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Izadi S, Koo DC, Shieh HF, Chiu MZ, Demehri FR, Mohammed S, Staffa SJ, Smithers J, Zendejas B. Botulinum Toxin Enhanced Foker Process for Long Gap Esophageal Atresia. J Pediatr Surg 2024:S0022-3468(24)00424-X. [PMID: 39097496 DOI: 10.1016/j.jpedsurg.2024.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Revised: 06/30/2024] [Accepted: 07/11/2024] [Indexed: 08/05/2024]
Abstract
BACKGROUND The traction-induced esophageal growth (Foker) process for the treatment of long gap esophageal atresia (LGEA) relies on applying progressive tension to the esophagus to induce growth. Due to its anti-fibrotic and muscle-relaxing properties, we hypothesize that Botulinum Toxin A (BTX) can enhance traction-induced esophageal growth. METHODS A retrospective two-center cohort study was conducted on children who underwent a BTX-enhanced Foker process for LGEA repair from 2021 to 2023. BTX (10 units/ml, 2 units/kg, per esophageal pouch) was applied at the time of traction initiation. Time on traction, complications, and anastomotic outcomes were compared against historical controls (Foker process without BTX) from 2014 to 2021. RESULTS Twenty infants (LGEA type A:12, B:4, C:4; 35% reoperative; median [IQR] age 3 [2-5] months), underwent BTX-enhanced Foker process (thoracotomy with external traction: 9; minimally invasive [MIS] multi-staged internal traction: 11). Mean gap lengths were similar between BTX-enhanced external and external traction control patients (mean [SD], 50.6 mm [12.6] vs. 44.5 mm [11.9], p = 0.21). When compared to controls, the BTX-enhanced external traction process was significantly faster (mean [SD], 12.1 [1.6] days vs. 16.6 [13.2] without BTX, p = 0.04) despite similar preoperative gap lengths. There was no difference in time on traction for those undergoing a minimally invasive process. There were no significant differences in complications or anastomotic outcomes in either cohort. CONCLUSION Botulinum toxin may play a role in accelerating the traction-induced esophageal growth process for LGEA repair. Minimizing time on traction can decrease sedation and paralysis burden while on external traction. Further studies are needed to elucidate the effects of BTX on the esophagus. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective, Two-center, Cohort study.
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Affiliation(s)
- Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Donna C Koo
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
| | - Megan Z Chiu
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Steven J Staffa
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St Petersburg, FL, USA
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Izadi S, Smithers J, Shieh HF, Demehri FR, Mohammed S, Hamilton TE, Zendejas B. The History and Legacy of the Foker Process for the Treatment of Long Gap Esophageal Atresia. J Pediatr Surg 2024; 59:1222-1227. [PMID: 38184432 DOI: 10.1016/j.jpedsurg.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on "traction-induced growth" when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair. Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that "one's own esophagus is best" and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond "just the esophagus", leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA.
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Affiliation(s)
- Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Thomas E Hamilton
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Zenlea IS, Melvin P, Huh SY, Mehta N, Reidy SJ, Rhodes ET, Ma NS. Risk Factors for Fractures in Children Hospitalized in Intensive and Intermediate Care Units. Hosp Pediatr 2017; 7:395-402. [PMID: 28588070 DOI: 10.1542/hpeds.2016-0213] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Fragility fractures are increasingly recognized in hospitalized children. Our study aim was to identify risk factors for fracture in children hospitalized in intensive and intermediate care units. METHODS We conducted a retrospective, case-control study comparing the clinical characteristics of children with fractures (cases) to children without fractures (controls) matched for age, sex, hospital unit, admission quarter and year, ICU length of stay, severity of illness, and resource utilization. Bivariate comparisons and matched multivariable logistic regression modeling were used to determine associations between potential risk factors and fracture. RESULTS Median age at fracture for the 35 patients was 5.0 months (interquartile range 2.0 to 10.0 months) and at a comparable interval for the 70 matched controls was 3.5 months (interquartile range 2.0 to 7.0 months). In bivariate analyses, factors associated with fracture included: primary diagnosis of tracheoesophageal fistula, esophageal atresia and stenosis; diagnosis of kidney disease; and per 5-day increase in median cumulative ICU days at risk. In the final model, a respiratory disease diagnosis (odds ratio 3.9, 95% confidence interval 1.1-13.7) and per 5-day increase in median cumulative ICU days at risk (odds ratio 1.3, 95% confidence interval 1.0-1.6) were significant independent risk factors for fracture. CONCLUSIONS Children prone to fracture in the hospital are young, medically complex patients who require extended periods of intensive level medical care and potentially life-sustaining treatment modalities. The children who would benefit most from fracture reduction efforts are those with respiratory disease and prolonged ICU stays.
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Affiliation(s)
- Ian S Zenlea
- Department of Pediatrics, and.,Division of Endocrinology
| | | | - Susanna Y Huh
- Department of Pediatrics, and.,Division of Gastroenterology, Hepatology and Nutrition
| | - Nilesh Mehta
- Division of Critical Care Medicine, and.,Department of Anesthesiology, Perioperative and Pain Medicine Harvard Medical School, Boston, Massachusetts; and
| | - Suzanne J Reidy
- Cardiovascular Program, Boston Children's Hospital, Boston, Massachusetts
| | - Erinn T Rhodes
- Department of Pediatrics, and.,Division of Endocrinology
| | - Nina S Ma
- Department of Pediatrics, and .,Division of Endocrinology
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Miranda DL, Putman M, Kandah R, Cubria M, Suarez S, Nazarian A, Snyder B. A pediatric animal model to evaluate the effects of disuse on musculoskeletal growth and development. J Biomech 2016; 49:3549-3554. [PMID: 27623705 DOI: 10.1016/j.jbiomech.2016.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 06/15/2016] [Accepted: 08/16/2016] [Indexed: 12/12/2022]
Abstract
Prolonged immobilization in hospitalized children can lead to fragility fractures and muscle contractures and atrophy. The purpose of this study was to develop a lower-extremity disuse rabbit model with musculoskeletal changes similar to those observed in children subjected to prolonged immobilization. Six-week-old rabbits were randomly assigned to control (CTRL, n=4) or bilateral sciatic and femoral neurectomy (bSFN, n=4) groups. Trans-axial helical CT scans of each rabbit׳s hind limbs were acquired after eight weeks. The rabbits were then euthanized and the tibiae and calcanea were harvested from each rabbit. μCT imaging was performed on the tibiae and calcanea mid-diaphysis. Four-point bending, gas pycnometry, and ashing were then performed on each tibia. All comparisons reflect the differences between the bSFN and CTRL rabbits. Significant decreases in tibiae bone mineral density (≥9.41%, p≤0.006), axial rigidity (≥50.47%, p≤0.02), and soft tissue mass (55.25%, p=0.006) were observed from the trans-axial helical CT scans. The μCT results indicated significant detriments in tibia and calcaneus cortical thickness and bone volume fraction (p≤0.011). Significant changes in stiffness, yield load, ultimate load, and ultimate displacement (≥30.05%, p≤0.025) were observed from mechanical testing. These data indicate that limb disuse at a time of rapid musculoskeletal growth severely impairs muscle and bone development, reflecting the musculoskeletal complications observed in children with chronic medical conditions causing immobilization. Interventions to reduce these musculoskeletal complications in children are urgently needed. This disuse rabbit model will be useful in pre-clinical studies evaluating novel interventions for improving pediatric musculoskeletal health.
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Affiliation(s)
- Daniel L Miranda
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, USA.
| | - Melissa Putman
- Division of Endocrinology, Boston Children׳s Hospital and Harvard Medical School, Boston, MA, USA
| | - Ruby Kandah
- Wyss Institute for Biologically Inspired Engineering at Harvard University, Boston, MA, USA
| | - Maria Cubria
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Sebastian Suarez
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Ara Nazarian
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Brian Snyder
- Center for Advanced Orthopaedic Studies, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Orthopedic Surgery, Boston Children׳s Hospital and Harvard Medical School, Boston, MA, USA
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Jennings R. Reply to letter to the editor. J Pediatr Surg 2015; 50:1807-8. [PMID: 26388127 DOI: 10.1016/j.jpedsurg.2015.08.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 08/30/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Russell Jennings
- Boston Children's Hospital, Fegan 304, 300 Longwood Ave, Boston, MA 02115, USA.
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