk or diluted milk-concentrate. Altered stools and then milk stools were passed until low small-bowel obstruction suddenly developed at ages 5 to 14 days. Studies indicated that milk-curd obstruction resulted from a combination of early feeding of high-caloric milk and the decreased ability of the infant to absorb proteins and amino acids. Of interest was

A state-wide survey of index pediatric surgical conditions

A statewide survey of pediatric surgery was sponsored by the Connecticut Society of American Board Surgeons to determine the general surgeons attitudes about performing routine and complex pediatric surgery, the absolute volume of index pediatric surgical conditions in the state, and the proportion treated by pediatric and nonpediatric surgeons. The incidence of index conditions studied was very similar to those previously reported. Approximately one half of all index cases were treated by nonpediatric surgeons, indicating that the number of pediatric surgeons could be increased, and possibly doubled, if all index procedures were performed by pediatric surgeons. Two-thirds of responding surgeons recognized the need for a regional neonatal surgical center. Regional or statewise surveys of index surgical conditions are recommended to determine regional manpower needs.