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Linton SC, Tian Y, Zeineddin S, Alayleh A, De Boer C, Goldstein SD, Ghomrawi HMK, Abdullah F. Intercostal Nerve Cryoablation Reduces Opioid Use and Length of Stay Without Increasing Adverse Events: A Retrospective Cohort Study of 5442 Patients Undergoing Surgical Correction of Pectus Excavatum. Ann Surg 2024; 279:699-704. [PMID: 37791468 DOI: 10.1097/sla.0000000000006113] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 10/05/2023]
Abstract
OBJECTIVE To examine differences in opioid use, length of stay, and adverse events after minimally invasive correction of pectus excavatum (MIRPE) with and without intercostal nerve cryoablation. BACKGROUND Small studies show that intraoperative intercostal nerve cryoablation provides effective analgesia with no large-scale evaluations of this technique. METHODS The pediatric health information system database was used to perform a retrospective cohort study comparing patients undergoing MIRPE at children's hospitals before and after the initiation of cryoablation. The association of cryoablation use with inpatient opioid use was determined using quantile regression with robust standard errors. Difference in risk-adjusted length of stay between the cohorts was estimated using negative binomial regression. Odds of adverse events between the two cohorts were compared using logistic regression with a generalized estimating equation. RESULTS A total of 5442 patients underwent MIRPE at 44 children's hospitals between 2016 and 2022 with 1592 patients treated after cryoablation was introduced at their hospital. Cryoablation use was associated with a median decrease of 80.8 (95% CI: 68.6-93.0) total oral morphine equivalents as well as a decrease in estimated median length of stay from 3.5 [3.2-3.9] days to 2.5 [2.2-2.9] days ( P value: 0.016). Cryoablation use was not significantly associated with an increase in any studied adverse events. CONCLUSIONS Introduction of cryoablation for perioperative analgesia was associated with decreased inpatient opioid use and length of stay in a large sample with no change in adverse events. This novel modality for perioperative analgesia offers a promising alternative to traditional pain management in thoracic surgery.
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Affiliation(s)
- Samuel C Linton
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Suhail Zeineddin
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amin Alayleh
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Chris De Boer
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Seth D Goldstein
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Hassan M K Ghomrawi
- Departments of Surgery and Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Fizan Abdullah
- Department of Surgery, Division of Pediatric Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Carter M, Prendergast F, Krauss J, Zeineddin S, Pitt JB, Sullivan GA, Abdullah F, Gulack BC, Goldstein SD. Evaluating Skeletal Maturity at Time of Surgical Correction of Pectus Excavatum Based on Medial Clavicle Epiphyseal Ossification. Am Surg 2024; 90:631-639. [PMID: 37824167 DOI: 10.1177/00031348231207296] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 10/13/2023]
Abstract
BACKGROUND Surgical correction of pectus excavatum (SCOPE) is dependent upon chest wall pliability with optimal timing prior to complete skeletal maturation. Measures of skeletal maturity are not readily available for operative planning; therefore, surgeons use age as proxy despite patient-specific rates of skeletal maturation. We aimed to determine whether preoperative skeletal maturity is associated with postoperative pain as surrogate for chest wall pliability. METHODS Children ≤18 years who underwent SCOPE from 2020 to 2022 were retrospectively identified. Preoperative CT within 3 months of procedure was reviewed by 2 radiologists and 1 surgeon. Skeletal maturity was determined by Schmeling-Kellinghaus classification which stages secondary epiphyseal ossification of the medial clavicle. Inter-rater reliability was evaluated. Schmeling-Kellinghaus stage and postoperative pain were compared. RESULTS Of twenty-eight records reviewed, 57% were Schmeling-Kellinghaus stage 1. High inter-rater reliability was identified (inter-radiologist: kappa = .95, P < .001, all raters: kappa = .78, P < .001). Median age at operation was 15.5 years (interquartile range: 14.8-16.0) and increased with skeletal maturity (P < .001). When comparing stage 1 (n = 16) to >1 (n = 12), stage 1 had lower maximum pain scores (P < .001), total morphine equivalents (P < .001), and benzodiazepine use (P < .001) after surgery. CONCLUSIONS The Schmeling-Kellinghaus classification system is a valid proxy of skeletal maturity that can be applied with high inter-rater reliability. SCOPE during stage 1 was found to have less postoperative pain and narcotic use than more mature stages. This is proof of concept that skeletal maturity should be considered when determining optimal timing of surgical correction. Future research will evaluate the impact of skeletal maturity on postoperative outcomes.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Francis Prendergast
- Department of Radiology, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jillian Krauss
- Department of Radiology, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Gwyneth A Sullivan
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brian C Gulack
- Division of Pediatric Surgery, Department of Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Pitt JB, Carter M, Zeineddin S, Sands L, Kujawa S, Perez A, Liszewski WJ, Abdullah F, Goldstein SD. Chest Wall Dermatitis Patterns Following Thoracoscopic Intercostal Nerve Cryoablation for Surgical Correction of Pectus Excavatum. J Pediatr Surg 2024:S0022-3468(24)00090-3. [PMID: 38403489 DOI: 10.1016/j.jpedsurg.2024.02.008] [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: 11/02/2023] [Revised: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Intercostal nerve cryoablation (INC) has been shown to reduce postoperative pain and length of stay following surgical correction of pectus excavatum (SCOPE). Some patients have developed chest wall dermatological symptoms after INC that can be mistaken for metal allergy or infection. The purpose of this study is to report the symptoms, severity, incidence, and treatment of post-cryoablation dermatitis. METHODS A retrospective single institution review was performed for patients who underwent SCOPE with and without INC between June 2016 and March 2023 to assess for incidence of postoperative dermatological findings. Characteristics associated with these findings were evaluated. RESULTS During study period, 383 patients underwent SCOPE, 165 (43.1%) without INC and 218 (56.9%) with. Twenty-three (10.6%) patients who received INC developed exanthems characteristic of post-cryoablation dermatitis with two distinct phenotypes identified. No patients who underwent SCOPE without INC developed similar manifestations. Early dermatitis, characterized by a painless, erythematous, and blanching rash across the anterior thorax, was observed in 16 patients, presenting on median postoperative day 6.0 [IQR 6.0-8.5], with median time to resolution of 23.0 [IQR 12-71.0] days after symptom onset. Late dermatitis, characterized by hyperpigmentation spanning the anterior thorax, was observed in 7 patients, presenting on median postoperative day 129.0 [IQR 84.5-240.0], with median time to resolution of 114.0 [IQR 48.0-314.3] days. CONCLUSION This is the first report of dermatological manifestations following SCOPE with INC, a phenomenon of unknown etiology and no known long-term sequela. In our experience, it is self-resolving and lacks systemic symptoms suggesting observation alone is sufficient for resolution. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States.
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Walter J Liszewski
- Department of Dermatology, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, United States
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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Ram C, Pitt JB, Wallace MW, Goldstein SD, Zamora IJ. Framework for pediatric robotic surgery program development. Semin Pediatr Surg 2024; 33:151389. [PMID: 38245993 DOI: 10.1016/j.sempedsurg.2024.151389] [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: 01/23/2024]
Abstract
Pediatric robotic surgery has seen increasing implementation for its many benefits over the past two decades. As more pediatric surgeons gain exposure to robotic surgery, the interest in utilizing this technology is growing. However, there are no guidelines or existing framework for developing pediatric general surgery robotic programs. Programmatic development can be challenging, requiring institutional support, a minimum 12-month multistep process in partnership with the robot manufacturer, and organization of a local dedicated team. A cornerstone to all program building is collaboration and communication with key stakeholders who are committed to establishing a robotic surgery program. In this manuscript, we detail numerous best practices for implementation, followed by three variations of programmatic development, each drawing lessons from one of three practice settings: (i) A children's hospital in a large medical center associated with an adult hospital, (ii) a free-standing children's hospital, and (iii) a community-based practice. We aim for this article to provide a framework that can serve as a guide for those beginning this process, consolidating the key resources and strategies used to develop a robust pediatric robotic surgery program.
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Affiliation(s)
- Chirag Ram
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Northwestern University, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA.
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Perez MN, Ferrantella A, Johnson KN, Goldstein SD. Intercostal spinal nerve cryoablation for analgesia following pectus excavatum repair. Semin Pediatr Surg 2024; 33:151382. [PMID: 38190771 DOI: 10.1016/j.sempedsurg.2024.151382] [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] [Indexed: 01/10/2024]
Abstract
Pectus excavatum is a common chest wall deformity, most often treated during adolescence, that presents a significant postoperative pain control challenge for pediatric surgeons following surgical correction. The purpose of this article is to review the technique and outcomes of intercostal spinal nerve cryoablation for postoperative analgesia following surgical correction of pectus excavatum. Contemporary and historic literature were reviewed. Findings are summarized to provide a concise synopsis of the benefits of intercostal spinal nerve cryoablation relative to alternative analgesic modalities, as well as advocate for more widespread inclusion of this technique into multimodal pain regimens.
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Affiliation(s)
- Mallory N Perez
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Anthony Ferrantella
- Department of Surgery, Phoenix Children's Hospital, Mayo Clinic College of Medicine and Science, Phoenix, AZ, USA
| | - Kevin N Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Seth D Goldstein
- Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Pitt JB, Zeineddin S, Carter M, Perez A, Sands L, Kujawa S, Reynolds M, Abdullah F, Goldstein SD. Demographics of Anterior Chest Wall Deformity Patients: A Tertiary Children's Hospital Experience. J Surg Res 2024; 293:451-457. [PMID: 37827024 DOI: 10.1016/j.jss.2023.09.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Anterior chest wall deformities consist of abnormal development of the chest, with the most common congenital deformities being pectus excavatum (PE) and pectus carinatum (PC). Surgical series are common, but less research is present assessing the demographics of all who present for initial evaluation. The purpose of this study is to describe the patient characteristics of those who present for ambulatory surgical evaluation. METHODS Data were collected from initial patient visits to an established multispecialty chest wall deformities program at a large Children's Hospital from 2017 to 2021. Variables assessed included primary diagnosis, age, sex, race/ethnicity, and whether surgical correction was performed. RESULTS A total of 1510 children were evaluated: 50.0% (n = 755) with PE, 43.3% (n = 653) with PC, 2.7% (n = 41) with mixed chest wall deformities, 0.7% (n = 10) with Poland syndrome, 1.1% (n = 17) with Currarino-Silverman syndrome, and 2.3% (n = 34) with other anterior chest wall deformities. Males and females presented at mean age of 12.8 (4.2) and 10.9 (5.5) years, respectively (P = 0.001). White children represented 61.1% of the overall population while Hispanic children represented 26.3%. White, non-Hispanic children represented 61.9% and 71.5% and Hispanic children represented 26.0% and 26.3% of the PE and PC populations, respectively. CONCLUSIONS Most patients seen in an urban chest wall deformities clinic were White, non-Hispanic; however, the proportion of other groups such as Hispanic and Asian is greater in this cohort than previously described. Further research is ongoing to ascertain the extent to which disease predisposition versus access to care play roles in this population.
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Affiliation(s)
- J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Laurie Sands
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suzanne Kujawa
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Marleta Reynolds
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Carter M, Inge M, Zeineddin S, Linton SC, Pitt JB, Robson P, Abdullah F, Goldstein SD. Measurement and Thermodynamic Modeling of Energy Flux During Intercostal Nerve Cryoablation. J Surg Res 2024; 293:231-238. [PMID: 37797391 DOI: 10.1016/j.jss.2023.08.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/02/2023] [Revised: 07/27/2023] [Accepted: 08/27/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Intercostal nerve cryoablation is an increasingly adopted technique to decrease postoperative pain in patients undergoing surgical correction of pectus excavatum (SCOPE). Concerns regarding cryo-induced systemic hypothermia have been raised in pediatric patients; however, assessment of a cooled cryoprobe on body temperature has not been performed. We aimed to determine the energy flux from a maximally cooled cryoprobe and model the possible effects on a whole-body system. METHODS To directly measure energy flux, a maximally cooled cryoSPHERE probe (AtriCure, Inc, Mason, OH) was isolated in a well-mixed water bath at 37°C. Real-time temperatures were recorded. Three models were created to estimate intraoperative flux. Perioperative temperatures of 50 patients who received cryoablation during SCOPE were compared to 50 patients who did not receive cryoablation. RESULTS Direct calorimetry measured average energy flux of the maximally cooled cryoprobe to be 28 J/s. Thermodynamic modeling demonstrated the following: 1) The highest possible cryoprobe flux is less than estimated basal metabolic rate (BMR) of the average teenager undergoing SCOPE and 2) Flux in a best model of human tissue energy transfer using available literature is far less than the effects of BMR and insensible losses. Clinically, there were no significant differences in the minimum intraoperative, end procedure or first postoperative body temperatures for patients who received cryoablation and those who did not. CONCLUSIONS Cryoprobe flux is significantly fewer joules per second than BMR. Furthermore, in a clinical series there were no empiric differences in body temperature due to cryoablation employment, contradicting concerns regarding hypothermia secondary to cryoablation.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Madeline Inge
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel C Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philip Robson
- Biomedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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McElhinney KL, Zeineddin S, Ahle SL, Goldstein SD, Lautz TB. Intercostal nerve cryoablation reduces opioid utilization after thoracotomy in children with cancer. Pediatr Blood Cancer 2024; 71:e30722. [PMID: 37843290 PMCID: PMC10841358 DOI: 10.1002/pbc.30722] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 09/10/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND Intercostal nerve cryoablation (INC) has shown promise as an adjunct method for analgesia in adults undergoing thoracotomy, but has yet to be widely used in children for this indication. We hypothesize that INC decreases opioid utilization in children undergoing thoracotomy for cancer operations. METHODS A retrospective review was performed of children who underwent thoracotomy for cancer diagnosis at a freestanding children's hospital from 2018 to 2023. Patient characteristics, intraoperative data, and data on clinical course were collected. Patients were divided into those who underwent INC and those who underwent routine care for comparison. RESULTS Twenty-six patients underwent 38 procedures at a median age of 16 years (range 5-21 years). INC was performed in 23 cases over a median of five intercostal levels (range 2-7). Total oral morphine equivalents during inpatient admission were significantly lower in INC patients (137.6 vs. 514.5 mg, p = .002). Routine care patients were more likely to be discharged with an opioid prescription (30.4% vs. 80.0%, p = .008). Length of stay was similar between patients with INC and routine care (4 vs. 5 days, p = .15). There were no differences in rates of reoperation or 30-day re-admission (emergency department or inpatient). CONCLUSTIONS INC is a feasible and safe adjunct for children undergoing thoracotomy for cancer. INC is associated with reduced postoperative opioid utilization with respect to both inpatient use and outpatient prescriptions.
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Affiliation(s)
- Kathryn L McElhinney
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Samantha L Ahle
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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Carter M, Linton S, Zeineddin S, Pitt JB, Figueroa A, Perez A, Park E, DeTella M, Kwon S, Goldstein SD, Ghomrawi H, Abdullah F. Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure. J Surg Res 2023; 292:7-13. [PMID: 37567031 DOI: 10.1016/j.jss.2023.07.002] [Citation(s) in RCA: 2] [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] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 06/23/2023] [Accepted: 07/05/2023] [Indexed: 08/13/2023]
Abstract
INTRODUCTION The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit. METHODS This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts. RESULTS Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18. CONCLUSIONS We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.
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Affiliation(s)
- Michela Carter
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - J Benjamin Pitt
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Angie Figueroa
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Amparo Perez
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Erica Park
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mia DeTella
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Soyang Kwon
- The Smith Child Health Research Program, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Hassan Ghomrawi
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Medicine (Rheumatology) and Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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11
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De Boer C, Zeineddin S, Ott K, Hu A, Linton S, George M, Rao VK, Abdullah F, Chin A, Goldstein SD. Measuring the Efficacy of Thymectomy for Pediatric Myasthenia Gravis Across Tertiary Children's Hospitals. Pediatr Neurol 2023; 148:17-22. [PMID: 37651972 DOI: 10.1016/j.pediatrneurol.2023.07.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/21/2023] [Revised: 07/23/2023] [Accepted: 07/31/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Thymectomy is a treatment for pediatric myasthenia gravis, but the efficacy over time is unknown. Multi-institutional data are also lacking. Therefore, the objective of this study was to determine the efficacy of thymectomy for pediatric myasthenia gravis using medication burden and health care utilization as proxies for disease severity. METHODS This was a cross-sectional study of the Pediatric Health Information System database among children who underwent thymectomy at one of 49 children's hospitals from 2004 to 2022. Differences in annual median number of doses of myasthenia-related medications, admissions, and health care costs in the year before thymectomy to three years after were compared. A comparison cohort that did not undergo thymectomy was utilized. Medians were compared using the Wilcoxon signed-rank test. Generalized linear regression estimated the effect of surgical approach on outcomes. RESULTS A total of451 patients (238 patients who underwent thymectomy and 213 nonthymectomy patients) were identified. Following thymectomy, the decrease in annual median total number of myasthenia-related doses was 12.0 (interquartile range: 6 to 31) (P < 0.001). The decrease in number of annual admissions was 2.0 (1 to 4) (P < 0.001), which represented a cost difference of $5292 ($3533 to $8681) (P < 0.001). No differences were observed in the control cohort. In a generalized linear regression model, surgical approach was not associated with the efficacy of thymectomy (P = 0.55). CONCLUSIONS Thymectomy is an effective treatment for pediatric myasthenia gravis, evidenced by the decreased medication burden and health care utilization after surgery. Surgical approach did not influence the success of surgery. Thymectomy should be considered earlier in the treatment algorithm.
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Affiliation(s)
- Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Katherine Ott
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Michael George
- Division of Rheumatology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Vamshi K Rao
- Division of Neurology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Anthony Chin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Fumero-Velázquez M, Hagstrom M, Dhillon S, Olivares S, Jennings LJ, Dittman D, Sukhanova M, Arva NC, Goldstein SD, Theos A, Pavlidakey P, Carr Z, Gerami P. Agminated presentation of fusion-driven melanocytic neoplasms. J Cutan Pathol 2023; 50:913-921. [PMID: 37407520 DOI: 10.1111/cup.14482] [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: 02/09/2023] [Revised: 05/09/2023] [Accepted: 05/31/2023] [Indexed: 07/07/2023]
Abstract
BACKGROUND The conventionally understood pathogenesis of agminated Spitz nevi includes a mosaic HRAS mutation followed by copy number gains in 11p. However, we have recently observed agminated presentations of fusion-driven melanocytic neoplasms. METHODS We retrieved cases from our database of benign fusion-induced melanocytic neoplasms with an agminated presentation. Both the primary lesion and the secondary lesion were sequenced. TERT-promoter mutational testing and the melanoma fluorescence in situ hybridization assay were also performed. RESULTS Three cases were included. Two had a PRKCA fusion (partners ATP2B4 and MPZL1) and one had a ZCCHC8::ROS1 fusion. None of the cases met morphologic or molecular criteria for malignancy. There was no evidence of tumor progression in secondary lesions. The same fusion was identified in the primary and secondary lesions. None of the patients developed evidence of nodal or systemic metastasis. CONCLUSIONS We present accumulating evidence that fusion-driven melanocytic neoplasms can present with an agminated presentation. The differential diagnosis of an agminated presentation versus a locally recurrent or potentially locally metastatic tumor is critical, and accurate diagnosis has significant prognostic and therapeutic consequences for the patient. As with HRAS mutations, fusion-driven melanocytic tumors may have an agminated presentation.
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Affiliation(s)
- Mónica Fumero-Velázquez
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Michael Hagstrom
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Soneet Dhillon
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Shantel Olivares
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Lawrence J Jennings
- Division of Molecular Pathology, Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David Dittman
- Division of Molecular Pathology, Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Madina Sukhanova
- Division of Molecular Pathology, Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Nicoleta C Arva
- Department of Pathology, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, Illinois, USA
| | - Seth D Goldstein
- Department of Surgery, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Amy Theos
- Department of Dermatology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Peter Pavlidakey
- Department of Dermatology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zachary Carr
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Pedram Gerami
- Department of Dermatology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Papastefan ST, De Boer C, Zeineddin S, Hu A, Harris CJ, Wall JK, Hunter CJ, Lautz TB, Goldstein SD. Innovation versus Experimentation: An Application of Ethical Frameworks to the Acceptance of Fluorescence-Guided Pediatric Surgery. J Pediatr Surg 2023; 58:1609-1612. [PMID: 37330376 DOI: 10.1016/j.jpedsurg.2023.05.011] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/26/2023] [Accepted: 05/14/2023] [Indexed: 06/19/2023]
Abstract
Innovation is essential to the advancement of the field of pediatric surgery. The natural skepticism toward new technologies in pediatrics leads to frequent confusion of surgical innovation and research. Using fluorescence-guided surgery as an archetype for this ethical discussion, we apply existing conceptual frameworks of surgical innovation to understand the distinction between innovation and experimentation, acknowledging the spectrum and "grey zone" in between. In this review, we discuss the role of Institutional Review Boards in evaluating surgical practice innovations, and the aspects of certain surgical innovations that are distinct from experimentation, including a thorough understanding of the risk profile, preexisting use in humans, and adaptation from related fields. Examining fluorescence-guided surgery through these existing frameworks as well as the concept of equipoise, we conclude that new applications of indocyanine green do not constitute human subjects research. Most importantly, this example gives practitioners a lens through which they may appraise potential surgical innovations to allow for a sensible and efficient improvement of the field of pediatric surgery. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Steven T Papastefan
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Christopher De Boer
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Suhail Zeineddin
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrew Hu
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Courtney J Harris
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - James K Wall
- Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Catherine J Hunter
- Division of Pediatric Surgery, Oklahoma Children's Hospital, Oklahoma City, OK, USA
| | - Timothy B Lautz
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Seth D Goldstein
- Department of Surgery, Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA; Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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14
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Zeineddin S, Hu A, Linton S, Zhang V, De Boer C, Raval MV, Abdullah F, Goldstein SD. Association between appendiceal stump closure method and post-operative bowel obstruction after laparoscopic appendectomy. J Pediatr Surg 2023; 58:643-647. [PMID: 36670005 DOI: 10.1016/j.jpedsurg.2022.12.015] [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: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Laparoscopic appendectomy is one of the most common urgent pediatric surgical operations. Endoscopic surgical staplers and pre-tied endoloop ligatures are both routinely used for closure of the appendiceal stump in children. Practice patterns vary for a number of reasons, including cost, size, and ease of use. While stapling is standard for some pediatric surgeons, others believe that staples can act as a nidus for small bowel obstruction (SBO). However, studies comparing closure methods have been conflicting in their results and limited in size. Therefore, we aim to determine if there is an association between appendiceal stump closure method and SBO using a national comparative pediatric database. METHODS We queried the Pediatric Health Information System (PHIS) for patients ages 3-18 years who underwent laparoscopic appendectomy for appendicitis between 1/1/2016 - 12/31/2020. We included hospitals that had greater than 50 patients with billing data and excluded patients with inflammatory bowel disease and simultaneous abdominal operations. We used billing data for the patient's appendectomy to determine if a stapler or a suture ligature was used during the case. Our primary outcome of interest was post-operative SBO or reoperation for lysis of adhesion or intestinal surgery within the first 30 post-operative days. Multivariable regression analyses were used to estimate the association between stump closure method and post-operative SBO or reoperation in addition to cost while adjusting for patient demographics and appendiceal perforation. RESULTS In total, 49,191 patients from 37 hospitals were included, of which, 29,733 (60.44%) were male, 21,403 (43.51%) were non-Hispanic white, and 18,291 (37.18%) had a diagnosis of complicated appendicitis. The median [IQR] age of the cohort was 11 [8-14] years. A surgical stapler was used during laparoscopic appendectomy in 35,788 (72.75%) patients, and early SBO or reoperation occurred in 653 (1.33%) patients. In adjusted analysis controlling for demographics and complicated appendicitis there was no statistically significant difference in the odds of SBO or reoperation between the two groups. (OR 1.17; 99% CI 0.86 - 1.6). Complicated appendicitis was the factor most associated with post-operative SBO or reoperation (OR 4.4; 99% CI 3.01 - 6.44). Median cumulative cost was slightly higher on unadjusted analysis in the stapler group ($10,329.3 vs $9,569.2). However, there was no significant difference on adjusted analysis. CONCLUSION SBO or reoperation following laparoscopic appendectomy for appendicitis is uncommon. Complicated appendicitis is the most predictive factor of this outcome. Adjusting for available patient, disease, and hospital characteristics, use of a surgical stapler does not appear to be meaningfully associated with the development of acute SBO or reoperation. Surgeon preference remains the mainstay for safe appendiceal stump closure method. LEVEL OF EVIDENCE Level III. STUDY TYPE Retrospective Comparative Study.
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Affiliation(s)
- Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Samuel Linton
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Veronica Zhang
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Christopher De Boer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Ott KC, Vacek JC, McMahon MA, Moeckel CM, Hu YY, Raval MV, Goldstein SD. Expedited Surgical Care of Appendicitis is Associated With Improved Resource Utilization. J Surg Res 2023; 282:93-100. [PMID: 36265430 DOI: 10.1016/j.jss.2022.08.012] [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: 12/27/2021] [Revised: 07/24/2022] [Accepted: 08/18/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Appendectomy for acute appendicitis is the most common pediatric intra-abdominal operation. Current literature supports the notion that modest in-hospital, preoperative delays are not associated with greater patient morbidity. However, there is less certainty regarding the role that hour-of-presentation plays in determining the timing of surgery. Thus, we aimed to evaluate how after-hours presentation may relate to the timing of surgery and to assess the outcomes and resource utilization associated with expedited appendectomy compared to nonexpedited. METHODS Patient records for children who underwent an appendectomy at a freestanding pediatric hospital from 2015 to 2019 were reviewed. Business hour presentations were defined as arrival at the emergency department from 7 AM to 6 PM. Primary outcomes were hospital length of stay (LOS), cost derived from the Pediatric Health Information System database, perforation, surgical complications, and 30-day readmissions. RESULTS Nine hundred forty-two patients underwent appendectomy over the study period. The median time to OR was 2.0 h in the expedited cohort and 9.8 h in the nonexpedited group. Presentation during business hours was associated with 4.4 higher odds (P < 0.001) of expedited workflow. Expedited appendectomies were associated with shorter hospital LOS (11.5 h, P < 0.001), less costly admissions ($1,155, P < 0.001); LOS measured in midnights, perforation and readmission rates were similar between groups. CONCLUSIONS We found reduced resource utilization associated with expedited appendectomy. Additionally, the demonstrated association between the time of presentation to the emergency department (ED) and the timing of surgery may be utilized to inform staffing and resource deployment decisions. Further research regarding the generalizability and sustainability of an expedited presurgical workflow in pediatric appendectomy is certainly indicated.
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Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Maxwell A McMahon
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Camille M Moeckel
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Zeineddin S, Goldstein SD, Linton S, DeBoer C, Alayleh A, Ortiz I, Sands L, Kujawa S, Suresh S, Ghomrawi H, Abdullah F. Effectiveness of one minute per level intercostal nerve cryoablation for postoperative analgesia after surgical correction of pectus excavatum. J Pediatr Surg 2023; 58:34-40. [PMID: 36283847 DOI: 10.1016/j.jpedsurg.2022.09.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 08/29/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Intraoperative intercostal nerve cryoablation has emerged as a promising modality for postoperative analgesia following Surgical Correction of Pectus Excavatum (SCOPE). Most centers use two-minute cryoablation per level, although data from histologic and adult studies suggest the effectiveness of one-minute freezes. We aimed to describe our center's experience with one minute per level cryoablation. METHODS A retrospective single institution review of patients undergoing SCOPE was performed to compare patients pre- and post-intercostal nerve cryoablation implementation. Cryoablation was performed as one minute for each of the thoracic intercostal nerves T3-T7. Multivariable regression analyses were conducted to compare the outcomes and cost between pre- and post-implementation groups. RESULTS During the study period, 198 patients underwent SCOPE with one Nuss bar, receiving either intraoperative intercostal nerve cryoablation (Cryo, n = 100) or preoperative thoracic paravertebral catheters (NoCryo, n = 98). Surgical time was on average 9 min longer for the Cryo group (p<0.01). Median length of stay for the Cryo group was 3 days shorter compared to the NoCryo group (p<0.01). The Cryo group had a 19-fold and 5.6-fold reduction in average inpatient and total postoperative opioid usage, respectively (p<0.01). Total hospital costs were significantly lower in the Cryo group (p<0.01). Overall complication rate was not statistically significant different between the two groups. CONCLUSIONS Intraoperative one minute per level cryoablation is a potent approach to postoperative analgesia for SCOPE patients that led to a shorter hospital length of stay, lower hospital costs, and decreased opioid use compared to conventional analgesia at our institution. Pediatric surgeons performing correction of chest wall deformities should consider offering this technique.
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Affiliation(s)
- Suhail Zeineddin
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Seth D Goldstein
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Samuel Linton
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Christopher DeBoer
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Amin Alayleh
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Irma Ortiz
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Laurie Sands
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Suzanne Kujawa
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA
| | - Santhanam Suresh
- Department of Pediatric Anesthesia, Children's Hospital of Chicago, Chicago, IL, USA
| | - Hassan Ghomrawi
- Department of Surgery, Northwestern University, Chicago, IL, USA; Department of Pediatrics, Northwestern University, Chicago, IL, USA
| | - Fizan Abdullah
- Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL, USA; Department of Surgery, Northwestern University, Chicago, IL, USA.
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Ott KC, McMahon MA, Vacek JC, Zeineddin S, Hu YY, Raval MV, Goldstein SD. The costs and benefits of emergent surgical workflow for acute appendicitis in children. J Pediatr Surg 2022; 57:896-901. [PMID: 35934527 DOI: 10.1016/j.jpedsurg.2022.06.018] [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: 02/28/2022] [Revised: 06/09/2022] [Accepted: 06/29/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Controversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls. METHODS Patient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome. RESULTS 298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS. CONCLUSION Hospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States.
| | - Maxwell A McMahon
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, 225 E Chicago Ave, Chicago, IL 60654, United States
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Chaudhury AS, Hu A, Mathur R, McMahon M, Ingram MC, Studer A, Goldstein SD, Raval MV. Novel Quality Improvement Targets to Address Healthcare Encounters After Pediatric Appendectomy. J Surg Res 2022; 279:511-517. [PMID: 35863100 DOI: 10.1016/j.jss.2022.06.035] [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: 04/02/2022] [Revised: 05/24/2022] [Accepted: 06/15/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Pediatric appendicitis clinical practice guidelines (CPGs) do not typically address postdischarge healthcare encounters. This study aims to examine common indications for returns to the health system to identify novel quality improvement targets. METHODS This retrospective cohort study analyzed patients aged 3 to 18 y undergoing appendectomy at a single institution from July 1, 2019, to July 31, 2020. The primary outcome was physical postdischarge encounters comprising emergency department (ED) visits and hospital readmissions. Indications for each encounter were categorized and stratified by appendicitis type (i.e., simple, gangrenous, or perforated). Multivariable logistic regression models were used to estimate association between appendicitis category and postdischarge encounters. RESULTS Of 434 patients, 240 (55.3%) had simple appendicitis, 77 (17.7%) gangrenous, and 117 (29.9%) perforated appendicitis. Overall, 48 patients had at least one instance of an unplanned postdischarge encounter with a total of 56 unplanned ED presentations and 24 readmissions. Perforated patients were significantly more likely to experience postdischarge ED (odds ratio 2.55; 95% confidence interval 1.29-5.02) and readmission encounters (odds ratio 6.63; 95% confidence interval 2.28-19.28). Common indications for ED encounters included abdominal pain (n = 20) with 25.0% readmitted, abdominal pain and gastrointestinal symptoms (e.g., diarrhea, vomiting, distention) (n = 16) with 87.5% readmitted, and incision concerns (n = 6) with 16.7% readmitted. Common indications for readmissions included intraabdominal abscesses (n = 8) and small bowel obstruction (n = 4). CONCLUSIONS Assessing indications for postdischarge healthcare encounters enables identification of novel quality improvement targets, including proactively addressing incision concerns and abdominal pain.
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Affiliation(s)
- Azraa S Chaudhury
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
| | - Radhika Mathur
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Maxwell McMahon
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Martha-Conley Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Abbey Studer
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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Linton SC, Ghomrawi HMK, Tian Y, Many BT, Vacek J, Bouchard ME, De Boer C, Goldstein SD, Abdullah F. Association of Operative Volume and Odds of Surgical Complication for Patients Undergoing Repair of Pectus Excavatum at Children's Hospitals. J Pediatr 2022; 244:154-160.e3. [PMID: 34968500 DOI: 10.1016/j.jpeds.2021.12.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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] [Received: 09/03/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine whether procedure-specific provider volume is associated with outcomes for patients undergoing repair of pectus excavatum at tertiary care children's hospitals. STUDY DESIGN We performed a cohort study of patients undergoing repair of pectus excavatum between January 1, 2013 and December 31, 2019, at children's hospitals using the Pediatric Health Information System database. The main exposures were the pectus excavatum repair volume quartile of the patient's hospital and the pectus excavatum repair volume category of their surgeon. Our primary outcome was surgical complication, identified using International Classification of Diseases, Ninth Revision, Clinical Modification, and International Classification of Diseases, Tenth Revision, Clinical Modification codes from Pediatric Health Information System. Secondary outcomes included high-cost admission and extended length of stay. RESULTS In total, 7183 patients with an average age of 15.2 years (SD 2.0), 83% male, 74% non-Hispanic White, 68% no comorbidities, 72% private insurance, and 82% from metro areas were analyzed. Compared with the lowest-volume (≤10 cases/year) quartile of hospitals, patients undergoing repair of pectus excavatum at hospitals in the second (>10-18 cases/year), third (>18-26 cases/year), and fourth (>26 cases/year) volume quartiles had decreased odds of complication of OR 0.52 (CI 0.34-0.82), 0.51 (CI 0.33-0.78), and 0.41 (CI 0.27-0.62), respectively. Patients with pectus excavatum who underwent repair by surgeons in the second (>1-5 cases/year), third (>5-10 cases/year), and fourth (>10 cases/year) volume categories had decreased odds of complication of OR 0.91 (CI 0.68-1.20), OR 0.73 (CI 0.51-1.04), and OR 0.55 (CI 0.39-0.76), respectively, compared with the lowest-volume (≤1 case/year) category of surgeons. CONCLUSIONS Procedure-specific case volume is an important factor when considering providers for elective surgery, even among specialized centers providing comprehensive patient care.
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Affiliation(s)
- Samuel C Linton
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Hassan M K Ghomrawi
- Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Health Services and Outcomes Research, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Benjamin T Many
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Jonathan Vacek
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Megan E Bouchard
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Christopher De Boer
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Seth D Goldstein
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Ott KC, Hu A, Gong EM, Lautz TB, Grabowski JE, Goldstein SD. Use of Near Infrared Ureteral Stent Fibers for Neonatal Colorectal Operations. Surg Innov 2022; 29:550-551. [PMID: 35343327 DOI: 10.1177/15533506221088401] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Katherine C Ott
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Andrew Hu
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Edward M Gong
- Division of Urology, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, 2429Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA
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21
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Buonpane CL, Vacek J, Harris CJ, Salazar Osuna JH, Van Arendonk KJ, Hunter CJ, Goldstein SD. Controversy in the classification of appendicitis and utilization of postoperative antibiotics. Surgery 2021; 171:1022-1026. [PMID: 34774292 DOI: 10.1016/j.surg.2021.10.006] [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] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 07/26/2021] [Accepted: 10/04/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is wide variability and considerable controversy regarding the classification of appendicitis and the need for postoperative antibiotics. This study aimed to assess interrater agreement with respect to the classification of appendicitis and its influence on the use of postoperative antibiotics amongst surgeons and surgical trainees. METHODS A survey comprising 15 intraoperative images captured during appendectomy was distributed to surgeons and surgical trainees. Participants were asked to classify severity of disease (normal, inflamed, purulent, gangrenous, perforated) and whether they would prescribe postoperative antibiotics. Statistical analysis included percent agreement, Krippendorff's alpha for interrater agreement, and logistic regression. RESULTS In total, 562 respondents completed the survey: 206 surgical trainees, 217 adult surgeons, and 139 pediatric surgeons. For classification of appendicitis, the statistical interrater agreement was highest for categorization as gangrenous/perforated versus nongangrenous/nonperforated (Krippendorff's alpha = 0.73) and lowest for perforated versus nonperforated (Krippendorff's alpha = 0.45). Fourteen percent of survey respondents would administer postoperative antibiotics for an inflamed appendix, 44% for suppurative, 75% for gangrenous, and 97% for perforated appendicitis. Interrater agreement of postoperative antibiotic use was low (Krippendorff's alpha = 0.28). The only significant factor associated with postoperative antibiotic utilization was 16 or more years in practice. CONCLUSIONS Surgeon agreement is poor with respect to both subjective appendicitis classification and objective utilization of postoperative antibiotics. This survey demonstrates that a large proportion (59%) of surgeons prescribe antibiotics after nongangrenous or nonperforated appendectomy, despite a lack of evidence basis for this practice. These findings highlight the need for further consensus to enable standardized research and avoid overtreatment with unnecessary antibiotics.
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Affiliation(s)
- Christie L Buonpane
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL; Geisinger Medical Center, Danville, PA.
| | - Jonathan Vacek
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/JonathanVacek
| | - Courtney J Harris
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/courtneyjharris
| | | | - Kyle J Van Arendonk
- Children's Hospital of Wisconsin, Milwaukee, WI. https://twitter.com/KyleVanArendonk
| | - Catherine J Hunter
- The Children's Hospital, Oklahoma City, OK. https://twitter.com/CJHunter18
| | - Seth D Goldstein
- Ann & Robert H. Lurie Children's Hospital of Chicago, IL. https://twitter.com/sethgoldsteinmd
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22
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McMahon M, Ott K, Vacek J, Hu A, De Boer C, Linton S, Bouchard ME, Hu YY, Raval MV, Goldstein SD. Urgent vs Emergent Surgical Workflow for Acute Appendicitis in Children. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.394] [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: 10/20/2022]
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Hu AJ, Elizabeth Ingram MC, Ares G, Raval MV, Goldstein SD. Bilateral congenital flank hernias due to complete lateral abdominal wall muscular agenesis. Journal of Pediatric Surgery Case Reports 2021. [DOI: 10.1016/j.epsc.2021.102003] [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] Open
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Affiliation(s)
- Seth D Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Timothy B Lautz
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sarkar A, Ingram MCE, Tian Y, Many BT, Rizeq Y, Goldstein SD, Rigsby CK, Raval MV. A Retrospective Cohort Study of Optimal Contrast for Successful Intussusception Reduction: Institutional Practices Matter. J Surg Res 2021; 267:159-166. [PMID: 34147862 DOI: 10.1016/j.jss.2021.05.020] [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: 01/18/2021] [Revised: 04/20/2021] [Accepted: 05/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The first-line treatment for intussusception is radiologic reduction with either air-contrast enema (AE) or liquid-contrast enema (LE). The purpose of this study was to explore relationships between self-reported institutional AE or LE intussusception reduction preferences and rates of operative intervention and bowel resection. METHODS Pediatric Health Information System (PHIS) hospitals were contacted to assess institutional enema practices for intussusception. A retrospective study using 2009-2018 PHIS data was conducted for patients aged 0-5 y to evaluate outcomes. Chi-squared tests were used to test for differences in the distribution of surgical patients by hospital management approach. RESULTS Of the 45 hospitals, 20 (44%) exclusively used AE, 4 (9%) exclusively used LE, and 21 (46%) used a mixed practice. Of 24,688 patients identified from PHIS, 13,231 (54%) were at exclusive AE/LE hospitals and 11,457 (46%) were at mixed practice hospitals. Patients at AE/LE hospitals underwent operative procedures at lower rates than at mixed practice hospitals (14.8% versus 16.5%, P< 0.001) and were more likely to undergo bowel resection (31.1% versus 27.1%, P= 0.02). CONCLUSIONS Practice variation exists in hospital-level approaches to radiologic reduction of intussusception and mixed practices may impact outcomes.
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Affiliation(s)
- Arjun Sarkar
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Martha-Conley E Ingram
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yao Tian
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Yazan Rizeq
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Cynthia K Rigsby
- Department of Medical Imaging, Department of Radiology, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.
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26
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Bouchard ME, Stewart DH, Hall M, Many BT, Vacek JC, Papastefan S, Van Arendonk K, Abdullah F, Goldstein SD. Trends in gastrostomy tube placement with concomitant Nissen fundoplication for infants and young children at Pediatric Tertiary Centers. Pediatr Surg Int 2021; 37:617-625. [PMID: 33486562 DOI: 10.1007/s00383-020-04845-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Accepted: 12/27/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE In infants and toddlers, gastrostomy tube placement (GT) is typically accompanied by consideration of concomitant Nissen fundoplication (NF). Historically, rates of NF have varied across providers and institutions. This study examines practice variation and longitudinal trends in NF at pediatric tertiary centers. METHODS Patients ≤ 2 years who underwent GT between 2008 and 2018 were identified in the Pediatric Health Information System database. Patient demographics and rates of NF were examined. Descriptive statistics were used to evaluate the variation in the proportion of GT with NF at each hospital, by volume and over time. RESULTS 40,348 patients were identified across 40 hospitals. Most patients were male (53.8%), non-Hispanic white (49.5%) and publicly-insured (60.4%). Rates of NF by hospital varied significantly from 4.2 to 75.2% (p < 0.001), though were not associated with geographic region (p = 0.088). Rates of NF decreased from 42.8% in 2008 to 14.2% in 2018, with a mean annual rate of change of - 3.07% (95% CI - 3.53, - 2.61). This trend remained when stratifying hospitals into volume quartiles. CONCLUSION There is significant practice variation in performing NF. Regardless of volume, the rate of NF is also decreasing. Objective NF outcome measurements are needed to standardize the management of long-term enteral access in this population.
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Affiliation(s)
- Megan E Bouchard
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA.
| | - Danielle Howard Stewart
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Matt Hall
- Children's Hospital Association, Lenexa, KS, USA
| | - Benjamin T Many
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Jonathan C Vacek
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Steven Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, WI, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, IL, 60611, USA
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Many BT, Benyamen B, Moeckel CM, Sarkar A, Goldstein SD, Grabowski J, Johnson EK, Raval MV. To wrap or not to wrap: A retrospective review of circumcision dressing and post-procedural bleeding. J Pediatr Surg 2021; 56:795-799. [PMID: 32593427 DOI: 10.1016/j.jpedsurg.2020.05.007] [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: 04/22/2020] [Revised: 04/30/2020] [Accepted: 05/01/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Bleeding is an infrequent, but important, complication after circumcision. Our aim was to examine postoperative bleeding events after circumcision comparing patients managed with a circumferential wrap to ointment alone. METHODS Boys ≤18 years of age who underwent circumcision at a tertiary children's hospital were retrospectively reviewed between 2017 and 2018. Postoperative bleeding was defined by phone calls, clinic or Emergency Department visits, or return to the operating room. Outcomes were examined by univariate association and multivariable modeling. RESULTS Of 681 boys undergoing circumcision, 503 (74%) patients received a wrap dressing and 178 (26%) only ointment. There were 28 (4%) patients who had a postoperative bleeding event: 14/503 (2.7%) among wrap dressings and 14/178 (7.8%) among ointment alone (p < 0.01). The majority of events were phone calls related to bleeding (75%). Univariate analysis demonstrated no association between postoperative bleeding and surgeon specialty (p = 0.72), age at circumcision (p = 0.44) or technique type (p = 0.09). After controlling for age, technique type, and surgeon specialty, dressing type remained significantly associated with postoperative bleeding (OR = 2.81, p < 0.01). CONCLUSION This single-center, retrospective review found circumferential wrap dressings are associated with a decrease in bleeding events after circumcision. LEVEL OF EVIDENCE III - retrospective case-control study.
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Affiliation(s)
- Benjamin T Many
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA.
| | - Beshoy Benyamen
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
| | - Camille M Moeckel
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
| | - Arjun Sarkar
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
| | - Seth D Goldstein
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
| | - Julia Grabowski
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
| | - Emilie K Johnson
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Urology, Department Of Urology, Chicago, IL, USA
| | - Mehul V Raval
- Northwestern University Feinberg School of Medicine and Ann & Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Department Of Surgery, Chicago, IL, USA
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Goldstein SD, Heaton TE, Bondoc A, Dasgupta R, Abdelhafeez A, Davidoff AM, Lautz TB. Evolving applications of fluorescence guided surgery in pediatric surgical oncology: A practical guide for surgeons. J Pediatr Surg 2021; 56:215-223. [PMID: 33189300 DOI: 10.1016/j.jpedsurg.2020.10.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 07/21/2020] [Revised: 09/09/2020] [Accepted: 10/06/2020] [Indexed: 01/10/2023]
Abstract
Fluorescence-guided surgery (FGS) is an increasingly available and popular method of visual field augmentation. The basic premise of FGS entails injection of fluorescent indocyanine green (ICG) and subsequent detection with a near-infrared (NIR) camera. For pediatric surgical oncologists, FGS remains experimental but is a promising modality for identifying tumor margins, locating metastases, performing sentinel lymph node biopsies, protecting peritumoral structures of interest, and facilitating reconstruction. Familiarity with basic ICG pharmacokinetics and NIR detection optics is critical for surgeons wishing to judiciously use FGS, as its success is firmly grounded in a thorough understanding of its capabilities and limitations. In this practical guide, we outline several well-described and innovative FGS applications by disease type, including their methods of administration, modes of detection, and typical ICG dosing paradigms. LEVEL OF EVIDENCE: V.
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Affiliation(s)
- Seth D Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Todd E Heaton
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Alexander Bondoc
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Roshni Dasgupta
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Timothy B Lautz
- Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Northwestern University Feinberg School of Medicine, Chicago, IL.
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Choudhury RA, Yoeli D, Hoeltzel G, Moore HB, Prins K, Kovler M, Goldstein SD, Holland-Cunz SG, Adams M, Roach J, Nydam TL, Vuille-Dit-Bille RN. STEP improves long-term survival for pediatric short bowel syndrome patients: A Markov decision analysis. J Pediatr Surg 2020; 55:1802-1808. [PMID: 32345501 DOI: 10.1016/j.jpedsurg.2020.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 08/03/2019] [Revised: 01/31/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Increasingly, for pediatric patients with short bowel syndrome (SBS), intestinal lengthening procedures such as serial transverse enteroplasty (STEP) are being offered with the hope of improving patients' chances for achieving enteral autonomy. However, it remains unclear to what extent STEP reduces the long-term need for intestinal transplant or improves survival. METHODS Based on existing literature, a decision analytic Markov state transition model was created to simulate the life of 1,000 pediatric SBS patients. Two simulations were modeled: 1) No STEP: patients were listed for transplant once medical management failed and 2) STEP: patients underwent STEP therapy and subsequent transplant listing if enteral autonomy was not achieved. Sensitivity analysis of small bowel length and anatomy was completed. Base case patients were defined as neonates with a small bowel length of 30cm. RESULTS For base case patients with an ostomy and a NEC SBS etiology, STEP was associated with increased rates of enteral autonomy after 10 years for patients with an ICV (53.9% [STEP] vs. 51.1% [No STEP]) and without an ICV (43.4% [STEP] vs. 36.3% [No STEP]). Transplantation rates were also reduced following STEP therapy for both ICV (17.5% [STEP] vs. 18.2% [No STEP]) and non-ICV patients (20.2% [STEP] vs. 22.1% [No STEP]). 10-year survival was the highest in the (+) STEP and (+) ICV group (85.4%) and lowest in the (-) STEP and (-) ICV group (83.3%). CONCLUSIONS For SBS patients, according to our model, STEP increases rates of enteral autonomy, reduces need for intestinal transplantation, and improves long-term survival. TYPE OF STUDY Economic/Decision Analysis or Modeling Studies LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Rashikh A Choudhury
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO.
| | - Dor Yoeli
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Gerard Hoeltzel
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Hunter B Moore
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Kas Prins
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Mark Kovler
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Seth D Goldstein
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Stephan G Holland-Cunz
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Megan Adams
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Jonathan Roach
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Trevor L Nydam
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
| | - Raphael N Vuille-Dit-Bille
- University of Colorado Hospital, Department of Transplant Surgery, Aurora, CO; Johns Hopkins Hospital, Department of Pediatric Surgery, Baltimore, MD; Ann and Robert H. Lurie Children's Hospital of Chicago, Division of Pediatric Surgery, Chicago, IL; University Children's Hospital of Basel, Department of Pediatric Surgery, Basel, Switzerland; Colorado Children's Hospital, Department of Pediatric Surgery, Aurora, CO
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Salazar JH, Goldstein SD, Swarup A, Boss EF, Van Arendonk KJ, Abdullah F. Transfusions in Children’s Surgery: Characterization and Development of a Model for Benchmarking. J Surg Res 2020; 252:47-56. [DOI: 10.1016/j.jss.2019.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Revised: 11/05/2019] [Accepted: 11/23/2019] [Indexed: 11/25/2022]
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Goldstein SD, Kuntz NL. Difficulties classifying myasthenia gravis in the pediatric surgical literature. J Pediatr Surg 2020; 55:1679. [PMID: 32444173 DOI: 10.1016/j.jpedsurg.2020.03.033] [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] [Received: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Seth D Goldstein
- Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Box 63, Chicago, IL 60611-2605; Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 63, Chicago, IL 60611-2605.
| | - Nancy L Kuntz
- Mazza Foundation Neuromuscular Disorders Program, 225 East Chicago Avenue, Box 51, Chicago, IL 60611-2605; Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Avenue, Box 63, Chicago, IL 60611-2605; Northwestern University Feinberg School of Medicine, 225 E. Chicago Avenue, Box 63, Chicago, IL 60611-2605
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Many BT, Rizeq YK, Vacek J, Cheon EC, Johnson E, Hu YY, Raval MV, Abdullah F, Goldstein SD. A contemporary snapshot of circumcision in US children's hospitals. J Pediatr Surg 2020; 55:1134-1138. [PMID: 32199703 DOI: 10.1016/j.jpedsurg.2020.02.031] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 02/07/2020] [Accepted: 02/20/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND In 2012, the American Academy of Pediatrics (AAP) concluded the health benefits of circumcision during the neonatal period outweigh the risks. This study describes recent trends in male circumcision in freestanding children's hospitals in the United States. METHODS Using the Pediatric Health Information System (PHIS), male patients <18 years of age who were circumcised without any additional procedures between the years 2010 and 2017 were identified. Data included age at procedure (neonate: 0-30 days, infant: 31-365 days, early childhood: ≥1 to <5 years, and older child: ≥5 to<18 years), cost, and specialty performing the circumcision. RESULTS Of the 171,680 circumcisions performed, 85,270 (50%) were during neonatal period, 29,060 (17%) during infancy, 30,276 (18%) early childhood, and 26,355 (16%) thereafter. Circumcision in neonates increased from 39% to 58% (p < 0.001), and the proportion performed during infancy decreased over time. System level cost for ambulatory circumcision averaged $32 million USD annually, and median cost per ambulatory circumcision was $2892 USD. Obstetricians and Pediatricians are performing proportionally more circumcisions. CONCLUSION Since 2012, proportionally more neonates are undergoing circumcision in US children's hospitals. Perinatal specialties are performing an increasing proportion of circumcisions. Circumcision during the birth hospitalization in the neonatal period is more resource-effective than postponing until later in infancy. TYPE OF STUDY Retrospective, cross-sectional analysis. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Benjamin T Many
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Yazan K Rizeq
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Jonathan Vacek
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Eric C Cheon
- Division of Pediatric Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Emilie Johnson
- Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine; Division of Pediatric Urology, Ann and Robert H. Lurie Children's Hospital of Chicago
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Mehul V Raval
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Fizan Abdullah
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago; Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine
| | - Seth D Goldstein
- Division of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago.
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George MD, Baker JF, Winthrop KL, Goldstein SD, Alemao E, Chen L, Wu Q, Xie F, Curtis JR. Immunosuppression and the risk of readmission and mortality in patients with rheumatoid arthritis undergoing hip fracture, abdominopelvic and cardiac surgery. Ann Rheum Dis 2020; 79:573-580. [PMID: 32209540 DOI: 10.1136/annrheumdis-2019-216802] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 12/09/2019] [Revised: 03/04/2020] [Accepted: 03/05/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVES The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries. METHODS This retrospective cohort study used Medicare data 2006-2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes. RESULTS We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5-10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category. CONCLUSIONS Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk.
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Affiliation(s)
- Michael D George
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joshua F Baker
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Rheumatology, Philadelphia VAMC, Philadelphia, Pennsylvania, USA
| | - Kevin L Winthrop
- Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
| | - Seth D Goldstein
- Surgery, Northwestern University, Evanston, Illinois, USA.,Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - E Alemao
- Bristol-Myers Squibb, Princeton, New Jersey, USA
| | - Lang Chen
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Qufei Wu
- Rheumatology and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Fenglong Xie
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey R Curtis
- Immunology and Rheumatology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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34
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Goldstein SD. The Realities of External Validity in Global Surgery Research. JAMA Surg 2020; 155:172. [PMID: 31642887 DOI: 10.1001/jamasurg.2019.4089] [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] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Seth D Goldstein
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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35
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Kovler ML, Garcia AV, Beckman RM, Salazar JH, Vacek J, Many BT, Rizeq Y, Abdullah F, Goldstein SD. Conversion From Venovenous to Venoarterial Extracorporeal Membrane Oxygenation Is Associated With Increased Mortality in Children. J Surg Res 2019; 244:389-394. [DOI: 10.1016/j.jss.2019.06.058] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Revised: 04/25/2019] [Accepted: 06/14/2019] [Indexed: 10/26/2022]
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36
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Kovler ML, Beckman RM, Goldstein SD, Stewart D. Laparoscopic Spleen-Preserving Distal Pancreatectomy for Solid Pseudopapillary Neoplasm in Adolescents. J Laparoendosc Adv Surg Tech A 2019; 29:1372-1377. [DOI: 10.1089/lap.2019.0201] [Citation(s) in RCA: 5] [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: 12/26/2022] Open
Affiliation(s)
- Mark L. Kovler
- Division of Pediatric General Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Ross M. Beckman
- Division of Pediatric General Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Seth D. Goldstein
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Dylan Stewart
- Division of Pediatric General Surgery, Johns Hopkins Hospital, Baltimore, Maryland
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37
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Goldstein SD, Raval MV. Medical Overuse and Appendicitis Treatment. JAMA Pediatr 2019; 173:891-892. [PMID: 31329222 DOI: 10.1001/jamapediatrics.2019.2394] [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] [Indexed: 11/14/2022]
Affiliation(s)
- Seth D Goldstein
- Pediatric General and Thoracic Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Mehul V Raval
- Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Surgical Outcomes and Quality Improvement Center, Center for Healthcare Studies, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois.,Surgical Quality Improvement System Lead, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
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38
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Rizeq YK, Many BT, Vacek JC, Silver I, Goldstein SD, Abdullah F, Raval MV. Trends in perioperative opioid and non-opioid utilization during ambulatory surgery in children. Surgery 2019; 166:172-176. [DOI: 10.1016/j.surg.2019.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 03/12/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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Al-Hamad S, Hackam DJ, Goldstein SD, Huisman TAGM, Darge K, Hwang M. Contrast-Enhanced Ultrasound and Near-Infrared Spectroscopy of the Neonatal Bowel: Novel, Bedside, Noninvasive, and Radiation-Free Imaging for Early Detection of Necrotizing Enterocolitis. Am J Perinatol 2018; 35:1358-1365. [PMID: 29852509 DOI: 10.1055/s-0038-1655768] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [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] [Indexed: 10/14/2022]
Abstract
Despite extensive research and improvements in the field of neonatal care, the morbidity and mortality associated with necrotizing enterocolitis (NEC) have remained unchanged over the past three decades. Early detection of ischemia and necrotic bowel is vital in improving morbidity and mortality associated with NEC; however, strategies for predicting and preventing NEC are lacking. Contrast-enhanced ultrasound (CEUS) and near-infrared spectroscopy (NIRS) are novel techniques in pediatrics that have been proven as safe modalities. CEUS has benefits over conventional ultrasound (US) by its improved real-time evaluation of the micro- and macrovascularities of normally and abnormally perfused tissue. US has been implemented as a useful adjunct to X-ray for earlier evaluation of NEC. NIRS is another noninvasive technique that has shown promise in improving early detection of NEC. The purpose of this article is to review the current understanding of changes in bowel perfusion in NEC, discuss the accuracy of abdominal US in detecting NEC, and explain how the use of CEUS and NIRS will enhance the precise and early detection of altered/pathological bowel wall perfusion in the initial development and course of NEC.
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Affiliation(s)
- Suzanne Al-Hamad
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, Maryland
| | - David J Hackam
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Seth D Goldstein
- Division of Pediatric Surgery, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Thierry A G M Huisman
- Division of Pediatric Radiology and Pediatric Neuroradiology, Johns Hopkins Hospital, Baltimore, Maryland
| | - Kassa Darge
- Division of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Misun Hwang
- Division of Radiology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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40
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Maruf M, Kasprenski M, Jayman J, Goldstein SD, Benz K, Baumgartner T, Gearhart JP. Achieving urinary continence in cloacal exstrophy: The surgical cost. J Pediatr Surg 2018; 53:1937-1941. [PMID: 29555156 DOI: 10.1016/j.jpedsurg.2018.02.055] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/26/2018] [Accepted: 02/14/2018] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Cloacal exstrophy (CE) is a severe midline congenital abnormality that requires numerous surgical corrections to achieve an acceptable quality of life. Candidates for urinary continence undergo multiple procedures, most often continent bladder diversions, to become socially dry. Here, the authors investigate the number of genitourinary interventions that patients with CE undergo to attain urinary continence. MATERIALS AND METHODS A retrospective review of a prospectively maintained database of 1311 exstrophy epispadias complex patients was performed. Patients with CE who have had at least one continence procedure were included. A continence procedure was defined as bladder neck reconstruction with or without augmentation, bladder neck transection with continent urinary diversion, augmentation cystoplasty, or use of injectable bulking agents. Continence was defined as a dry interval greater than 3 hours without leakage at night. RESULTS In total, 140 CE and CE variant patients have been managed at the authors' institution. Of the 116 CE patients, 59 received at least one continence procedure, 14 were excluded for incontinent diversion or cystectomy, and the remaining 43 patients are awaiting a continence procedure. At the time of analysis, 42 (71%) patients who underwent a continence procedure were dry. The median number of total urologic procedures to reach urinary continence was 4 (range 2-10). This included 1 bladder closure (range 1-3), 2 urinary continence procedures (range 1-4), and 1 (range 0-4) "other" genitourinary procedures. The median time to urinary continence was 11.0 years (95% CI [9.2-14.2]). CONCLUSIONS A majority of CE patients who undergo a diversion procedure can achieve urinary continence. However multiple continence procedures are likely necessary. Of patients who are candidates for a continence procedure, half will be continent by the age of 11. LEVEL OF EVIDENCE Level IV, Case series with no comparison group.
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Affiliation(s)
- Mahir Maruf
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Matthew Kasprenski
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John Jayman
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Seth D Goldstein
- Division of General Pediatric Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD, USA
| | - Karl Benz
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - Timothy Baumgartner
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA
| | - John P Gearhart
- Robert D. Jeffs Division of Pediatric Urology, The James Buchanan Brady Urological Institutions, The Johns Hopkins Hospital, Johns Hopkins Medical Institutions, Charlotte Bloomberg Children's Hospital, Baltimore, MD, USA.
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DiBrito SR, Cerullo M, Goldstein SD, Ziegfeld S, Stewart D, Nasr IW. Reliability of Glasgow Coma Score in pediatric trauma patients. J Pediatr Surg 2018; 53:1789-1794. [PMID: 29429772 DOI: 10.1016/j.jpedsurg.2017.12.027] [Citation(s) in RCA: 15] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 11/27/2017] [Accepted: 12/27/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS. METHODS We conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearson's correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates. RESULTS We identified 5306 patients. Pearson's correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score. CONCLUSIONS GCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients. LEVEL OF EVIDENCE III, Prognostic.
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Affiliation(s)
- Sandra R DiBrito
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Marcelo Cerullo
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Seth D Goldstein
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Susan Ziegfeld
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Dylan Stewart
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
| | - Isam W Nasr
- Department of Surgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Tower 110, Baltimore, MD, USA 21287.
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42
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Goldstein SD, Beaulieu RJ, Niño DF, Chun Y, Banerjee A, Sodhi CP, Hackam DJ. Early detection of necrotizing enterocolitis using broadband optical spectroscopy. J Pediatr Surg 2018; 53:1192-1196. [PMID: 29602549 PMCID: PMC6214666 DOI: 10.1016/j.jpedsurg.2018.02.083] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [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: 02/18/2018] [Accepted: 02/27/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE The definitive diagnosis of necrotizing enterocolitis (NEC) is typically at an advanced stage, indicating the need for sensitive and noninvasive diagnostic modalities. Near infrared spectroscopy (NIRS) has been utilized to noninvasively measure intraabdominal tissue oxygenation and to diagnose NEC, but specificity is lacking, in part because sensors are limited to a narrow band of the electromagnetic spectrum. Here, we introduce the concept of broadband optical spectroscopy (BOS) as a noninvasive method to characterize NEC. METHODS NEC was induced in 7-day old mice by gavage feeding with formula supplemented with enteric bacteria plus hypoxia. Transabdominal spectroscopy was performed daily using a broad-spectrum halogen light source coupled with a spectroradiometer capable of detection from 400 to 1800nm. RESULTS A feature extraction algorithm was developed based on the spectral waveforms from mice with NEC. When subsequently tested on cohorts of diseased and control mice by a blinded examiner, noninvasive BOS was able to detect disease with 100% specificity and sensitivity. CONCLUSIONS We reveal that the use of BOS is able to accurately and noninvasively discriminate the presence of NEC in a mouse model, thus introducing a noninvasive early diagnostic modality for this devastating disease.
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Affiliation(s)
- Seth D. Goldstein
- Johns Hopkins School of Medicine, Baltimore, MD,Corresponding author at: Johns Hopkins Hospital, 1800 Orleans St, Bloomberg 7337, Baltimore, MD 21287. Tel.: +1 410 955 1983. (S.D. Goldstein)
| | | | | | - Young Chun
- Johns Hopkins School of Medicine, Baltimore, MD
| | - Amit Banerjee
- Johns Hopkins Applied Physics Laboratory, Baltimore, MD
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Beaulieu RJ, Goldstein SD, Singh J, Safar B, Banerjee A, Ahuja N. Automated diagnosis of colon cancer using hyperspectral sensing. Int J Med Robot 2018; 14:e1897. [PMID: 29479794 DOI: 10.1002/rcs.1897] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 03/15/2017] [Revised: 12/03/2017] [Accepted: 01/08/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Surgical management of colorectal cancer relies on accurate identification of tumor and possible metastatic disease. Hyperspectral (HS) sensing is a passive, non-ionizing diagnostic method that has been considered for multiple tumor types. The ability to use HS for identification of tumor specimens during surgical resection of colorectal cancers was explored. METHODS Patients with colorectal cancer who underwent operative resection were enrolled. HS measurements were performed both intra- and extra-luminally. Spectral results were correlated with pathologic evaluation. RESULTS Fifteen patient specimens were analyzed. For patients with confirmed colorectal cancer, extraluminal spectra analysis yielded 61.68% sensitivity with 90% specificity. For intraluminal specimens, sensitivity increased to 91.97% with 90% specificity. CONCLUSIONS Hyperspectral sensing can reliably detect tumors in resected colon specimens. This research offers promising results for a diagnostic technology that is non-ionizing and does not require the use of contrast agents to achieve accurate colorectal cancer detection.
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Affiliation(s)
| | - Seth D Goldstein
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Jasvinder Singh
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bashar Safar
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Amit Banerjee
- Applied Physics Laboratory, Johns Hopkins University, Laurel, MD, USA
| | - Nita Ahuja
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Goldstein SD, Trucco M, Bautista Guzman W, Hayashi M, Loeb DM. A monoclonal antibody against the Wnt signaling inhibitor dickkopf-1 inhibits osteosarcoma metastasis in a preclinical model. Oncotarget 2018; 7:21114-23. [PMID: 27049730 PMCID: PMC5008272 DOI: 10.18632/oncotarget.8522] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [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: 02/24/2016] [Accepted: 03/28/2016] [Indexed: 02/04/2023] Open
Abstract
The outcome of patients with metastatic osteosarcoma has not improved since the introduction of chemotherapy in the 1970s. Development of therapies targeting the metastatic cascade is a tremendous unmet medical need. The Wnt signaling pathway has been the focus of intense investigation in osteosarcoma because of its role in normal bone development. Although the role of Wnt signaling in the pathogenesis of osteosarcoma is controversial, there are several reports of dickkopf-1 (DKK-1), a Wnt signaling antagonist, possibly playing a pro-tumorigenic role. In this work we investigated the effect of anti-DKK-1 antibodies on the growth and metastasis of patient-derived osteosarcoma xenografts. We were able to detect human DKK-1 in the blood of tumor-bearing mice and found a correlation between DKK-1 level and tumor proliferation. Treatment with the anti-DKK-1 antibody, BHQ880, slowed the growth of orthotopically implanted patient-derived osteosarcoma xenografts and inhibited metastasis. This effect was correlated with increased nuclear beta-catenin staining and increased expression of the bone differentiation marker osteopontin. These findings suggest that Wnt signaling is anti-tumorigenic in osteosarcoma, and support the targeting of DKK-1 as an anti-metastatic strategy for patients with osteosarcoma.
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Affiliation(s)
- Seth D Goldstein
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Matteo Trucco
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Wendy Bautista Guzman
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Masanori Hayashi
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - David M Loeb
- Division of Pediatric Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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Mehta A, Goldstein SD, Makary MA. Global trends in center accreditation by the Joint Commission International: growing patient implications for international medical and surgical care. J Travel Med 2017; 24:4090960. [PMID: 28931151 DOI: 10.1093/jtm/tax048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Indexed: 11/14/2022]
Abstract
Millions of patients travel internationally for medical and surgical care. We found that the annual number of centers accredited by the Joint Commission International increased from one center in 1999 to 132 centers in 2016; there are currently 939 accredited centers across 66 countries. Public health and medicolegal implications related to medical travel deserve attention.
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Affiliation(s)
- Ambar Mehta
- School of Medicine, Johns Hopkins University, Baltimore, MD, USA.,Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Seth D Goldstein
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Martin A Makary
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
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Hayashi M, Baker A, Goldstein SD, Albert CM, Jackson KW, McCarty G, Kahlert UD, Loeb DM. Inhibition of porcupine prolongs metastasis free survival in a mouse xenograft model of Ewing sarcoma. Oncotarget 2017; 8:78265-78276. [PMID: 29108227 PMCID: PMC5667961 DOI: 10.18632/oncotarget.19432] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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: 05/12/2017] [Accepted: 06/26/2017] [Indexed: 12/12/2022] Open
Abstract
The most pressing unmet clinical need for patients with Ewing sarcoma (ES) is the prevention and treatment of metastasis. The Wnt signaling pathway regulates a number of cellular functions associated with metastasis, including proliferation, motility, and stem cell self-renewal. Functional interaction between Wnt ligands and their receptors requires palmitoylation by Porcupine (Porcn), making this an ideal therapeutic target. We studied the effect of WNT974, a potent, selective Porcn inhibitor, on ES metastasis. In vitro, WNT974 does not affect ES proliferation or sarcosphere formation, but suppresses multiple transcriptional regulators of metastasis and inhibits cell migration. In vivo, in an orthotopic implantation/amputation model of spontaneous distant metastasis, single agent WNT974 treatment leads to a significant delay in formation of lung metastasis and a substantial improvement in post-amputation survival without a major effect on primary tumor growth. The drug produces no survival benefit in a tail vein injection model, supporting the hypothesis that WNT974 inhibits early steps in the metastatic cascade, such as migration and invasion. Our findings strongly implicate Wnt signaling in the early steps of ES metastasis and demonstrate that WNT974 has the potential to significantly improve the survival of ES patients through the specific inhibition of metastasis.
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Affiliation(s)
- Masanori Hayashi
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Alissa Baker
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Seth D Goldstein
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Catherine M Albert
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.,Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Kyle W Jackson
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Gregory McCarty
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
| | - Ulf D Kahlert
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA.,Neurosurgical Clinic, University Medical Center Düsseldorf, Düsseldorf, Germany
| | - David M Loeb
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD, USA
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Abstract
Choledochal cysts are rare congenital disorders first described by Vater and Ezler in 1723. Their exact etiology remains incompletely understood; however, an anomalous pancreaticobiliary union (APBDU) and subsequent reflux of biliary contents into the biliary tree are thought to play a role. Accordingly, APBDU-associated choledochal cyst patients are significantly more likely to have evidence of hepatitis, cholangitis or pancreatitis and pathologically confirmed inflammation. In 1977, Todani and colleagues modified the original Alonso-Lej classification to include five types of CC. Type I and IV are the most common and most likely to be associated with malignancy. The majority of choledochal cysts are diagnosed in childhood. Clinical presentation varies and most often consists of nonspecific abdominal pain. Diagnosis is typically accomplished using multimodality imaging techniques including computed tomography, magnetic resonance imaging, ultrasound and MRCP. The use of diagnostic PTC and ERCP in CC has been largely replaced by MRCP. Appropriate management consists of prompt, complete cyst excision followed by restoration of biliary enteric continuity when necessary. Minimally invasive CC resection in the pediatric population has demonstrated acceptable outcomes. Prognosis is generally excellent; however, malignancy risk remains higher than the general population even after complete surgical excision.
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Affiliation(s)
- Kevin C Soares
- Division of Surgical Oncology, Department of Surgery, The Johns Hopkins University School of Medicine, Blalock 688, 600 N. Wolfe Street, Baltimore, MD, 21287, USA
| | - Seth D Goldstein
- Division of General Pediatric Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mounes A Ghaseb
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ihab Kamel
- Department of Radiology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David J Hackam
- Division of General Pediatric Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Timothy M Pawlik
- The Urban Meyer III and Shelley Meyer Chair for Cancer Research, Department of Surgery, Wexner Medical Center, Ohio State University, 395 W. 12th Ave., Suite 670, Columbus, OH, USA.
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Sacco Casamassima MG, Goldstein SD, Yang J, Gause CD, Abdullah F, Meoded A, Makary MA, Colombani PM. The impact of surgical strategies on outcomes for pediatric chronic pancreatitis. Pediatr Surg Int 2017; 33:75-83. [PMID: 27815641 DOI: 10.1007/s00383-016-3999-6] [Citation(s) in RCA: 12] [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] [Accepted: 10/26/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE To review our institutional experience in the surgical treatment of pediatric chronic pancreatitis (CP) and evaluate predictors of long-term pain relief. METHODS Outcomes of patients ≤21 years surgically treated for CP in a single institution from 1995 to 2014 were evaluated. RESULTS Twenty patients underwent surgery for CP at a median of 16.6 years (IQR 10.7-20.6 years). The most common etiology was pancreas divisum (n = 7; 35%). Therapeutic endoscopy was the first-line treatment in 17 cases (85%). Surgical procedures included: longitudinal pancreaticojejunostomy (n = 4, 20%), pancreatectomy (n = 9, 45%), total pancreatectomy with islet autotransplantation (n = 2; 10%), sphincteroplasty (n = 2, 10%) and pseudocyst drainage (n = 3, 15%). At a median follow-up of 5.3 years (IQR 4.2-5.3), twelve patients (63.2%) were pain free and five (26.3%) were insulin dependent. In univariate analysis, previous surgical procedure or >5 endoscopic treatments were associated with a lower likelihood of pain relief (OR 0.06; 95% CI 0.006-0.57; OR 0.07; 95%, CI 0.01-0.89). However, these associations were not present in multivariate analysis. CONCLUSION In children with CP, the step-up practice including a limited trial of endoscopic interventions followed by surgery tailored to anatomical abnormalities and gene mutation status is effective in ensuring long-term pain relief and preserving pancreatic function.
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Affiliation(s)
| | - Seth D Goldstein
- Division of Pediatric Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jingyan Yang
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Colin D Gause
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Fizan Abdullah
- Department of Surgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Avner Meoded
- Division of Pediatric Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Martin A Makary
- Department of Surgery, Pancreatitis Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul M Colombani
- Department of Surgery, Johns Hopkins All Children's Hospital, 601 5th Street South, Suite 501, St Petersburg, FL, 33701, USA.
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Ludwig WW, Goldstein SD, Gearhart JP. Bladder exstrophy and postoperative intussusception due to Meckel's diverticulum: A confluence of congenital anomalies. Journal of Pediatric Surgery Case Reports 2017. [DOI: 10.1016/j.epsc.2016.10.012] [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: 10/20/2022] Open
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50
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Sacco Casamassima MG, Gause CD, Goldstein SD, Abdullah F, Meoded A, Lukish JR, Wolfgang CL, Cameron J, Hackam DJ, Hruban RH, Colombani PM. Pancreatic surgery for tumors in children and adolescents. Pediatr Surg Int 2016; 32:779-88. [PMID: 27364750 DOI: 10.1007/s00383-016-3925-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [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] [Accepted: 06/22/2016] [Indexed: 12/11/2022]
Abstract
PURPOSE Pancreatic neoplasms are uncommon in children. This study sought to analyze the clinical and pathological features of surgically resected pancreatic tumors in children and discuss management strategies. METHODS We conducted a retrospective review of patients ≤21 years with pancreatic neoplasms who underwent surgery at a single institution between 1995 and 2015. RESULTS Nineteen patients were identified with a median age at operation of 16.6 years (IQR 13.5-18.9). The most common histology was solid pseudopapillary neoplasm (SPN) (n = 13), followed by pancreatic neuroendocrine tumor (n = 3), serous cystadenoma (n = 2) and pancreatoblastoma (n = 1). Operative procedures included formal pancreatectomy (n = 17), enucleation (n = 1) and central pancreatectomy (n = 1). SPNs were noninvasive in all but one case with perineural, vascular and lymph node involvement. Seventeen patients (89.5 %) are currently alive and disease free at a median follow-up of 5.7 (IQR 3.7-10.9) years. Two patients died: one with metastatic insulinoma and another with SPN who developed peritoneal carcinomatosis secondary to a concurrent rectal adenocarcinoma. CONCLUSIONS Pediatric pancreatic tumors are a heterogeneous group of neoplastic lesions for which surgery can be curative. SPN is the most common histology, is characterized by low malignant potential and in selected cases can be safely and effectively treated with a tissue-sparing resection and minimally invasive approach.
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Affiliation(s)
| | - Colin D Gause
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Seth D Goldstein
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Fizan Abdullah
- Division of Pediatric Surgery, Department of Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Avner Meoded
- Division of Pediatric Radiology, The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University, Baltimore, MD, USA
| | - Jeffrey R Lukish
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Christopher L Wolfgang
- Department of Surgery, The Sol Goldman Pancreatic Research Center, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - John Cameron
- Department of Surgery, The Sol Goldman Pancreatic Research Center, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - David J Hackam
- Division of Pediatric Surgery, The Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Ralph H Hruban
- Department of Pathology, The Sol Goldman Pancreatic Research Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul M Colombani
- Department of Surgery, Johns Hopkins All Children's Hospital, 601 5th Street South, Suite 501, Saint Petersburg, FL, 33701, USA.
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