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Ramai D, Heaton J, Fang J. Safety of Percutaneous Endoscopic Jejunostomy Placement Compared With Surgical and Radiologic Jejunostomy Placement: A Nationwide Inpatient Assessment. J Clin Gastroenterol 2023:00004836-990000000-00235. [PMID: 38019077 DOI: 10.1097/mcg.0000000000001948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/27/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND AND AIMS We compared the safety and outcomes of percutaneous jejunostomy tubes placed endoscopically (PEJ), fluoroscopically by interventional radiology (IR-jejunostomy), and open jejunostomy placed surgically (surgical jejunostomy). METHODS Using the Nationwide Readmissions Database, we identified hospitalized patients who underwent a jejunostomy from 2016 to 2019. Selected patients were divided into 3 cohorts: PEJ, IR-jejunostomy, and surgical jejunostomy. Adjusted odds ratios (OR) for adverse events were calculated using multivariable logistic regression analysis. RESULTS A total of 6022 (65.2±9.8 y) surgical jejunostomy patients, 3715 (63.6±11.0 y) endoscopic jejunostomy patients, and 14,912 (64.8±11.6 y) IR-jejunostomy patients were identified. Compared with surgery, PEJ patients were 32% less likely to experience postprocedure complications (OR: 0.68; 95% CI: 0.58-0.79, P<0.001) while IR-jejunostomy patients were 17% less likely to experience complications (OR: 0.83; 95% CI: 0.73-0.94, P<0.001); test of proportion showed that endoscopy had significantly fewer total adverse events compared with IR (P<0.001). For individual complications, compared with surgery, the odds of intestinal perforation using PEJ and IR, respectively, were 0.26 (95% CI: 0.14-0.49, P<0.001) and 0.31 (95% CI: 0.21-0.47, P<0.001), for postprocedure infection 0.32 (95% CI: 0.20-0.50; P<0.001) and 0.61 (95% CI: 0.45-0.83; P=0.001); and for hemorrhage requiring blood transfusion 0.71 (95% CI: 0.56-0.91; P=0.005) and 0.75 (95% CI: 0.61-0.91; P=0.003). CONCLUSIONS Endoscopic placement of percutaneous jejunostomy tubes (PEJ) in inpatients is associated with significantly lower risks of adverse events and mortality compared with IR and surgical jejunostomy.
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Affiliation(s)
- Daryl Ramai
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
| | - Joseph Heaton
- Department of Medicine, Jersey Shore University Medical Center, Neptune City, NJ
| | - John Fang
- Gastroenterology and Hepatology, University of Utah Health, Salt Lake City, UT
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Toyoda S, Nishiofuku H, Matsumoto T, Sato T, Maeda S, Chanoki Y, Oshima K, Irizato M, Masada T, Sueyoshi S, Tanaka T. Percutaneous Trans-jejunum Pancreatojejunostomy Reconstruction for Intractable Pancreatic Fistula after Pancreatoduodenectomy. INTERVENTIONAL RADIOLOGY (HIGASHIMATSUYAMA-SHI (JAPAN) 2023; 8:161-164. [PMID: 38020460 PMCID: PMC10681759 DOI: 10.22575/interventionalradiology.2023-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 03/23/2023] [Indexed: 12/01/2023]
Abstract
We present an interventional radiology technique for percutaneous trans-jejunal pancreatojejunostomy reconstruction for intractable pancreatic fistula. A 70-year-old man with pancreatic cancer who had undergone pancreatoduodenectomy underwent percutaneous drainage for leakage from the anastomosis of the pancreatic duct to the jejunum. The leakage continued and the hole at the anastomosis site in the jejunum closed completely after 5 months. We performed percutaneous jejunostomy; the previously placed drainage catheter was then replaced with a balloon catheter, which was punctured by a 19-gauge needle from inside the jejunum through the percutaneous jejunostomy tube. The seeking catheter was inserted into the pancreatic duct. Finally, a side-holed 6-Fr straight catheter was successfully placed in the pancreatic duct through the percutaneous jejunostomy route.
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Affiliation(s)
- Shohei Toyoda
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Hideyuki Nishiofuku
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Takeshi Matsumoto
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Takeshi Sato
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Shinsaku Maeda
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Yuto Chanoki
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Keisuke Oshima
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Mariko Irizato
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
| | - Tetsuya Masada
- Department of Radiology, Nara Prefecture General Medical Center, Japan
| | | | - Toshihiro Tanaka
- Department of Diagnostic and Interventional Radiology, Nara Medical University, Japan
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Teixeira Farinha H, Bouriez D, Grimaud T, Rotariu AM, Collet D, Mantziari S, Gronnier C. Gastro-Intestinal Disorders and Micronutrient Deficiencies following Oncologic Esophagectomy and Gastrectomy. Cancers (Basel) 2023; 15:3554. [PMID: 37509216 PMCID: PMC10376982 DOI: 10.3390/cancers15143554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 07/06/2023] [Accepted: 07/07/2023] [Indexed: 07/30/2023] Open
Abstract
Primary surgical indications for the esophagus and stomach mainly involve cancer surgeries. In recent years, significant progress has been made in the field of esogastric surgery, driven by advancements in surgical techniques and improvements in perioperative care. The rate of resectability has increased, and surgical strategies have evolved to encompass a broader patient population. However, despite a reduction in postoperative mortality and morbidity, malnutrition remains a significant challenge after surgery, leading to weight loss, muscle mass reduction, and deficiencies in essential nutrients due to digestive complications. Malnutrition worsens quality of life and increases the risk of tumor recurrence, significantly affecting prognosis. Nevertheless, the nutritional consequences following surgery are frequently overlooked, mainly due to a lack of awareness regarding their long-term effects on patients who have undergone digestive surgery, extending beyond six months. Micronutrient deficiencies are frequently observed following both partial and total gastrectomy, as anticipated. Surprisingly, these deficiencies appear to be similarly prevalent in patients who have undergone esophagectomy with iron, vitamins A, B1, B12, D, and E deficiencies commonly observed in up to 78.3% of the patients. Recognizing the distinct consequences associated with each type of intervention underscores the importance of implementing preventive measures, early detection, and prompt management.
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Affiliation(s)
- Hugo Teixeira Farinha
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Damien Bouriez
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Thomas Grimaud
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
| | - Ana-Maria Rotariu
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
| | - Denis Collet
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Styliani Mantziari
- Department of Visceral Surgery, University Hospital of Lausanne, Rue du Bugnon 46, 1011 Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
| | - Caroline Gronnier
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600 Pessac, France
- Faculty of Biology and Medicine, University of Lausanne (UNIL), 1015 Lausanne, Switzerland
- Faculty of Medicine, Bordeaux Ségalen University, 33000 Bordeaux, France
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Chen Y, Tian X, Liu C, Zhang L, Xv Y, Xv S. Application of visual placement of a nasojejunal indwelling feeding tube in intensive care unit patients receiving mechanical ventilation. Front Med (Lausanne) 2022; 9:1022815. [PMID: 36482910 PMCID: PMC9722953 DOI: 10.3389/fmed.2022.1022815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
Background Compared with nasogastric nutrition, nasojejunal nutrition may prevent some complications of critically ill patients by maintaining better nutritional status, and blind placement of nasojejunal dwelling feeding tubes is widely used. However, the visual placement seems to be safer and more effective than the blind placement, and is still seldom reported. Objective We tried to develop visual placement of a nasojejunal feeding tube in intensive care unit patients. Methods A total of 122 patients receiving mechanical ventilation were admitted to the Department of Critical Care Medicine of the Fifth Affiliated Hospital of Wenzhou Medical University and received the placement of nasojejunal feeding tubes. These patients were randomly and evenly assigned into two groups, one group receiving visual placement of nasojejunal dwelling feeding tubes and another group receiving blind placement. Actual tube placement was confirmed by X-ray. The primary outcome included the success rates of first placement of feeding tubes. The secondary outcome included the time of tube placement, complications, the total cost, heart rates and respiratory rates. Results The primary outcome showed that the success rates of first placement were 96.70% (59 cases/61 cases) in the visual placement group, and two cases failed due to pyloric stenosis and gastroparesis. The success rates were 83.6% (51 cases/61 cases) in the blind placement group and 10 cases failed due to either wrong placement or retrograde tube migration. The success rates in the visual placement group were higher than that in the blind placement group (P = 0.015). The secondary outcome showed that the time of tube placement in the visual placement group was shorter than that in the blind placement group (P < 0.0001). The cost of tube placement in the visual placement group was higher than that in the blind placement group (P < 0.0001). The statistical differences in complications, heart and respiratory rates were insignificant between the two groups (P > 0.05). Conclusion Compared with the blind placement, the visual placement shortened the time of nasojejunal tube placement and increased success rates of first placement. The visual placement was more efficient, easy to operate, safe, and has potential clinical applications.
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Affiliation(s)
- Yuequn Chen
- Department of Intensive Care Unit, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China
| | - Xin Tian
- Department of Intensive Care Unit, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China,*Correspondence: Xin Tian
| | - Cheng Liu
- Department of Intensive Care Unit, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China
| | - Liqin Zhang
- Department of Intensive Care Unit, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China
| | - Yueyuan Xv
- Department of Digestive Internal Medicine, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China
| | - Shuang Xv
- Department of Equipment Department, The Fifth Affiliated Hospital of Wenzhou Medical University, Lishui Municipal Central Hospital, Lishui, China
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Postpyloric Feeding Access in Infants and Children: A State of the Art Review. J Pediatr Gastroenterol Nutr 2022; 75:237-243. [PMID: 35696699 DOI: 10.1097/mpg.0000000000003518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Achieving postpyloric feeding access is a clinical challenge faced by the pediatric gastroenterologist in everyday practice. Currently, there is limited literature published on the topic. This article provides a practical summary of the literature on the different methods utilized to achieve postpyloric feeding access including bedside, fluoroscopic, endoscopic and surgical options. Indications and complications of these methods are discussed as well as a general approach to infants and children that require intestinal feeding.
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Itou C, Arai Y, Sone M, Sugawara S, Onishi Y, Kimura S. Percutaneous Radiologic Gastrostomy in Patients After Partial Gastrectomy: A Retrospective Study to Assess the Technical Feasibility of Postsurgical Remnant Stomach Access. Cardiovasc Intervent Radiol 2022; 45:1214-1224. [PMID: 35396611 DOI: 10.1007/s00270-022-03114-1] [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] [Received: 09/17/2021] [Accepted: 03/01/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the technical feasibility of percutaneous radiologic gastrostomy in patients after partial gastrectomy. MATERIALS AND METHODS This retrospective study included 15 consecutive gastrectomized patients with attempted percutaneous radiologic gastrostomy at our institution between April 2014 and March 2021. When the stomach was sufficiently insufflated to distend below the left anterior subcostal margin, percutaneous radiologic gastrostomy with gastropexy was conventionally performed by the Seldinger technique. When the stomach was still highly positioned and/or overlaid by the other organs, some adjunctive maneuvers, such as hydro-displacement, intragastric balloon support, or cephalad oblique puncture or left intercostal puncture, were employed as modified gastrostomy. Ultrasonography or x-ray or computed tomography fluoroscopy was used for imaging guidance during the gastric puncture. Adequate tube placement was defined as technical success. Technical details, clinical outcomes, and complications were reviewed. RESULTS One patient underwent percutaneous radiologic jejunostomy instead of gastrostomy because safe gastric access could not be ensured. Seven patients underwent conventional gastrostomy; the other seven underwent modified gastrostomy with no gastropexy. The technical success rate was 100% (7/7) in the conventional group and 85.7% (6/7) in the modified group. The stomach was punctured under x-ray or computed tomography fluoroscopy for conventional gastrostomy. In contrast, the combination of various modalities was used for modified gastrostomy except for one failed case with unintentional transhepatic access. During a median follow-up of 108 days, no major complications occurred. CONCLUSION The adequate combination of multimodal imaging guidance and technical modifications could secure radiological creation of gastrostomy for the postsurgical stomach. LEVEL OF EVIDENCE Level 4, Case Series.
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Affiliation(s)
- Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Yasuyuki Onishi
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Itou C, Arai Y, Sone M, Sugawara S, Onishi Y, Kimura S. Transgastric Feeding Tube Insertion into the Jejunum after Esophagectomy: Direct Puncture of the Gastric Conduit. J Vasc Interv Radiol 2021; 32:1464-1469. [PMID: 34363940 DOI: 10.1016/j.jvir.2021.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 07/22/2021] [Accepted: 07/27/2021] [Indexed: 02/07/2023] Open
Abstract
PURPOSE To evaluate the safety and efficacy of percutaneous ultrasound (US)-guided direct puncture of a reconstructed gastric conduit after esophagectomy for performing a percutaneous radiologic gastrojejunostomy. MATERIALS AND METHODS Between 2014 and 2020, 26 consecutive patients with esophageal cancer (mean age, 70 years ± 8.3) with a total of 27 attempts of percutaneous radiologic gastrojejunostomy for postsurgical enteral feeding at the National Cancer Center Hospital were included in this study. One patient required a repeat procedure because of persistent anorexia after the removal of the first tube. All patients except 1 had a gastric conduit reconstructed via a retrosternal route. All procedures were performed under local anesthesia with moderate sedation and analgesia. A gastric conduit was directly punctured with an 18-gauge needle under ultrasonographic guidance, followed by feeding tube insertion into the proximal jejunum. Technical details of the procedures, technical success (defined as adequate tube placement), procedure-related complications, and clinical outcomes were reviewed. RESULTS The mean procedure time was 25 minutes ± 15, and technical success was obtained in every attempt. Minor complications included mild local pain (n = 7), unintentional tube removal (n = 2), local abdominal wall hematoma (n = 1), and superficial cellulitis (n = 1); no major complications were observed. During a mean follow-up period of 118.3 days ± 85.8, 13 patients resumed oral intake, and the feeding tube could be removed in 4 patients. No procedure-related deaths occurred. CONCLUSIONS The US-guided direct puncture technique is feasible for percutaneous gastrojejunal tube insertion in postsurgical patients with esophageal cancer with gastric conduit reconstruction.
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Affiliation(s)
- Chihiro Itou
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan.
| | - Yasuaki Arai
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Miyuki Sone
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shunsuke Sugawara
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Yasuyuki Onishi
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
| | - Shintaro Kimura
- Department of Diagnostic Radiology, National Cancer Center Hospital, Tokyo, Japan
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Kim CY, Shin JH. Recent update of percutaneous radiologic jejunostomy. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2021. [DOI: 10.18528/ijgii210009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Charles Y. Kim
- Department of Radiology, Duke University Medical Center, Durham, NC, USA
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, Seoul, Korea
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Shahi N, Phillips R, Acker SN, Meier M, Goldsmith A, Shirek G, Ladd P, Moulton SL, Bensard D. Enough is enough: Radiation doses in children with gastrojejunal tubes. J Pediatr Surg 2021; 56:668-673. [PMID: 32921427 DOI: 10.1016/j.jpedsurg.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Many children with gastric feeding intolerance require postpyloric tube feeding via a gastrojejunal (GJ) tube. Placement or positioning of these tubes is typically a procedure with a low dose of radiation. Although the risk of developing cancer from radiation exposure owing to computed tomography scans is well-documented in children, the risk of cumulative radiation exposure owing to frequent GJ tube replacement often goes unnoticed in the clinical decision-making process. We sought to define the frequency and cost of GJ tube replacement, quantify the radiation doses associated with the initial placement and replacements, and assess the number of conversions to surgical jejunostomies. METHODS All pediatric patients who underwent GJ tube placement or replacement by Interventional Radiology (IR), surgery, and gastroenterology between 2010 and 2018 at a single center were reviewed. We evaluated the total cost of the initial placement and replacement of each GJ tube, the total number of replacements, and the cumulative radiation dose (mGy). RESULTS We identified 203 patients who underwent GJ tube placement and/or replacement, of which 150 had radiation data available. Patients underwent a median of five GJ tube replacement procedures, and there was a wide range in the number of replacements per patient, from zero to 88. Patients were exposed to a median cumulative dose of 6.0 mGy (IQR: 2.2, 22.6). Nine percent of patients with available radiation data were exposed to more than 50 mGy, solely from GJ tube replacements. The median cost per replacement was $1170. The sum of the cost of the replacements for dislodged GJs translated to more than $1.4 million during the study period. CONCLUSIONS Overall, the average dose per GJ replacement was 3.50 mGy among all patients with available data. Nine percent of patients (14/150) were exposed to greater than 50 mGy cumulative radiation solely from GJ replacements. Patients who receive more than 50 mGy of cumulative radiation dose, who undergo seven GJ tube replacements in one year, or two consecutive GJ tube replacement procedures with radiation doses exceeding 10 mGy (per replacement) should be considered for a surgical jejunostomy. LEVEL OF EVIDENCE IV TYPE OF STUDY: Treatment study.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Patricia Ladd
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Radiology, Children's Hospital Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, CO, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA; Department of Surgery, Denver Health Medical Center, Denver, CO, USA
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