Publications by authors named "Bethany J Slater"

48 Publications

Provider education leads to sustained reduction in pediatric opioid prescribing after surgery.

J Pediatr Surg 2021 Aug 8. Epub 2021 Aug 8.

Lurie Children's Hospital of Chicago, Pediatric Surgery, Northwestern University, Chicago, IL, USA.

Background: The majority of opioid overdose admissions in pediatric patients are associated with prescription opioids. Post-operative prescriptions are an addressable source of opioids in the household. This study aims to assess for sustained reduction in opioid prescribing after implementation of provider-based education at nine centers.

Methods: Opioid prescribing information was collected for pediatric patients undergoing umbilical hernia repair at nine centers between December 2018 and January 2019, one year after the start of an education intervention. This was compared to prescribing patterns in the immediate pre- and post-intervention periods at each of the nine centers.

Results: In the current study period, 29/127 (22.8%) patients received opioid prescriptions (median 8 doses) following surgery. There were no medication refills, emergency department returns or readmissions related to the procedure. There was sustained reduction in opioid prescribing compared to pre-intervention (22.8% vs 75.8% of patients, p<0.001, Fig. (1). Five centers showed statistically significant improvement and the other four demonstrated decreased prescribing, though not statistically significant.

Conclusions: Our multicenter study demonstrates sustained reduction in opioid prescribing after pediatric umbilical hernia repair after a provider-based educational intervention. Similar low-fidelity provider education interventions may be beneficial to improve opioid stewardship for a wider variety of pediatric surgical procedures.

Levels Of Evidence: (treatment study)-level 3.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2021.08.004DOI Listing
August 2021

SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD).

Surg Endosc 2021 Sep 19;35(9):4903-4917. Epub 2021 Jul 19.

Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA.

Background: Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques.

Methods: Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed.

Results: The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication.

Conclusions: These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08625-5DOI Listing
September 2021

Outcomes in gastroschisis: expectations in the postnatal period for simple vs complex gastroschisis.

J Perinatol 2021 Jul 25;41(7):1755-1759. Epub 2021 May 25.

Department of Surgery, Children's Mercy Kansas City, Kansas City, MO, USA.

Objective: To provide generalizable estimates for expected outcomes of simple gastroschisis (SG) and complex gastroschisis (CG) patients from a large multi-institutional cohort for use during counseling.

Study Design: A retrospective study of 394 neonates with gastroschisis at 11 children's hospitals from January 2013 to March 2017 was performed. Analysis by Fisher's exact tests and Wilcoxon rank sum tests were performed. Outcomes of complex and simple gastroschisis are reported.

Result: There were 315 (80%) SG and 79 (20%) CG. CG had increased time from birth to closure (6 vs 4.4 days), closure to goal feeds (69 vs 23 days), ventilator use (90% vs 73%), SSIs (31% vs 11%), NEC (14% vs 6%), PN use (71 vs 24 days), LOS (104.5 vs 33 days), and mortality (11% vs 0%).

Conclusion: This study provides generalizable estimates for expected outcomes of patients with both SG and CG that can be utilized during counseling. CG has significantly worse in-hospital outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41372-021-01093-8DOI Listing
July 2021

Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines development: standard operating procedure.

Surg Endosc 2021 06 19;35(6):2417-2427. Epub 2021 Apr 19.

Department of Surgery, Stony Brook University, Stony Brook, USA.

Introduction: The mission of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is to innovate, educate, and collaborate to improve patient care. A critical element in meeting this mission is the publishing of trustworthy and current guidelines for the practicing surgeon.

Methods: In this manuscript, we outline the steps of developing high quality practice guidelines using a completely volunteer-based professional organization.

Results: SAGES has developed a standardized approach to train volunteer surgeons and trainees alike to develop clinically pertinent guidelines in a timely manner, without sacrificing quality.

Conclusions: This methodology can be used more widely by volunteer organizations to efficiently develop effective tools for practicing physicians.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08469-zDOI Listing
June 2021

Surgical treatment of GERD: systematic review and meta-analysis.

Surg Endosc 2021 Aug 2;35(8):4095-4123. Epub 2021 Mar 2.

Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.

Background: Gastroesophageal reflux disease (GERD) has a high worldwide prevalence in adults and children. There is uncertainty regarding medical versus surgical therapy and different surgical techniques. This review assessed outcomes of antireflux surgery versus medical management of GERD in adults and children, robotic versus laparoscopic fundoplication, complete versus partial fundoplication, and minimal versus maximal dissection in pediatric patients.

Methods: PubMed, Embase, and Cochrane databases were searched (2004-2019) to identify randomized control and non-randomized comparative studies. Two independent reviewers screened for eligibility. Random effects meta-analysis was performed on comparative data. Study quality was assessed using the Cochrane Risk of Bias and Newcastle Ottawa Scale.

Results: From 1473 records, 105 studies were included. Most had high or uncertain risk of bias. Analysis demonstrated that anti-reflux surgery was associated with superior short-term quality of life compared to PPI (Std mean difference =  - 0.51, 95%CI  - 0.63, - 0.40, I = 0%) however short-term symptom control was not significantly superior (RR = 0.75, 95%CI 0.47, 1.21, I = 82%). A proportion of patients undergoing operative treatment continue PPI treatment (28%). Robotic and laparoscopic fundoplication outcomes were similar. Compared to total fundoplication, partial fundoplication was associated with higher rates of prolonged PPI usage (RR = 2.06, 95%CI 1.08, 3.94, I = 45%). There was no statistically significant difference for long-term symptom control (RR = 0.94, 95%CI 0.85, 1.04, I = 53%) or long-term dysphagia (RR = 0.73, 95%CI 0.52, 1.02, I = 0%). Ien, minimal dissection during fundoplication was associated with lower reoperation rates than maximal dissection (RR = 0.21, 95%CI 0.06, 0.67).

Conclusions: The available evidence regarding the optimal treatment of GERD often suffers from high risk of bias. Additional high-quality randomized control trials may further inform surgical decision making in the treatment of GERD.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00464-021-08358-5DOI Listing
August 2021

Correction to: Laparoscopic Duodenojejunostomy for Superior Mesenteric Artery Syndrome.

Dig Dis Sci 2021 Mar;66(3):928

Department of Surgery, Stanford University Medical Center, Stanford, CA, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s10620-021-06880-zDOI Listing
March 2021

Pediatric surgical wait priority score (pSWAPS): Modifying a health system's adult-based elective surgery prioritization system for children's surgery during the COVID-19 pandemic.

J Pediatr Surg 2021 May 14;56(5):911-917. Epub 2021 Jan 14.

Department of Surgery, Advocate Children's Hospital, Oak Lawn, IL, United States.

Background: With the rise of COVID-19 cases, societies recommended canceling all elective surgical procedures because of perioperative concerns, transmission risk, and the need to divert resources. Once the number of cases stabilized, there was recognition that a system was needed to triage and prioritize scheduling operations.

Methods: A universal scoring system to triage surgical elective cases was developed for the Advocate Aurora Health system (Surgical Wait Priority Score, SWAPS) and was modified for use in pediatrics (pSWAPS). Resource-related, patient-related, and case urgency factors were used to create the overall score. Interrater reliability of ten cases was determined by four surgeons' scores and calculating Fleiss' Kappa coefficient. The system has been used for two months at two operating rooms with different resource restrictions with the goal of prioritizing elective cases.

Results: 18 factors were identified as significant contributors to the pWAPS creating a cumulative score ranging from 0 to 120. In the first month, 61 and 99 procedures were screened at the Oak Lawn (OL) and Park Ridge (PR) campuses respectively, and in the second month, 94 (OL) and 135 (PR) procedures were evaluated. The average pSWAPS scores were 37.9 at OL and 54.3 at PR. All cases that had scores within the immediate group were scheduled and completed.

Conclusion: The pSWAPS system is a simple, flexible scoring system that takes into consideration resource constraints. pSWAPS has been used for two months. It has served as an effective tool for safe and methodical reintroduction of elective procedures during the COVID-19 pandemic and could be used again for another surge.

Level Of Evidence: prognosis study, level of evidence - 4.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.12.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836842PMC
May 2021

Does Use of a Feeding Protocol Change Outcomes in Gastroschisis? A Report from the Midwest Pediatric Surgery Consortium.

Eur J Pediatr Surg 2020 Dec 27. Epub 2020 Dec 27.

Department of Surgery, Center for Prospective Trials, Children's Mercy Hospital, Kansas City, Missouri, United States.

Introduction:  Gastroschisis feeding practices vary. Standardized neonatal feeding protocols have been demonstrated to improve nutritional outcomes. We report outcomes of infants with gastroschisis that were fed with and without a protocol.

Materials And Methods:  A retrospective study of neonates with uncomplicated gastroschisis at 11 children's hospitals from 2013 to 2016 was performed.Outcomes of infants fed via institutional-specific protocols were compared with those fed without a protocol. Subgroup analyses of protocol use with immediate versus delayed closure and with sutured versus sutureless closure were conducted.

Results:  Among 315 neonates, protocol-based feeding was utilized in 204 (65%) while no feeding protocol was used in 111 (35%). There were less surgical site infections (SSI) in those fed with a protocol (7 vs. 16%,  = 0.019). There were no differences in TPN duration, time to initial oral intake, time to goal feeds, ventilator use, peripherally inserted central catheter line deep venous thromboses, or length of stay. Of those fed via protocol, less SSIs occurred in those who underwent sutured closure (9 vs. 19%,  = 0.026). Further analyses based on closure timing or closure method did not demonstrate any significant differences.

Conclusion:  Across this multi-institutional cohort of infants with uncomplicated gastroschisis, there were more SSIs in those fed without an institutional-based feeding protocol but no differences in other outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1721074DOI Listing
December 2020

Non-operative management of acute appendicitis in a pediatric patient with concomitant COVID-19 infection.

J Pediatr Surg Case Rep 2020 Aug 31;59:101512. Epub 2020 May 31.

University of Chicago Medicine, USA.

Introduction: In late December 2019, reports emerged from Wuhan, China of a novel corovonavirus SARS-CoV-2, which caused severe acute respiratory distress syndrome referred to as COVID-19. As the virus spread, reports of severe perioperative complications, including fatalities, began to emerge in the literature. We present a case of a previously healthy patient who developed classic symptoms of appendicitis. The patient was also found to be positive for COVID-19. Given the risks to both the patient and surgical team, we elected to pursue a non-operative management strategy for this patient with appendicitis.

Materials And Methods: A 13 year old female with COVID-19 presented with a day of right lower quadrant abdominal pain. A computerized tomography (CT) scan diagnosed uncomplicated appendicitis. The patient was successfully treated non-operatively with antibiotics and discharged home.

Conclusion: To our knowledge, this case illustrates the first report of a pediatric patient with concomitant appendicitis and COVID-19 infection. We have been able to utilize a non-operative management strategy to effectively treat the patient's acute appendicitis, while protecting her from the risks of undergoing a general anesthetic as well as the operative team. We hope this report can provide others with a potential management strategy for similar patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.epsc.2020.101512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261356PMC
August 2020

Abdominal Wall Defects.

Neoreviews 2020 06;21(6):e383-e391

Division of Pediatric Surgery, Children's Hospital, University of Missouri, Columbia, MO.

The 2 most common congenital abdominal wall defects are gastroschisis and omphalocele. Both are usually diagnosed prenatally with fetal ultrasonography, and affected patients are treated at a center with access to high-risk obstetric services, neonatology, and pediatric surgery. The main distinguishing features between the 2 are that gastroschisis has no sac and the defect is to the right of the umbilicus, whereas an omphalocele typically has a sac and the defect is at the umbilicus. In addition, patients with an omphalocele have a high prevalence of associated anomalies, whereas those with gastroschisis have a higher likelihood of abnormalities related to the gastrointestinal tract, with the most common being intestinal atresia. As such, the prognosis in patients with omphalocele is primarily affected by the severity and number of other anomalies and the prognosis for gastroschisis is correlated with the amount and function of the bowel. Because of these distinctions, these defects have different management strategies and outcomes. The goal of surgical treatment for both conditions consists of reduction of the abdominal viscera and closure of the abdominal wall defect; primary closure or a variety of staged approaches can be used without injury to the intra-abdominal contents through direct injury or increased intra-abdominal pressure, or abdominal compartment syndrome. Overall, the long-term outcome is generally good. The ability to stratify patients, particularly those with gastroschisis, based on risk factors for higher morbidity would potentially improve counseling and outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1542/neo.21-6-e383DOI Listing
June 2020

The economics of a pediatric surgical ICU.

Curr Opin Pediatr 2020 06;32(3):424-427

Surgery and Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA.

Purpose Of Review: The purpose of this review is to describe quality and financial economic principles that form the foundation for complex care delivery systems for the critically ill pediatric surgical population.

Recent Findings: Advances in neonatology along with innovation in surgical techniques in children led to the need to care for more complex postoperative surgical patients. Several studies have demonstrated improved outcomes in specialized pediatric centers. Furthermore, there is some evidence to suggest that there is overall financial benefit with decreased costs and more efficient resource use to pediatric subspecialty critical care.

Summary: As more becomes known regarding the impact of specialized ICU environments, pediatric surgical critical care, and pediatric surgical ICUs have the potential to improve the value of care delivered to these complex patients. Well-designed, prospective, observational studies are needed to assist in defining appropriate outcome and quality measures to inform the development of these specialized units. Currently, there are a variety of models used in children's hospitals to care for critically ill surgical patients. This represents a tremendous opportunity for a collaborative, multidisciplinary effort amongst pediatric medical and surgical intensivists.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/MOP.0000000000000893DOI Listing
June 2020

Sutureless vs sutured abdominal wall closure for gastroschisis: Operative characteristics and early outcomes from the Midwest Pediatric Surgery Consortium.

J Pediatr Surg 2020 Nov 20;55(11):2284-2288. Epub 2020 Feb 20.

Department of Surgery, Children's Mercy Kansas City, Kansas City, MO.

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.02.017DOI Listing
November 2020

Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes.

J Laparoendosc Adv Surg Tech A 2019 Oct 16;29(10):1202-1206. Epub 2019 Sep 16.

Department of Radiology, University of Chicago, Chicago, Illinois.

The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2019.0199DOI Listing
October 2019

Esophageal stents in children: Bridge to surgical repair.

Indian J Radiol Imaging 2018 Apr-Jun;28(2):242-246

Division of Interventional Radiology, Department of Radiology, Texas Children's Hospital, Houston, Texas, USA.

Management of complex esophageal problems in children is challenging. We report our experience with the use of esophageal stents in three children with esophageal strictures, leaks, or airway-esophageal fistulae refractory to conventional treatment. The stent played a key role in allowing extubation of a child with a large tracheo-esophageal-pleural fistula and in the resolution of pulmonary infection in a child with esophago-bronchial fistula, both followed by surgery. In the third child, with stricture, stents were complicated with migration, esophageal erosion, and esophago-bronchial fistula. In our experience, esophageal stents were useful mainly as a bridge to definitive surgical repair.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ijri.IJRI_313_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6038208PMC
July 2018

Use of the 5-mm Endoscopic Stapler for Ligation of Fistula in Laparoscopic-Assisted Repair of Anorectal Malformation.

J Laparoendosc Adv Surg Tech A 2018 Jun 15;28(6):780-783. Epub 2018 Feb 15.

Rocky Mountain Hospital for Children , Denver, Colorado.

Objective: Laparoscopic anorectoplasty (LARRP) for the treatment of select anorectal malformations has gained popularity due to enhanced visualization of the fistula and the ability to place the rectum within the sphincter complex while minimizing division of muscles and the perineal incision. However, given the technical challenges and reported complications of ligation, a number of techniques have been described, including using clips, suture ligation, endoloops, or division without closure. We aimed to evaluate fistula closure and division for high imperforate anus using a 5-mm stapler (JustRight Surgical, Boulder, CO).

Materials And Methods: A retrospective chart review was performed on patients who underwent LAARP for imperforate anus between March 2015 and December 2016.

Results: Four patients underwent LAARP with division of the fistula using the 5-mm stapler. The average age was 3.2 months and average weight was 4.5 kg. The location of the fistula was rectoprostatic in 3 cases and rectobladder neck in 1 case. There were no complications.

Conclusion: Division of a fistula at or above the level of the prostate can safely and effectively be performed with the 5-mm stapler. The stapler allows for division flush with the urethra or bladder ergonomically and quickly.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2017.0111DOI Listing
June 2018

Fundoplication.

Clin Perinatol 2017 12 20;44(4):795-803. Epub 2017 Sep 20.

Pediatric Surgery, Rocky Mountain Hospital for Children, 2055 High Street, Suite 370, Denver, CO 80205, USA.

Gastroesophageal reflux disease (GERD) is a common condition in infants. Symptoms from pathologic GERD include regurgitation, irritability when feeding, failure to thrive, and respiratory problems. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in neonates and infants include poor weight gain, failure to thrive, acute life-threatening events, and continued respiratory symptoms. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. In this procedure, the fundus of the stomach is wrapped 360° posteriorly around the lower esophagus.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clp.2017.08.009DOI Listing
December 2017

Gastroesophageal reflux.

Semin Pediatr Surg 2017 Apr 3;26(2):56-60. Epub 2017 Feb 3.

Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, Colorado.

Gastroesophageal reflux disease (GERD) is a very common condition and affects approximately 7-20% of the pediatric population. Symptoms from pathological GERD include regurgitation, irritability when feeding, respiratory problems, and substernal pain. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, and complications such as esophagitis. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. The key technical aspects of laparoscopic Nissen fundoplication include creation of an adequate intra-abdominal esophagus, minimal dissection of the hiatus with exposure of the right crus to identify the gastroesophageal junction, crural repair, and creation of floppy, 360° wrap that is oriented at the 11 o׳clock position.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.sempedsurg.2017.02.007DOI Listing
April 2017

Outcomes of Laparoscopic Cholecystectomy for Biliary Dyskinesia in Children.

J Laparoendosc Adv Surg Tech A 2017 Aug 28;27(8):845-850. Epub 2017 Mar 28.

2 Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children , Denver, Colorado.

Purpose: To determine the outcomes of laparoscopic cholecystectomy as a treatment for biliary dyskinesia in children.

Methods: With ethics approval, a retrospective chart review was performed on children (<21 years) at a single center diagnosed with biliary dyskinesia (defined as gallbladder ejection fraction [EF] <35% and/or pain with cholecystokinin [CCK] on cholescintigraphy, in the absence of gallstones or cholecystitis on ultrasound) and treated with laparoscopic cholecystectomy between March 2010 and February 2016. Demographic, medical history, diagnostic imaging, pathology, and outcome data were collected and analyzed based on degree of symptom resolution.

Results: Laparoscopic cholecystectomy was performed in 215 children with biliary dyskinesia (156/215 [72.6%] female, age 13.8 ± 3.4 years, body mass index [BMI] 22.3 ± 6.3 kg/m). 181/206 (87.9%) had EF <35%. CCK reproduced symptoms in 149/177 (84.2%). 34/215 (15.8%) were lost to follow-up. Median follow-up time was 2.7 weeks. Pain improved in 162/181 (89.5%). Chronic cholecystitis was found in 183/213 (85.9%) and unexpected cholelithiasis in 4/213 (1.9%) on pathology. Postoperatively, 6/181 (3.3%) had wound infections and 8/181 (4.4%) required common bile duct stents for the following indications: 6 sphincter of Oddi dysfunction, 1 choledocholithiasis, and 1 stricture. Virgin abdomen (odds ratio [OR] 4.03, confidence interval [95% CI] 1.12-14.53, P = .0460) and follow-up <6 months (OR 7.35, 95% CI 2.68-20.21, P = .0002) were associated with better outcomes.

Conclusions: Laparoscopic cholecystectomy is safe and effective in symptom resolution for biliary dyskinesia in children. Virgin abdomen and follow-up <6 months were associated with better outcomes. Prospective long-term studies comparing surgical and nonoperative management of biliary dyskinesia are required to determine the utility of cholecystectomy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2016.0338DOI Listing
August 2017

Two-Site Appendectomy in Children: Description of Technique and Outcomes.

J Laparoendosc Adv Surg Tech A 2017 Apr 18;27(4):438-440. Epub 2017 Jan 18.

Rocky Mountain Hospital for Children , Denver, Colorado.

Purpose: Laparoscopic appendectomy is one of the most common operations. Single-site appendectomy has been gaining popularity; however, it has certain disadvantages. The purpose of this study was to review the results of an essentially scarless laparoscopic appendectomy technique.

Methods: A retrospective review of all patients who underwent two-site appendectomy for appendicitis between January 2015 and February 2016 was performed. For all cases, a 4 mm trocar and a 5 mm trocar were placed through an infraumbilical incision and a 3 mm trocar was placed in the suprapubic region.

Results: Fifty patients underwent appendectomy using this technique. The average age was 9.7 years (5-16 years) and average weight was 40 kg (15.7-73.3 kg). The classifications of appendicitis consisted of 32 simple, 5 suppurative, 4 gangrenous, and 8 perforated. The average operative time was 29 minutes (6-53 minutes) and average length of stay was 1.9 days (1-6 days). There were three minor complications, and all cases were completed with this technique, including in obese patients and for perforated appendicitis. All patients reported satisfaction with their postoperative cosmetic outcome.

Conclusions: This technique allows for the main incision to be hidden at the umbilicus, creating an essentially scarless cosmetic result. The addition of a 3 mm suprapubic port leads to increased maneuverability of the instruments and better retraction of the appendix. It is also feasible in obese children and cases of perforated appendicitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2016.0243DOI Listing
April 2017

Two-Incision Laparoscopic Cholecystectomy in Children.

J Laparoendosc Adv Surg Tech A 2017 Mar 13;27(3):306-310. Epub 2017 Jan 13.

2 Rocky Mountain Pediatric Surgery, Rocky Mountain Hospital for Children , Denver, Colorado.

Purpose: To evaluate two-incision laparoscopic cholecystectomy (2I-LC) in children, and compare outcomes with four-port laparoscopic cholecystectomy (4P-LC).

Methods: A retrospective review was performed on children (≤21 years) with gallbladder disease treated with 2I-LC or 4P-LC between February 2010 and February 2016. 2I-LC is performed using two 5-mm ports and a 2-mm endoscopic grasper within a 12-mm umbilical incision, and a 3-mm subxiphoid port for dissection. Demographic, diagnostic, operative, and outcome data were recorded, and the two groups were compared with chi-squared, Fisher, and t-tests. Patients requiring conversion from 2I-LC to 4P-LC were examined to determine factors predicting the need for additional ports.

Results: Three hundred eighty-nine laparoscopic cholecystectomies were performed (2I-LC 72.0%, 4P-LC 19.0%). Body mass index (BMI) was greater in the 4P-LC group. 2I-LC was more commonly performed for biliary dyskinesia, but not biliary colic, acute cholecystitis, choledocholithiasis, and gallstone pancreatitis. Operative time was greater in 4P-LC. There were 6 wound infections (2I-LC 1.8%, 4P-LC 1.5%), 1 common bile duct injury (2I-LC 0.4%, 4P-LC 0.0%), and 1 small bowel injury (2I-LC 0.0%, 4P-LC 1.5%). 2.4% of 2I-LC required conversion to 4P-LC, with BMI and operative time greater than the 2I-LC group, but not different from 4P-LC with no complications.

Conclusions: 2I-LC is a safe alternative to 4P-LC for pediatric gallbladder disease, allowing for traction and countertraction to expose the critical view. Operative time was longer in the 4P-LC group, likely secondary to selection bias with higher BMI and preoperative diagnosis of gallstone disease. Overweight patients are more likely to require additional ports.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2016.0221DOI Listing
March 2017

Tracheoesophageal fistula.

Semin Pediatr Surg 2016 Jun 21;25(3):176-8. Epub 2016 Feb 21.

Department of Pediatrics Surgery, Rocky Mountain Hospital for Children, 2055 High St, Suite 370, Denver, Colorado 80205; Department of Surgery, Columbia University College of Physician and Surgeons, Morgan Stanley Children׳s Hospital of New York-Presbyterian, New York, New York.

Tracheoesophageal fistula (TEF) is a relatively rare congenital anomaly. Surgical intervention is required to establish esophageal continuity and prevent aspiration and overdistension of the stomach. Since the first successful report of thoracoscopic TEF repair in 2000, the minimally invasive approach has become increasingly utilized. The main advantages of the thoracoscopic technique include avoidance of a thoracotomy, improved cosmesis, and superior visualization of the anatomy and fistula afforded by the laparoscope׳s magnification.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.sempedsurg.2016.02.010DOI Listing
June 2016

Childhood and adolescent tracheobronchial mucoepidermoid carcinoma (MEC): a case-series and review of the literature.

Pediatr Surg Int 2016 Apr 20;32(4):417-24. Epub 2016 Jan 20.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, 77030, TX, USA.

Tracheobronchial mucoepidermoid carcinomas (MEC) are rare in the pediatric population with literature limited primarily to case reports. Here we present our institutional experience treating MEC in three patients and review the literature of 142 pediatric cases previously published from 1968 to 2013. Although rare, tracheobronchial MEC should be included in the differential diagnosis in a child with recurrent respiratory symptoms. Conservative surgical management is often sufficient to achieve complete resection and good outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00383-015-3849-yDOI Listing
April 2016

Thoracoscopic Management of Patent Ductus Arteriosus and Vascular Rings in Infants and Children.

J Laparoendosc Adv Surg Tech A 2016 Jan 27;26(1):66-9. Epub 2015 Aug 27.

Department of Pediatric Surgery, Rocky Mountain Hospital for Children , Denver, Colorado.

Introduction: Both patent ductus arteriosus (PDA) and vascular rings often require surgical treatment to prevent complications and alleviate symptoms, respectively. Management in infants and children has traditionally required an open thoracotomy. However, given the known advantages of the thoracoscopic approach, increased technical experience, and improved instrumentation, the minimally invasive technique to repair these thoracic vascular anomalies has grown in popularity.

Subjects And Methods: We report our experience with thoracoscopic PDA ligation and vascular ring division at a single institution. From October 1993 to March 2014, 78 patients underwent thoracoscopic PDA ligation, and 13 patients presented with vascular rings. Ages ranged from 2 days to 17 years (mean, 18 months), and weights ranged from 2 to 60 kg (mean, 8.5 kg) for the thoracoscopic PDA group, whereas ages ranged from 6 weeks to 13 years (mean, 19 months), and weights ranged from 3.6 to 38 kg (mean, 10 kg) for the thoracoscopic vascular ring division group. In the thoracoscopic PDA group, the mean operative time was 36 minutes. Complications consisted of one death not related to the procedure, one conversion to open for a torn ductus, one recurrence requiring re-operative thoracoscopic repair, and one residual PDA requiring cardiac catheterization with occlusion. In the vascular ring group, one procedure was unable to be completed thoracoscopically and was converted to open. In 2 cases, thoracoscopic exploration revealed no significant compression from the vascular ring, and dissection was stopped.

Conclusions: Thoracoscopic closure of PDA and division of vascular rings are safe and effective techniques that minimize physiologic and cosmetic adverse effects.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2015.0126DOI Listing
January 2016

Laparoscopic gastroscopic transgastric cystogastrostomy and cholecystectomy for pseudopancreatic cyst after gallstone pancreatitis in children.

European J Pediatr Surg Rep 2014 Jun 12;2(1):10-2. Epub 2013 Dec 12.

Division of Pediatric Surgery, Michael E Debakey Department of General Surgery, Baylor College of Medicine and Texas Children Hospital, Houston, Texas, United States.

A 15-year-old girl presented with gallstone pancreatitis. Subsequently, a pseudopancreatic cyst developed that was diagnosed on computed tomographic scan. She underwent a laparoscopic and gastroscopic transgastric cystogastrostomy. In the following report, we describe our novel approach and technique for the above condition.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0033-1357503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4335947PMC
June 2014

Thoracoscopic Thoracic Duct Ligation for Congenital and Acquired Disease.

J Laparoendosc Adv Surg Tech A 2015 Jul 28;25(7):605-7. Epub 2015 Jan 28.

Rocky Mountain Hospital for Children , Denver, Colorado.

Purpose: Congenital and acquired chylothorax presents a unique management challenge in neonates and infants. A failure of conservative therapy requires surgical ligation to prevent continued fluid and protein losses. This article examines a 15-year experience with thoracoscopic ligation of the thoracic duct.

Patients And Methods: From June 1999 to December 2013, 21 patients presented with chylothorax refractory to conservative management. Sixteen patients presented following cardiac procedures, 1 after tracheoesophageal fistula repair, 1 after extracorporeal membrane oxygenation cannulation, and 1 after trauma, and 2 had congenital chylothorax. Ages ranged from 3 weeks to 5 years, and weights ranged from 2.6 to 12.7 kg. All procedures were performed in the right chest with three ports. All cases consisted of sealing of the duct at the level of the diaphragm, a mechanical pleurodesis, and fibrin glue.

Results: All cases were completed successfully thoracoscopically. Operative time ranged from 20 to 55 minutes. There were no intraoperative complications. One patient with congenital bilateral chylothorax required a left partial pleurectomy. The chest tube duration postoperatively ranged from 4 to 14 days. Ligation failed in 2 patients, requiring a subsequent thoracoscopic pleurectomy and chemical pleurodesis, respectively.

Conclusions: Thoracoscopic thoracic duct ligation is a safe and effective procedure even in post-cardiac surgery patients. The site of the leak can be identified in the majority of cases, and tissue-sealing technology appears to be effective. The minimally invasive nature of the procedure has led to more expedient operative repair to avoid the morbidity associated with chyle leak.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/lap.2014.0360DOI Listing
July 2015

Extrarenal Wilms tumor: a case report and review of the literature.

J Pediatr Surg 2013 Jun;48(6):E33-5

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

Extrarenal Wilms tumors are extremely rare with only isolated case reports in the pediatric literature. We present the case of a 2-year old boy who presented with a large abdominal mass and constipation. Pathologic diagnosis of the tumor was extrarenal Wilms tumor (ERWT) with favorable histology. We discuss the diagnostic workup, radiologic and operative findings, treatment and review of the literature.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2013.04.021DOI Listing
June 2013

Complications related to the Nuss procedure: minimizing risk with operative technique.

J Pediatr Surg 2013 May;48(5):1044-8

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.

Introduction: Pectus Excavatum (PEx) is the most frequent congenital chest wall deformity; surgical correction has a complication rate of 10%-50%. The purpose of this study was to evaluate outcomes in a recent cohort of pediatric patients from a single institution and investigate factors associated with complications.

Methods: A review of all patients with PEx treated with a Nuss procedure from 2003 to 2011 was performed. Complications included hemo/pneumothorax, infection, bar migration, and operative injury. Chi-square, Student's t-test, and logistic regression were performed.

Results: The study included 127 Nuss patients with a the median age of 15.2 years (5.4-18.7) and a mean Haller index of 4.2 (+1.6). The total complication rate was 26% and bar migration rate was 18%. The use of a stabilizer was associated with fewer overall complications (17% vs 41%,p=0.006), decreased reoperation (16% vs 41%,p=0.003), decreased readmission (15% vs 39%,p=0.004), and decreased bar migration rate (9% vs 36%,p=0.001) compared to patients without a stabilizer. On multivariate analysis, the use of a stabilizer (OR 0.18,p=0.011,95% CI 0.049-0.68) and the use of a pericostal suture (OR 0.19,p=0.03,95% CI 0.41-0.85) were associated with decreased rates of bar migration.

Conclusion: The use of a lateral stabilizer and pericostal sutures decreased complication and reoperation rates for the Nuss procedure.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2013.02.025DOI Listing
May 2013

The surgical management of Rapunzel syndrome: a case series and literature review.

J Pediatr Surg 2013 Apr;48(4):830-4

Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine, Houston, TX 77030, USA.

Background/purpose: The surgical removal of a trichobezoar is the rare end complication of the psychiatric disorders trichotillomania and trichophagia. The more severe form of the disease is termed Rapunzel syndrome, where the bezoar extends from the gastric body beyond the pylorus into the duodenum. Traditional therapy has included endoscopy, often with subsequent laparotomy, and associated psychiatric intervention. We present the largest and most recent series of patients with trichobezoars managed in a single institution.

Methods: A retrospective review of all cases of trichobezoar at our institution from 2003 to 2011 was performed. Demographic data, presenting complaints, imaging, surgical treatment, and subsequent management were collected.

Results: All 7 patients were female, ages 5 to 23 years (mean, 11.5 years). Although multiple imaging modalities were necessary for preoperative diagnosis, most patients were accurately diagnosed without endoscopic evaluation (85%). All patients required an exploratory laparotomy for definitive treatment. At laparotomy, 5 patients were found to have postpyloric extension of the trichobezoar (71%). One of 7 patients had a wound infection postoperatively. There were no other surgical complications or recurrences requiring further exploration.

Conclusions: Our series of trichobezoar patients appear to have a high rate of Rapunzel syndrome, and perhaps postpyloric extension should be considered the rule rather than the exception. Our series demonstrates that diagnosis can be established with a thorough history combined with radiography, and treatment should be a combination of laparoscopy and/or laparotomy with psychiatric consultation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2012.07.046DOI Listing
April 2013

A prospective randomized trial of ultrasound- vs landmark-guided central venous access in the pediatric population.

J Am Coll Surg 2013 May 7;216(5):939-43. Epub 2013 Mar 7.

Department of Surgery, Lucile Packard Children's Hospital - Stanford University Medical Center, Palo Alto, CA 94305, USA.

Background: The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts.

Study Design: With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Student's t-test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05.

Results: There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001).

Conclusions: Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jamcollsurg.2013.01.054DOI Listing
May 2013
-->