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Maspero M, Hull TL. State of the Art: Pouch Surgery in the 21st Century. Dis Colon Rectum 2024; 67:S1-S10. [PMID: 38441240 DOI: 10.1097/dcr.0000000000003326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
BACKGROUND An ileoanal pouch with IPAA is the preferred method to restore intestinal continuity in patients who require a total proctocolectomy. Pouch surgery has evolved during the past decades thanks to increased experience and research, changes in the medical management of patients who require an ileal pouch, and technological innovations. OBJECTIVE To review the main changes in pouch surgery over the past 2 decades, with a focus on staging, minimally invasive and transanal approaches, pouch design, and anastomotic configuration. RESULTS The decision on the staging approach depends on the patient's conditions, their indication for surgery, and the risk of anastomotic leak. A minimally invasive approach should be performed whenever feasible, but open surgery still has a role in this technically demanding operation. Transanal IPAA may be performed in experienced centers and may reduce conversion to open surgery in the hostile pelvis. The J-pouch is the easiest, fastest, and most commonly performed design, but other designs may be used when a J-pouch is not feasible. A stapled anastomosis without mucosectomy can be safely performed in the majority of cases, with a low incidence of rectal cuff neoplasia and better functional outcomes than handsewn. Finally, Crohn's disease is not an absolute contraindication to an ileoanal pouch, but pouch failure may be higher compared to other indications. CONCLUSIONS Many technical nuances contribute to the success of an ileoanal pouch. The current standard of care is a laparoscopic J-pouch with double-stapled anastomosis, but this should not be seen as a dogma, and the optimal approach and design should be tailored to each patient. See video from symposium.
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Affiliation(s)
- Marianna Maspero
- Department of Colon and Rectal Surgery, Cleveland Clinic, Cleveland, Ohio
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Greene AC, Mankarious MM, Finkelstein A, El-Mallah JC, Kulaylat AS, Kulaylat AN. Increasing Adoption of Laparoscopy in Urgent and Emergent Colectomies for Pediatric Ulcerative Colitis. J Surg Res 2024; 295:399-406. [PMID: 38070253 DOI: 10.1016/j.jss.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/21/2023] [Accepted: 11/08/2023] [Indexed: 02/25/2024]
Abstract
INTRODUCTION While minimally invasive surgery (MIS) approaches are commonly utilized in the elective surgical setting for pediatric ulcerative colitis (UC), their role in urgent and emergent disease is less clear. We aim to assess trends in the surgical approaches for pediatric UC patients requiring urgent and emergent colectomies and their associated outcomes. METHODS Retrospective review of 81 pediatric UC patients identified in National Surgical Quality Improvement Program Pediatric who underwent urgent or emergent colectomy (2012-2019). Trends in approach were assessed using linear regression. Patient characteristics and clinical outcomes were stratified by approach and compared using standard univariate statistics. Multivariable analysis was used to model the influence of covariates on postoperative length of stay. RESULTS The proportion of MIS cases increased by 5.53% per year (P = 0.01) over the study interval. Sixty-three patients (77.8%) received MIS resections and 18 patients (22.2%) received open resections. Patients undergoing open colectomies were younger and had a higher proportion of preoperative conditions, most notably preoperative sepsis (27.8% versus 4.8%, P = 0.01), and higher American Society of Anesthesiologists [III-IV] classification (83.3% versus 58.8%, P = 0.004). Mean operative time was comparable (open, 173.6 versus MIS, 206.1 min). In the univariate analysis, open approach was associated with increased postoperative length of stay (13.1 versus 7.2 d, P = 0.002). However, after adjusting for confounders, there was no significant difference. CONCLUSIONS There has been a steady increase in the adoption of laparoscopy in urgent and emergent colectomy for pediatric UC. Short-term outcomes between approaches appear comparable.
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Affiliation(s)
- Alicia C Greene
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Marc M Mankarious
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Adam Finkelstein
- The Pennsylvania State University College of Medicine, Hershey, Pennsylvania
| | - Jessica C El-Mallah
- Department of Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Audrey S Kulaylat
- Division of Colon and Rectal Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Afif N Kulaylat
- Division of Pediatric Surgery, Penn State Children's Hospital, Hershey, Pennsylvania.
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Ostertag-Hill CA, Nandivada P, Thaker H, Estrada CR, Dickie BH. Robotic-assisted laparoscopic Malone appendicostomy: a 6-year perspective. Pediatr Surg Int 2024; 40:58. [PMID: 38400936 DOI: 10.1007/s00383-024-05641-z] [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] [Accepted: 01/28/2024] [Indexed: 02/26/2024]
Abstract
PURPOSE A robotic-assisted laparoscopic approach to appendicostomy offers the benefits of a minimally invasive approach to patients who would typically necessitate an open procedure, those with a larger body habitus, and those requiring combined complex colorectal and urologic reconstructive procedures. We present our experience performing robotic-assisted appendicostomies with a focus on patient selection, perioperative factors, and functional outcomes. METHODS A retrospective review of patients who underwent a robotic-assisted appendicostomy/neoappendicostomy at our institution was performed. RESULTS Twelve patients underwent robotic-assisted appendicostomy (n = 8) and neoappendicostomy (n = 4) at a range of 8.8-25.8 years. Five patients had a weight percentile > 50% for their age. Seven patients underwent combined procedures. Median operative time for appendicostomy/neoappendicostomy only was 185.0 min. Complications included surgical site infection (n = 3), stricture requiring minor operative revision (n = 2), conversion to an open procedure due to inadequate appendiceal length (prior to developing our technique for robotic neoappendicostomies; n = 1), and granuloma (n = 1). At a median follow-up of 10.8 months (range 1.7-74.3 months), 91.7% of patients were consistently clean with antegrade enemas. DISCUSSION Robotic-assisted laparoscopic appendicostomy and neoappendicostomy with cecal flap is a safe and effective operative approach. A robotic approach can potentially overcome the technical difficulties encountered in obese patients and can aid in patients requiring both a Malone and a Mitrofanoff in a single, combined minimally invasive procedure.
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Affiliation(s)
- Claire A Ostertag-Hill
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, USA
| | - Prathima Nandivada
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, USA
| | - Hatim Thaker
- Department of Urology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Carlos R Estrada
- Department of Urology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Belinda H Dickie
- Department of Surgery, Boston Children's Hospital, 300 Longwood Avenue, Fegan 3, Boston, MA, 02115, USA.
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Gupta P, Palosaari A, Quan T, Ifarraguerri AM, Tabaie S. Evaluating the association between race and complications following pediatric upper extremity surgery. J Pediatr Orthop B 2023; 32:553-556. [PMID: 36912085 DOI: 10.1097/bpb.0000000000001073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
Race can influence perioperative care and outcomes in adult and pediatric orthopedic surgery. However, no prior study has evaluated any associations between race and complications following upper extremity surgery in pediatric patients. Thus, the purpose of this study was to evaluate whether there are any differences in risks for complications, readmission, or mortality following upper extremity surgery between African American and Caucasian pediatric patients. Pediatric patients who had a primary upper extremity procedure from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were categorized into two cohorts: patients who were Caucasian and patients who were African American. Differences in demographics, comorbidities, and postoperative complications were assessed and compared between the two-patient population using bivariate and multivariable regression analyses. Of the 25 848 pediatric patients who underwent upper extremity surgeries, 21 693 (83.9%) were Caucasian, and 4155 (16.1%) were African American. Compared to Caucasian patients, African American patients were more likely to have a higher American Society of Anesthesiologists classification ( P < 0.001), as well as pulmonary comorbidities ( P < 0.001) and hematologic disorders ( P = 0.004). Following adjustment on multivariable regression analysis to control for baseline characteristics, there were no differences in any postoperative complications between Caucasian and African American patients. In conclusion, African American pediatric patients are not at an increased risk for postoperative complications compared to Caucasian patients following upper extremity surgery. Race should not be used independently when evaluating patient risk for postoperative complications. Level of Evidence: III.
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Affiliation(s)
- Puneet Gupta
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Quan T, Pizzarro J, Mcdaniel L, Manzi JE, Agarwal AR, Chen FR, Tabaie S. Is seizure disorder a risk factor for complications following surgical treatment of hip dysplasia in the pediatric population? J Pediatr Orthop B 2023; 32:318-323. [PMID: 35762671 DOI: 10.1097/bpb.0000000000000998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The impact of seizure disorders on pediatric patients who undergo hip dysplasia surgery has yet to be elucidated. This study focused on identifying the effect of seizure disorders on the incidence of complications following surgical management of hip dysplasia. Pediatric patients undergoing surgical treatment for hip dysplasia from 2012 to 2019 were identified in the National Surgical Quality Improvement Program-Pediatric database. Patients were divided into two cohorts: patients with and patients without a seizure disorder. Patient demographics, comorbidities and postoperative outcomes were compared between the two groups. Bivariate and multivariate analyses were performed. Of 10 853 pediatric patients who underwent hip dysplasia surgery, 8117 patients (74.8%) did not have a seizure disorder whereas 2736 (25.2%) had a seizure disorder. Bivariate analyses revealed that compared to patients without a seizure disorder, patients with a seizure disorder were at increased risk of developing surgical site infections, pneumonia, unplanned reintubation, urinary tract infection, postoperative transfusion, sepsis, extended operation time and length of stay and readmission ( P < 0.05 for all). Following adjustment for patient demographics and comorbidities on multivariate analysis, there were no differences in any postoperative complications between pediatric patients with and without a seizure disorder. There were no differences in 30-day postoperative complications in patients with and without a seizure disorder. Due to potential decreased bone mineral density as an effect of antiepileptic drugs and the risk of femur fracture during surgery for hip dysplasia, pediatric patients with a seizure disorder should be closely monitored as they may be more susceptible to injury. Level of Evidence: III.
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Affiliation(s)
- Theodore Quan
- Department of Orthopedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
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Abstract
Robotic colorectal surgery allows adult and pediatric surgeons to overcome the technical limitations of laparoscopic surgery. It also provides improved ergonomics in the field of surgery. Robotic surgery has several advantages in colorectal operations that require complex minimally invasive skills including anorectal malformations, Hirschsprung disease, and inflammatory bowel disease. In this section, we discuss the key aspects of colorectal surgery where robotic instrumentation seems ideal.
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Affiliation(s)
- Hira Ahmad
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, Washington, USA.
| | - Donald B Shaul
- Division of Pediatric Surgery, Children's Hospital Orange County, Orange, California; Voluntary Associate Professor of Surgery, University of California, Irvine, USA
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Muacevic A, Adler JR, Kraft D, Mathur A, Ramamurti P, Tabaie S. Racial Disparities in Outcomes Following Open Treatment of Pediatric Femoral Shaft Fractures. Cureus 2022; 14:e33149. [PMID: 36601175 PMCID: PMC9803589 DOI: 10.7759/cureus.33149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 01/01/2023] Open
Abstract
Introduction Femoral shaft fractures are a common pediatric injury that can require non-operative or operative management. Several studies have shown that race impacts pain management and a number of emergency department visits in the pediatric femur fracture population. This study aimed to investigate any association between pediatric patient race and number of comorbidities, 30-day postoperative outcomes, and length of stay following open surgical treatment of femoral shaft fractures. Methods Pediatric patients who underwent open treatment of femoral shaft fracture were identified in the National Surgical Quality Improvement Program-Pediatric database from 2012-2019. Patients were categorized into two cohorts: White and underrepresented minority (URM). URM groups included Black or African American, Hispanic, Native American or Alaskan, and Native Hawaiian or Pacific Islander. Demographics, comorbidities, and postoperative complications were compared using bivariate and multivariable regression analyses. Results Of the 5,284 pediatric patients who underwent open treatment of femoral shaft fracture, 3,650 (69.1%) were White, and 1,634 (30.9%) were URM. Compared to White patients, URM patients were more likely to have a higher American Society of Anesthesiologists score (p=0.012), more likely to have pulmonary comorbidities (p=0.005), require preoperative blood transfusion (p=0.006), and have an increased risk of prolonged hospital stay (OR 2.36; p=0.007). Conclusion Pediatric URM patients undergoing open treatment of femoral shaft fractures have an increased risk of extended hospital stay postoperatively compared to White patients. As the racial and ethnic constitution of the pediatric population changes, understanding racial and ethnic health disparities will be crucial to providing equitable care to all patients.
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Herman K, Nemeth S, Shen B, Church JM, Kiran RP. Laparoscopic ileal pouch-anal anastomosis reduces the risk of surgical site infections: An ACS-NSQIP study. SURGERY IN PRACTICE AND SCIENCE 2022. [DOI: 10.1016/j.sipas.2022.100114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022] Open
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Saberi RA, Gilna GP, Rodriguez C, Ramsey WA, Huerta CT, O'Neil CF, Parreco JP, Langshaw AH, Thorson CM, Sola JE, Perez EA. Does surgical approach matter in the treatment of pediatric ulcerative colitis? J Pediatr Surg 2022; 57:1104-1109. [PMID: 35216799 DOI: 10.1016/j.jpedsurg.2022.01.026] [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: 12/29/2021] [Accepted: 01/22/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study aims to compare the morbidity of open versus laparoscopic colectomy or proctocolectomy for pediatric patients with ulcerative colitis (UC) using national readmission outcomes. MATERIALS AND METHODS The 2010-2014 Nationwide Readmissions Database was used to identify patients < 18 years (excluding newborns) who underwent colectomy or proctocolectomy for UC. Patients with planned readmissions for staged procedures were excluded from readmission analysis. Demographics, hospital factors, and outcomes were compared by operative approach (open vs. laparoscopic) using standard statistical analysis. Results were weighted for national estimates. RESULTS There were 1922 patients (51% female, age 13 ± 3 years) with UC who underwent colectomy or proctocolectomy during index admission. Most cases were performed open (54%) and as elective admissions (64%). Compared to open approach, laparoscopy was associated with shorter index hospital length of stay (8 [5-17] days vs. 9 [6-18] days, p = 0.015), fewer surgical site infections (< 2% vs. 2%, p = 0.022), and less post-operative gastrointestinal dysfunction (5% vs. 8%, p = 0.008). After stratifying to control for elective and unplanned index admissions, laparoscopic approach was associated with fewer small bowel obstructions during index hospitalizations in both elective (9% vs. 15%, p = 0.003) and unplanned (5% vs. 16%, p<0.001) settings. Readmission for surgical site infection was also less common following laparoscopic approach in both elective (0% vs. 7%, p = 0.008) and unplanned (0% vs. < 7%, p = 0.017) settings. CONCLUSIONS In pediatric patients with ulcerative colitis, laparoscopic colectomy or proctocolectomy is associated with shorter hospital length of stay, less post-operative complications, and improved readmission outcomes.
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Affiliation(s)
- Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America.
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Cindy Rodriguez
- Florida State University College of Medicine, Tallahassee, Florida, United States of America
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Carlos T Huerta
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Christopher F O'Neil
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Joshua P Parreco
- Memorial Regional Hospital, Division of Trauma and Surgical Critical Care, Hollywood, Florida, United States of America
| | - Amber H Langshaw
- Division of Pediatric Gastroenterology, University of Miami Miller School of Medicine, Miami, Florida, United States of America
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, United States of America
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Evaluation of Surgical Morbidity After Hysterectomy During an Obesity Epidemic. Obstet Gynecol 2022; 139:589-596. [DOI: 10.1097/aog.0000000000004699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022]
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Temporal trends in ileoanal pouch surgery for paediatric onset ulcerative colitis in England from 1997 to 2015 using hospital episode statistics. J Pediatr Surg 2022; 57:257-260. [PMID: 34865832 DOI: 10.1016/j.jpedsurg.2021.10.027] [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: 10/13/2021] [Accepted: 10/23/2021] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Ileal pouch-anal anastomosis (IPAA) following colectomy for ulcerative colitis (UC) achieves restoration of intestinal continuity with potential return of continence. It is undertaken relatively infrequently in children. We aimed to investigate the national frequency of IPAA in paediatric UC and report outcomes useful for surgeon/centre benchmarking. METHODS Hospital Episode Statistics data were obtained for all admissions in England (1997-2015) in children (< 18 years) who underwent IPAA for UC using OPCS-4 procedural codes. Surgeon specialty, readmission, and reoperation rates were identified. Data are median (interquartile range). RESULTS UC was diagnosed in 7604 children in whom 346 (4.6%) underwent IPAA at age 15 [13-17] years. Laparoscopy was used in 55 (15.9%) cases and in the most recent 10 years more commonly by specialist paediatric surgeons (SPS) than general surgeons (GS) (34.3%vs14.7%, p = 0.001). National frequency of IPAA ranged from 12 to 34 annually. Where specialty was available, 95/342 (57%) cases were undertaken by GS and 147/342 (43%) cases by SPS. The proportion of cases undertaken by SPS increased significantly compared to GS over the study period, p = 0.0003. Post-operative length of stay was 8 [6-11] days. During the index admission, unplanned return to theatre was required in 25/346 (7.2%). Following discharge 58 (16.8%) were readmitted within 30 days. Overall return to theatre rate within 30 days of pouch surgery was 11.0% (38/346). CONCLUSION IPAA for UC within childhood is undertaken infrequently in England, with a shift towards SPS undertaking surgery. These data can be used by surgeons to benchmark outcomes. LEVEL OF EVIDENCE IV.
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Ferrantella A, Saberi RA, Willobee BA, Quiroz HJ, Langshaw AH, Pandya S, Thorson CM, Sola JE, Perez EA. Prophylactic colectomy for children with familial adenomatous polyposis: resource utilization and outcomes for open and laparoscopic surgery. Transl Gastroenterol Hepatol 2021; 6:40. [PMID: 34423161 DOI: 10.21037/tgh-20-190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 07/15/2020] [Indexed: 11/06/2022] Open
Abstract
Background Laparoscopic approach for the surgical management of familial adenomatous polyposis (FAP) has become increasingly common for pediatric patients. The purpose of this study was to compare short-term outcomes and resource utilization between open and laparoscopic surgery for prophylactic colectomy in children with FAP. Methods The Kids' Inpatient Database (2009 and 2012) was analyzed for children (age ≤20 years) with FAP that underwent prophylactic total colectomy or proctocolectomy. Patient demographics, treating hospital characteristics, hospital charges, and short-term outcomes were compared according to the surgical technique utilized (open versus laparoscopic). Results Overall, we identified 216 patients with FAP that underwent elective total colectomy, of which 95 cases were performed by open surgery and 121 were done laparoscopically. The majority of patients were treated at large, not-for-profit, urban teaching hospitals, and the median age was equal (16 years) in both groups. Complications that were more common for open procedures included accidental perforation or hemorrhage (4% vs. 0%, P=0.023), reopening of surgical site (3% vs. 0%, P=0.049), and pneumonia (3% vs. 0%, P=0.049). Simultaneous proctectomy was performed more commonly in the open cohort (91% vs. 71%, P<0.001) as well as ileostomy creation (74% vs. 49%, P<0.001). The median length of stay was similar in the open and laparoscopic groups (7 vs. 6 days, P=0.712). Median total hospital charges were also similar ($67,334 vs. $68,717, P=0.080). Conclusions A laparoscopic approach for prophylactic colectomy can be safely performed in children with FAP, and total hospital charges are equivalent compared to open surgery. However, simultaneous proctectomy was performed less often with laparoscopic surgery.
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Affiliation(s)
- Anthony Ferrantella
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rebecca A Saberi
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Brent A Willobee
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hallie J Quiroz
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Amber H Langshaw
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samir Pandya
- Division of Pediatric Surgery, Department of Surgery, UT Southwestern Medical Center, Dallas, TX, USA
| | - Chad M Thorson
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Willobee BA, Nguyen JA, Ferrantella A, Quiroz HJ, Hogan AR, Brady AC, Pandya S, Langshaw AH, Sola JE, Thorson CM, Perez EA. A retrospective comparison of outcomes for open vs. laparoscopic surgical techniques in pediatric ulcerative colitis. Transl Gastroenterol Hepatol 2021; 6:41. [PMID: 34423162 DOI: 10.21037/tgh-20-189] [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: 04/16/2020] [Accepted: 06/20/2020] [Indexed: 11/06/2022] Open
Abstract
Background Ulcerative colitis (UC) is an aggressive disease in the pediatric population and a cause of significant, lifelong morbidity. The aim of this study is to compare surgical complications in pediatric patients undergoing laparoscopic vs. open surgical treatment for UC. Methods We queried the Kids' Inpatient Database (KID) for all cases of UC undergoing surgical treatment in 2009 and 2012. We identified patients who received total colectomy without proctectomy (n=413) or total proctocolectomy (n=196) and performed univariate and multivariate analyses comparing laparoscopic vs. open procedures. Results In pediatric UC patients undergoing total colectomy without proctectomy, open procedures were associated with more complications than laparoscopic, including fluid and electrolyte disorders (40% vs. 28%), surgical wound dehiscence (6% vs. 2%), septicemia (18% vs. 2%), and gastrointestinal disorders (16% vs. 7%) among others, all P<0.05. Likewise, in patients with UC undergoing total proctocolectomy, there were more complications in open vs. laparoscopic technique, including increased transfusion requirements (25% vs. 7%, P=0.001) and significantly more gastrointestinal upset, including nausea, vomiting, and diarrhea (11% vs. 1%, P=0.003). In multivariate analysis, patients who underwent total colectomy with or without proctectomy had an increased risk of experiencing any complication when their procedure was performed in an open or non-elective fashion (all odds ratio >2.4; all P<0.001). Conclusions The laparoscopic approach was associated with significantly lower rates of surgical complications in pediatric patients undergoing total colectomy with or without proctectomy for UC. These findings demonstrate that laparoscopic technique compares favorably, and may be preferable, to the open approach in selected pediatric patients with UC.
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Affiliation(s)
- Brent A Willobee
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Jennifer A Nguyen
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anthony Ferrantella
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Hallie J Quiroz
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Anthony R Hogan
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Ann-Christina Brady
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Samir Pandya
- Department of Surgery, UT Southwestern Medical Center, Dallas, TX USA
| | - Amber H Langshaw
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
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Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2020 for the Clinical Practice of Hereditary Colorectal Cancer. Int J Clin Oncol 2021; 26:1353-1419. [PMID: 34185173 PMCID: PMC8286959 DOI: 10.1007/s10147-021-01881-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 01/10/2021] [Indexed: 12/14/2022]
Abstract
Hereditary colorectal cancer (HCRC) accounts for < 5% of all colorectal cancer cases. Some of the unique characteristics commonly encountered in HCRC cases include early age of onset, synchronous/metachronous cancer occurrence, and multiple cancers in other organs. These characteristics necessitate different management approaches, including diagnosis, treatment or surveillance, from sporadic colorectal cancer management. There are two representative HCRC, named familial adenomatous polyposis and Lynch syndrome. Other than these two HCRC syndromes, related disorders have also been reported. Several guidelines for hereditary disorders have already been published worldwide. In Japan, the first guideline for HCRC was prepared by the Japanese Society for Cancer of the Colon and Rectum (JSCCR), published in 2012 and revised in 2016. This revised version of the guideline was immediately translated into English and published in 2017. Since then, several new findings and novel disease concepts related to HCRC have been discovered. The currently diagnosed HCRC rate in daily clinical practice is relatively low; however, this is predicted to increase in the era of cancer genomic medicine, with the advancement of cancer multi-gene panel testing or whole genome testing, among others. Under these circumstances, the JSCCR guidelines 2020 for HCRC were prepared by consensus among members of the JSCCR HCRC Guideline Committee, based on a careful review of the evidence retrieved from literature searches, and considering the medical health insurance system and actual clinical practice settings in Japan. Herein, we present the English version of the JSCCR guidelines 2020 for HCRC.
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Initial experience with transanal proctectomy in children. J Pediatr Surg 2021; 56:821-824. [PMID: 33358416 DOI: 10.1016/j.jpedsurg.2020.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 12/04/2020] [Accepted: 12/08/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND The use of transanal proctectomy may have particular advantages for pediatric patients with small pelvic working space. We report short-term outcomes of transanal completion proctectomy (taCP) during surgery for inflammatory bowel disease. METHODS All patients (age≤19) underwent taCP from January 1, 2018 to December 31, 2019. Prior total abdominal colectomy (TAC) was performed using a single-incision technique. At operation, patients underwent single-incision laparoscopy with taCP. Patient demographics, pre and perioperative details, and postoperative complications were abstracted. RESULTS Seven patients (n = 6) with a median age of 18 years [Range: 13-19] were included in this initial series. All patients had a prior TAC with end-ileostomy with taCP occurring a median of 6 [Range: 3-89] months after TAC. Six of 7 had a diagnosis of ulcerative colitis (UC) while 1 patient had Crohn's colitis. For patients with UC, taCP was part of an ileal pouch-anal anastomosis with the majority (n = 4) proceeding as a modified-two stage and the remaining (n = 2) a three-stage approach. Single-incision laparoscopy through the prior ileostomy site was used in all IPAA patients. Median operative time was 226 [Range: 150-264] minutes with no conversions to more invasive technique. Median hospital length of stay (LOS) was 5 [Range: 2-8] days. In-hospital complications occurred in two patients who had watery diarrhea that prolonged LOS but resolved postdischarge. One patient was readmitted for bowel obstruction that resolved with placement of red rubber catheter at the ileostomy site. Of the 4 patients with a functioning ileal pouch, 1 patient reported 6-10 bowel movements per day, while 3 others reported ≤5 bowel movements per day. Half (n = 2) reported 1-2 nocturnal bowel movements at their first postoperative visit. No patients reported soiling or leakage, though one patient had a single episode of incontinence. CONCLUSION In this pilot series, transanal proctectomy was effective and safe. Future work should compare traditional MIS completion proctectomy to taCP for applications in pediatric inflammatory bowel disease. TYPE OF STUDY Case series. LEVEL OF EVIDENCE IV.
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Luo WY, Holubar SD, Bordeianou L, Cosman BC, Hyke R, Lee EC, Messaris E, Saraidaridis J, Scow JS, Shaffer VO, Smith R, Steinhagen RM, Vaida F, Eisenstein S. Better characterization of operation for ulcerative colitis through the National surgical quality improvement program: A 2-year audit of NSQIP-IBD. Am J Surg 2020; 221:174-182. [PMID: 32928540 DOI: 10.1016/j.amjsurg.2020.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/04/2020] [Accepted: 05/28/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION There is little consensus of quality measurements for restorative proctocolectomy with ileal pouch-anal anastomosis(RPC-IPAA) performed for ulcerative colitis(UC). The National Surgical Quality Improvement Program(NSQIP) cannot accurately classify RPC-IPAA staged approaches. We formed an IBD-surgery registry that added IBD-specific variables to NSQIP to study these staged approaches in greater detail. METHODS We queried our validated database of IBD surgeries across 11 sites in the US from March 2017 to March 2019, containing general NSQIP and IBD-specific perioperative variables. We classified cases into delayed versus immediate pouch construction and looked for independent predictors of pouch delay and postoperative Clavien-Dindo complication severity. RESULTS 430 patients received index surgery or completed pouches. Among completed pouches, 46(28%) and 118(72%) were immediate and delayed pouches, respectively. Significant predictors for delayed pouch surgery included higher UC surgery volume(p = 0.01) and absence of colonic dysplasia(p = 0.04). Delayed pouch formation did not significantly predict complication severity. CONCLUSIONS Our data allows improved classification of complex operations. Curating disease-specific variables allows for better analysis of predictors of delayed versus immediate pouch construction and postoperative complication severity. SHORT SUMMARY We applied our previously validated novel NSIP-IBD database for classifying complex, multi-stage surgical approaches for UC to a degree that was not possible prior to our collaborative effort. From this, we describe predictive factors for delayed pouch formation in UC RPC-IPAA with the largest multicenter effort to date.
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Affiliation(s)
- William Y Luo
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - Stefan D Holubar
- Department of Colon & Rectal Surgery, Cleveland Clinic, 9500 Euclid Avenue A30, Cleveland, OH, 44195, USA.
| | - Liliana Bordeianou
- Colorectal Surgery Program, Massachusetts General Hospital, 15 Parkman Street, Boston, MA, 02114-3117, USA.
| | - Bard C Cosman
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA; Department of Surgery, Veteran Affairs San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, USA.
| | - Roxanne Hyke
- Stanford Health Care, 500 Pasteur Dr, Palo Alto, CA, 94304, USA.
| | - Edward C Lee
- Division of General Surgery, Albany Medical Center, 50 New Scotland Avenue MC-193, 5th Floor, Albany, NY, 12208, USA.
| | - Evangelos Messaris
- Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Shapiro Building, 3rd Floor, Boston, MA, 02215-5400, USA.
| | - Julia Saraidaridis
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, 41 Mall Road Burlington, MA, 01805, USA.
| | - Jeffrey S Scow
- Department of Surgery, Penn State Health, 200 Campus Dr, Suite 3100
- Entrance 4, Hershey, PA, 17033, USA.
| | - Virginia O Shaffer
- Department of Surgery, Emory University School of Medicine, Room B206, 1364 Clifton Road, NE, Atlanta, GA, 30322, USA.
| | - Radhika Smith
- Department of Surgery, Washington University School of Medicine in St. Louis, 5201 Midamerica Plaza, St. Louis, MO, 63141, USA.
| | - Randolph M Steinhagen
- Department of Surgery, The Mount Sinai Hospital, 5 East 98th Street, 14th Floor, Suite D, Box 1259, New York, NY, 10029, USA.
| | - Florin Vaida
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
| | - Samuel Eisenstein
- University of California, San Diego School of Medicine, 9500 Gilman Drive, La Jolla, CA, 92093, USA.
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Abstract
Polyps in gastrointestinal tract are mostly benign and result from hamartomas or lymphoid hyperplasia of submucosa. They usually occur as isolated lesions in children and are referred to as juvenile polyps. Multiple polyps with inherited origin are called polyposis and can be seen as a part of the syndrome. The polyps with adenomatous histopathology have malignant potential and necessitate genetic testing and colonoscopy to define the risk of cancer. Although simple endoscopic removal is adequate in the treatment of juvenile polyps, children with familial adenomatous polyposis (FAP) need total colectomy with ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA). The timing of prophylactic colectomy and the type of surgical treatment are controversial in children. The clinical features, the assessment of cancer risk, and the alternatives of the surgical treatment of polyps are reviewed in this paper.
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Affiliation(s)
- Tutku Soyer
- Department of Paediatric Surgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
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Traynor MD, McKenna NP, Potter DD, Moir CR, Klinkner DB. The effect of diversion on readmission following ileal pouch-anal anastomosis in children. J Pediatr Surg 2020; 55:549-553. [PMID: 31818436 DOI: 10.1016/j.jpedsurg.2019.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 11/07/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Readmission rates as high as 20% have been reported after ileal pouch-anal anastomosis (IPAA) in children, with obstruction and dehydration as the most commonly listed reasons. We hypothesized that a diverting ileostomy contributes to unplanned readmission after IPAA creation. METHODS Children (age <18) who underwent IPAA creation from January 2007 to August 2018 at two affiliated institutions were reviewed. Patient demographics, operative details, and post-operative length of stay (LOS) were abstracted. Unplanned readmission within 30 days and details on patient readmission were reviewed. RESULTS Ninety-three patients (57% female) with a median age of 15 years (range: 18 months-17 years) underwent IPAA. Indications for IPAA included ulcerative colitis (n = 63; 68%), familial adenomatous polyposis (n = 24; 26%), indeterminate colitis (n = 5; 5%), and total colonic Hirschsprung's (n = 1; 1%). Sixty-one (66%) patients were diverted at the time of IPAA creation. Fourteen patients (15%) were readmitted, and reasons for readmission included bowel obstruction (n = 9; 64%), dehydration (n = 2; 14%), anastomotic leak (n = 2; 14%), and gastrointestinal (GI) bleeding (n = 1; 6%). Patients with a diverting ileostomy at the time of IPAA were more often readmittted than patients who were not diverted (21% vs 3%, p = 0.03). Further, 10 (71%) of the readmitted patients had complications attributable to their ileostomy. In patients readmitted for obstructive symptoms, six (67%) required red rubber catheter insertion for resolution, two (22%) patients required reoperation for obstructions at the level of the stoma, and one (11%) resolved with bowel rest alone. CONCLUSION Readmission following IPAA creation in children is often secondary to preventable issues related to diverting ileostomy. Surgeons should carefully consider the necessity of diversion. When it is necessary, particular attention to fascial aperture size and post-discharge initiatives to reduce dehydration may reduce readmission rates. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Michael D Traynor
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN.
| | | | - D Dean Potter
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Christopher R Moir
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN
| | - Denise B Klinkner
- Division of Pediatric Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN.
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Abstract
OBJECTIVE Few studies report the impact of depression on inflammatory bowel disease (IBD)-related hospitalizations. We evaluated the association between depression and pediatric IBD-related hospitalizations. Our primary aim was to test the hypothesis that depression is associated with hospital length of stay (LOS); our secondary goal was to evaluate if patients with depression are at higher risk for undergoing additional imaging and procedures. METHODS Data were extracted from the 2012 Kids Inpatient Database (KID), the largest nationally representative publicly available all-payer pediatric inpatient cross-sectional database in the United States. Hospitalizations for patients less than 21 years with a primary diagnosis Crohn disease (CD) or ulcerative colitis (UC) by ICD-9 code were included. Multivariable logistic regression was used to predict long LOS controlling for patient- and hospital-level variables and for potential disease confounders. RESULTS For primary IBD-related hospitalizations (N = 8222), depression was associated with prolonged LOS (odds ratio [OR] 1.50; 95% confidence interval [CI] 1.19-1.90) and total parenteral nutrition use (OR 1.54; 95% CI 1.04-2.27). Depression was not associated with increased likelihood of surgery (OR 0.97; 95% CI 0.72-1.30), endoscopy (OR 0.91; 95% CI 0.74-1.14), blood transfusion (OR 0.85; 95% CI 0.58-1.23), or abdominal imaging (OR 1.15; 95% CI 0.53-2.53). CONCLUSIONS Depression is associated with prolonged LOS in pediatric patients with IBD, even when controlling for gastrointestinal disease severity. Future research evaluating the efficacy of standardized depression screening and early intervention may be beneficial to improving inpatient outcomes in this population.
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Traynor MD, Yonkus J, Moir CR, Klinkner DB, Potter DD. Altering the Traditional Approach to Restorative Proctocolectomy After Subtotal Colectomy in Pediatric Patients. J Laparoendosc Adv Surg Tech A 2019; 29:1207-1211. [DOI: 10.1089/lap.2019.0106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | | | | | | | - D. Dean Potter
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota
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Traynor MD, McKenna NP, Habermann EB, Yonkus J, Moir CR, Potter DD, Ishitani MB, Klinkner DB. Utilization of Maneuvers to Increase Mesenteric Length Employed in Children Undergoing Ileal Pouch-Anal Anastomosis. J Laparoendosc Adv Surg Tech A 2019; 29:1285-1291. [DOI: 10.1089/lap.2019.0124] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michael D. Traynor
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Elizabeth B. Habermann
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | - D. Dean Potter
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Denise B. Klinkner
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
- Division of Pediatric Surgery, Mayo Clinic, Rochester, Minnesota
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