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O'Guinn ML, Keane OA, Lee WG, Gayer CP, Zobel MJ. A Standardized Post-gastrostomy Feeding Protocol for Pediatric Patients Reduces Time to Postoperative Goal Feeding Volume. Am Surg 2024:31348241248789. [PMID: 38684325 DOI: 10.1177/00031348241248789] [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: 05/02/2024]
Abstract
BACKGROUND Gastrostomy creation is a common pediatric surgical procedure, but the time to initiation of feeds and to goal feeding volumes postoperatively varies greatly. Delays in reaching goal feeding volumes promote malnutrition and may prolong hospital length of stay. We hypothesized that implementing an accelerated, standardized post-gastrostomy feeding protocol would allow patients to reach goal feeding volumes sooner, without increasing postoperative complications. METHODS We conducted a retrospective cohort study of children who underwent gastrostomy tube placement between 1/1/2022 and 11/30/2023. The feeding protocol was implemented on 11/16/2022, with patients separated into pre- and post-protocol cohorts. Abstracted data included comorbidities, time to initiation of enteral feeds, time to goal feeding volume, and postoperative complications. RESULTS 322 patients were included: 166 pre-protocol and 156 post-protocol. The post-protocol cohort had a greater proportion of patients with gastrointestinal and/or cardiac comorbidities (P < .001). Through the protocol, postoperative enteral feeds were initiated significantly faster (5.4 hrs [IQR 43-7.7] vs 7.0 hrs [IQR 5.6-14.3]; P < .001). The post-protocol cohort also achieved goal feeding volumes sooner (12.8 hrs [IQR 9.1-25.3] vs 26.3 hrs [IQR 21.6-38.9]; P < .001). Postoperative complication rates did not differ between cohorts. Sub-analysis of children with complex cardiac conditions also demonstrated faster time to goal nutrition without an associated increase in postoperative events. DISCUSSION These findings demonstrate that our accelerated post-gastrostomy feeding protocol was effective in achieving goal enteral nutrition earlier without increasing postoperative adverse outcomes. This protocol may be used by other centers to safely expedite time to goal enteral feeds in children postoperatively.
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Affiliation(s)
- MaKayla L O'Guinn
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Olivia A Keane
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - William G Lee
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Christopher P Gayer
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
- Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Michael J Zobel
- Department of Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
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Lascano D, Zobel MJ, Lee WG, Chen SY, Zamora A, Asuelime GE, Choi SY, Chronopoulos A, Asgharzadeh S, Marachelian A, Park J, Sheard MA, Kim ES. Anti-CCL2 antibody combined with etoposide prolongs survival in a minimal residual disease mouse model of neuroblastoma. Sci Rep 2023; 13:19915. [PMID: 37964011 PMCID: PMC10645976 DOI: 10.1038/s41598-023-46968-2] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 11/07/2023] [Indexed: 11/16/2023] Open
Abstract
C-C motif chemokine ligand 2 (CCL2) is a monocyte chemoattractant that promotes metastatic disease and portends a poor prognosis in many cancers. To determine the potential of anti-CCL2 inhibition as a therapy for recurrent metastatic disease in neuroblastoma, a mouse model of minimal residual disease was utilized in which residual disease was treated with anti-CCL2 monoclonal antibody with etoposide. The effect of anti-CCL2 antibody on neuroblastoma cells was determined in vitro with cell proliferation, transwell migration, and 2-dimensional chemotaxis migration assays. The in vivo efficacy of anti-CCL2 antibody and etoposide against neuroblastoma was assessed following resection of primary tumors formed by two cell lines or a patient-derived xenograft (PDX) in immunodeficient NOD-scid gamma mice. In vitro, anti-CCL2 antibody did not affect cell proliferation but significantly inhibited neuroblastoma cell and monocyte migration towards an increasing CCL2 concentration gradient. Treatment of mice with anti-CCL2 antibody combined with etoposide significantly increased survival of mice after resection of primary tumors, compared to untreated mice.
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Affiliation(s)
- Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Michael J Zobel
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - William G Lee
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Abigail Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Grace E Asuelime
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - So Yung Choi
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Antonios Chronopoulos
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Shahab Asgharzadeh
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Araz Marachelian
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Jinseok Park
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Michael A Sheard
- The Saban Research Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA, USA.
- Division of Hematology, Oncology and Blood and Marrow Transplantation, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
- Department of Surgery, Cedars-Sinai Medical Center, 116 N. Robertson Blvd, Suite PACT 700, Los Angeles, CA, 90048, USA.
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Harris CJ, Helenowski I, Murphy AJ, Mansfield SA, LaQuaglia MP, Heaton TE, Cavalli M, Murphy JT, Newman E, Overmen RE, Kartal TT, Cooke-Barber J, Donaher A, Malek MM, Kalsi R, Kim ES, Zobel MJ, Goodhue CJ, Naik-Mathuria BJ, Jefferson IN, Roach JP, Mata C, Piché N, Joharifard S, Sultan S, Short SS, Meyers RL, Bleicher J, Le HD, Janek K, Bütter A, Davidson J, Aldrink JH, Richards HW, Tracy ET, Commander SJ, Fialkowski EA, Troutt M, Dasgupta R, Lautz TB. Implications of Tumor Characteristics and Treatment Modality on Local Recurrence and Functional Outcomes in Children With Chest Wall Sarcoma: A Pediatric Surgical Oncology Research Collaborative Study. Ann Surg 2022; 276:e969-e975. [PMID: 33156070 PMCID: PMC8093319 DOI: 10.1097/sla.0000000000004579] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development, and (3) patient-reported quality of life in children with sarcoma of the chest wall. SUMMARY OF BACKGROUND DATA Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery, and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence. METHODS A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008 and 2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys. RESULTS The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (interquartile range = 1-3), and number of ribs resected did not correlate with margin status ( P = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor(HR 2.24, P = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posteriorrib resection (HR 8.43; P= 0.003) and increased number of ribs resected (HR 1.78; P = 0.02). Overall, patient-reported quality of life is not impaired after chest wall tumor resection. CONCLUSIONS Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent.
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Affiliation(s)
- Courtney J Harris
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Irene Helenowski
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Andrew J Murphy
- Division of General Pediatric Surgery, Surgery Department, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Sara A Mansfield
- Division of General Pediatric Surgery, Surgery Department, St Jude Children’s Research Hospital, Memphis, Tennessee
| | - Michael P LaQuaglia
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Todd E Heaton
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Michele Cavalli
- Division of Pediatric Surgery, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Joseph T Murphy
- Division of Pediatric Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Erika Newman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor MI
| | - Richard E Overmen
- Section of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor MI
| | - Tanvi T Kartal
- Section of Pediatric Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor MI
| | - Jo Cooke-Barber
- Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Addison Donaher
- Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ranjeet Kalsi
- Division of Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Eugene S Kim
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Catherine J Goodhue
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Bindi J Naik-Mathuria
- Division of Pediatric Surgery, Department of Surgery, Texas Children’s Hospital, Houston, Texas
| | - Imory N Jefferson
- Division of Pediatric Surgery, Department of Surgery, Texas Children’s Hospital, Houston, Texas
| | - Jonathan P Roach
- Children’s Hospital of Colorado, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - Claudia Mata
- Children’s Hospital of Colorado, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado
| | - Nelson Piché
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Ste-Justine, Montreal, Quebec, Canada
| | - Shahrzad Joharifard
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Los Angeles, California
| | - Serge Sultan
- Department of Psychology and Pediatrics, University of Montreal, Centre Hospitalier Universitaire Ste-Justine Research Center, Montreal, Quebec, Canada
| | - Scott S Short
- Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Rebecka L Meyers
- Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Josh Bleicher
- Division of Pediatric Surgery, Primary Children’s Hospital, University of Utah School of Medicine, Salt Lake City, Utah
| | - Hau D Le
- Division of Pediatric Surgery, American Family Children’s Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin Janek
- Division of Pediatric Surgery, American Family Children’s Hospital, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Andreana Bütter
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jacob Davidson
- Division of Pediatric Surgery, Children’s Hospital, London Health Sciences Centre, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Holden W Richards
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Sarah J Commander
- Division of Pediatric Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Elizabeth A Fialkowski
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, Oregon
| | - Misty Troutt
- Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Roshni Dasgupta
- Division of Pediatric Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Lascano D, Zobel MJ, Chen SY, Sheard MA, Kim ES. C-C Motif Chemokine Ligand 2 Inhibitor with Chemotherapy Prolongs Survival in a Minimal Residual Disease Mouse Model of Metastatic Neuroblastoma. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.368] [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: 11/28/2022]
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Zobel MJ, Nowicki D, Gomez G, Lee J, Howell L, Miller J, Zeinati C, Anselmo DM. Management of cervicofacial lymphatic malformations requires a multidisciplinary approach. J Pediatr Surg 2021; 56:1062-1067. [PMID: 33982660 DOI: 10.1016/j.jpedsurg.2020.09.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/03/2020] [Revised: 09/09/2020] [Accepted: 09/17/2020] [Indexed: 01/18/2023]
Abstract
BACKGROUND/PURPOSE Cervicofacial lymphatic malformations (CFLM) are rare, potentially life-threatening vascular anomalies, yet reports on multidisciplinary treatment strategies are lacking. We evaluated outcomes for CFLMs following sclerotherapy, surgical resection, and/or medical management. METHODS We identified children with a CFLM at a vascular anomalies center from 2004 to 2019. EXCLUSION CRITERIA retro-orbital malformations, untreated malformations, patients without follow-up. Primary clinical outcome was contour improvement, with significance defined as LM volume reduction of >50% by cross-sectional imaging. RESULTS Sixty-three children met inclusion criteria: 35 with macrocystic CFLMs, six with microcystic CFLMs, and 22 with mixed-type malformations. Mean post-intervention follow-up was 27.5 months. Fifty-eight patients underwent sclerotherapy (median: two treatments). Doxycycline and/or bleomycin were used in 95% of patients. After sclerotherapy, 97% of macrocystic CFLMs improved significantly compared to 82% of mixed and 67% of microcystic lesions. Sixteen children underwent surgical resection with 75% significantly improving; two additional patients were successfully treated with sclerotherapy after debulking surgery. Six children received sirolimus for microcystic disease, of which 33% significantly improved. CONCLUSION Sclerotherapy is very effective for macrocystic components of CFLMs, albeit less so for microcystic disease. Microcystic CFLMs frequently require surgical resection. Sirolimus is a helpful therapeutic adjunct, particularly for microcystic lesions, but more study is needed. LEVEL OF EVIDENCE Level II, prognosis study.
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Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Donna Nowicki
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Gabriel Gomez
- Division of Otolaryngology - Head and Neck Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027; Department of Surgery, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, USA 90089
| | - Jessica Lee
- Department of Surgery, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, USA 90089; Division of Pediatric Plastic and Maxillofacial Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Lori Howell
- Department of Surgery, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, USA 90089; Division of Pediatric Plastic and Maxillofacial Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Joseph Miller
- Division of Interventional Radiology, Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Chadi Zeinati
- Division of Interventional Radiology, Department of Radiology, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027
| | - Dean M Anselmo
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., MS#100, Los Angeles, CA, USA 90027; Department of Surgery, Keck School of Medicine, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, USA 90089.
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Zobel MJ, Moses W, Walther A, Nowicki D, Howell L, Miller J, Zeinati C, Anselmo DM. Management challenges of a large upper extremity vascular malformation in a patient with capillary malformation-arteriovenous malformation syndrome. J Vasc Surg Venous Lymphat Disord 2020; 9:781-784. [PMID: 32687897 DOI: 10.1016/j.jvsv.2020.07.001] [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] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/07/2020] [Indexed: 12/01/2022]
Abstract
We describe a 17-year-old boy with capillary malformation-arteriovenous malformation syndrome and a massive vascular malformation of the right chest wall, shoulder, and upper arm. Persistent growth of the malformation caused cutaneous ulcerations and recurrent massive bleeding episodes. We proceeded with a modified shoulder disarticulation preceded by ligation of the subclavian artery and innominate vein by median sternotomy. After a staged debulking resection of the residual chest wall arteriovenous malformation with rotational transverse rectus abdominis myocutaneous flap coverage, the patient was discharged home safely. This report demonstrates that a multidisciplinary approach is critical for management of life-threatening complications in capillary malformation-arteriovenous malformation patients.
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Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Willieford Moses
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Ashley Walther
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif
| | - Donuta Nowicki
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Lori Howell
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif; Division of Pediatric Plastic and Maxillofacial Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Joseph Miller
- Division of Interventional Radiology, Department of Radiology, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Chadi Zeinati
- Division of Interventional Radiology, Department of Radiology, Children's Hospital Los Angeles, Los Angeles, Calif
| | - Dean M Anselmo
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, Calif.
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Zobel MJ, Padilla BE. Surgical management of benign thyroid disease in children. Semin Pediatr Surg 2020; 29:150922. [PMID: 32571507 DOI: 10.1016/j.sempedsurg.2020.150922] [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: 11/24/2022]
Abstract
Benign thyroid disease in children represents a wide spectrum of disease. While most benign thyroid disorders may be either monitored or managed medically, surgery is an important treatment, particularly for Graves' disease or large multinodular goiters. Multidisciplinary teams including specialists in pediatric endocrinology, genetics, radiology, pathology and surgery at high volume centers offer the safest and most effective management.
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Affiliation(s)
- Michael J Zobel
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ
| | - Benjamin E Padilla
- Department of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, AZ.
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Zamora AK, Zobel MJ, Ourshalimian S, Zhou S, Shillingford NM, Kim ES. The Effect of Gross Total Resection on Patients with Pleuropulmonary Blastoma. J Surg Res 2020; 253:115-120. [PMID: 32353636 DOI: 10.1016/j.jss.2020.03.019] [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] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/01/2020] [Accepted: 03/08/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pleuropulmonary blastoma (PPB) is the most common primary lung cancer in children. While rare, these tumors are highly aggressive. Tumor recurrence and overall survival are dependent on histologic grade and extent of surgical resection. We sought to examine our institutional experience with PPB to determine the effect of gross total resection (GTR) on recurrence and patient outcomes. MATERIALS AND METHODS After IRB approval, a retrospective chart review from 1998 to 2018 was performed. Cases were confirmed by histology and Dehner Grade (I to III). Data collection included demographics, treatment, extent of surgical resection, and patient outcomes. RESULTS Eight patients with nine procedures were identified. Histologically, three cases were type 1, 2 type 2, and four poor prognosis type 3. Three patients received neoadjuvant chemotherapy to facilitate surgical resection. The operative goal was to achieve GTR (>95%), and to this end, three partial lobectomies, five lobectomies, and one pneumonectomy were performed. All nine cases achieved GTR, of which eight had negative microscopic margins. Two patients with type III disease recurred (one locally, one distant) and died. One type 3 patient had a positive microscopic hilar margin not amenable to further resection. The patient recurred (distant) but is in remission. With respect to patient outcomes, the event-free survival was 2.3 y with an overall survival of 3.3 y. CONCLUSIONS From our experience, GTR of PPB is associated with minimal surgical morbidity and good overall survival. Multi-institutional studies are needed to determine if positive surgical margins affect outcomes given the morbidity of mediastinal dissection.
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Affiliation(s)
- Abigail K Zamora
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Michael J Zobel
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Shengmei Zhou
- Department of Pathology and Laboratory Medicine, Children's Hospital, Los Angeles, California
| | - Nick M Shillingford
- Department of Pathology and Laboratory Medicine, Children's Hospital, Los Angeles, California
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
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Zobel MJ, Long R, Gosnell J, Sosa JA, Padilla BE. Postoperative Hypoparathyroidism After Total Thyroidectomy in Children. J Surg Res 2020; 252:63-68. [PMID: 32234570 DOI: 10.1016/j.jss.2020.02.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [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: 12/09/2019] [Revised: 01/17/2020] [Accepted: 02/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Postoperative hypocalcemia because of hypoparathyroidism is the most common complication of total thyroidectomy in children. We hypothesized that most children with postoperative hypocalcemia would be eucalcemic by 12 mo and sought to define risk factors for permanent hypoparathyroidism. METHODS We retrospectively reviewed children who underwent total thyroidectomy at a single children's hospital from 2012 to 2019. Patients with prior neck surgery were excluded. Indication for operation, final pathologic diagnosis, and postoperative serum calcium up to 12 mo were recorded. Permanent hypoparathyroidism was defined as supplemental calcium requirement beyond 1 y postoperatively. RESULTS Sixty-eight patients underwent total thyroidectomy. Graves' disease was the most common benign indication for surgery (38 patients). Twenty-six patients (38%) had cancer on final pathology. Central lymph node dissection (CLND) was performed in 12 cancer patients. Twenty-eight patients (41%) had postoperative hypocalcemia. Eight patients (12%) had hypocalcemia at 6 mo. Risk factors for hypoparathyroidism at 6 mo were a cancer diagnosis (odds ratio [OR] 6.7; P = 0.02), CLND (OR 12.6; P < 0.01), and parathyroid tissue in the surgical specimen on pathologic analysis (OR 19.5; P < 0.01). Only two patients (3%) developed permanent hypoparathyroidism, both of whom had thyroidectomy for cancer and underwent CLND. CONCLUSIONS Children with thyroid cancer are at high risk for postoperative hypocalcemia after total thyroidectomy. The risk is further increased by CLND, which should be performed selectively. A majority of patients with hypoparathyroidism at 6 mo postoperatively regain normal parathyroid function by 1 y. Permanent hypoparathyroidism in children after total thyroidectomy at a pediatric endocrine surgery center is rare.
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Affiliation(s)
- Michael J Zobel
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Roger Long
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California San Francisco, San Francisco, California
| | - Jessica Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Julie Ann Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Benjamin E Padilla
- Department of Surgery, University of California San Francisco, San Francisco, California.
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Zobel MJ, Ewbank C, Mora R, Idowu O, Kim S, Padilla BE. The incidence of neuropathic pain after intercostal cryoablation during the Nuss procedure. Pediatr Surg Int 2020; 36:317-324. [PMID: 31760443 DOI: 10.1007/s00383-019-04602-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [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] [Accepted: 11/14/2019] [Indexed: 01/02/2023]
Abstract
PURPOSE Intercostal nerve cryoblation during the Nuss procedure for pectus excavatum decreases pain, opiate requirement, and hospital length of stay (LOS) compared to thoracic epidural analgesia. However, long-term complications of cryoablation, including neuropathic pain development, are not well studied. METHODS We conducted a multi-institutional retrospective review of patients following intercostal nerve cryoablation during Nuss bar insertion (11/2015-7/2018). Patients completed the Leeds Assessment of Neuropathic Symptoms and Signs, a validated questionnaire for detecting neuropathic symptoms. Primary outcome was neuropathic pain development. Secondary outcomes included duration of chest numbness and LOS. T test was performed; p < 0.05 is significant. RESULTS 43 patients underwent intercostal cryoablation during the Nuss procedure. Ages at repair ranged 11-47 years (median 16). Patients were grouped by age: ≤ 21 years (30 patients) or older (13 patients). Mean LOS was shorter for the younger group, 2.0 versus 3.9 days (p = 0.03). No patients in the younger group, and three in the older, experienced neuropathic pain. Mean time to numbness resolution was shorter for the younger group, 3.4 versus 10.8 months (p = 0.003). CONCLUSION In pediatric patients, intercostal cryoablation provides effective analgesia following the Nuss procedure with minimal risk of post-operative neuropathic pain. Adult patients are at greater risk of experiencing neuropathic pain and prolonged numbness.
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Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Clifton Ewbank
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Roberta Mora
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA
| | - Olajire Idowu
- Division of Pediatric Surgery, Department of Surgery, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | - Sunghoon Kim
- Division of Pediatric Surgery, Department of Surgery, UCSF Benioff Children's Hospital Oakland, 747 52nd Street, Oakland, CA, 94609, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, 550 16th Street, Fifth Floor, San Francisco, CA, 94158-0570, USA.
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Zobel MJ, McFarland C, Ferrera-Cook CT, Padilla BE. Surgical management of medically-refractory hyperinsulinism. Am J Surg 2019; 219:947-951. [PMID: 31757439 DOI: 10.1016/j.amjsurg.2019.09.003] [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] [Received: 06/03/2019] [Revised: 08/21/2019] [Accepted: 09/08/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Congenital hyperinsulinism (CHI) and insulinomas are the most common causes of medically-refractory pediatric hyperinsulinism. METHODS Children with CHI or insulinoma treated from 1/1/2014-1/1/2019 at an academic center were retrospectively analyzed. Primary outcome was persistent intravenous dextrose requirement at discharge. RESULTS Eleven patients were identified: six with diffuse-type CHI, three with focal-type CHI, two with insulinoma. Median age at diagnosis was 20 days (1 day-16 years). Preoperative functional imaging (18F-Fluoro-l-DOPA PET-CT scan) accurately localized 66% of focal-type CHI lesions. All patients with focal-type CHI and insulinoma were cured by local resection. All patients with diffuse-type CHI underwent near-total pancreatectomy (NTP): four patients were cured of hyperinsulinism, of which 2 developed insulin-dependent diabetes, while two patients were palliated to home enteral glucose infusion. CONCLUSIONS Localized resection cures children with focal, insulin-secreting lesions. NTP may cure diffuse-type CHI; potential complications include diabetes, exocrine insufficiency, and persistent hypoglycemia from residual hypersecreting pancreatic tissue. SUMMARY Congenital hyperinsulinism (CHI) and insulinomas are the most common causes of medically-refractory pediatric hyperinsulinism, causing potential complications including permanent brain injury. 18F-Fluoro-l-DOPA PET-CT scan can be used to localize focal insulin-secretion lesions preoperatively. Focal-type CHI and insulinoma are cured by localized resection. Diffuse-type CHI requires near-total pancreatectomy for cure, but complications include diabetes, exocrine insufficiency, or persistent hypoglycemia from residual foci of hypersecreting pancreatic tissue.
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Affiliation(s)
- Michael J Zobel
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, USA
| | - Carrie McFarland
- Division of Pediatric Surgery, Department of Surgery, University of California, San Francisco, USA
| | - Christine T Ferrera-Cook
- Division of Pediatric Endocrinology, Department of Pediatrics, University of California, San Francisco, USA
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Luu HY, Zobel MJ, Jonzzon S, Lin M, Lee D, Eichler C, Lin MYC. Predictors and Outcomes of Paramedian Incisional Hernia After Anterior Spine Exposure. J Surg Res 2019; 247:380-386. [PMID: 31753554 DOI: 10.1016/j.jss.2019.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/19/2019] [Revised: 09/22/2019] [Accepted: 10/01/2019] [Indexed: 12/01/2022]
Abstract
BACKGROUND Anterior exposures for lumbar spine surgery are increasingly common for treating various spinal pathologies. A retroperitoneal approach via a paramedian incision has grown rapidly in popularity, but little is known about the risk of incisional hernia development with this technique. We sought to assess the incidence of paramedian incisional hernia development and identify risk factors that are associated with occurrence. MATERIALS AND METHODS We conducted a retrospective review of all patients who underwent anterior lumbar spine exposure by a paramedian approach between 2012 and 2017 at a single, tertiary medical center. The primary outcome was the development of postoperative paramedian incisional hernia. RESULTS Of the 735 patients included in the study, 445 (60.5%) were women, and the mean (standard deviation) age of all patients was 60 y (12.4). Nearly all (97.4%) paramedian approaches were performed with a vascular surgeon present. Median follow-up time was 10 mo (interquartile range 3.5-19.9). Postoperative paramedian hernia developed in 20 patients (2.7%), of which 14 underwent repair. The mean (standard deviation) size of the hernia was 13.5 cm (5.5); 9 of 14 (64%) were repaired with synthetic mesh, whereas 3 of 14 (21%) required bowel resection. On multivariate analysis, risk factors associated with hernia development were male gender (0.045), higher American Society of Anesthesiologists class (0.039), history of abdominal surgery (P = 0.013), and postoperative intensive care unit admission (P = 0.02). CONCLUSIONS A paramedian approach for anterior lumbar spine exposure resulted in a low rate of incisional hernia with minimal morbidity. Surgeons involved in these collaborative procedures should consider the risk factors that predispose patients to develop these hernias.
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Affiliation(s)
- Hubert Y Luu
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Michael J Zobel
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Soren Jonzzon
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Michele Lin
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Danny Lee
- University of California, San Francisco School of Medicine, San Francisco, California
| | - Charles Eichler
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, California
| | - Matthew Y C Lin
- Division of General Surgery and Minimally Invasive Surgery, Department of Surgery, University of California, San Francisco, San Francisco, California.
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Graves CE, Moyer J, Zobel MJ, Mora R, Smith D, O'Day M, Padilla BE. Intraoperative intercostal nerve cryoablation During the Nuss procedure reduces length of stay and opioid requirement: A randomized clinical trial. J Pediatr Surg 2019; 54:2250-2256. [PMID: 30935731 PMCID: PMC6920013 DOI: 10.1016/j.jpedsurg.2019.02.057] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [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: 11/07/2018] [Revised: 01/29/2019] [Accepted: 02/22/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Minimally-invasive repair of pectus excavatum by the Nuss procedure is associated with significant postoperative pain, prolonged hospital stay, and high opiate requirement. We hypothesized that intercostal nerve cryoablation during the Nuss procedure reduces hospital length of stay (LOS) compared to thoracic epidural analgesia. DESIGN This randomized clinical trial evaluated 20 consecutive patients undergoing the Nuss procedure for pectus excavatum between May 2016 and March 2018. Patients were randomized evenly via closed-envelope method to receive either cryoanalgesia or thoracic epidural analgesia. Patients and physicians were blinded to study arm until immediately preoperatively. SETTING Single institution, UCSF-Benioff Children's Hospital. PARTICIPANTS 20 consecutive patients were recruited from those scheduled for the Nuss procedure. Exclusion criteria were age < 13 years, chest wall anomaly other than pectus excavatum, previous repair or other thoracic surgery, and chronic use of pain medications. MAIN OUTCOMES AND MEASURES Primary outcome was postoperative LOS. Secondary outcomes included total operative time, total/daily opioid requirement, inpatient/outpatient pain score, and complications. Primary outcome data were analyzed by the Mann-Whitney U-test for nonparametric continuous variables. Other continuous variables were analyzed by two-tailed t-test, while categorical data were compared via Chi-squared test, with alpha = 0.05 for significance. RESULTS 20 patients were randomized to receive either cryoablation (n = 10) or thoracic epidural (n = 10). Mean operating room time was 46.5 min longer in the cryoanalgesia group (p = 0.0001). Median LOS decreased by 2 days in patients undergoing cryoablation, to 3 days from 5 days (Mann-Whitney U, p = 0.0001). Cryoablation patients required significantly less inpatient opioid analgesia with a mean decrease of 416 mg oral morphine equivalent per patient (p = 0.0001), requiring 52%-82% fewer milligrams on postoperative days 1-3 (p < 0.01 each day). There was no difference in mean pain score between the groups at any point postoperatively, up to one year, and no increased incidence of neuropathic pain in the cryoablation group. No complications were noted in the cryoablation group; among patients with epidurals, one patient experienced a symptomatic pneumothorax and another had urinary retention. CONCLUSIONS AND RELEVANCE Intercostal nerve cryoablation during the Nuss procedure decreases hospital length of stay and opiate requirement versus thoracic epidural analgesia, while offering equivalent pain control. TYPE OF STUDY Treatment study. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
| | | | | | | | | | | | - Benjamin E. Padilla
- Corresponding author at: University of California, San Francisco Department of Surgery Division of Pediatric Surgery 550 16th St, Fifth Floor San Francisco, CA 94158-0570 United States. (B.E. Padilla)
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Zamora AK, Zobel MJ, Sun J, Sheard MA, Seeger RC, Kim ES. Treatment-Resistant Neuroblastoma Populations after Anti-GD2 Immunotherapy. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.474] [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: 10/25/2022]
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