Publications by authors named "Cristine S Velazco"

24 Publications

  • Page 1 of 1

A child presents with perianal symptoms - how often is this Crohn's disease?

J Pediatr Surg 2020 Nov 20. Epub 2020 Nov 20.

Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States.

Background: The cumulative incidence and predictors of future diagnosis of Crohn's disease (CD) following presentation with perianal symptoms, such as anorectal abscess, fistula or fissure, is unknown.

Methods: A 5-year retrospective review of children presenting with perianal symptoms without prior CD diagnosis was performed. Institutional cumulative incidence of CD was calculated to determine the risk of CD presenting with perianal symptoms.

Results: 1140 children presented for evaluation of an anorectal abscess (n = 232), fistula (n = 49), or fissure (n = 859). Thirty-five were later diagnosed with CD, resulting in an incidence of 3%. Prognostic indicators of future CD diagnosis included increased age per every additional year (RR 1.19, 95% CI: 1.14-1.25, p < 0.001), male sex (RR 2.12, 95% CI 1.07-4.22, p = 0.024), or perianal fistula (RR 4.67, 95% CI 2.26-9.67, p = 0.022). Among those diagnosed with CD, 57% experienced and had a documented history of a CD-associated symptom prior to perianal symptom onset. Absence of symptoms resulted in delayed diagnosis (43 vs 3 days, p < 0.02).

Conclusion: Of children presenting with a perianal symptom, three percent will eventually be diagnosed with CD. At highest risk (35%) were males aged 10 years or older with a perianal fistula; which should prompt expeditious workup.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.11.016DOI Listing
November 2020

Mentorship in pediatric surgery: A need for structure?

J Pediatr Surg 2021 May 6;56(5):892-899. Epub 2020 Oct 6.

Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016. Electronic address:

Introduction: Mentorship in surgical training is critical but differs greatly from the early apprenticeship model and often spans generations. This study evaluates the current state of and desire for structured mentorship in pediatric surgical training from the perspective of program directors (PDs) and trainees.

Methods: A survey addressing demographics, presence of or desire for structured mentorship, and proposed mentoring topics was emailed to pediatric surgery PDs (n = 58) and trainees completing fellowship in 2018-2020 (n = 72).

Results: The response rate was 38.5%. 50% of trainees were female versus 15% of PDs (p = 0.02). 19% of trainees reported having a structured mentorship program versus 26% of PDs (p = 0.72). The majority, 83%, of trainees felt a structured mentorship program is warranted versus 40% of PDs (p = 0.002). There were differing opinions between trainees and PDs regarding important components of a mentoring program. Trainees felt the following were more important: transition to practice, job negotiation, CV review, financial planning and performance review. PDs felt the following were more important: quality improvement projects and work/life balance. Both agreed academic development and job search were important.

Conclusions: The majority of pediatric surgery trainees desire structured mentorship programs; however, few institutions have them. Training programs and program directors warrant a response to this gap.

Level Of Evidence: IV.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2020.09.059DOI Listing
May 2021

Pleuroperitoneal (Denver) Shunt for Recurrent Nonmalignant Breast Seroma in a Metastatic Breast Cancer Patient.

Plast Reconstr Surg Glob Open 2020 Jun 23;8(6):e2928. Epub 2020 Jun 23.

Division of Plastic Surgery, Mayo Clinic Arizona, Phoenix, Ariz.

Pleuroperitoneal (Denver) shunts have been used primarily for palliation of refractory malignant and chylous peritoneal and pleural collections. We used a pleuroperitoneal (Denver) shunt for a recurrent, nonmalignant breast seroma in the palliation of metastatic breast cancer as a novel use of this shunt.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/GOX.0000000000002928DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7339355PMC
June 2020

Outcomes and Health Care Utilization After Early Hospital Dismissal in Kidney Transplantation: An Analysis of 1001 Consecutive Cases.

Ann Surg 2020 Jun 9. Epub 2020 Jun 9.

Department of Surgery, Mayo Clinic, Phoenix, Arizona.

Objective: To understand whether reduced lengths of stay after kidney transplantation were associated with excess health care utilization in the first 90 days or long-term graft and patient survival outcomes.

Background: Reducing length of stay after kidney transplant has an unknown effect on post-transplant health care utilization. We studied this association in a cohort of 1001 consecutive kidney transplants.

Methods: We retrospectively reviewed 2011-2015 data from a prospectively-maintained kidney transplant database from a single center.

Results: A total of 1001 patients underwent kidney transplant, and were dismissed from the hospital in 3 groups: Early [≤2 days] (19.8%), Normal [3-7 days] (79.4%) and Late [>7 days] (3.8%). 34.8% of patients had living donor transplants (Early 51%, Normal 31.4%, Late 18.4%, P < 0.001). Early patients had lower delayed graft function rates (Early 19.2%, Normal 32%, Late73.7%, P = 0.001). By the hospital dismissal group, there were no differences in readmissions or emergency room visits at 30 or 90 days. Glomerular filtration rate at 12 months and rates of biopsy-proven acute rejection were also similar between groups. The timing of hospital dismissal was not associated with the risk-adjusted likelihood of readmission. Early and Normal patients had similar graft and patient survival. Late dismissal patients, who had higher rates of cardiovascular complications, had significantly higher late mortality versus Normal dismissal patients in unadjusted and risk-adjusted models.

Conclusion: Dismissing patients from the hospital 2 days after kidney transplant is safe, feasible, and improves value. It is not associated with excess health care utilization or worse short or long-term transplant outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/SLA.0000000000003948DOI Listing
June 2020

A Newly Described, Highly Prevalent Arterial Pedicle Perfuses Both Gracilis and Profunda Artery Perforator Flap Tissues: An Angiographic Study of the Medial Thigh.

J Reconstr Microsurg 2020 Mar 16;36(3):177-181. Epub 2019 Oct 16.

Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona.

Background:  Novel secondary flap options are paramount for patients who are not candidates for common reconstructive methods. The purpose of this study is to identify the prevalence of single arterial pedicle supplying both the gracilis muscle and medial thigh tissue carried in a profunda artery perforator (PAP) flap. Such a pedicle could allow the creation of a chimeric gracilis and PAP flap with a single-arterial anastomosis.

Methods:  We conducted a retrospective review of 157 lower extremity computed tomography (CT) angiograms to assess the vasculature of the thigh soft tissues. Imaging evaluation was supervised by a board-certified musculoskeletal radiologist.

Results:  Prevalence of a single-arterial pedicle to a gracilis and PAP flap in each patient was 59% (31% within the right leg and 28% in the left leg). Furthermore, 16% of patients had a common arterial pedicle in both lower extremities.

Conclusion:  Existence of a single-arterial pedicle to both the gracilis muscle and PAP flap tissues is frequently present in most patients in at least one lower extremity. This chimeric flap configuration could serve as a reconstructive avenue for patients, particularly those who have exhausted other more common flap options. Screening angiography is warranted in patients looking for this anatomic variation to establish its presence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0039-1698438DOI Listing
March 2020

Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy.

Ann Surg Oncol 2020 Jan 11;27(1):303-312. Epub 2019 Oct 11.

Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC.

Methods: Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes.

Results: Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57).

Conclusions: Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1245/s10434-019-07900-zDOI Listing
January 2020

Blunt Thigh Trauma and a Pulsatile Mass: An Unusual Case of Pseudoaneurysm of the Medial Geniculate Artery.

J Emerg Med 2019 Jul 16;57(1):100-101. Epub 2019 Apr 16.

Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, Arizona; Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jemermed.2019.02.017DOI Listing
July 2019

The Opioid Crisis and Surgeons: National Survey of Prescribing Patterns and the Influence of Motivators, Experience, and Gender.

Am J Surg 2019 06 3;217(6):1116-1120. Epub 2018 Dec 3.

Department of Surgery, Mayo Clinic, Scottsdale, AZ, USA. Electronic address:

Background: Surgeons are the fifth largest prescribers of opioids in the US. Few studies exist to describe surgeon prescribing practices.

Methods: A survey was conducted of surgical providers at all ACGME-accredited surgical residency programs. Statistical comparisons between groups were made.

Results: A total of 114 providers from 21 states responded; 58% male, 57% residents. Only 8% reported being told they were over-prescribing opioids. Oxycodone ± acetaminophen was most commonly prescribed (49%). Median opioids prescribed exceeded guidelines for acute pain management for every procedure except laparoscopic appendectomy/cholecystectomy, lumpectomy and laparoscopic inguinal hernia repair. Attending surgeons more often gave no opioids after laparoscopic appendectomy/cholecystectomy (9% vs 0%; p=0.012), more likely reported patient attempts to return opioids to them (33% vs 16%; p=0.04), and less likely considered patients giving their opioids to someone else (39% vs. 74%; p<0.001). PGY 1-2 residents prescribe fewer opioids than advanced residents for simple mastectomy (p=0.04), exploratory laparotomy (p=0.05), and thoracotomy (p=0.03).

Conclusions: Surgeons vary significantly in their opioid prescriptions, even for the same operation. There are few differences by gender but some important differences by experience.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2018.11.032DOI Listing
June 2019

Cardiopulmonary Function in Thoracic Wall Deformities: What Do We Really Know?

Eur J Pediatr Surg 2018 Aug 13;28(4):327-346. Epub 2018 Aug 13.

Department of Pediatric Surgery, Children's Hospital of the King's Daughters, Norfolk, Virginia, United States.

Patients with pectus excavatum (PE) frequently present with complaints of exercise intolerance and cardiopulmonary symptoms. There continues to be controversy regarding the physiologic benefits of repair. The aim of this review is to summarize and discuss recent data regarding the cardiopulmonary effects of PE deformity and the evidence for improvement obtained after surgical repair including (1) a greater efficiency of breathing (chest wall mechanics), (2) improvement in pulmonary restrictive deficits, (3) an increase in cardiac chamber size and output, with improved cardiac strain and strain rate, and (4) improvement in exercise capacity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0038-1668130DOI Listing
August 2018

Nuss procedure in the adult population for correction of pectus excavatum.

Semin Pediatr Surg 2018 Jun;27(3):161-169

Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States. Electronic address:

Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1053/j.sempedsurg.2018.05.002DOI Listing
June 2018

High Rates of Positive Severe Combined Immunodeficiency Screening Among Newborns with Severe Intestinal Failure.

JPEN J Parenter Enteral Nutr 2018 Jan 13;42(1):239-246. Epub 2017 Dec 13.

Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.

Purpose: Severe combined immunodeficiency (SCID) screening by T-cell receptor excision circles (TREC) has been part of Massachusetts routine newborn screening since 2009. Tetratricopeptide repeat domain 7A gene (TTC7A) mutations responsible for hereditary multiple intestinal atresia with combined immunodeficiency (MIA-CID) were also recently identified. We reviewed newborn SCID screening among infants with intestinal failure and correlated results with patient characteristics and outcomes.

Methods: Records of infants with severe intestinal failure and available newborn screen results treated at a single center 2009-2016 were reviewed retrospectively. Patients with 1 or more positive SCID screens (<252 TREC copies/μL) were compared with those without positive screens. TREC copies/μL were compared with population norms.

Results: Of 70 included infants, 34% had newborn screens with TREC <252 copies/μL, compared with 0.3% of the general population; TREC levels for the cohort were lower than the general population (p<0.001). Of those with positive screens, 42% had prior or subsequent negative screening, 8% had no further workup, and 50% had flow cytometry showing: severe T-cell lymphopenia (absolute CD3+ <1500 cells/mcL) in 8, 3 of whom had TTC7A mutation-associated MIA-CID. Four had CD3+ >1500 cells/mcL. MIA-CID patients had the lowest serum citrulline in the cohort; 4 of the 8 patients with CD3+ <1500 cells/mcL on flow cytometry had newborn screening notable for severe hypocitrullinemia (<3 μM).

Conclusion: Infants with intestinal failure have lower TREC copies/μL than the general population; one-third had levels concerning for SCID, and 11% were diagnosed with severe T-cell lymphopenia. The clinical implications and etiology of this phenomenon remain unknown, but may be related to hypocitrullinemia.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jpen.1013DOI Listing
January 2018

Morbidity and mortality among "big" babies who develop necrotizing enterocolitis: A prospective multicenter cohort analysis.

J Pediatr Surg 2017 Oct 12. Epub 2017 Oct 12.

Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA. Electronic address:

Background: Necrotizing enterocolitis (NEC) is classically a disease of prematurity, with less reported regarding morbidity and mortality of this disease among other infants.

Methods: Data were prospectively collected from 2009 to 2015 at 252 Vermont Oxford Network member centers on neonates with birth weight>2500g admitted to a participating NICU within 28days of birth.

Results: Of 1629 neonates with NEC, gestational age was 37 (36, 39) weeks, and 45% had major congenital anomalies, most commonly gastrointestinal defects (20%), congenital heart defects (18%), and chromosomal anomalies (7%). For the 23% of infants who had surgery for NEC, mortality and length of stay were 23% and 63 (36, 94) days versus 8% and 34 (22, 61) days in medical NEC. Independent predictors of mortality were congenital heart defects (p<0.0001), chromosomal abnormalities (p<0.05), other congenital malformations (p<0.001), surgical NEC (p<0.0001), and sepsis (p<0.05). All of these in addition to gastrointestinal defects were independent predictors of increased length of stay. Nutritional morbidity at discharge included 6% receiving no enteral feeds and 27% who were <10th percentile weight-for-age.

Conclusions: Major congenital anomalies are present in nearly half of >2500g birth weight infants diagnosed with necrotizing enterocolitis. Morbidity and mortality increase with sepsis, surgical disease, and congenital anomalies.

Type Of Study: Prognosis Study.

Level Of Evidence: Level II.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2017.10.028DOI Listing
October 2017

Severe neurodevelopmental disability and healthcare needs among survivors of medical and surgical necrotizing enterocolitis: A prospective cohort study.

J Pediatr Surg 2017 Oct 12. Epub 2017 Oct 12.

Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA. Electronic address:

Purpose: This study characterizes neurodevelopmental outcomes and healthcare needs of extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to ELBW infants without NEC.

Methods: Data were collected prospectively on neonates born 22-27weeks' gestation or 401-1000g at 47 Vermont Oxford Network member centers from 1999 to 2012. Detailed neurodevelopmental evaluations were conducted at 18-24months corrected age. Information regarding rehospitalizations, postdischarge surgeries, and feeding was also collected. "Severe neurodevelopmental disability" was defined as: bilateral blindness, hearing impairment requiring amplification, inability to walk 10 steps with support, cerebral palsy, and/or Bayley Mental or Psychomotor Developmental Index <70. Diagnosis of NEC required both clinical and radiographic findings.

Results: There were 9063 children without NEC, 417 with medical NEC, and 449 with surgical NEC evaluated. Significantly higher rates of morbidity were observed among infants with a history of NEC. Those with surgical NEC were more frequently affected across all outcome measures at 18-24months corrected age: 38% demonstrated severe neurodevelopmental disability, nearly half underwent postdischarge operations, and a quarter required tube feeding at home.

Conclusion: At 18-24months, extremely low birth weight survivors of necrotizing enterocolitis were at markedly increased risk (p<0.001) for severe neurodevelopmental disability, postdischarge surgery, and tube feeding.

Level Of Evidence: II (prospective cohort study with <80% follow-up rate).
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2017.10.029DOI Listing
October 2017

Ileostomy Prolapse in Children with Intestinal Dysmotility.

Gastroenterol Res Pract 2017 18;2017:7182429. Epub 2017 Sep 18.

Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.

Background: A relationship between intestinal motility and ileostomy prolapse has been suggested but not demonstrated objectively.

Aims: This study evaluated the association between ileostomy prolapse and intestinal dysmotility in children.

Methods: IRB-approved retrospective review of 163 patients with ileostomies (1998-2014) at a single institution. Patients were categorized as having clinical dysmotility as a primary diagnosis ( = 33), clinically suspected dysmotility based on underlying diagnosis ( = 60), or intestinal dysmotility unlikely ( = 70) at the time of ileostomy present. Intestinal manometry was categorized as normal ( = 13) or abnormal ( = 10). Primary outcome was pathologic stoma prolapse. Multivariate analysis using a logistic regression model and log-rank test to compare stoma prolapse rates over time between motility groups were used.

Results: Clinical diagnosis of dysmotility ( ≤ 0.001) and manometric findings of dysmotility ( = 0.024) were independently associated with stoma prolapse. Clinical dysmotility correlated with manometric findings ( = 0.53). Prolapse occurred in 42% of patients with dysmotility, 34% of patients with suspected dysmotility, and 24% of patients with normal motility. One-year prolapse-free stoma "survival" was 45% for dysmotility, 72% for suspected dysmotility, and 85% for intestinal dysmotility unlikely groups ( = 0.006).

Conclusions: Children with intestinal dysmotility are at great risk for stoma prolapse. Intestinal manometry could help identify these patients preoperatively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2017/7182429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5624168PMC
September 2017

Radiographic measurement of intestinal length among children with short bowel syndrome: Retrospective determination remains problematic.

J Pediatr Surg 2017 Dec 5;52(12):1921-1924. Epub 2017 Sep 5.

Department of Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA. Electronic address:

Purpose: Small bowel length is the most reliable predictor of enteral independence in pediatric short bowel syndrome. Retrospectively measured bowel lengths on upper GI with small bowel follow-through (UGI/SBFT) were compared to operative measurements.

Methods: A pediatric radiologist and surgical trainees blinded to operative measurements retrospectively analyzed UGI/SBFT studies using the digital radiography curved measurement tool. Children with SBS and severe intestinal failure (parenteral nutrition >90days) at a multidisciplinary intestinal failure program 2002-2015 were included. Data were expressed as median (Q1, Q3).

Results: Thirty-six children aged 0.8 (0.4, 3.7) years were analyzed. Fifty-six percent had intestinal malrotation, and 58% had prior serial transverse enteroplasty. Studies were conducted within 10 (7, 20) days of surgery. Intraoperative bowel length was 90cm (45, 142), while UGI/SBFT measurement by radiologist was 45cm (28, 63), with a mean difference of 47cm (SD 58cm, p<0.001) and a mean percent error of 50%. Radiographic assessment underestimated intestinal length in 83% of patients.

Conclusion: Bowel length measured retrospectively from upper GI with small bowel follow-through studies usually underestimated intraoperative bowel length. The limits of agreement were too wide for this technique to be clinically useful. Operative measurement remains necessary to assess intestinal length and rehabilitation potential.

Type Of Study: Study of Diagnostic Test.

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.2017.08.055DOI Listing
December 2017

Discussion of: "Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve".

Am J Surg 2017 12 30;214(6):1094-1095. Epub 2017 Sep 30.

Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2017.09.026DOI Listing
December 2017

Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve.

Am J Surg 2017 Dec 19;214(6):1091-1093. Epub 2017 Sep 19.

Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA. Electronic address:

Background: Radioactive seed localization (RSL) is an alternative to wire localization. We compared the rate of positive margins for evidence of a learning curve in implementing RSL.

Methods: A retrospective review of RSL by three surgeons at a single institution from 2002 to 2016. Positive margins were defined as ink on tumor.

Results: Surgeon experience with RSL for ranged from 142 to >500 cases. The positive margin rate among the first 100 of each surgeons' experience (n = 300) was 2.3% and the rate during the most recent up to 100 cases after experience with at least 100 RSL procedures (n = 242) was 4.1% (p = 0.32). Individual surgeon's positive margin rates ranged from 2 to 5% in the early experience and 2-7% in the later experience (p = NS).

Conclusions: RSL for breast conservation surgery has a low rate of positive margins even early in a surgeon's experience. Implementation of RSL can be done with no evidence of a learning curve.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.amjsurg.2017.08.025DOI Listing
December 2017

Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study.

J Pediatr 2017 09 13;188:192-197.e6. Epub 2017 Jul 13.

Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.

Objective: To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis.

Study Design: Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS).

Results: Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome.

Conclusions: Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpeds.2017.06.013DOI Listing
September 2017

Robotic inferior vena cava surgery.

J Vasc Surg Venous Lymphat Disord 2017 03 9;5(2):194-199. Epub 2016 Nov 9.

Division of Vascular Surgery, Department of Surgery, Mayo Clinic, Phoenix, Ariz.

Objective: Inferior vena cava (IVC) surgery is uncommon and has traditionally been performed through open surgical approaches. Renal cell carcinoma with IVC extension generally requires vena cavotomy and reconstruction. Open removal of malpositioned IVC filters (IVCF) is occasionally required after endovascular retrieval attempts have failed. As our experience with robotic surgery has advanced, we have applied this technology to surgery of the IVC. We reviewed our institution's experience with robotic surgical procedures involving the IVC to determine its safety and efficacy.

Methods: All patients undergoing robotic surgery that included cavotomy and repair from 2011 to 2014 were retrospectively reviewed. Data were obtained detailing preoperative demographics, operative details, and postoperative morbidity and mortality.

Results: Ten patients (6 men) underwent robotic vena caval procedures at our institution. Seven patients underwent robotic nephrectomy with removal of IVC tumor thrombus and retroperitoneal lymph node dissection. Three patients underwent robotic explantation of an IVCF after multiple endovascular attempts at removal had failed. The patients with renal cell carcinoma were a mean age of was 65.4 years (range, 55-74 years). Six patients had right-sided malignancy. All patients had T3b lesions at time of diagnosis. Mean tumor length extension into the IVC was 5 cm (range, 1-8 cm). All patients underwent robotic radical nephrectomy, with caval tumor thrombus removal and retroperitoneal lymph node dissection. The average operative time for patients undergoing surgery for renal cell carcinoma was 273 minutes (range, 137-382 minutes). Average intraoperative blood loss was 428 mL (range, 150-1200 mL). The patients with IVCF removal were a mean age of 33 years (range, 24-41 years). Average time from IVCF placement until robotic removal was 35.5 months (range, 4.3-57.3 months). Before robotic IVCF removal, a minimum of two endovascular retrievals were attempted. Average operative time for patients undergoing IVCF removal was 163 minutes (range, 131-202 minutes). Intraoperative blood loss averaged 250 mL (range, 150-350 mL). All procedures were completed robotically. The mean length of stay for all patients was 3.5 days (range, 1-8 days). All patients resumed ambulation on postoperative day 1. Nine patients resumed a regular diet on postoperative day 2. One patient with a renal tumor sustained a colon injury during initial adhesiolysis, before robotic radical nephrectomy, which was recognized at the initial operation and repaired robotically. Robotic radical nephrectomy and caval tumor removal were then completed. No blood transfusions were required intraoperatively, but three patients required blood transfusions postoperatively.

Conclusions: Although robotic IVC surgery is uncommon, our initial limited experience demonstrates it is safe and efficacious.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvsv.2016.08.003DOI Listing
March 2017

High prevalence of same-sex twins in patients with cloacal exstrophy: Support for embryological association with monozygotic twinning.

J Pediatr Surg 2017 May 30;52(5):807-809. Epub 2017 Jan 30.

Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.

Purpose: Previous studies have hypothesized that cloacal exstrophy may be caused by errors early in embryological development related to monozygotic twinning. This study reports the prevalence of twins in a large cohort of patients with cloacal exstrophy.

Methods: Patients with cloacal exstrophy treated 1974-2015 were reviewed for reports of multiple gestation or conjoined twinning. The genetic sex of the patient and their twin, and any mention of anomaly in the twin were recorded. Neither placental exam nor genetic testing results were available to definitively determine zygosity.

Results: Of 71 patients, 10 had a live born twin (14%), all of whom were of the same genetic sex as the affected patient. One additional patient's twin suffered intrauterine fetal demise, and another patient had a conjoined heteropagus twin. None of the twins were affected by exstrophy-epispadias complex. The rate of twin birth in this cohort was 4.4-7.7 higher than that reported by the Centers for Disease Control in the general population time period (P<0.001), with a striking preponderance of same-sex pairs.

Conclusions: The highly significant prevalence of same-sex twin pairs within this cohort supports the hypothesis that the embryogenesis of cloacal exstrophy may be related to errors in monozygotic twinning.

Level Of Evidence: 2b.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2017.01.043DOI Listing
May 2017

Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit.

J Pediatr Surg 2017 Jan 28;52(1):145-148. Epub 2016 Oct 28.

Division of Critical Care Medicine; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital; Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115. Electronic address:

Purpose: Inadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU).

Methods: In a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate.

Results: Five hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score -0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery.

Conclusion: Enteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population.

Level Of Evidence: I.

Type Of Study: Prospective study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jpedsurg.2016.10.041DOI Listing
January 2017

Immediate versus Delayed Sarcoma Reconstruction: Impact on Outcomes.

Sarcoma 2016 13;2016:7972318. Epub 2016 Jul 13.

Division of Plastic and Reconstructive Surgery, Mayo Clinic in Arizona, 5777 E. Mayo Boulevard, Phoenix, AZ 85054, USA.

Background. Sarcoma is a rare malignancy, and more recent management algorithms emphasize a multidisciplinary approach and limb salvage, which has resulted in an increase in overall survival and limb preservation. However, limb salvage has resulted in a higher rate of wound complications. Objective. To compare the complications between immediate and delayed (>three weeks) reconstruction in the multidisciplinary limb salvage sarcoma patient population. Methods. A ten-year retrospective review of patients who underwent sarcoma resection was performed. The outcome of interest was wound complication in the postoperative period based on timing of reconstruction. We defined infection as any infection requiring intravenous antibiotics, partial flap failure as any flap requiring a debridement or revision, hematoma/seroma as any hematoma/seroma requiring drainage, and wound dehiscence as a wound that was not completely intact by three weeks postoperatively. Results. 70 (17 delayed, 53 immediate) patients who underwent sarcoma resection and reconstruction met the inclusion criteria. Delayed reconstruction significantly increased the incidence of postoperative wound infection and wound dehiscence. There was no difference in partial or total flap loss, hematoma, or seroma between the two groups. Discussion and Conclusion. Immediate reconstruction results in decreased wound complications may reduce the morbidity associated with multidisciplinary treatment in the limb salvage sarcoma patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1155/2016/7972318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4961807PMC
August 2016

Factors contributing to suboptimal rates of childhood vaccinations in Vermont.

J Child Health Care 2015 Dec 12;19(4):558-68. Epub 2014 May 12.

University of Vermont College of Medicine, USA

Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1367493514530955DOI Listing
December 2015

Paranodal reorganization results in the depletion of transverse bands in the aged central nervous system.

Neurobiol Aging 2012 Jan 2;33(1):203.e13-24. Epub 2010 Oct 2.

Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA 23298, USA.

Paranodal axo-glial junctional complexes anchor the myelin sheath to the axon and breakdown of these complexes presumably facilitates demyelination. Myelin deterioration is also prominent in the aging central nervous system (CNS); however, the stability of the paranodal complexes in the aged CNS has not been examined. Here, we show that transverse bands, prominent components of paranodal junctions, are significantly reduced in the aged CNS; however, the number of paired clusters of both myelin and axonal paranodal proteins is not altered. Ultrastructural analyses also reveal that thicker myelin sheaths display a "piling" of paranodal loops, the cytoplasm-containing sacs that demarcate the paranode. Loops involved in piling are observed throughout the paranode and are not limited to loops positioned in either the nodal- or juxtanodal-most regions. Here, we propose that as myelination continues, previously anchored loops lose their transverse bands and recede away from the axolemma. Newly juxtaposed loops then lose their transverse bands, move laterally to fill in the gap left by the receded loops and finally reform their transverse bands. This paranodal reorganization results in conservation of paranodal length, which may be important in maintaining ion channel spacing and axonal function. Furthermore, we propose that transverse band reformation is less efficient in the aged CNS, resulting in the significant reduction of these junctional components. Although demyelination was not observed, we propose that loss of transverse bands facilitates myelin degeneration and may predispose the aged CNS to a poorer prognosis following a secondary insult.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.neurobiolaging.2010.08.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3282488PMC
January 2012