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Cruz-Centeno N, Stewart S, Marlor DR, Aguayo P, Rentea RM, Hendrickson RJ, Juang D, Snyder CL, Fraser JD, St Peter SD, Oyetunji TA. Duodenal Atresia Repair: A Single-Center Comparative Study. Am Surg 2023; 89:5911-5914. [PMID: 37257499 DOI: 10.1177/00031348231180910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND The use of laparoscopy in the repair of duodenal atresia has been increasing. However, there is no consensus regarding which surgical approach has better outcomes. We aimed to compare the different surgical approaches and types of anastomoses for duodenal atresia repair. METHODS Patients who underwent duodenal atresia repair at a single pediatric center were identified between January 2006 and June 2022. Those with concomitant gastrointestinal anomalies or who required other simultaneous operations were excluded. The primary outcome was rate of complications, defined as rate of leak, stricture, and re-operation by surgical approach and technique of anastomosis. RESULTS A total of 78 patients were included. The majority were female (51.3%, n = 40), with a median age of 4 days (IQR 3.0,8.0) and a median weight of 2.7 kg (IQR 2.2,3.3) at repair. The re-operation rate was 7.7% (n = 6), of which two were anastomotic leaks, and four were anastomotic strictures. The leak rate was 5.6% (n = 1/18) for the open handsewn and 4.8% (n = 1/21) for the laparoscopic handsewn technique. The stricture rate was 12.5% (n = 1/8) for the laparoscopic-assisted handsewn, 9.1% (n = 2/22) for the laparoscopic U-clip, 4.8% (n = 1/21) for the laparoscopic handsewn, and none with laparoscopic stapled and laparoscopic converted to open handsewn techniques. No differences were found in complication rate when controlling for surgical approach. CONCLUSION The method of surgical approach did not affect the outcomes or complications in the repair of duodenal atresia.
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Affiliation(s)
- Nelimar Cruz-Centeno
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shai Stewart
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Derek R Marlor
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Rebecca M Rentea
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Richard J Hendrickson
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Charles L Snyder
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Jason D Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- University of Missouri-Kansas City, School of Medicine, Kansas City, MO, USA
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Cruz-Centeno N, Fraser JA, Stewart S, Marlor DR, Rentea RM, Aguayo P, Juang D, Hendrickson RJ, Snyder CL, St Peter SD, Fraser JD, Oyetunji TA. Hypertrophic Pyloric Stenosis Protocol: A Single Center Study. Am Surg 2023; 89:5697-5701. [PMID: 37132378 DOI: 10.1177/00031348231175126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Initial treatment of hypertrophic pyloric stenosis (HPS) is correction of electrolyte disturbances with fluid resuscitation. In 2015, our institution implemented a fluid resuscitation protocol based on previous data that focused on minimizing blood draws and allowing immediate ad libitum feeds postoperatively. Our aim was to describe the protocol and subsequent outcomes. METHODS We conducted a single-center retrospective review of patients diagnosed with HPS from 2016 to 2023. All patients were given ad libitum feeds postoperatively and discharged home after tolerating three consecutive feeds. The primary outcome was the postoperative hospital length of stay (LOS). Secondary outcomes included the number of preoperative labs drawn, time from arrival to surgery, time from surgery to initiation of feeds, time from surgery to full feeds, and re-admission rate. RESULTS The study included 333 patients. A total of 142 patients (42.6%) had electrolytic disturbances that required fluid boluses in addition to 1.5x maintenance fluids. The median number of lab draws was 1 (IQR 1,2), with a median time from arrival to surgery of 19.5 hours (IQR 15.3,24.9). The median time from surgery to first and full feed was 1.9 hours (IQR 1.2,2.7) and 11.2 hours (IQR 6.4,18.3), respectively. Patients had a median postoperative LOS of 21.8 hours (IQR 9.7,28.9). Re-admission rate within the first 30 postoperative days was 3.6% (n = 12) with 2.7% of re-admissions occurring within 72 hours of discharge. One patient required re-operation due to an incomplete pyloromyotomy. DISCUSSION This protocol is a valuable tool for perioperative and postoperative management of patients with HPS while minimizing uncomfortable intervention.
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Affiliation(s)
- Nelimar Cruz-Centeno
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - James A Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Shai Stewart
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Derek R Marlor
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
| | - Rebecca M Rentea
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Richard J Hendrickson
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Charles L Snyder
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Jason D Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, MO, USA
- School of Medicine, Kansas City, University of Missouri-Kansas City, MO, USA
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Stewart S, Fraser JA, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, St Peter SD, Oyetunji TA. Institutional outcomes of blunt liver and splenic injury in the Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium era. J Trauma Acute Care Surg 2023; 95:295-299. [PMID: 36649594 DOI: 10.1097/ta.0000000000003870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium practice management guideline was created to standardize management of blunt liver or spleen injury across pediatric trauma centers. We describe our outcomes since guideline adoption at our institution and hypothesize that blunt liver or spleen injury may be managed more expeditiously than currently reported without compromising safety. METHODS A retrospective cohort study was conducted on patients younger than 18 years presenting with blunt liver and/or splenic injuries from March 2016 to March 2021 at one participating center. RESULTS A total of 199 patients were included. There were no clinically relevant differences for age, body mass index, or sex among the cohort. Isolated splenic injuries (n = 91 [46%]) and motor vehicle collisions (n = 82 [41%]) were the most common injury and mechanism, respectively. The overall median length of stay (LOS) was 1.2 days (interquartile range, 0.45-3.3 days). Intensive care unit utilization was 23% (n = 46). There was no statistically significant difference in median LOS among patients with isolated solid organ injuries, regardless of injury grade. There were no readmissions associated with non-operative management. CONCLUSION The Arizona-Texas-Oklahoma-Memphis-Arkansas Consortium guideline fosters high rates of nonoperative management with low intensive care unit utilization and LOS while demonstrating safety in implementation, irrespective of injury grade. LEVEL OF EVIDENCE Therapeutic/Care Management; Level IV.
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Affiliation(s)
- Shai Stewart
- From the Division of Pediatric Surgery, Department of Surgery (S.S., J.A.F., R.M.R., P.A., D.J., J.D.F., C.L.S., R.J.H., S.D.S., T.A.O.), Children's Mercy Kansas City University of Missouri-Kansas City School of Medicine (S.S., R.M.R., P.A., D.J., J.D.F., C.L.S., R.J.H., S.D.S., T.A.O.), Kansas City, Missouri
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Stewart S, Fraser JA, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, Oyetunji TA, St Peter SD. Management of primary spontaneous pneumothorax in children: A single institution protocol analysis. J Pediatr Surg 2023:S0022-3468(23)00075-1. [PMID: 36803908 DOI: 10.1016/j.jpedsurg.2022.12.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 12/13/2022] [Accepted: 12/31/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The Midwest Pediatric Surgery Consortium (MWPSC) suggested a simple aspiration of primary spontaneous pneumothorax (PSP) protocol, failing which, Video-Assisted Thoracoscopic Surgery (VATS) should be considered. We describe our outcomes using this suggested protocol. METHODS A single institution retrospective analysis was conducted on patients between 12 and 18 years who were diagnosed with PSP from 2016 to 2021. Initial management involved aspiration alone with a ≤12 F percutaneous thoracostomy tube followed by clamping of the tube and chest radiograph at 6 h. Success was defined as ≤2 cm distance between chest wall and lung at the apex and no air leak when the clamp was released. VATS followed if aspiration failed. RESULTS Fifty-nine patients were included. Median age was 16.8 years (IQR 15.9, 17.3). Aspiration was successful in 33% (20), while 66% (39) required VATS. The median LOS with successful aspiration was 20.4 h (IQR 16.8, 34.8), while median LOS after VATS was 3.1 days (IQR 2.6, 4). In comparison, in the MWPSC study, the mean LOS for those managed with a chest tube after failed aspiration was 6.0 days (±5.5). Recurrence after successful aspiration was 45% (n = 9), while recurrence after VATS was 25% (n = 10). Median time to recurrence after successful aspiration was sooner than that of the VATS group [16.6 days (IQR 5.4, 19.2) vs. 389.5 days (IQR 94.1, 907.0) p = 0.01]. CONCLUSION Simple aspiration is safe and effective initial management for children with PSP, although most will require VATS. However, early VATS reduces length of stay and morbidity. LEVEL OF EVIDENCE IV. Retrospective study.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA.
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Fraser JA, Briggs KB, Svetanoff WJ, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, St Peter SD, Oyetunji TA. Umbilical access in laparoscopic surgery in infants less than 3 months: A single institution retrospective review. J Pediatr Surg 2022; 57:277-281. [PMID: 34872728 DOI: 10.1016/j.jpedsurg.2021.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/04/2021] [Accepted: 11/08/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Umbilical access in laparoscopic surgery has been cited as a factor for increased complications in low-birth-weight infants and those less than three months old. In a previous series, 10.6% of pediatric surgeons reported complications in this population associated with umbilical access, citing carbon dioxide (CO2) embolism as the most common complication. To further examine the safety of this technique, we report our outcomes with blunt transumbilical laparoscopic access at our institution over four years. METHODS A retrospective review was performed of patients less than three months of age who underwent laparoscopic pyloromyotomy or inguinal hernia repair from 2016 to 2019. Operative reports, anesthesia records, and postoperative documentation were reviewed for complications related to umbilical access. Complications included bowel injury, vascular injury, umbilical vein cannulation, CO2 embolism, umbilical surgical site infection (SSI), umbilical hernia requiring repair, and death. RESULTS Of 365 patients, 246 underwent laparoscopic pyloromyotomy, and 119 underwent laparoscopic inguinal hernia repairs. Median age at operation was 5.9 weeks [4.3,8.8], and median weight was 3.9 kg [3.4,4.6]. Nine complications (2.5%) occurred: 5 umbilical SSIs (1.4%), 1 bowel injury upon entry requiring laparoscopic repair (0.2%), 1 incisional hernia repair 22 days postoperatively (0.2%), and 2 cases of hypotension and bradycardia upon insufflation that resolved with desufflation (0.5%). There were no intraoperative mortalities or signs/symptoms of CO2 embolism. CONCLUSION In this series, umbilical access for laparoscopic surgery in neonates less than three months of age was safe, with minimal complications. Although concern for umbilical vessel injury, cannulation, and CO2 embolism exists, these complications are not exclusively associated with umbilical access technique.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA; University of Missouri-Kansas City School of Medicine, Kansas City, MO USA.
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Fraser JA, Osuchukwu O, Briggs KB, Svetanoff WJ, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, St Peter SD, Oyetunji TA. Evaluation of a fluid resuscitation protocol for patients with hypertrophic pyloric stenosis. J Pediatr Surg 2022; 57:386-389. [PMID: 34839945 DOI: 10.1016/j.jpedsurg.2021.10.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 10/12/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION We previously developed an institutional, evidence-based fluid resuscitation protocol for neonates with infantile hypertrophic pyloric stenosis (HPS) based on the severity of electrolyte derangement on presentation. We aim to evaluate this protocol to determine its efficacy in reducing the number of preoperative lab draws, time to electrolyte correction, and overall length of stay. METHODS A single center, retrospective review of 319 infants with HPS presenting with electrolyte derangement from 2008 to 2020 was performed; 202 patients managed pre-protocol (2008-2014) and 117 patients managed per our institutional fluid resuscitation algorithm (2016-2020). The number of preoperative lab draws, time to electrolyte correction, and length of stay before and after protocol implementation was recorded. RESULTS Use of a fluid resuscitation algorithm decreased the number of infants who required four or more preoperative lab draws (20% vs. 6%) (p < .01), decreased median time to electrolyte correction between the pre and post protocol cohorts (15.1 h [10.6, 22.3] vs. 11.9 h [8.5, 17.9]) (p < .01), and decreased total length of hospital stay (49.0 h [40.3, 70.7] vs. 45.7 h [34.3, 65.9]) (p < .05). CONCLUSION Implementation of a fluid resuscitation algorithm for patients presenting with hypertrophic pyloric stenosis decreases the frequency of preoperative lab draws, time to electrolyte correction, and total length of hospital stay. Use of a fluid resuscitation protocol may decrease discomfort through fewer preoperative lab draws and shorter length of stay while setting clear expectations and planned intervention for parents. LEVEL OF EVIDENCE III - Retrospective comparative study.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Obiyo Osuchukwu
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States.
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Stewart S, Briggs KB, Fraser JA, Dekonenko C, Svetanoff WJ, Rentea RM, Aguayo P, Juang D, Hendrickson RJ, Snyder CL, Peter SDS, Oyetunji TA, Fraser JD. Laparoscopic Gastrostomy in Infants During an Open Abdominal Procedure: A Novel Approach. J Laparoendosc Adv Surg Tech A 2022; 32:1005-1009. [PMID: 35666589 DOI: 10.1089/lap.2022.0117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Introduction: Infants with intra-abdominal pathology necessitating open abdominal surgery may also require placement of a gastrostomy tube (GT). Use of laparoscopy provides better visualization for gastrostomy placement and lowers the risk of complications compared with an open approach. We describe a series of patients who underwent laparoscopic GT placement at the time of an open abdominal procedure. Methods: All patients who underwent an open abdominal procedure with concurrent laparoscopic gastrostomy from January 2010 to June 2020 were reviewed. Descriptive statistics were performed with categorical variables reported as proportions and continuous variables reported as medians with interquartile range [IQR]. Results: Twelve patients were included; 8 (67.5%) were male. The median age at time of surgery was 10 weeks [IQR 6, 14], with a median weight of 4.1 kg [IQR 3.4, 4.8]. Ten patients had the laparoscope placed through the open incision, whereas 2 had the laparoscope placed through a separate incision. Median operative time was 106 minutes [IQR 80, 125]. There were no intraoperative complications. Postoperative complications included surgical site infection in 5 (41.7%), leaking around the GT in 3 (25%), and malfunction of the tube in 1 (8.3%). One patient required reoperation 28 days postoperatively due to malfunction. Conclusion: Laparoscopic GT can be safely performed at the time of an open abdominal procedure, and frequently through the same incision, harnessing the benefits of a laparoscopic approach even when an open incision is needed.
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Affiliation(s)
- Shai Stewart
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA.,Department of Surgery, Quality Improvement and Surgical Equity Research (QISER) Center, Kansas City, Missouri, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
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Fraser JA, Briggs KB, Svetanoff WJ, Aguayo P, Juang D, Fraser JD, Snyder CL, Oyetunji TA, St Peter SD. Short and long term outcomes of using cryoablation for postoperative pain control in patients after pectus excavatum repair. J Pediatr Surg 2022; 57:1050-1055. [PMID: 35277249 DOI: 10.1016/j.jpedsurg.2022.01.051] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 01/31/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION We report the findings of a three-year prospective observational study elucidating long-term symptoms and complications of patients who underwent minimally invasive pectus excavatum repair with intercostal nerve cryoablation with specific attention to postoperative pain control associated with the cryoablation technique. METHODS Surveys were administered to patients who underwent bar placement for pectus excavatum with intercostal nerve cryoablation from 2017 to 2021 regarding pain scores, pain medication usage, and limitations to activity beginning on the day of surgery, on the day of discharge, and at two-week and three-month follow-up. RESULTS Of 110 patients, forty-eight (44%) completed the discharge survey; sharp pain and pressure on the first postoperative night were the most described pain characteristics, most frequently in the middle of the chest. On follow-up, 55% of patients reported tolerable residual pain at two weeks and 41% at three months, with 25% requiring intermittent pain medication at three months. There were three readmissions for inadequate pain control and 110 calls to the surgery clinic by three-month follow-up, most commonly for persistent pain and frequent popping sensation with movement. DISCUSSION Although cryoablation is an excellent pain control modality, these data suggest that patients underreport functional symptoms and experience more frequent discomfort and alteration of daily living activities.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO USA; Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, 2401 Gillham Road Kansas City, Kansas City, MO 64108, USA.
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Snyder CL. Weighing the Risks and Benefits of Nonoperative Management of Appendicitis. Pediatrics 2022; 149:186780. [PMID: 35434743 DOI: 10.1542/peds.2021-056034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2022] [Indexed: 11/24/2022] Open
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Fraser JA, Briggs KB, Svetanoff WJ, Rentea RM, Aguayo P, Juang D, Fraser JD, Snyder CL, Hendrickson RJ, St. Peter SD, Oyetunji TA. Behind the mask: extended use of surgical masks is not associated with increased risk of surgical site infection. Pediatr Surg Int 2022; 38:325-330. [PMID: 34665318 PMCID: PMC8524207 DOI: 10.1007/s00383-021-05032-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE COVID-19 has prompted significant policy change, with critical attention to the conservation of personal protective equipment (PPE). An extended surgical mask use policy was implemented at our institution, allowing use of one disposable mask per each individual, per day, for all the cases. We investigate the clinical impact of this policy change and its effect on the rate of 30-day surgical site infection (SSI). METHODS A single-institution retrospective review was performed for all the elective pediatric general surgery cases performed pre-COVID from August 2019 to October 2019 and under the extended mask use policy from August 2020 to October 2020. Procedure type, SSI within 30 days, and postoperative interventions were recorded. RESULTS Four hundred and eighty-eight cases were reviewed: 240 in the pre-COVID-19 cohort and 248 in the extended surgical mask use cohort. Three SSIs were identified in the 2019 cohort, and two in the 2020 cohort. All postoperative infections were superficial and resolved within 1 month of diagnosis with oral antibiotics. There were no deep space infections, readmissions, or infections requiring re-operation. CONCLUSION Extended surgical mask use was not associated with increased SSI in this series of pediatric general surgery cases and may be considered an effective and safe strategy for resource conservation with minimal clinical impact.
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Affiliation(s)
- James A. Fraser
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA
| | - Kayla B. Briggs
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA
| | - Wendy Jo Svetanoff
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA
| | - Rebecca M. Rentea
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Pablo Aguayo
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - David Juang
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Jason D. Fraser
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Charles L. Snyder
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Richard J. Hendrickson
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Shawn D. St. Peter
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA
| | - Tolulope A. Oyetunji
- Department of Surgery, Children’s Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108 USA ,University of Missouri-Kansas City School of Medicine, Kansas City, MO USA ,Quality Improvement and Surgical Equity Research (QISER) Center, Kansas City, USA
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Briggs KB, Fraser JA, Svetanoff WJ, Staszak JK, Snyder CL, Aguayo P, Juang D, Rentea RM, Hendrickson RJ, Fraser JD, St Peter SD, Oyetunji TA. Review of Perioperative Prophylactic Antibiotic Use during Laparoscopic Cholecystectomy and Subsequent Surgical Site Infection Development at a Single Children's Hospital. Eur J Pediatr Surg 2022; 32:85-90. [PMID: 34942672 DOI: 10.1055/s-0041-1740461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES With the rise of antibiotic resistance, the use of prophylactic preoperative antibiotics (PPA) has been questioned in cases with low rates of surgical site infection (SSI). We report PPA usage and SSI rates after elective laparoscopic cholecystectomy at our institution. MATERIALS AND METHODS A retrospective review of children younger than 18 years who underwent elective outpatient laparoscopic cholecystectomy between July 2010 and August 2020 was performed. Demographic, preoperative work-up, antibiotic use, intraoperative characteristics, and SSI data were collected via chart review. SSI was defined as clinical signs of infection that required antibiotics within 30 days of surgery. RESULTS A total of 502 patients met the inclusion criteria; 50% were preoperatively diagnosed with symptomatic cholelithiasis, 47% with biliary dyskinesia, 2% with hyperkinetic gallbladder, and 1% with gallbladder polyp(s). The majority were female (78%) and Caucasian (80%). In total, 60% (n = 301) of patients received PPA, while 40% (n = 201) did not; 1.3% (n = 4) of those who received PPA developed SSI, compared with 5.5% (n = 11) of those who did not receive PPA (p = 0.01). Though PPA use was associated with a 77% reduction in the risk of SSI in multivariate analysis (p = 0.01), all SSIs were superficial. One child required readmission for intravenous antibiotics, while the remainder were treated with outpatient antibiotics. Gender, age, body mass index, ethnicity, and preoperative diagnosis did not influence the likelihood of receiving PPA. CONCLUSION Given the relatively low morbidity of the superficial SSI, conservative use of PPA is advised to avoid contributing to antibiotic resistance.
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Affiliation(s)
- Kayla B Briggs
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - James A Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Wendy Jo Svetanoff
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jessica K Staszak
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Charles L Snyder
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Pablo Aguayo
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - David Juang
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Rebecca M Rentea
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Richard J Hendrickson
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jason D Fraser
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shawn D St Peter
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Tolulope A Oyetunji
- Department of Pediatric Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Svetanoff WJ, Briggs K, Fraser JA, Lopez J, Fraser JD, Juang D, Aguayo P, Hendrickson RJ, Snyder CL, Oyetunji TA, St Peter SD, Rentea RM. Outpatient Botulinum Injections for Early Obstructive Symptoms in Patients with Hirschsprung Disease. J Surg Res 2021; 269:201-206. [PMID: 34587522 DOI: 10.1016/j.jss.2021.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/23/2021] [Accepted: 07/22/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Botulinum toxin (BT) injections may play a role in preventing Hirschsprung associated enterocolitis (HAEC) episodes related to internal anal sphincter (IAS dysfunction). Our aim was to determine the association of outpatient BT injections for early obstructive symptoms on the development of HAEC. METHODS A retrospective review of children who underwent definitive surgery for Hirschsprung disease (HSCR) from July 2010 - July 2020 was performed. The timing from pull-through to first HAEC episode and to first BT injection was recorded. Primary analysis focused on the rate of HAEC episodes and timing between episodes in patients who did and did not receive BT injections. RESULTS Eighty patients were included. Sixty patients (75%) were male, 15 (19%) were diagnosed with trisomy 21, and 58 (72.5%) had short-segment disease. The median time to pull-through was 150 days (IQR 16, 132). Eight patients (10%) had neither an episode of HAEC or BT injections and were not included in further analysis. Forty-six patients (64%) experienced at least one episode of HAEC, while 64 patients (89%) had at least one outpatient BT injection. Compared to patients who never received BT injections (n = 9) and those who developed HAEC prior to BT injections (n = 35), significantly fewer patients who received BT injections first (n = 28) developed enterocolitis (P < 0.001), with no patient developing more than one HAEC episode. CONCLUSION Outpatient BT is associated with decreased episodes of HAEC and increased interval between HAEC episodes requiring inpatient treatment. Scheduling outpatient BT injections to manage obstructive symptoms may be beneficial after pull-through for HSCR.
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Affiliation(s)
| | - Kayla Briggs
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - James A Fraser
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - Joseph Lopez
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - David Juang
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri
| | - Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital; Kansas City, Missouri; University of Missouri-Kansas City School of Medicine; Kansas City, Missouri.
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Svetanoff WJ, Fraser JA, Briggs KB, Staszak JK, Dekonenko C, Rentea RM, Juang D, Aguayo P, Fraser JD, Snyder CL, Hendrickson RJ, St Peter SD, Oyetunji T. A single institution experience with Laparoscopic Hernia repair in 791 children. J Pediatr Surg 2021; 56:1185-1189. [PMID: 33741178 DOI: 10.1016/j.jpedsurg.2021.02.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 01/10/2023]
Abstract
INTRODUCTION There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique. METHODS A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis. RESULTS 791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically. CONCLUSIONS The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.
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Affiliation(s)
| | - James A Fraser
- Department of Surgery, Children's Mercy, Kansas City, USA
| | - Kayla B Briggs
- Department of Surgery, Children's Mercy, Kansas City, USA
| | | | | | - Rebecca M Rentea
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - David Juang
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Richard J Hendrickson
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Tolulope Oyetunji
- Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA.
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Dekonenko C, Svetanoff WJ, Osuchukwu OO, Pierce AL, Orrick BA, Sayers KL, Rentea RM, Aguayo P, Fraser JD, Juang D, Hendrickson RJ, Snyder CL, Andrews WS, St Peter SD, Oyetunji TA. Same-day discharge for pediatric laparoscopic gastrostomy. J Pediatr Surg 2021; 56:26-29. [PMID: 33109344 DOI: 10.1016/j.jpedsurg.2020.09.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 09/22/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Laparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy. METHODS We performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017-September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education. RESULTS Sixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9-4.1], and the median weight was 10.5 kg [IQR 7.6-15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16-29]. The median time to initiation of feeds was 4.4 h [IQR 3.4-5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7-10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room <30 days at a median 5 days [IQR 3-12] post-operatively, primarily for mechanical complications. CONCLUSION Same-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits. TYPE OF STUDY Prospective Observational Study. LEVEL OF EVIDENCE Level II.
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Taylor JA, Snyder CL, Lillehei C, Powell DM. Analyzing a follow-up needs assessment: Increased use of internet-based APSA educational programs by pediatric surgeons. J Pediatr Surg 2020; 55:2083-2087. [PMID: 32106965 DOI: 10.1016/j.jpedsurg.2020.01.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 01/10/2020] [Accepted: 01/24/2020] [Indexed: 10/25/2022]
Abstract
PURPOSE Needs assessment is a critical component of educational program design. Follow-up is important for improvement. Two electronic educational programs, Exam-based Pediatric surgery Educational Reference Tool (ExPERT) and Pediatric Surgery Not a Textbook (NaT), offered by the American Pediatric Surgical Association (APSA) have been functional for over three years, allowing for follow-up assessment. METHODS A 22-question survey was distributed via email to APSA members. Questions included practice demographics, learning preferences and APSA material use. Mann-Whitney analysis was performed (p<0.05). RESULTS 294 members responded. 43% were in academic practice with a pediatric surgery fellowship. Top preferences for obtaining/maintaining medical knowledge were national meetings (27%), ExPERT (24%), and the NaT (20%). Comparatively, in a 2014 assessment, electronic programs were less desired (16%). Cost was cited by >1/3 for not subscribing to ExPERT or NaT. Question discussions were often read regardless of response. >86% would subscribe to APSA resources if there were no CME requirement. The most frequently cited knowledge gap was fetal therapy (30%). CONCLUSIONS This is the first publication documenting increased acceptance of electronic educational platforms for pediatric surgeons. Well-utilized and valued, the data justify and encourage continued development of electronic educational resources. Room for improvement exists in affordability, knowledge gaps, and individualizing curriculum development. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Janice A Taylor
- University of Florida Division of Pediatric Surgery, 1600 SW Archer Rd, PO Box 100119, Gainesville, FL 32610, USA.
| | - Charles L Snyder
- Children's Mercy Hospital Division of Pediatric Surgery, 2401 Gillham Rd, Kansas City, MO 64108, USA
| | - Craig Lillehei
- Boston Children's Hospital Department of Surgery, 300 Longwood Ave, Fegan, 3rd Floor, Boston, MA 02115, USA
| | - David M Powell
- Stanford University Division of Pediatric Surgery, 730 Welch Rd, 2nd floor-MC 5883, Palo Alto, CA 94304, USA
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Dekonenko C, Dorman RM, Duran Y, Juang D, Aguayo P, Fraser JD, Oyetunji TA, Snyder CL, Holcomb GW, Millspaugh DL, St Peter SD. Postoperative pain control modalities for pectus excavatum repair: A prospective observational study of cryoablation compared to results of a randomized trial of epidural vs patient-controlled analgesia. J Pediatr Surg 2020; 55:1444-1447. [PMID: 31699436 DOI: 10.1016/j.jpedsurg.2019.09.021] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pain following bar placement for pectus excavatum is the dominant factor post-operatively and determines length of stay (LOS). We recently adopted intercostal cryoablation as our preferred method of pain control following minimally invasive pectus excavatum repair. We compared the outcomes of cryoablation to results of a recently concluded trial of epidural (EPI) and patient-controlled analgesia (PCA) protocols. METHODS We conducted a prospective observational study of patients undergoing bar placement for pectus excavatum using intercostal cryoablation. Results are reported and compared with those of a randomized trial comparing EPI with PCA. Comparisons of medians were performed using Kruskal-Wallis H tests with alpha 0.05. RESULTS Thirty-five patients were treated with cryoablation compared to 32 epidural and 33 PCA patients from the trial. Cryoablation was associated with longer operating time (101 min, versus 58 and 57 min for epidural and PCA groups, p < 0.01), resulted in less time to pain control with oral medication (21 h, versus 72 and 67 h, p < 0.01), and decreased LOS (1 day, versus 4.3 and 4.2 days, p < 0.01). CONCLUSION Intercostal cryoablation during minimally invasive pectus excavatum repair reduces LOS and perioperative opioid consumption compared with both EPI and PCA. LEVEL OF EVIDENCE II.
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Affiliation(s)
| | - Robert M Dorman
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Yara Duran
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - David Juang
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | - George W Holcomb
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
| | | | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO.
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Dekonenko C, Hill JA, Sobrino JA, Snyder CL, St Peter SD, Oyetunji TA. Ligament of Treitz Release With Duodenal Lowering for Pediatric Superior Mesenteric Artery Syndrome. J Surg Res 2020; 254:91-95. [PMID: 32422431 DOI: 10.1016/j.jss.2020.04.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 03/26/2020] [Accepted: 04/11/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND Operative approaches for superior mesenteric artery syndrome (SMAS) vary from Roux-en-Y duodenojejunostomy to the more conservative division of the ligament of Treitz with inferior duodenal derotation known as the Strong procedure. We sought to examine outcomes following a modified version of Strong procedure where the duodenum is lowered as opposed to derotated for the management of SMAS. MATERIALS AND METHODS We conducted a retrospective chart review of children who underwent surgical management of SMAS between January 2008 and December 2017. An online survey regarding symptom resolution, feeding practices, and the need for additional procedures was distributed. Data are reported as medians with interquartile range (IQR) and proportions as percentages. RESULTS Seven patients with a median age of 15 y (IQR 8, 16) and median body mass index of 16.9 (IQR, 12.6, 22.1) were included. Presenting symptoms included pain (71%), nausea (57%), and vomiting (43%). Six patients initially underwent duodenal lowering, whereas one patient underwent duodenoduodenostomy. One patient underwent adhesiolysis for bowel obstruction in the early postoperative period. All patients had symptom resolution at a postoperative follow-up of 22 d (IQR, 15, 45). Two patients had symptom recurrence, and one patient required reoperation. Six patients completed the survey at a median of 2.3 y (IQR, 1.7, 3.2) postoperatively, of which four underwent duodenal lowering. Of these, 75% (n = 3) were asymptomatic. One patient with recurrence reported occasional nausea and emesis but has not required additional surgery. CONCLUSIONS Release of the ligament of Treitz with duodenal lowering results in resolution of symptoms in 75% of patients. This operative approach may be considered before performing more complex operations for SMAS.
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Joshua A Hill
- School of Medicine, University of Missouri Kansas City, Kansas City, Missouri
| | - Justin A Sobrino
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri; Department of Surgery, Quality Improvement and Surgical Equity Research (QISER) Center, Children's Mercy Kansas City, Kansas City, Missouri.
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Rentea RM, Snyder CL. Reverend Bayes and Appendicitis. Pediatrics 2020; 145:peds.2019-3349. [PMID: 31964757 DOI: 10.1542/peds.2019-3349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2019] [Indexed: 11/24/2022] Open
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Orrick BA, Pierce AL, Snyder CL, Alon US. Successful Brace Treatment of Pectus Carinatum in Osteogenesis Imperfecta Using the Dynamic Compression System. European J Pediatr Surg Rep 2020; 7:e117-e120. [PMID: 31908907 PMCID: PMC6938457 DOI: 10.1055/s-0039-3399557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/25/2019] [Indexed: 11/02/2022] Open
Abstract
Osteogenesis imperfecta (OI) is a genetic disorder of collagen resulting in a "fragile" skeleton with increased fracture risk and other complications, dependent on the specific variant. Pectus deformities of the chest wall, while not common, can be associated with OI. The use of a pectus carinatum brace in a patient with OI poses unknown risks for fractures and adverse treatment outcomes. We successfully applied external compression bracing using the dynamic compression system to one such patient. This case illustrates the ability to treat an OI patient with pectus carinatum using a nonsurgical brace, without complications, resulting in an excellent cosmetic result.
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Affiliation(s)
- Beth A Orrick
- Department of Pediatric Surgery, Center for Pectus Excavatum and Carinatum, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Amy L Pierce
- Department of Pediatric Surgery, Center for Pectus Excavatum and Carinatum, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Charles L Snyder
- Department of Pediatric Surgery, Center for Pectus Excavatum and Carinatum, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Uri S Alon
- Bone and Mineral Disorders Clinic, Division of Pediatric Nephrology, Children's Mercy Hospital, Kansas City, Missouri, United States
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Dekonenko C, Dorman RM, Pierce A, Orrick BA, Juang D, Aguayo P, Fraser JD, Oyetunji TA, Snyder CL, St Peter SD, Holcomb GW. Outcomes Following Dynamic Compression Bracing for Pectus Carinatum. J Laparoendosc Adv Surg Tech A 2019; 29:1223-1227. [PMID: 31241400 DOI: 10.1089/lap.2019.0171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction: Children with pectus carinatum (PC) are particularly vulnerable to psychosocial effects of poor body image, even though they may not experience physical symptoms. Nonoperative treatment with orthotic bracing is effective in PC correction. We describe our experience with dynamic compression bracing (DCB) for PC patients and their satisfaction with bracing. Materials and Methods: Prospective institutional data of patients undergoing DCB from July 2011 to June 2018 were reviewed and analyzed for those who entered the retainer mode after correction, defined by a correction pressure of <1 psi. A telephone survey was conducted regarding their bracing experience and satisfaction with the outcome on a scale of 1-10. Results: Of 460 PC patients, 144 reached the retainer mode. Median time to retainer mode was 5.5 months. There was no statistically significant relationship between initial correction pressure or carinatum height and time to retainer mode (P = .08 and P = .10, respectively). Fifty-seven percent were compliant with brace use, and median time to retainer mode in this subset was significantly shorter than noncompliant patients (3.5 months versus 10 months, P < .001). Fifty-three percent responded to the survey 13 months [interquartile ratios 3, 33] after the last clinic visit. The main barrier to compliance with wearing the brace was discomfort (37%), while the main motivation for compliance was appearance (58%). All endorsed bracing as worthwhile, with 94% reporting a satisfaction rating of 8 or greater for the correction outcome. Conclusion: DCB is effective in achieving correction of PC in compliant patients. Regardless of time to retainer mode, patients reported high satisfaction with bracing.
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Affiliation(s)
| | - Robert M Dorman
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Amy Pierce
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Beth A Orrick
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | | | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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21
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Affiliation(s)
- Charles L Snyder
- Children's Mercy Hospital, Kansas City, Missouri and University of Missouri at Kansas City, Kansas City, Missouri
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Poola AS, Pierce AL, Orrick BA, Peter SDS, Snyder CL, Juang D, Aguayo P, Fraser JD, Holcomb GW. A Single-Center Experience with Dynamic Compression Bracing for Children with Pectus Carinatum. Eur J Pediatr Surg 2018; 28:12-17. [PMID: 28946165 DOI: 10.1055/s-0037-1606845] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Bracing for pectus carinatum (PC) has emerged as an alternative to surgical correction. However, predictive factors for bracing remain poorly understood, as much of the data have been reported from small series. MATERIALS AND METHODS We reviewed a prospective dataset in patients with PC who underwent dynamic compression bracing (DCB) from July 2011 to July 2016. Bracing was initiated in patients > 10 years of age with a significant PC and desire for bracing. Data were analyzed for those observed two or more times after the brace was fitted to the patient. RESULTS A total of 503 patients were evaluated for PC and 340 (68%) underwent DCB. Eighty-five percent were males with an average age of 14 ± 2 years. There was a positive correlation of age with pressure of initial correction (PIC, r = 0.2). One patient underwent operative correction as the initial therapy. Two hundred seventeen patients had two or more visits after the patient was fitted for the brace. The mean PIC in this cohort was 4 psi (range: 1.5-7.8), and the median duration of bracing in this group was 16 months (IQR: 7-23 months). One hundred three patients (47%) achieved complete correction after an average bracing time of 7.5 months and were then placed in the retainer mode. Thirty patients successfully completed bracing therapy and required an average of 23 months of therapy (2 months-4 years). No patient recurred after bracing was completed, but one failed bracing and required operative correction. Complications included mechanical problems (8%), skin complications (10%), complaints of tightness (3%), and pain (2%). CONCLUSION DCB has both early and lasting effects in the correction of PC with minimal complications. Predictive factors for successful resolution of the PC include increased duration of DCB and lower initial PIC.
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Affiliation(s)
- Ashwini Suresh Poola
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Amy L Pierce
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Beth A Orrick
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shawn David St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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23
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Affiliation(s)
- Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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Alemayehu H, Sharp NE, Gonzalez K, Poola AS, Snyder CL, St Peter SD. The role of 2-octyl cyanoacrylate in prevention of penile adhesions after circumcision: A prospective, randomized trial. J Pediatr Surg 2017; 52:1886-1890. [PMID: 28939185 DOI: 10.1016/j.jpedsurg.2017.08.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 08/28/2017] [Indexed: 11/28/2022]
Abstract
PURPOSE Penile adhesions are the most common complication after circumcision, although strategies to decrease them are poorly studied. We conducted a prospective, randomized trial comparing the use of 2-octyl cyanoacrylate (glue) skin adhesive to hydrophobic ointment after circumcision. METHODS Patients <7years old undergoing circumcision were randomized to glue around the sutures and corona of the penis or antibiotic ointment. The primary outcome variable was postoperative penile adhesions. Utilizing a power of 0.8 and an alpha of 0.05, 168 patients were calculated for each arm. Because of high attrition, we planned to include up to 500 patients. Presence/absence of adhesions was evaluated 2-4weeks postop. Parents subjectively scored happiness, comfort, distress, and concern on a Likert scale 1-5. RESULTS From 11/2012 through 7/2016, 409 patients were enrolled. Adhesion data were available on 243 patients. There was no difference between glue (16.8%) and those with antibiotic ointment (15.2%) (p=0.88) or in parental satisfaction across all areas measured. 165 patients were lost to follow-up, evenly distributed between the two groups (38% vs. 42%, p=0.49). CONCLUSION The placement of 2-octyl cyanoacrylate skin adhesive does not decrease the rate of postoperative penile adhesions after circumcision. Parent satisfaction outcomes are similar. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Hanna Alemayehu
- The Children's Mercy Hospital, Kansas City, MO, United States
| | - Nicole E Sharp
- The Children's Mercy Hospital, Kansas City, MO, United States
| | | | - Ashwini S Poola
- The Children's Mercy Hospital, Kansas City, MO, United States
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25
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Snyder CL. Alternatives to Appendectomy for Acute Appendicitis. Pediatrics 2017; 140:peds.2017-1232. [PMID: 28759419 DOI: 10.1542/peds.2017-1232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2017] [Indexed: 11/24/2022] Open
Affiliation(s)
- Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri
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26
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Berman L, Hronek C, Raval MV, Browne ML, Snyder CL, Heiss KF, Rangel SJ, Goldin AB, Rothstein DH. Pediatric Gastrostomy Tube Placement: Lessons Learned from High-performing Institutions through Structured Interviews. Pediatr Qual Saf 2017; 2:e016. [PMID: 30229155 PMCID: PMC6132912 DOI: 10.1097/pq9.0000000000000016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2015] [Accepted: 01/12/2016] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Gastrostomy tube (GT) placement is one of the most common operations performed in children, and it is plagued by high complication rates. Previous studies have shown variation in readmission and emergency room visit rates across different children's hospitals, with both low and high outliers. There is an opportunity to learn how to optimize outcomes by identifying practices at high-performing institutions. METHODS Surgeons and nurses routinely involved in GT care at 8 high-performing pediatric centers were identified. We conducted structured interviews focusing on the approach to GT education, technical aspects of GT placement, and postoperative management. Summary statistics were performed on quantitative data, and the open-ended responses were analyzed by 2 independent reviewers using content analysis. RESULTS Several common practices among high-performing centers were identified (standardized approach to education, availability by phone and in clinic to manage GT-related issues, and empowering families to feel confident with troubleshooting and dealing with GT problems). There was substantial variation in operative technique and postoperative care. The participants expressed that technical aspects of operative placement and postoperative management of feedings and common complications are not as important as education, availability, and empowerment in optimizing outcomes. CONCLUSIONS We have identified common themes among pediatric centers with favorable outcomes after GT placement. Identifying which components of GT care are associated with optimal outcomes is critical to our understanding of current practice and may help identify opportunities to improve care quality.
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Affiliation(s)
- Loren Berman
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Carla Hronek
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Mehul V. Raval
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Marybeth L. Browne
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Charles L. Snyder
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Kurt F. Heiss
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Shawn J. Rangel
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - Adam B. Goldin
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
| | - David H. Rothstein
- From the Nemours-A.I. duPont Hospital for Children, Wilmington, Dle.; Sidney Kimmel College of Medicine, Philadelphia, Pa.; Children’s Hospital Association, Overland Park, Kans.; Emory University, Children’s Healthcare of Atlanta, Atlanta, Ga.; Lehigh Valley Children’s Hospital, Morsani College of Medicine, University of South Florida, Allentown, Pa.; Children’s Mercy Hospital, Kansas City, Mo.; Boston Children’s Hospital, Harvard Medical School, Boston, Mass.; Department of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, Wash.; University of Washington School of Medicine, Seattle, Wash.; Department of Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, N.Y.; and Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, N.Y
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Abstract
Appendicitis is a common cause of abdominal pain in children. The diagnosis and treatment of the disease have undergone major changes in the past two decades, primarily as a result of the application of an evidence-based approach. Data from several randomized controlled trials, large database studies, and meta-analyses have fundamentally affected patient care. The best diagnostic approach is a standardized clinical pathway with a scoring system and selective imaging. Non-operative management of simple appendicitis is a reasonable option in selected cases, with the caveat that data in children remain limited. A minimally invasive (laparoscopic) appendectomy is the current standard in US and European children's hospitals. This article reviews the current 'state of the art' in the evaluation and management of pediatric appendicitis.
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Affiliation(s)
- Rebecca M Rentea
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA.
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas, MO, 64108, USA
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Gould JL, Sharp RJ, Peter SDS, Snyder CL, Juang D, Aguayo P, Fraser JD, Holcomb GW. The Minimally Invasive Repair of Pectus Excavatum Using a Subxiphoid Incision. Eur J Pediatr Surg 2017; 27:2-6. [PMID: 27522122 DOI: 10.1055/s-0036-1587585] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose Several surgeons have documented outcomes following the Nuss operation. Most reports have described the use of thoracoscopy to avoid cardiac injury. Since 1999, our group has utilized a subxiphoid incision, allowing insertion of the surgeon's finger into the substernal space to help guide the bar across the mediastinum. Our initial experience has been reported and we are now reporting our entire experience to date. Methods A retrospective review was conducted on all patients who underwent pectus excavatum repair using a subxiphoid incision from December, 1999 to September, 2015. Results During the study period, 554 repairs were performed. A total of 80% of the patients were male. The mean age was 14.3 years ± 3.1, the mean operating time was 52 minutes ± 17.4, the mean length of stay was 4.2 days ± 1.1, and the mean time to bar removal was 2.7 years ± 0.7. A total of 20 patients (3.6%) received two bars. No patients sustained cardiac injury or evidence of pericarditis. Postoperatively, 22 patients (4%) developed an infection, either cellulitis or a local abscess requiring incision and drainage and/or antibiotics. In four of these 22 patients, the wound infection developed after the bar had been removed. Only one patient required bar removal before 2 years due to an infection. A total of 12 patients required either repositioning of the bar due to rotation (4) or removal of a stabilizer due to chronic discomfort (8), 2 required early bar removal for chronic pain, and 1 patient developed a tension pneumothorax in the operating room. A recurrence has developed in two patients but neither patient has desired correction. Conclusion In this relatively large series of patients, the addition of a subxiphoid incision to the technique has allowed for safe passage of the bar across the mediastinum to avoid cardiac injury during the Nuss operation.
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Affiliation(s)
- Joanna L Gould
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Ronald J Sharp
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shawn David St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - David Juang
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Pablo Aguayo
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Abstract
Appendectomy has been the standard of care for appendicitis since the late 1800s, and remains one of the most common operations performed in children. The advent of data-driven medicine has led to questions about every aspect of the operation-whether appendectomy is even necessary, when it should be performed (timing), how the procedure is done (laparoscopic variants versus open and irrigation versus no irrigation), length of hospital stay, and antibiotic duration. The goal of this analysis is to review the current status of, and available data regarding, the surgical management of appendicitis in children.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108.
| | - Charles L Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, Missouri 64108
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St Peter SD, Snyder CL. Preface. Semin Pediatr Surg 2016; 25:197. [PMID: 27521707 DOI: 10.1053/j.sempedsurg.2016.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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31
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Gonzalez KW, Dalton BGA, Poola AS, Marty Knott E, Kurtz B, Snyder CL, St Peter SD, Holcomb GW. The impact of developing a pectus center for chest wall deformities. Pediatr Surg Int 2016; 32:701-4. [PMID: 27278391 DOI: 10.1007/s00383-016-3904-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE In 2011, we established a dedicated center for patients with chest wall deformities. Here, we evaluate the center's effect on patient volume and management. METHODS A retrospective review of 699 patients with chest wall anomalies was performed. Patients were compared, based on the date of initial consultation, before the pectus center opened (July 2009-June 2011, Group 1) versus after (July 2011-June 2013, Group 2). Analysis was performed utilizing Chi-square and Mann-Whitney U tests. RESULTS 320 patients were in Group 1 and 379 in Group 2, an 18.4 % increase in patient volume. Excavatum patients increased from 172 (Group 1) to 189 (Group 2). Carinatum patients increased from 125 (Group 1) to 165 (Group 2). Patients undergoing operative repair of carinatum/mixed defects dropped significantly from 15 % (Group 1) to 1 % (Group 2) (p < 0.01), whereas those undergoing nonoperative bracing for carinatum/mixed defects rose significantly from 19 % (Group 1) to 63 % (Group 2) (p < 0.01). Patients traveled 3-1249 miles for a single visit. CONCLUSION Initiating a dedicated pectus center increased patient volume and provided an effective transition to nonoperative bracing for carinatum patients. The concentrated focus of medical staff dedicated to chest wall deformities has allowed us to treat patients on a local and regional level.
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Affiliation(s)
- Katherine W Gonzalez
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brian G A Dalton
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Ashwini S Poola
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - E Marty Knott
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Brendan Kurtz
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - George W Holcomb
- Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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32
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Goldin AB, Heiss KF, Hall M, Rothstein DH, Minneci PC, Blakely ML, Browne M, Raval MV, Shah SS, Rangel SJ, Snyder CL, Vinocur CD, Berman L, Cooper JN, Arca MJ. Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement. J Pediatr 2016; 174:139-145.e2. [PMID: 27079966 DOI: 10.1016/j.jpeds.2016.03.032] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/25/2016] [Accepted: 03/10/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To define the incidence of 30-day postdischarge emergency department (ED) visits and hospital readmissions following pediatric gastrostomy tube (GT) placement across all procedural services (Surgery, Interventional-Radiology, Gastroenterology) in 38 freestanding Children's Hospitals. STUDY DESIGN This retrospective cohort study evaluated patients <18 years of age discharged between 2010 and 2012 after GT placement. Factors significantly associated with ED revisits and hospital readmissions within 30 days of hospital discharge were identified using multivariable logistic regression. A subgroup analysis was performed comparing patients having the GT placed on the date of admission or later in the hospital course. RESULTS Of 15 642 identified patients, 8.6% had an ED visit within 30 days of hospital discharge, and 3.9% were readmitted through the ED with a GT-related issue. GT-related events associated with these visits included infection (27%), mechanical complication (22%), and replacement (19%). In multivariable analysis, Hispanic ethnicity, non-Hispanic black race, and the presence of ≥3 chronic conditions were independently associated with ED revisits; gastroesophageal reflux and not having a concomitant fundoplication at time of GT placement were independently associated with hospital readmission. Timing of GT placement (scheduled vs late) was not associated with either ED revisits or hospital readmission. CONCLUSIONS GT placement is associated with high rates of ED revisits and hospital readmissions in the first 30 days after hospital discharge. The association of nonmodifiable risk factors such as race/ethnicity and medical complexity is an initial step toward understanding this population so that interventions can be developed to decrease these potentially preventable occurrences given their importance among accountable care organizations.
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Affiliation(s)
- Adam B Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA.
| | - Kurt F Heiss
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Matt Hall
- Children's Hospital Association, Overland Park, KS
| | | | - Peter C Minneci
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | | | - Marybeth Browne
- Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Mehul V Raval
- Emory University, Children's Healthcare of Atlanta, Atlanta, GA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Shawn J Rangel
- Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Loren Berman
- Nemours-Alfred I. DuPont Hospital for Children, Wilmington, DE
| | - Jennifer N Cooper
- The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Marjorie J Arca
- Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, WI
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Abstract
PURPOSE Factors precipitating persistence of gastrocutaneous fistulas (GCFs) are not clearly understood. The role of proton pump inhibitors (PPIs) or histamine receptor antagonists in GCF closure is not yet studied. We aimed to identify whether these medications influence spontaneous GCF closure. METHODS Retrospective review was performed on children who underwent gastrostomy tube insertion and removal from January 2010 to February 2013. Spontaneous GCF closure rates and medication use during gastrostomy tube removal were investigated. RESULTS Of the 97 patients included, 48 had spontaneous GCF closure, whereas 49 required operative closure. When comparing these two groups, no significant difference existed in spontaneous GCF closure rates among patients who were on ranitidine, PPIs, or both (p = 0.09, p = 0.83, p = 0.06 respectively). Spontaneous closure occurred more in older patients (2.7 ± 4.1 vs. 0.9 ± 1.6 years, p < 0.01) and in patients without fundoplication at time of tube insertion (12.5 vs. 30.6%, p = 0.05). There were more laparoscopic placements in the group that closed spontaneously (83 vs. 61%, p = 0.02). Mean gastrostomy tube presence was longer in patients who required surgery than those with spontaneous closures (18.7 ± 10.3 vs. 35.5 ± 36.6 months, p < 0.01). CONCLUSION Ranitidine or PPI use upon removal of gastrostomy tubes does not seem to facilitate spontaneous GCF closure in children.
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Affiliation(s)
- Priscilla G Thomas
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Nicole E Sharp
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Katherine Schnell
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Charles L Snyder
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States
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Ostlie DJ, Leys CM, Fraser JD, Snyder CL, St. Peter SD. Laparoscopic Orchiopexy Requiring Vascular Division: A Randomized Study Comparing the Primary and Two-Stage Approaches. J Laparoendosc Adv Surg Tech A 2015; 25:536-9. [DOI: 10.1089/lap.2015.0183] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Daniel J. Ostlie
- American Family Children's Hospital, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Charles M. Leys
- American Family Children's Hospital, Department of Surgery, University of Wisconsin, Madison, Wisconsin
| | - Jason D. Fraser
- The Center for Prospective Clinical Trials, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Charles L. Snyder
- The Center for Prospective Clinical Trials, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Shawn D. St. Peter
- The Center for Prospective Clinical Trials, Children's Mercy Hospital and Clinics, Kansas City, Missouri
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Cunningham JP, Knott EM, Gasior AC, Juang D, Snyder CL, St Peter SD, Ostlie DJ. Is routine chest radiograph necessary after chest tube removal? J Pediatr Surg 2014; 49:1493-5. [PMID: 25280653 DOI: 10.1016/j.jpedsurg.2014.01.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2013] [Revised: 01/07/2014] [Accepted: 01/11/2014] [Indexed: 10/25/2022]
Abstract
BACKGROUND Obtaining a chest radiograph (CXR) after chest tube (CT) removal to rule out a pneumothorax is a universal practice. However, the yield of this CXR has not been well documented. Additionally, most iatrogenic pneumothoraces resulting from CT removal are atmospheric in origin, asymptomatic, and can be observed. Recently, we have begun to discontinue routine CXR for CT removal. We evaluated our experience with CT removal to clarify the usefulness of routine post CT removal CXR. METHODS After IRB approval, a retrospective study was conducted on patients who had a CT placed in the past decade. Cardiac patients requiring a CT were excluded. Patient demographics, diagnosis, treatments, and outcomes were collected. Patients were divided into two groups, those with a CXR after CT removal (Group 1) and those without (Group 2). Percentages were compared with Chi square with Yates correction. RESULTS 462 patients were identified (group 1=327, group 2=135). Indications for CT included; empyema (n=176), lung resection (n=146), pneumothorax (n=71), pleural effusion (n=26), spinal fusion (n=20), trauma (n=16), and miscellaneous (n=7). Seven patients (2.1%) in group 1 required reinsertion for pneumothorax (n=4), empyema (n=2), and pleural effusion (n=1) compared to 1 patient (0.7%) in group 2 who required reinsertion for pleural effusion. This difference was not significant (P=0.2). CONCLUSIONS In non-cardiac patients with a CT, tube reinsertion is uncommon and tube replacement is secondary to symptoms. Therefore, routine post CT removal CXR is not necessary. CXR in these patients should be obtained based upon clinical indications after CT removal.
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Affiliation(s)
| | | | | | - David Juang
- The Children's Mercy Hospital, Kansas City, MO
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Alemayehu H, Snyder CL, St Peter SD, Ostlie DJ. Incidence and outcomes of unexpected pathology findings after appendectomy. J Pediatr Surg 2014; 49:1390-3. [PMID: 25148744 DOI: 10.1016/j.jpedsurg.2014.01.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Revised: 12/13/2013] [Accepted: 01/12/2014] [Indexed: 01/25/2023]
Abstract
PURPOSE Pathologic evaluation of the appendix after appendectomy is routine and can identify unexpected findings. We evaluated our experience in children undergoing appendectomy to review the clinical course of patients with unexpected appendiceal pathology. METHODS After IRB approval, a retrospective review was conducted on patients who underwent appendectomy from January 1, 1995 to March 1, 2011. Patient demographics, diagnosis, pathological findings, disease outcomes, and treatment were collected only on patients with abnormal pathology. RESULTS 3602 patients underwent appendectomy. 113 patients had normal appendices, and 86 patients had unexpected findings, including carcinoid tumor (n=9), pinworm (n=34), granuloma (n=14), eosinophilic infiltrates (n=18), and other (n=11). All cases of carcinoid tumor were completely resected, with no recurrence or need for reoperation. Of the 34 patients with pinworm infestation, 41.2% underwent antimicrobial therapy, and none had post-operative symptoms. One patient (7%) with an appendiceal granuloma developed Crohn's disease. Three patients (16.7%) with eosinophilia developed symptomatic intestinal eosinophilia. CONCLUSIONS Pediatric appendiceal carcinoid is an incidental finding; in this series, none required further intervention. Appendiceal granulomas are not commonly associated with developing Crohn's disease in the short term. Routine antibiotics for the treatment of pinworms are adequate. Patients with appendiceal eosinophilia may develop symptomatic intestinal eosinophilia.
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Alemayehu H, Hall M, Desai AA, St Peter SD, Snyder CL. Demographic disparities of children presenting with symptomatic Meckel's diverticulum in children's hospitals. Pediatr Surg Int 2014; 30:649-53. [PMID: 24811048 DOI: 10.1007/s00383-014-3513-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/22/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE Most of the literature about Meckel's diverticulum (MD) consists of single institutional longitudinal case series. We queried the pediatric hospital information system (PHIS) database to obtain information about the epidemiology of MD from a large number of children at geographically diverse locations. METHODS After IRB approval, the PHIS database was queried over a 9-year period for de-identified patients with both ICD-9 diagnoses of MD and a procedure code for Meckel's diverticulectomy. Data from five hospitals were excluded due to incomplete information. RESULTS 4,338,396 were children admitted during the study interval; 945 had a symptomatic MD. The incidence decreased with age: 56.4% were under 5 years old, 26.8% were between the ages of 6-12 years, and 16.8% were older than 12 years. 74% were male, which was significantly higher than the PHIS population (53.8% male, P < 0.0001). Caucasians are over-represented in the symptomatic MD group (63.4%) compared to the rest of the PHIS population (48.1%, P < 0.0001). CONCLUSIONS According to the PHIS data, there appears to be significant gender and race influence on symptomatic MD. Males present more commonly, as do non-Hispanic White patients, while it is less common among non-Hispanic Black patients.
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Affiliation(s)
- Hanna Alemayehu
- Section of General Surgery, Department of Surgery, The Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA
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Adibe OO, Iqbal CW, Sharp SW, Juang D, Snyder CL, Holcomb GW, Ostlie DJ, St Peter SD. Protocol versus ad libitum feeds after laparoscopic pyloromyotomy: a prospective randomized trial. J Pediatr Surg 2014; 49:129-32; discussion 132. [PMID: 24439596 DOI: 10.1016/j.jpedsurg.2013.09.044] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND We conducted a prospective, randomized trial comparing protocol to ad libitum (ad lib) feeding after laparoscopic pyloromyotomy. METHODS Infants undergoing laparoscopic pyloromyotomy were randomized to protocol versus ad lib feeding strategies. The protocol started with Pedialyte® two hours post-operative. This was repeated by another round of Pedialyte®, then two rounds of half-strength formula or breast milk, followed by two rounds of full strength formula or breast milk, followed by the home feeding regimen, at which time the patient was discharged if feeding well. The ad lib group was allowed formula or breast milk two hours after the operation and considered for discharge after tolerating three consecutive feeds. The primary outcome variable was the length of postoperative hospitalization. RESULTS One hundred fifty infants were enrolled between January 2010 and December 2011. There were no differences in patient characteristics at presentation. While the ad lib group reached goal feeds sooner than the protocol group, this did not translate into a difference in duration of postoperative hospitalization. There were more patients with emesis in the ad lib group after goal feeding was reached, but no difference in readmissions. CONCLUSION Ad lib feeding allows patients to reach goal feeds more rapidly than protocol feeding following laparoscopic pyloromyotomy. However, this goal is usually reached beyond discharge hours, resulting in a similar duration of hospitalization.
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Affiliation(s)
- Obinna O Adibe
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - Corey W Iqbal
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - Susan W Sharp
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - David Juang
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - Charles L Snyder
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - George W Holcomb
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - Daniel J Ostlie
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
| | - Shawn D St Peter
- The Center for Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO.
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St Peter SD, Aguayo P, Juang D, Sharp SW, Snyder CL, Holcomb GW, Ostlie DJ. Follow up of prospective validation of an abbreviated bedrest protocol in the management of blunt spleen and liver injury in children. J Pediatr Surg 2013; 48:2437-41. [PMID: 24314183 DOI: 10.1016/j.jpedsurg.2013.08.018] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 08/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Current APSA recommendations for blunt spleen/liver injury (BSLI) entail bedrest equal to grade of injury plus one. We reported our experience 3 years ago with a prospectively implemented abbreviated protocol, one concern of which was that more numbers would be needed to support the safety of such a protocol. We are now reporting the final experience with this protocol as we move forward with further investigation. METHODS Following IRB approval, data were collected prospectively in all patients with BSLI up to 8 weeks after discharge. There were no exclusion criteria, and patient accrual was consecutive. Bedrest was restricted to one night for Grade I & II injuries and two nights for Grade ≥ III. RESULTS Between 11/2006 and 10/2012, 249 patients were admitted with BSLI. Mean age and weight were 10.3±4.8 years and 40.1±19.8 kg, respectively. Injuries included isolated spleen in 130 (52%), liver only in 107 (43%), and both in 12 (5%). One splenectomy was required for a grade V injury. Transfusions were used in 40 patients (16%), with 28 (11%) due to the injured solid organ. Bedrest for solid organ injury was applicable to 199 patients (80%), for which the mean grade of injury was 2.7±1.0 and mean bedrest was 1.6±0.6 days, resulting in 2.5±1.9 days of hospitalization. The need for bedrest was the limiting factor for length of stay in 155 patients (62%), for which mean grade of injury was 2.5±1.0 and mean bedrest was 1.6±0.6 days, resulting in 1.7±0.8 days of hospitalization. There were 4 deaths, 3 from brain injury and 1 from grade V liver injury. There were no patients readmitted for complications of solid organ injury. CONCLUSIONS These data further validate that an abbreviated protocol of one night of bedrest for grade I and II injuries and two nights for grade ≥ III can be safely employed, resulting in dramatic decreases in hospitalization compared to the current APSA recommendations.
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Affiliation(s)
- Shawn D St Peter
- The Center For Prospective Clinical Trials The Children's Mercy Hospital Kansas City, MO
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Gasior AC, Knott EM, Fike FB, Moratello VE, St. Peter SD, Ostlie DJ, Snyder CL. Ghost publications in the pediatric surgery match. J Surg Res 2013; 184:37-41. [DOI: 10.1016/j.jss.2013.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Revised: 04/09/2013] [Accepted: 04/17/2013] [Indexed: 10/26/2022]
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Gasior AC, Knott EM, Sharp SW, Snyder CL, St Peter SD. Predictive factors for successful balloon catheter extraction of esophageal foreign bodies. Pediatr Surg Int 2013; 29:791-4. [PMID: 23793986 DOI: 10.1007/s00383-013-3331-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/11/2013] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Foreign bodies in the esophagus are common in children. Time from ingestion to presentation is variable, and may not be known. Our center usually performs Foley catheter balloon extraction under fluoroscopy as the first step to attempt removal to prevent all patients from going to the operating room. The efficacy of this procedure has been reported. However, information is lacking about the relationship between presentation variables and the likelihood of success. METHODS After IRB approval, we performed a retrospective single-center review from January 1988 to August 2011 of children with an esophageal foreign body. Pearson's correlation was used to evaluate the relationship between variables and successful balloon extraction for P < 0.05. A logistic regression was done to evaluate for independence. RESULTS 819 patients presented with esophageal foreign bodies, with a mean age of 3.3 years. 572 patients underwent balloon extraction, 83 % successful. Mean ingestion duration was 16.6 h with fluoroscopy time of 2.3 min and mean number of attempts was 1.5. Successful balloon extraction had a negative correlation with refusal to eat, respiratory distress, cough, wheeze, upper respiratory infection symptoms, stridor, fever, duration of ingestion >1 day, unwitnessed ingestion, fluoroscopy time and number of balloon catheter attempts. There was a positive correlation between success and both age and duration of ingestion <1 day. Independent predictive factors were number of balloon catheter attempts. CONCLUSIONS Patients with longer duration of ingestion, symptoms from the foreign body and increased number of removal attempts have a decreased likelihood of success with balloon catheter extraction and should not undergo prolonged efforts of removal.
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Affiliation(s)
- Alessandra C Gasior
- Department of Pediatric Surgery, Children's Mercy Hospital and Clinics, 2401 Gillham Road, Kansas City, MO 64108, USA
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Ostlie DJ, Juang OOAD, Iqbal CW, Sharp SW, Snyder CL, Andrews WS, Sharp RJ, Holcomb GW, St Peter SD. Single incision versus standard 4-port laparoscopic cholecystectomy: a prospective randomized trial. J Pediatr Surg 2013; 48:209-14. [PMID: 23331817 DOI: 10.1016/j.jpedsurg.2012.10.039] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 10/13/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Laparoscopy through a single umbilical incision is an emerging technique supported by case series, but prospective comparative data are lacking. Therefore, we conducted a prospective, randomized trial comparing single site umbilical laparoscopic cholecystectomy to 4-port laparoscopic cholecystectomy. METHODS After IRB approval, patients were randomized to laparoscopic cholecystectomy via a single umbilical incision or standard 4-port access. The primary outcome variable was operative time. Utilizing a power of 0.8 and an alpha of 0.05, 30 patients were calculated for each arm. Patients with complicated disease or weight over 100 kg were excluded. Post-operative management was controlled. Surgeons subjectively scored degree of technical difficulty from 1=easy to 5=difficult. RESULTS From 8/2009 through 7/2011, 60 patients were enrolled. There were no differences in patient characteristics. Operative time and degree of difficulty were greater with the single site approach. There were more doses of analgesics used and greater hospital charges in the single site group that trended toward significance. CONCLUSION Single site laparoscopic cholecystectomy produces longer operative times with a greater degree of difficulty as assessed by the surgeon. There was a trend toward more doses of post-operative analgesics and greater hospital charges with the single site approach.
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Affiliation(s)
- Daniel J Ostlie
- The Center for Prospective Clinical Trials, The Children's Mercy Hospital, Kansas City, MO, USA.
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Fike FB, Mortellaro VE, Iqbal CW, Sharp SW, Ostlie DJ, Holcomb GW, Sharp RJ, Snyder CL, St Peter SD. Experience with a simple technique for pectus bar removal. J Pediatr Surg 2012; 47:490-3. [PMID: 22424343 DOI: 10.1016/j.jpedsurg.2011.07.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Revised: 06/20/2011] [Accepted: 07/22/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND There have been numerous reports of techniques used for pectus bar removal after correction of pectus excavatum. We use 2 operating tables positioned perpendicular to each other in a T-shaped configuration with the patients thorax circumferentially exposed so the bar is removed in 1 motion without bending the bar. In this study, we report the results of this procedure. METHODS A retrospective chart review of patients undergoing bar removal after repair of pectus excavatum at our institution from August 2000 to March 2010 was performed. RESULTS There were 230 patients with a mean age of 16.7 years (range, 7.8-25.3 years) at bar removal. Mean operative time for bar removal was 28.6 minutes, and average estimated blood loss (EBL) was 9.5 mL (range, 5-400 mL). One patient demonstrated significant hemorrhage from the bar tract after bar removal, which was controlled with circumferential compression wrap. Calcification was noted in 11 patients, and chondroma, in 8 patients. Wound infection after bar removal occurred in 3% of patients. No patient required the bar to be bent into a straight configuration for removal. CONCLUSIONS Removal of pectus bars using this 2-table T-configuration technique is safe, is time efficient, and obviates the need for bending the bar.
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Affiliation(s)
- Frankie B Fike
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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Juang D, Garey CL, Ostlie DJ, Snyder CL, Holcomb GW, St. Peter SD. Contralateral Inguinal Hernia After Negative Laparoscopic Evaluation: A Rare But Real Phenomenon. J Laparoendosc Adv Surg Tech A 2012; 22:200-2. [DOI: 10.1089/lap.2011.0092] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- David Juang
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
| | - Carrisa L. Garey
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
| | - Daniel J. Ostlie
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
| | - Charles L. Snyder
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
| | - George W. Holcomb
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
| | - Shawn D. St. Peter
- Department of Surgery, Center for Prospective Clinical Trials, Children's Mercy Hospital, Kansas City, Missouri
- Presented at the International Pediatric Endosurgery Group's 20th Annual Congress for Endosurgery in Children, Prague, Czechoslovakia, May 3–7, 2011
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St Peter SD, Weesner KA, Weissend EE, Sharp SW, Valusek PA, Sharp RJ, Snyder CL, Holcomb GW, Ostlie DJ. Epidural vs patient-controlled analgesia for postoperative pain after pectus excavatum repair: a prospective, randomized trial. J Pediatr Surg 2012; 47:148-53. [PMID: 22244408 DOI: 10.1016/j.jpedsurg.2011.10.040] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 10/08/2011] [Indexed: 11/25/2022]
Abstract
PURPOSE Management of postoperative pain is a challenge after the minimally invasive repair of pectus excavatum. Pain is usually managed by either a thoracic epidural or patient-controlled analgesia with intravenous narcotics. We conducted a prospective, randomized trial to evaluate the relative merits of these 2 pain management strategies. METHODS After obtaining permission/assent (Institutional Review Board no. 06 08 128), patients were randomized to either epidural or patient-controlled analgesia with fixed protocols for each arm. The primary outcome variable was length of stay with a power of .8 and α of .05. RESULTS One hundred ten patients were enrolled. There was no difference in length of stay between the 2 arms. A longer operative time, more calls to anesthesia, and greater hospital charges were found in the epidural group. Pain scores favored epidural for the few days and favored patient-controlled analgesia thereafter. The epidural catheter could not be placed or was removed within 24 hours in 12 patients (22%). CONCLUSIONS There is longer operating room time, increase in calls to anesthesia, and greater hospital charges with epidural analgesia after repair of pectus excavatum. Pain scores favor the epidural approach early in the postoperative course and patient-controlled analgesia later.
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Affiliation(s)
- Shawn D St Peter
- Department of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA.
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St Peter SD, Juang D, Garey CL, Laituri CA, Ostlie DJ, Sharp RJ, Snyder CL. A novel measure for pectus excavatum: the correction index. J Pediatr Surg 2011; 46:2270-3. [PMID: 22152863 DOI: 10.1016/j.jpedsurg.2011.09.009] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Accepted: 09/03/2011] [Indexed: 12/01/2022]
Abstract
OBJECTIVE The Haller Index (HI), the standard metric for the severity of pectus excavatum, is dependent on width and does not assess the depth of the defect. Therefore, we performed a diagnostic analysis to assess the ability of HI to separate patients with pectus excavatum from healthy controls compared to a novel index. METHODS After institutional review board approval, computed tomography scans were evaluated from patients who have undergone pectus excavatum repair and controls. The correction index (CI) used the minimum distance between posterior sternum and anterior spine and the maximum distance between anterior spine most anterior portion of the chest. The difference between the two is divided by the latter (×100) to give the percentage of chest depth the defect represents. RESULTS There were 220 controls and 252 patients with pectus. Mean HI was 2.35, and the mean CI was 0.92 for the controls. The mean HI was 4.06, and the mean CI was 31.75 in the patients with pectus. In the patients with pectus, HI demonstrated a 47.8% overlap with the controls, while there was no overlap for CI. CONCLUSIONS The Haller index demonstrates 48% overlap between normal patients and those with pectus excavatum. However, the proposed correction index perfectly separates the normal and diseased populations.
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Fraser JD, Aguayo P, St Peter S, Ostlie DJ, Holcomb GW, Andrews WA, Murphy JP, Sharp RJ, Snyder CL. Analysis of the pediatric surgery match: factors predicting outcome. Pediatr Surg Int 2011; 27:1239-44. [PMID: 21523340 DOI: 10.1007/s00383-011-2912-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2011] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Applicants in the NRMP for pediatric surgery have little objective data available regarding factors predicting successful matching. We analyzed data from applicants at our institution to attempt to identify parameters correlated with three outcomes: successfully matching, or attaining either a top ten or top three ranking in our final submitted match list. METHODS After IRB approval, we reviewed ERAS documents for all applicants (n = 146) over 3 years (candidates for the 2007, 2008, and 2009 fellowship years). An interview was offered to 75% of the applicants (Table 1). We analyzed over 20 factors; including demographics, number of publications and first author publications, number of book chapters, national presentations, prior match attempts, advanced degrees, quality of recommendation letters, and ABSITE scores. Significant variables were evaluated with multiple logistic regression analysis to identify independent predictors. RESULTS Variables correlated with successful outcome for each of the three endpoints are shown in Table 2. The number of peer-reviewed publications and first author publications, and AOA membership were highly correlated with a favorable outcome for all three endpoints. High ABSITE scores were significantly correlated with top ten rank. Research experience and outstanding letters of recommendation were significantly associated with a top ten ranking and overall match success. Variables associated only with overall match success included number of book chapters, graduation from a US medical school, quality of recommendation letters, and being granted an interview at our institution. Logistic regression analysis demonstrated no independent factors for overall match success; number of publications was significant for both top ten and top three ranking (P = 0.006 for each); number of first author publications (P = 0.002) and AOA membership (P = 0.03) were independent predictors for top three ranking. CONCLUSIONS Applicant variables associated with success in the match included quality of letters, number and type of publications, research experience, graduation from a US medical school, and AOA membership. Factors not correlated with outcome included advanced degrees (PhD, Masters), other fellowship training, and community-based versus university-based residency training. Logistic regression analysis demonstrated no independent factors for overall match success.
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Affiliation(s)
- Jason D Fraser
- Department of Surgery, The Children's Mercy Hospital, Kansas, MO 64108, USA
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Abstract
BACKGROUND Children with anterior mediastinal masses are at risk for life-threatening airway compromise during anesthesia, and can present a diagnostic and management challenge for pediatric surgeons. METHODS We performed a retrospective chart review of all children presenting with an anterior mediastinal mass from 1994-2009. Parameters studied included demographics, historical and physical findings at diagnosis, radiographic evidence of airway compression, diagnostic studies, diagnosis, and complications. RESULTS There were 26 patients with anterior mediastinal masses over a 15-year period. The mean age was 11.3 years, and there were no gender differences. The diagnoses were lymphoma (62%, 16/26), leukemia (15%, 4/26), and other (23%, 6/26). Diagnosis was made by CBC/peripheral smear in 2/4 patients with leukemia, by bone marrow biopsy in 2/4 patients with leukemia, by thoracentesis in 3/16 patients with lymphoma, by lymph node biopsies in 6/16 patients with lymphoma, and by biopsy of a mediastinal mass in 7/16 patients with lymphoma and in 6/6 patients with other diagnoses. Radiographic evidence of airway compression was seen in 62% (16/26) of children. Only 12% (3/26) had a tracheal cross-sectional area (TCA) <50%. Correlation of symptoms with anatomical airway obstruction or complications was poor. Pulmonary function studies were obtained in 38%, 10/26 children. Only 2 children had a PEFR (peak expiratory flow rate) <50% predicted. This data also correlated poorly with anatomical airway obstruction or complications. 3 patients had anesthesia-related complications: one desaturation during induction prior to median sternotomy, one with significant desaturation and bradycardia during biopsy under local anesthesia with minimal sedation, and one with prolonged (5 days) mechanical ventilation after general anesthesia. 2 of these patients had a TCA <50%, and 2 had SVC obstructions. There were no anesthesia-related deaths, and the overall survival was 85% (22/26). CONCLUSION Anterior mediastinal masses in children should be approached in a step-wise fashion with multi-disciplinary involvement, starting with the least invasive techniques and progressing cautiously. The surgeon should have a well-defined and preoperatively established contingency plan if these children require general anesthesia for diagnosis.
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Affiliation(s)
- C L Garey
- Department of Surgery, Children's Mercy Hospital, Kansas City 64108, United States
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Mortellaro VE, Juang D, Fike FB, Saites CG, Potter DD, Iqbal CW, Snyder CL, St. Peter SD. Treatment of Appendicitis in Neutropenic Children. J Surg Res 2011; 170:14-6. [PMID: 21514602 DOI: 10.1016/j.jss.2011.03.061] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Revised: 03/07/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022]
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Laituri CA, Valusek PA, Rivard DC, Garey CL, Ostlie DJ, Snyder CL, St Peter SD. The utility of computed tomography in the management of patients with spontaneous pneumothorax. J Pediatr Surg 2011; 46:1523-5. [PMID: 21843718 DOI: 10.1016/j.jpedsurg.2011.01.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Revised: 01/04/2011] [Accepted: 01/06/2011] [Indexed: 02/02/2023]
Abstract
BACKGROUND Spontaneous pneumothorax may result from rupture of subpleural blebs. Computed tomography (CT) has been used to identify blebs to serve as an indication for thoracoscopy. We reviewed our experience with spontaneous pneumothorax to assess the utility of CT in these patients. METHODS A retrospective review was conducted of all patients who underwent an operation for spontaneous pneumothorax from January 1999 to October 2009. All procedures were performed thoracoscopically. RESULTS We identified 39 pneumothoraces in 34 patients who underwent evaluation and a procedure for spontaneous pneumothorax. Mean age was 16.1 years (range, 10-23 years), with an average of 1.7 spontaneous pneumothoraces before operation (range, 1-4). Preoperative chest CT scans were obtained in 26 cases. Blebs were demonstrated on 8 CT scans. The presence of blebs was confirmed at operation in all 8 patients. Of the 18 negative scans, 14 (77.8%) were found to have blebs intraoperatively, 7 of these patients were initially managed nonoperatively and developed recurrence. The sensitivity of CT for identifying blebs was 36%. CONCLUSIONS Chest CT does not appear to be precise in the identification of pleural blebs and a negative examination does not predict freedom from recurrence. Operative decisions should be based on clinical judgment without the use of preoperative CT.
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Affiliation(s)
- Carrie A Laituri
- Department of Surgery, Children's Mercy Hospital, Kansas City, MO 64108, USA
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