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Fraser JA, Deans KJ, Fallat ME, Helmrath M, Kabre R, Leys CM, Markel TA, Dillon PA, Downard C, Wright TN, Gadepalli SK, Grabowski JE, Hirschl R, Johnson KN, Kohler JE, Landman MP, Mak GZ, Minneci PC, Rymeski B, Sato TT, Slater BJ, Peter SDS, Fraser JD. Evaluating the risk of peri-umbilical hernia after sutured or sutureless gastroschisis closure. J Pediatr Surg 2022; 57:786-791. [PMID: 35450699 DOI: 10.1016/j.jpedsurg.2022.03.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/18/2022] [Revised: 03/11/2022] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION We evaluate the incidence, outcomes, and management of peri‑umbilical hernias after sutured or sutureless gastroschisis closure. METHODS A retrospective, longitudinal follow-up of neonates with gastroschisis who underwent closure at 11 children's hospitals from 2013 to 2016 was performed. Patient encounters were reviewed through 2019 to identify the presence of a peri‑umbilical hernia, time to spontaneous closure or repair, and associated complications. RESULTS Of 397 patients, 375 had follow-up data. Sutured closure was performed in 305 (81.3%). A total of 310 (82.7%) infants had uncomplicated gastroschisis. Peri-umbilical hernia incidence after gastroschisis closure was 22.7% overall within a median follow-up of 2.5 years [IQR 1.3,3.9], and higher in those with uncomplicated gastroschisis who underwent primary vs. silo assisted closure (53.0% vs. 17.2%, p< 0.001). At follow-up, 50.0% of sutureless closures had a persistent hernia, while 16.4% of sutured closures had a postoperative hernia of the fascial defect (50.0% vs. 16.4%, p< 0.001). Spontaneous closure was observed in 38.8% of patients within a median of 17 months [9,26] and most frequently observed in those who underwent a sutureless primary closure (52.2%). Twenty-seven patients (31.8%) underwent operative repair within a median of 13 months [7,23.5]. Rate and interval of spontaneous closure or repair were similar between the sutured and sutureless closure groups, with no difference between those who underwent primary vs. silo assisted closure. CONCLUSION Peri-umbilical hernias after sutured or sutureless gastroschisis closure may be safely observed similar to congenital umbilical hernias as spontaneous closure occurs, with minimal complications and no additional risk with either closure approach. LEVELS OF EVIDENCE Level II.
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Affiliation(s)
- James A Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City MO 64108, United States.
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Michael Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, United States
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Troy A Markel
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Patrick A Dillon
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, United States
| | - Cynthia Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY, United States
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL, United States
| | - Ronald Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, United States
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute and Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, United States
| | - Beth Rymeski
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Bethany J Slater
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL, United States
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City MO 64108, United States
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City MO 64108, United States.
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Thanh DQL, Giau HTN, Huong TNG, Linh TNU, Phuc VM, Vuong NL. Sutureless Closure Versus Conventional Technique in the Primary Surgery of Total Anomalous Pulmonary Venous Connection: A Systematic Review and Meta-analysis. Pediatr Cardiol 2022; 43:943-951. [PMID: 35426500 DOI: 10.1007/s00246-022-02904-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 03/31/2022] [Indexed: 11/24/2022]
Abstract
Sutureless closure has been used for primary repair of total anomalous pulmonary venous connection (TAPVC) for over 20 years but its superiority over conventional technique is still uncertain. This systematic review was conducted to compare the effectiveness of sutureless closure and conventional surgery as the primary repair for TAPVC. Systematic search was performed in June 2021 on 12 databases. All studies comparing sutureless and conventional surgery for TAPVC were included. The primary endpoints were early mortality, overall mortality, postoperative pulmonary venous stenosis (PVS), and reoperation. Meta-analysis of two-arm studies was performed with several sensitivity and subgroup analyses. Six retrospective studies with 767 patients were included in meta-analyses. Sutureless closure significantly reduced the risk of early mortality, overall mortality, postoperative PVS, and reoperation by 53%, 45%, 77%, and 67% compared to conventional technique, respectively. No heterogeneity was found and presence of publication bias was non-significant. The results were consistent in all sensitivity analyses. Subgroup analyses revealed that sutureless closure was superior to conventional technique in patients with and without preoperative pulmonary venous obstruction, and neonates and non-neonates. Sutureless closure is better than conventional closure as the primary surgery for TAPVC patients. We advocate using sutureless closure for patients with TAPVC. Future large-scale observational studies or clinical trials are required to confirm our findings.
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Affiliation(s)
- Dinh Quang Le Thanh
- Department of Cardiac Surgery, Children's Hospital 1, 341 Su Van Hanh, Ward 10, District 10, Ho Chi Minh City, Vietnam
| | - Hoang Thi Ngoc Giau
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Tran Nguyen Giang Huong
- University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Truong Nguyen Uy Linh
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Vu Minh Phuc
- Faculty of Medicine, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam
| | - Nguyen Lam Vuong
- Faculty of Public Health, University of Medicine and Pharmacy at Ho Chi Minh City, 217 Hong Bang, Ward 11, District 5, Ho Chi Minh City, Vietnam.
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Miyata S, Joharifard S, Trudeau MO, Villeneuve A, Yang J, Bouchard S. Tu-be or not tu-be? Is routine endotracheal intubation necessary for successful bedside reduction and primary closure of gastroschisis? J Pediatr Surg 2022; 57:350-355. [PMID: 34304903 DOI: 10.1016/j.jpedsurg.2021.06.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/20/2021] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Wide practice variation exists in the management of gastroschisis. Routine endotracheal intubation for bedside closure may lead to longer duration of mechanical ventilation. METHODS The Canadian Association of Pediatric Surgery Network gastroschisis dataset was queried for all patients undergoing attempted bedside reduction and closure. Patients with evidence of intestinal necrosis or perforation were excluded. A propensity score analysis was used to compare the rate of successful primary repair and post-operative outcomes between intubated and non-intubated patients. RESULTS In propensity score matched analysis, the successful primary repair rate did not reach statistical significance between patients who were intubated for attempted bedside closure and those who were not intubated (Odds Ratio: 2.18, 95% Confidence Interval: 0.79, 6.03). Intubated patients experienced 3.02 more ventilator days than patients who were not intubated at the time of initial attempted closure. Other post-operative parameters were similar between both groups. CONCLUSIONS It is reasonable to attempt primary bedside gastroschisis closure without intubation in otherwise healthy infants.
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Affiliation(s)
- Shin Miyata
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada; Division of Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, 1465 S. Grand Boulevard, St. Louis, MO, 63104, USA.
| | - Shahrzad Joharifard
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada; Division of Pediatric General Surgery, Department of Surgery, BC Children's Hospital, 4500 Oak St, Vancouver, BC, V6H 3N1 Canada
| | - Maeve O'Neill Trudeau
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
| | - Andréanne Villeneuve
- Division of Neonatology, CHU Sainte-Justine, Montreal, QC Canada, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
| | - Junmin Yang
- Department of Pediatrics, Mount Sinai Hospital, Toronto, Ontario
| | - Sarah Bouchard
- Department of Surgery, University Hospital Center Sainte-Justine, 3175 Chemin de la Côte Ste-Catherine, Montréal, Québec, H3T 1C5, Canada
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Fraser JD, Deans KJ, Fallat ME, Helmrath MA, Kabre R, Leys CM, Burns RC, Corkum K, Dillon PA, Downard CD, Gadepalli SK, Grabowski JE, Hernandez E, Hirschl RB, Johnson KN, Kohler JE, Landman MP, Landisch RM, Lawrence AE, Mak GZ, Minneci PC, Rymeski B, Sato TT, Scannell M, Slater BJ, Wilkinson KH, Wright TN, St Peter SD. Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg 2020; 55:2284-2288. [PMID: 32151403 DOI: 10.1016/j.jpedsurg.2020.02.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [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: 11/04/2019] [Revised: 01/14/2020] [Accepted: 02/06/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. METHODS A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. RESULTS Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. CONCLUSION Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO.
| | - Katherine J Deans
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Michael A Helmrath
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rashmi Kabre
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Charles M Leys
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - R Cartland Burns
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Kristine Corkum
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Patrick A Dillon
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Julia E Grabowski
- Division of Pediatric Surgery, Department of Surgery, Feinberg School of Medicine of Northwestern University, Chicago, IL
| | - Edward Hernandez
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Ronald B Hirschl
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Kevin N Johnson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jonathan E Kohler
- Division of Pediatric Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Matthew P Landman
- Division of Pediatric Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Rachel M Landisch
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amy E Lawrence
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Grace Z Mak
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | - Peter C Minneci
- Center for Surgical Outcomes Research, The Research Institute at Nationwide Children's Hospital, Department of Surgery, University of Ohio, Columbus, OH
| | - Beth Rymeski
- Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Thomas T Sato
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Madeline Scannell
- Division of Pediatric Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO
| | - Bethany J Slater
- Section of Pediatric Surgery, Department of Surgery, The University of Chicago Medicine, Chicago, IL
| | - Kathryn H Wilkinson
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tiffany N Wright
- Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY
| | - Shawn D St Peter
- Department of Surgery, Children's Mercy Kansas City, Kansas City, MO
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Affiliation(s)
- Charlene Dekonenko
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA
| | - Jason D Fraser
- Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; University of Missouri Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108, USA.
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Miyake H, Seo S, O'Connell JS, Janssen Lok M, Pierro A. Safety and usefulness of plastic closure in infants with gastroschisis: a systematic review and meta-analysis. Pediatr Surg Int 2019; 35:107-16. [PMID: 30392129 DOI: 10.1007/s00383-018-4381-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/18/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Recently, plastic closure of abdominal defect in infants with gastroschisis has been used. Timing of gastroschisis closure can be mainly divided into two groups: primary closure and delayed closure after silo forming. Safety and usefulness of plastic closure in gastroschisis remains unclear. We aimed to evaluate the current evidence for plastic closure in infants with gastroschisis. METHODS The analysis was done for primary closure as well as closure after silo. Outcomes were mortality, wound infection, duration of ventilation, time to feeding, and length of hospital stay (LOS). The quality of evidence was summarized using the GRADE approach. RESULTS In the "primary" group, there was no significant difference in mortality, time to feeding initiation and LOS. In the "silo" group, wound infection was significantly lower in plastic closure (Odds ratio 0.24, 95%CI 0.09-0.69, p = 0.008). Duration of ventilation, time to feeding initiation and LOS were significantly shorter after plastic closure (Ventilation; mean difference (MD) - 5.76, p = 0.03. Feeding initiation; MD - 9.42, p < 0.0001. LOS; MD - 14.06, p = 0.002). Quality of evidence was very low for all outcomes. CONCLUSIONS Current results suggest that plastic closure may be beneficial for infants with gastroschisis requiring silo formation. However, this evidence is suboptimal and further studies are needed.
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Tullie LGC, Bough GM, Shalaby A, Kiely EM, Curry JI, Pierro A, De Coppi P, Cross KMK. Umbilical hernia following gastroschisis closure: a common event? Pediatr Surg Int 2016; 32:811-4. [PMID: 27344584 DOI: 10.1007/s00383-016-3906-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [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] [Accepted: 06/01/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE To assess incidence and natural history of umbilical hernia following sutured and sutureless gastroschisis closure. METHODS With audit approval, we undertook a retrospective clinical record review of all gastroschisis closures in our institution (2007-2013). Patient demographics, gastroschisis closure method and umbilical hernia occurrence were recorded. Data, presented as median (range), underwent appropriate statistical analysis. RESULTS Fifty-three patients were identified, gestation 36 weeks (31-38), birth weight 2.39 kg (1-3.52) and 23 (43 %) were male. Fourteen patients (26 %) underwent sutureless closure: 12 primary, 2 staged; and 39 (74 %) sutured closure: 19 primary, 20 staged. Sutured closure was interrupted sutures in 24 patients, 11 pursestring and 4 not specified. Fifty patients were followed-up over 53 months (10-101) and 22 (44 %) developed umbilical hernias. There was a significantly greater hernia incidence following sutureless closure (p = 0.0002). In sutured closure, pursestring technique had the highest hernia rate (64 %). Seven patients underwent operative hernia closure; three secondary to another procedure. Seven patients had their hernias resolve. One patient was lost to follow-up and seven remain under observation with no reported complications. CONCLUSIONS There is a significant umbilical hernia incidence following sutureless and pursestring sutured gastroschisis closure. This has not led to complications and the majority have not undergone repair.
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Affiliation(s)
- L G C Tullie
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - G M Bough
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - A Shalaby
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - E M Kiely
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - J I Curry
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - A Pierro
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.,Division of General Surgery, Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - P De Coppi
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.,Stem Cells and Regenerative Medicine Section, DBC, Institute of Child Health, University College London, London, WC1N 1EH, UK
| | - K M K Cross
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
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