Publications by authors named "David H Rothstein"

97 Publications

Histologic type predicts disparate outcomes in pediatric hepatocellular neoplasms: A Pediatric Surgical Oncology Research Collaborative study.

Cancer 2022 May 13. Epub 2022 May 13.

Division of Pediatric Surgery, Children's Hospital, London Health Sciences Center, London, Ontario, Canada.

Background: Hepatocellular carcinoma (HCC) is a rare cancer in children, with various histologic subtypes and a paucity of data to guide clinical management and predict prognosis.

Methods: A multi-institutional review of children with hepatocellular neoplasms was performed, including demographic, staging, treatment, and outcomes data. Patients were categorized as having conventional HCC (cHCC) with or without underlying liver disease, fibrolamellar carcinoma (FLC), and hepatoblastoma with HCC features (HB-HCC). Univariate and multivariate analyses identified predictors of mortality and relapse.

Results: In total, 262 children were identified; and an institutional histologic review revealed 110 cHCCs (42%; 69 normal background liver, 34 inflammatory/cirrhotic, 7 unknown), 119 FLCs (45%), and 33 HB-HCCs (12%). The authors observed notable differences in presentation and behavior among tumor subtypes, including increased lymph node involvement in FLC and higher stage in cHCC. Factors associated with mortality included cHCC (hazard ratio [HR], 1.63; P = .038), elevated α-fetoprotein (HR, 3.1; P = .014), multifocality (HR, 2.4; P < .001), and PRETEXT (pretreatment extent of disease) stage IV (HR, 5.76; P < .001). Multivariate analysis identified increased mortality in cHCC versus FLC (HR, 2.2; P = .004) and in unresectable tumors (HR, 3.4; P < .001). Disease-free status at any point predicted survival.

Conclusions: This multi-institutional, detailed data set allowed a comprehensive analysis of outcomes for children with these rare hepatocellular neoplasms. The current data demonstrated that pediatric HCC subtypes are not equivalent entities because FLC and cHCC have distinct anatomic patterns and outcomes in concert with their known molecular differences. This data set will be further used to elucidate the impact of histology on specific treatment responses, with the goal of designing risk-stratified algorithms for children with HCC.

Lay Summary: This is the largest reported granular data set on children with hepatocellular carcinoma. The study evaluates different subtypes of hepatocellular carcinoma and identifies key differences between subtypes. This information is pivotal in improving understanding of these rare cancers and may be used to improve clinical management and subsequent outcome in children with these rare malignancies.
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http://dx.doi.org/10.1002/cncr.34256DOI Listing
May 2022

Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study.

J Pediatr Surg 2022 Feb 23. Epub 2022 Feb 23.

Children's Hospital Colorado, Aurora, CO, United States.

Background: Pulmonary nodules that are deep within lung parenchyma and/or small in size can be challenging to localize for biopsy. This study describes current trends in performance of image-guided localization techniques for pulmonary nodules in pediatric patients.

Methods: A retrospective review was performed on patients < 21 years of age undergoing localization of pulmonary nodules at 15 institutions. Localization and resection success, time in interventional radiology (IR), operating room (OR) and total anesthesia time, complications, and technical problems were compared between techniques.

Results: 225 patients were included with an average of 1.3 lesions (range 1-5). Median nodule size and depth were 4 mm (range 0-30) and 5.4 mm (0-61), respectively. The most common localization techniques were: wire + methylene blue dye (MBD) (28%), MBD only (25%), wire only (14%), technetium-99 only (11%), coil + MBD (7%) and coil only (5%). Localization technique was associated with institution (p < 0.01); technique and institution were significantly associated with mean IR, OR, and anesthesia time (all p < 0.05). Comparing techniques, there was no difference in successful IR localization (range 92-100%, p = 0.75), successful resection (94-100%, p = 0.98), IR technical problems (p = 0.22), or operative complications (p = 0.16).

Conclusions: Many IR localization techniques for small pulmonary nodules in children can be successful, but there is wide variability in application by institution and in procedure time.

Level Of Evidence: Retrospective review, Level 3.
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http://dx.doi.org/10.1016/j.jpedsurg.2022.01.061DOI Listing
February 2022

Global dissemination of knowledge through virtual platforms: Reflections and recommendations from APSA/IPEG.

J Pediatr Surg 2022 Jan 15. Epub 2022 Jan 15.

Department of Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, United States.

Background: The COVID-19 pandemic forced the cancelation of conventional in-person academic conferences due to the risk of virus transmission and limited ability to travel. Both the American Pediatric Surgical Association (APSA) and International Pediatric Endosurgery Group (IPEG) converted to a virtual format for their 2020 annual meetings. The purpose of this article is to review the successful implementation of the APSA and IPEG virtual meetings and reflect upon lessons learned for future virtual conferences.

Methods: Logistics, structure, and attendance statistics were reviewed. Informal interviews were conducted with key stakeholders and the number of presenters and participants were analyzed. Finally, post-meeting attendee surveys were conducted to elicit feedback after both virtual meetings.

Results: The meetings were organized in different ways, with APSA spreading a mix of scientific and clinical educational content over several months and IPEG keeping the meeting compressed, similar to previous in-person versions. Both meetings were free and therefore attracted a high proportion of participants (720 for APSA and 834 for IPEG). The meetings were felt to be educationally appropriate by most, although timing and lack of Continuing Medical Education (CME) opportunities were detractors. Most attendees said they would be willing to pay fees similar to in-person amounts. IPEG compressed presentations into four 2-hour sessions spread over 4 weeks, but also made material available on-line through a proprietary application. There was a broad range of international attendees. IPEG attracted a larger percentage of non-members than did APSA (3:1 nonmember to member ratio). Both societies reported net losses, largely due to lost registration revenue and non-refundable costs from having to switch from an in-person meeting.

Conclusions: The main advantage of the virtual meeting was increased participation while disadvantages included the lack of networking. The key lessons learned from the meetings include methods to increase interactivity, adjustments of technical logistics, and creation of enduring material. In the future, hybrid conferences will likely become more prevalent with advantages of both platforms.

Level-of-evidence: Level V - Expert Opinion.
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http://dx.doi.org/10.1016/j.jpedsurg.2022.01.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8760846PMC
January 2022

Surgeon perceptions of volume threshold and essential practices for pediatric thyroidectomy.

J Pediatr Surg 2022 Jan 15. Epub 2022 Jan 15.

Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL. Electronic address:

Introduction: The topics of sub-specialization and regionalization of care have garnered increased attention among pediatric surgeons. Thyroid surgeries are one such sub-specialty and are commonly concentrated within practices. A national survey was conducted examining current surgeon practices and beliefs surrounding pediatric thyroid surgery.

Methods: Non-resident members of the American Pediatric Surgical Association (APSA) were surveyed in October 2020. Respondents were stratified based on self-reported thyroid surgical experience. Those who performed thyroid surgery were asked about surgical technique and operative practices; those who did not were asked about referral patterns. All respondents were asked about perceptions surrounding the volume-outcome relationship for pediatric thyroid surgery.

Results: Among 1015 APSA members, 405 (40%) responded, with 79% (317/400) practicing at academic hospitals, 58% (232/401) practicing in major metropolitan area, and 41% (161/392) with over 10 years of attending pediatric surgery experience. Most respondents (88%, n = 356) agreed that thyroid surgery volume affects outcome, though wide variation was reported in the annual case threshold for "high volume" surgery. Eighty-four respondents (21%) reported performing ≥ 1 pediatric thyroid surgery in the past year. Of these, 82% routinely use recurrent laryngeal nerve monitoring, 32% routinely send hemithyroidectomy patients home the same day, and there was little consensus surrounding postoperative hypocalcemia management. The majority of respondents endorse performing thyroid procedures with a colleague.

Conclusions: Pediatric thyroid surgery appears to be performed by a subset of active pediatric surgeons, most of whom endorse the use of a dual operating team. More evidence is needed to build consensus around additional perioperative practices.
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http://dx.doi.org/10.1016/j.jpedsurg.2022.01.001DOI Listing
January 2022

Patent ductus arteriosus: From pharmacology to surgery.

Semin Pediatr Surg 2021 Dec 23;30(6):151123. Epub 2021 Oct 23.

Pediatric General and Thoracic Surgery, University of Washington Medical School, Seattle Children's Hospital, 4800 Sand Point Way NE, OA.9.220, Seattle, WA, USA. Electronic address:

Patent ductus arteriosus (PDA) may be found in 0.1-0.2% of term infants, but the average incidence is at least five-fold higher in premature infants, correlating inversely with birth weight and gestational age. While not all patients with a PDA require treatment, the deleterious effects of persistent left-to-right shunting across the ductus can have important short- and long-term consequences. Medical and interventional approaches to PDA closure have evolved greatly in the past decade and add to the decision-making pathways. This article summarizes the pathophysiology of PDA and characterizes the medical, surgical and endovascular treatment approaches.
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http://dx.doi.org/10.1016/j.sempedsurg.2021.151123DOI Listing
December 2021

Post-Procedural Opioid Prescribing in Children: A Survey of the American Academy of Pediatrics.

J Surg Res 2022 01 8;269:1-10. Epub 2021 Sep 8.

Division of Pediatric Surgery, Department of Surgery, University of Rochester, Golisano Children's Hospital, Rochester, New York.

Introduction: North America is in the midst of an opioid epidemic. The role of pediatric surgeons and other procedural specialists in this public health crisis remains unclear. There is likely considerable variation in the use of opioid and non-opioid analgesics, but the spectrum of practice is still uncertain.

Methods: We performed an online survey in July 2018 of the 2086 pediatric surgeons and proceduralists who were active members in the American Academy of Pediatrics. The survey inquired about practice environment, use of opioid and non-opioid pain medications, and attitudes towards the opioid epidemic.

Results: 178 specialists completed the survey for a response rate of 8.5%. Most respondents utilize oral acetaminophen (86%) and ibuprofen (80%) after procedures >75% of the time. Self-reported opioid prescribing increases with age after both outpatient and inpatient procedures (P < 0.001). Pediatric general surgeons prescribe opioids less frequently than other specialists, particularly after inpatient procedures. The majority of respondents (81%) believe that the opioid epidemic is a major problem but only 31% indicated that they have a major role to play.

Conclusions: There is significant variation in opioid prescribing patterns as reported by pediatric surgeons and proceduralists. Guidelines are needed to standardize the use of non-opioid analgesics and decrease reliance on opioids for outpatient and inpatient procedures.
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http://dx.doi.org/10.1016/j.jss.2021.07.044DOI Listing
January 2022

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

J Pediatr Surg 2022 Mar 8;57(3):474-478. 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.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.08.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8996746PMC
March 2022

Association of same-day discharge with hospital readmission after pediatric thyroidectomy.

Pediatr Surg Int 2021 Sep 20;37(9):1259-1264. Epub 2021 May 20.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 1001 Main Street, Buffalo, NY, 14203, USA.

Background: Studies have demonstrated that same-day discharge (SDD) following thyroid resection is safe and feasible in adults but there are no similar studies in the pediatric age group. The purpose of this study is to evaluate the influence of SDD on 30-day readmission rates following thyroid surgery in pediatric patients.

Methods: This retrospective cohort study used the American College of Surgeons National Surgical Quality Improvement Program-Pediatric database to evaluate 30-day readmission rates among patients < 19 years of age who underwent thyroid resection between 2012 and 2017. Patients excluded were those discharged more than 2 days after surgery. The main exposure variable was SDD and the primary outcome was 30-day readmission. Secondary outcomes included wound complications, unplanned reoperation and death. Patient characteristics were compared using chi-squared testing and odds ratios for readmission were calculated using multivariate logistic regression.

Results: Of the 1125 patients (79% female, median age 15 years), 122 (11%) were discharged on the day of surgery. Total or near-total thyroidectomy represented the majority of operations (714, 63.5%) and patients undergoing these operations were less likely to be discharged on the same day as surgery compared to those undergoing thyroid lobectomy (4.3 vs. 22.1%, P < 0.001). Twenty-nine patients were readmitted within 30 days (3 in the same day group, 26 in the later group). There was no difference in the odds of readmission between the two groups (adjusted odds ratio in SDD compared to later discharge 1.04 [95% CI 0.29-3.75, P = 0.96; readmission rate, 2.46 vs. 2.59%). Wound complications were reported in two patients, both in the later discharge group.

Conclusion: Same-day discharge in pediatric patients undergoing thyroidectomy is not associated with an increase in 30-day readmissions or wound complications when compared to patients discharged 1 or 2 days after surgery. In selected patients, SDD may be an appropriate alternative to traditional overnight stay.
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http://dx.doi.org/10.1007/s00383-021-04927-wDOI Listing
September 2021

Update on pediatric testicular germ cell tumors.

J Pediatr Surg 2022 Apr 15;57(4):690-699. Epub 2021 Apr 15.

Department of Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, United States.

Background: Testicular germ cell tumors are uncommon tumors that are encountered by pediatric surgeons and urologists and require a knowledge of appropriate contemporary evaluation and surgical and medical management.

Method: A review of the recommended diagnostic evaluation and current surgical and medical management of children and adolescents with testicular germ cell tumors based upon recently completed clinical trials was performed and summarized in this article.

Results: In this summary of childhood and adolescent testicular germ cell tumors, we review the initial clinical evaluation, surgical and medical management, risk stratification, results from recent prospective cooperative group studies, and clinical outcomes. A summary of recently completed clinical trials by pediatric oncology cooperative groups is provided, and best surgical practices are discussed.

Conclusions: Testicular germ cell tumors in children are rare tumors. International collaborations, data-sharing, and enrollment of patients at all stages and risk classifications into active clinical trials will enhance our knowledge of these rare tumors and most importantly improve outcomes of patients with testicular germ cell tumors.

Level Of Evidence: This is a review article of previously published and referenced level 1 and 2 studies, but also includes expert opinion level 5, represented by the American Pediatric Surgical Association Cancer Committee.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.04.001DOI Listing
April 2022

Anaplastic lymphoma kinase inhibitor therapy in the treatment of inflammatory myofibroblastic tumors in pediatric patients: Case reports and literature review.

J Pediatr Surg 2021 Dec 11;56(12):2364-2371. Epub 2021 Feb 11.

Division of Pediatric Hematology/Oncology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences and Department of Pediatrics, Roswell Park Comprehensive Cancer Center, Buffalo, NY, United States.

Background: Inflammatory myofibroblastic tumors (IMTs) are a rare subtype of inflammatory pseudotumor frequently associated with rearrangement of the anaplastic lymphoma kinase (ALK) gene. Their treatment has historically relied on at-times challenging and morbid surgical excision. Recent studies have shown that neo/adjuvant therapy with ALK inhibitors can significantly enhance outcomes in select patients.

Methods: A systematic literature review was performed to characterize comprehensive treatment of ALK-positive IMTs in the pediatric population. This report also includes two patients from our home institutions not previously reported in the literature.

Results: We identified a total of 27 patients in 12 studies in addition to 2 patients from the senior authors' institution for a total of 29 patients (median age, 7 years; 52% male). The IMTs comprised a wide range of anatomic locations. Almost half (12, 41.3%) were treated with ALK-inhibitors alone and felt to be in remission. The remainder was treated with ALK-inhibitors either before or after surgery and had a curative response.

Conclusions: ALK-positive IMTs can be successfully treated with ALK-inhibition alone or in combination with surgical resection. Further genetic characterization may be helpful in determining more precise treatment and defining needed durations thereof.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.004DOI Listing
December 2021

Defining the role of advanced care practitioners in pediatric surgery practice.

J Pediatr Surg 2021 Dec 5;56(12):2263-2269. Epub 2020 Dec 5.

Division of Pediatric Surgery, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, Cohen Children's Medical Center, 1111 Marcus Avenue, New Hyde Park, NY, United States.

Introduction: The role of advanced care practitioners (ACPs) in pediatric surgery is increasingly important and not well described.

Methods: Electronic surveys were sent to pediatric surgery division chiefs within the Children's Hospital Association.

Results: We received 77/163 survey responses (47%). The median number of ACPs per service was 3.0 (range 0-35). ACP number correlated with inpatient census, surgeon number, case volume, trauma centers, intensive care unit status, and fellowship programs but not with presence of residents/hospitalists, hospital setting, or practice type. Nearly all programs incorporated nurse practitioners while almost half utilized physician assistants. Approximately one-third of ACPs were designated for subspecialties (35%) such as trauma and colorectal. Only 9% of centers had surgeon-specific ACPs. ACP responsibilities included both inpatient and outpatient tasks. Nearly all ACPs participated in procedures (89%), mostly bedside (80%). All ACPs worked daytime shifts, with less nights and weekends. Most ACPs billed for services (80%). Satisfaction with ACP coverage was widespread and did not correlate with ACP number. Most respondents felt that ACPs enhance, and not hinder, resident/fellow training (85%).

Conclusion: ACPs are useful adjuncts in pediatric surgery. A better understanding of practice patterns may help optimize utilization to enhance patient care and can be used to advocate for appropriate resources.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.11.030DOI Listing
December 2021

Dissecting a department of surgery: Exploring organizational culture and competency expectations.

Am J Surg 2021 02 24;221(2):298-302. Epub 2020 Oct 24.

Department of Surgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.

Introduction: In order to recruit high-potential trainees, surgery residency and fellowship programs must first understand what competencies and attributes are required for success in their respective programs. This study performed a systematic analysis to define organizational culture and competency expectations across training programs within one academic surgery department.

Methods: Subject matter experts rated the importance and frequency of 22 competencies and completed a 44-item organizational culture inventory along 1 to 5 Likert-type scales.

Results: Importance and frequency attributions of competencies varied significantly among programs (p < .05 by ANOVA), but there was substantial agreement on organizational culture; self-directed (x̄ = 3.8), perfectionist (x̄ = 3.7) and social (x̄ = 3.7) attributes were most representative of the program, while oppositional (x̄ = 1.8), competitive (x̄ = 2.5) and hierarchical (x̄ = 2.7) characteristics were least representative.

Conclusions: Residency and fellowship programs within the same department have shared perceptions of the culture and values of their institution, but seek different competencies among entering trainees.
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http://dx.doi.org/10.1016/j.amjsurg.2020.10.011DOI Listing
February 2021

Appendectomy in pediatric patients with synchronous oncologic diagnosis is safe: an analysis using the national surgical quality improvement project, pediatric.

Pediatr Surg Int 2020 Nov 11;36(11):1333-1338. Epub 2020 Sep 11.

Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, 14214, USA.

Background: Optimal treatment of children who develop appendicitis while undergoing treatment for an oncologic diagnosis has not been defined, in part due to theoretical concerns for an increased risk of postoperative wound complications. We hypothesized that synchronous oncologic diagnosis conferred no increased odds of developing a wound complication in pediatric patients undergoing appendectomy.

Methods: Retrospective cohort study using the National Surgical Quality Improvement Program, Pediatric (2012-2017) of patients < 18 years of age undergoing appendectomy. The main exposure variable was active treatment for an oncologic diagnosis. The primary outcomes of interest were 30-day wound complications (superficial or deep infections or dehiscence, and abscess). For univariate analysis comparison of baseline differences between patients with/without a cancer diagnosis we employed Pearson's χ and two sample t tests. Multivariate logistic regression was used to evaluate which covariates were independently associated with our outcome.

Results: We identified 28,219 patients who had undergone appendectomy; 95 (0.3%) were undergoing oncologic treatment at the time of surgery. Patients in the cancer group were more likely to be receiving steroids, have lower white blood cell counts and have higher American Society of Anesthesiology classes as compared to the noncancer patients. Age, gender, rates of perforation, and laparoscopy were similar between the two groups. Patients with an active cancer diagnosis suffered wound complications (measured individually and as an aggregate) at no higher odds than those without a cancer diagnosis.

Conclusion: Pediatric patients undergoing treatment for cancer do not have increased odds of suffering postoperative wound complications following appendectomy as compared to the general population.
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http://dx.doi.org/10.1007/s00383-020-04743-8DOI Listing
November 2020

Surgical Repair of Orofacial Clefts in North Kivu Province of Eastern Democratic Republic of Congo (DRC).

Cleft Palate Craniofac J 2020 11 13;57(11):1314-1319. Epub 2020 Aug 13.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA.

Background: There is a high prevalence of orofacial clefts in low- and middle-income countries with significant unmet need, despite having 50% of the population younger than 18 years in countries such as the Democratic Republic of Congo (DRC). The purpose of this article is to report on the experience of general surgeons with orofacial clefts at a single institution.

Methods: This is a retrospective study of patients treated for cleft lip/palate in the province of North Kivu, DRC between 2008 and 2017.

Results: A total of 1112 procedures (122/year) were performed. All procedures were performed by general surgeons following training by an international nongovernmental aid organization. A total of 59.2% of patients were male and the median age was 3.4 years (interquartile range: 0.7-13 years). Average distance from surgical center to patient location was 242.6 km (range: 2-1375 km) with outreach performed for distances >200 kms. A majority (82.1%) of patients received general anesthesia (GA) with significant differences in use of GA, age, weight, and length of stay by major orofacial cleft category. Of the 1112 patients, 86.1% were reported to have cleft lip alone, 10.5% had cleft lip and palate, and 3.4% cleft palate alone. Despite this, only 5.3% of patients underwent surgical repair of cleft palate.

Conclusions: Multiple factors including malnutrition, risk of bleeding, procedural complexity, and cosmetic results may contribute to the distribution of procedures performed where most cleft palates are not treated. Based on previously published estimates, unmet needs and social burden of cleft lip and palate are high in the DRC.
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http://dx.doi.org/10.1177/1055665620947604DOI Listing
November 2020

Pancreaticoduodenectomy for the treatment of pancreatic neoplasms in children: A Pediatric Surgical Oncology Research Collaborative study.

Pediatr Blood Cancer 2020 09 13;67(9):e28425. Epub 2020 Jul 13.

Division of Pediatric Surgery, CHU Sainte-Justine, University of Montreal, Montreal, QC, Canada.

Background: To better characterize short-term and long-term outcomes in children with pancreatic tumors treated with pancreaticoduodenectomy (PD).

Methods: Patients 21 years of age or younger who underwent PD at Pediatric Surgical Oncology Collaborative (PSORC) hospitals between 1990 and 2017 were identified. Demographic, clinical information, and outcomes (operative complications, long-term pancreatic function, recurrence, and survival) were collected.

Results: Sixty-five patients from 18 institutions with a median age of 13 years (4 months-22 years) and a median (IQR) follow-up of 2.8 (4.3) years were analyzed. Solid pseudopapillary tumor of the pancreas (SPN) was the most common histology. Postoperative complications included pancreatic leak in 14% (n = 9), delayed gastric emptying in 9% (n = 6), marginal ulcer in one patient, and perioperative (30-day) death due to hepatic failure in one patient. Pancreatic insufficiency was observed in 32% (n = 21) of patients, with 23%, 3%, and 6% with exocrine, or endocrine insufficiencies, or both, respectively. Children with SPN and benign neoplasms all survived. Overall, there were 14 (22%) recurrences and 11 deaths (17%). Univariate analysis revealed non-SPN malignant tumor diagnosis, preoperative vascular involvement, intraoperative transfusion requirement, pathologic vascular invasion, positive margins, and need for neoadjuvant chemotherapy as risk factors for recurrence and poor survival. Multivariate analysis only revealed pathologic vascular invasion as a risk factor for recurrence and poor survival.

Conclusion: This is the largest series of pediatric PD patients. PD is curative for SPN and benign neoplasms. Pancreatic insufficiency is the most common postoperative complication. Outcome is primarily associated with histology.
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http://dx.doi.org/10.1002/pbc.28425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7674210PMC
September 2020

Geospatial Mapping of Pediatric Surgical Capacity in North Kivu, Democratic Republic of Congo.

World J Surg 2020 Nov;44(11):3620-3628

Department of Pediatric Surgery, John R. Oishei Children's Hospital, 1001 Main Street, Buffalo, NY, 14203, USA.

Background: Despite recent attention to the provision of healthcare in low- and middle-income countries, improvements in access to surgical services have been disproportionately lagging.

Methods: This study analyzes the geographic variability in access to pediatric surgical services in the province of North Kivu, Democratic Republic of Congo (DRC). On-site data collection was conducted using the Global Assessment of Pediatric Surgery tool. Spatial distribution of providers was mapped using the Geographical Information System and open-sourced spatial data to determine distances traveled to access surgical care.

Results: Forty facilities were evaluated across 32 health zones; 68.9% of the provincial population was within 15 km of these facilities. Eleven facilities met a minimum World Health Organization safety score of 8; 48.1% of the population was within 15 km of corresponding facilities. The majority of children were treated by someone with specific pediatric surgery training in only 4 facilities; one facility had a trained pediatric anesthesia provider. Fifty-seven percent of the population was within 15 km of a facility with critical care and emergency medicine (EM) capabilities. There was one pediatric critical care provider and no pediatric EM providers identified within the province. Location-allocation assessment is needed to combine geographic area with potential for greatest impact and facility assessment.

Conclusions: Limitations in access to surgical care in the DRC are multifactorial with poor resources, few formally trained surgical providers, and near-absent access to pediatric anesthesiologists. The study highlights the deficits in the capacity for surgical care while demonstrating a reproducible model for assessment and identification of ways to improve access to care.
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http://dx.doi.org/10.1007/s00268-020-05680-2DOI Listing
November 2020

Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study.

J Surg Res 2020 11 30;255:449-455. Epub 2020 Jun 30.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.

Background: To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings.

Methods: We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort.

Results: Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86.

Conclusions: In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.
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http://dx.doi.org/10.1016/j.jss.2020.05.088DOI Listing
November 2020

Does academic authorship reflect gender bias in pediatric surgery? An analysis of the Journal of Pediatric Surgery, 2007-2017.

J Pediatr Surg 2020 Oct 23;55(10):2071-2074. Epub 2020 May 23.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY; Department of Surgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY. Electronic address:

Background: Gender representation in academic publications has been considered a surrogate for gender equity in medicine, although this concept has not been evaluated in pediatric surgery.

Methods: First and last author genders for Journal of Pediatric Surgery articles from United States and/or Canadian institutions (2007, 2012, 2017) were identified. These data were compared to gender proportions for applicants to and matriculants in pediatric surgery fellowships as well as among American Pediatric Surgical Association (APSA) members.

Results: Authorship gender was identified for 632/640 primary articles (98.8%). From 2007 to 2017, the proportion of women as first authors increased from 33.0% to 53.9% (p < 0.001) and as last authors from 16.2% to 26.4% (p = 0.01). The proportion of women fellowship applicants rose from 35.9% to 57.6% (p < 0.001); among those who successfully matched the rise was nonlinear (20.5%-34.0%, p = 0.16). APSA junior and senior women membership proportions rose during the study period [from 28.1% to 43.4% (p = 0.06 for linear trend) and 17.9% to 24.4% (p = 0.005 for linear trend), respectively].

Conclusions: Over the past decade, the overall proportion of women authors in a leading academic pediatric surgery journal has increased significantly, although representation among last authors remains disproportionately low. The numbers of women applicants to pediatric surgery fellowship increased but there was not a concordant rise in the number of women accepted into training positions.

Type Of Study: Bibliometric analysis.

Level Of Evidence: n/a.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.05.020DOI Listing
October 2020

Retroperitoneal Sclerosing Lipogranuloma in an Adolescent With Congenital Atresia of the Inferior Vena Cava: Case Report and Literature Review.

J Pediatr Hematol Oncol 2021 05;43(4):e525-e528

Hematology/Oncology, John R. Oishei Children's Hospital.

Sclerosing lipogranuloma (SLG) in children is a rare, benign disease of unknown etiology suspected to be due to abnormal fatty tissue reaction. A 13-year-old girl presented with progressively worsening back pain. Cross-sectional imaging identified a retroperitoneal mass compressing the left ureter as well as infrarenal inferior vena cava atresia with extensive venous collaterals and chronic partially occlusive thromboses of the iliac veins. Surgical biopsy was consistent with SLG and it resolved spontaneously. SLG is typically a disease of adulthood but may be seen in children. The association between inferior vena cava atresia with venous thrombosis and development of SLG has not been reported previously.
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http://dx.doi.org/10.1097/MPH.0000000000001855DOI Listing
May 2021

Association of anesthesia type with prolonged postoperative intubation in neonates undergoing inguinal hernia repair.

J Perinatol 2021 03 4;41(3):571-576. Epub 2020 Jun 4.

John R. Oishei Children's Hospital, Buffalo, NY, USA.

Purpose: The purpose of this study is to determine factors associated with prolonged intubation after inguinal herniorrhaphy in neonates.

Methods: Retrospective, single institution review of neonates undergoing inguinal herniorrhaphy between 2010 and 2018. Variables recorded included demographics, comorbidities, ventilation status at time of hernia repair, and anesthetic technique.

Results: We identified 97 neonates (median corrected gestational age 39.9 weeks, IQR 6.6). The majority (87.6%) received general anesthesia (GA); the remainder received caudal anesthesia (CA). Among the GA subjects, 25.8% remained intubated for at least 6 h after surgery, whereas none of the CA patients required intubation postoperatively (p = 0.03). Two risk factors associated with prolonged postoperative intubation: a history of intubation before surgery (p = 0.04) and a diagnosis of bronchopulmonary dysplasia (p = 0.03).

Conclusions: Neonates undergoing inguinal herniorrhaphy under GA have a greater rate of prolonged postoperative intubation compared with those undergoing CA. A history of previous intubation and bronchopulmonary dysplasia were significant risk factors for prolonged postoperative intubation.
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http://dx.doi.org/10.1038/s41372-020-0703-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7270742PMC
March 2021

COVID 19: Surgery & the question of race.

Am J Surg 2020 10 20;220(4):845-846. Epub 2020 May 20.

University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA; Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA.

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http://dx.doi.org/10.1016/j.amjsurg.2020.05.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7237362PMC
October 2020

Gastrostomy tube placement in neonates undergoing tracheostomy: an opportunity to coordinate care?

J Perinatol 2020 08 1;40(8):1228-1235. Epub 2020 Jun 1.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY, USA.

Objectives: To describe variations in timing of gastrostomy tube (GT) placement for neonates undergoing tracheostomy.

Methods: Database study of neonates undergoing tracheostomy and GT placement using the Pediatric Health Information System (2012-2015). The primary outcome was timing of GT relative to tracheostomy. Logistic regression evaluated associations of patient- and hospital-level characteristics with GT timing.

Results: Of 1156 patients undergoing GT and tracheostomy placement, 42.4% had concurrent GT placement, 23.3% GT placement prior to tracheostomy, and 34.3% GT placement after tracheostomy. The proportion of patients undergoing concurrent placement ranged from 0 to 80% among 47 hospitals. Neonates born at 31-35 weeks, having cardiovascular comorbidities, history of diaphragmatic hernia repair, or gastroesophageal reflux disorder were more likely to receive GT placement prior to tracheostomy.

Conclusion: Significant variability exists in the timing of neonatal tracheostomy and GT placement. Opportunities may exist to optimize coordination of care for neonates and reduce anesthetic exposure and hospital resource utilization.
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http://dx.doi.org/10.1038/s41372-020-0699-9DOI Listing
August 2020

Subspecialization in pediatric surgery: Results of a survey to the American Pediatric Surgical Association.

J Pediatr Surg 2020 Oct 15;55(10):2058-2063. Epub 2020 Feb 15.

Division of Pediatric Surgery, John R. Oishei Children's Hospital, Department of Surgery, University of Buffalo, Buffalo, NY.

Background: Current practice patterns and opinions regarding subspecialization within pediatric surgery are not well known. We aimed to characterize the prevalence of and attitudes surrounding subspecialization within pediatric surgery.

Methods: An anonymous survey regarding subspecialization was distributed to all nonresident members of the American Pediatric Surgical Association.

Results: Of 1118 surveys, we received 458 responses (41%). A majority of respondents labeled themselves 'general pediatric surgeons' (63%), while 34% considered themselves general surgeons with a specific clinical focus, and 3% reported practicing solely within a specific niche. Subspecialists commonly serve as consultants for relevant cases (52%). Common niches included oncology (10%) and anorectal malformations (9%). Subspecialists felt to be necessary included transplant (79%) and fetal (78%) surgeons. Opinions about subspecialization were variable: 41% felt subspecialization improves patient care while 39% believe it is detrimental to surgeon well-roundedness. Only 10% felt subspecialists should practice solely within their subspecialty. Practicing at an academic hospital or fellowship program correlated with subspecialization, while length of time in practice did not.

Conclusion: While pediatric surgeons report that subspecialization may benefit patient care, concerns exist regarding the unfavorable effect it may have on the individual surgeon. A better understanding of how subspecialization affects quality and outcomes would help clarify its utility.

Type Of Study: Review article.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.02.006DOI Listing
October 2020

Improving the performance of the Revised Trauma Score using Shock Index, Peripheral Oxygen Saturation, and Temperature-a National Trauma Database study 2011 to 2015.

Surgery 2020 05 14;167(5):821-828. Epub 2020 Feb 14.

Division of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY.

Background: The Revised Trauma Score is the standard physiologic injury severity indicator used in trauma research and quality control. Shock index, peripheral oxygen saturation, and temperature have emerged as strong predictors for mortality and morbidity. We hypothesized that replacing systolic blood pressure and respiratory rate with age-adjusted shock index and peripheral oxygen saturation and adding temperature would generate a more accurate model, valid across all ages.

Methods: This is a retrospective database analysis using children and adults from the National Trauma Data Bank for years 2011 to 2015. Glasgow Coma Scale, systolic blood pressure, heart rate, respiratory rate, peripheral oxygen saturation, temperature, and shock index (calculated as heart rate/systolic blood pressure) were used as predictor variables, alone or in combination, in logistic models with survival as primary outcome. Bayesian information criterion and area under the receiver operator characteristic curve were used to compare models' performances. To adjust for age, models tested on the entire population (children and adults) used Z-scores derived on age-based homogenous intervals rather than the raw value.

Results: The analysis included 283,724 pediatric and 1,555,478 adult patients. Overall mortality was 0.7% and 2.7%, respectively. The Glasgow Coma Scale + shock index + peripheral oxygen saturation + temperature model outperformed the revised trauma score in both adults (Bayesian information criterion 296,345.94 vs 298,494.72; area under the receiver operator characteristic curve 0.831 vs 0.809, P < .001) and children (Bayesian information criterion 12,251.48 vs 12,283.48; area under the receiver operator characteristic curve 0.974 vs 0.968, P = .05) cohorts. On the merged (children and adults) cohort the Glasgow Coma Scale + Z-scores derived on age-based homogenous intervals + peripheral oxygen saturation + temperature model outperformed the Revised Trauma Score (Bayesian information criterion 313,814.78 vs 317,781.31; area under the receiver operator characteristic curve 0.852 vs 0.809, P < .001).

Conclusions: Replacing systolic blood pressure and respiratory rate with shock index and peripheral oxygen saturation in the Revised Trauma Score model and adding temperature generated a more accurate model in both children and adults. Adjusting shock index for age rendered the model accurate across all ages. Calibration on population-derived nomograms of vital signs would further increase the model's accuracy and precision.
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http://dx.doi.org/10.1016/j.surg.2019.12.003DOI Listing
May 2020

The adherence of adult trauma centers to American Pediatric Surgical Association guidelines on management of blunt splenic injuries.

J Pediatr Surg 2020 Sep 16;55(9):1748-1753. Epub 2020 Jan 16.

Division of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, NY.

Background: Nonoperative management (NOM) is commonly utilized in hemodynamically stable children with blunt splenic injuries (BSI). Guidelines published by the American Pediatric Surgical Association over the past 15 years support this approach. We sought to determine the rates and outcomes of NOM in pediatric BSI and compare trends between pediatric (PTC), mixed (MTC) and adult trauma centers (ATC).

Methods: This was a retrospective database analysis of the NTDB data from 2011 to 2015 including pediatric patients with BSI, as described by ICD-9-CM Codes 865.00-865.09. Patients with head injuries with AIS > 2, multiple intraabdominal injuries, and transfers-out were excluded. According to ACS and/or state designation, trauma facilities were defined as PTC (level I/II pediatric only), MTC (level I/II adult and pediatric) and ATC (level I/II adult only). OM group was defined as presence of procedure codes reflecting exploratory laparotomy/laparoscopy and/or any splenic procedures. NOM group consisted of patients who were observed, transfused or had transarterial embolization (TAE). Variables analyzed were age, ISS, spleen AIS, amount and type of blood products transfused, and intensive care unit (ICU) and hospital (H) length of stay (LOS).

Results: 5323 children met the inclusion criteria. 11.4% received care at PTC (NOM, 97%), 40.7% at MTC (NOM, 89.9%) and 47.8% at ATC (NOM, 83.8%) (P < 0.001). In NOM group, PTC patients had the highest spleen AIS (3.46 ± 0.95, P < 0.001). TAE was predominantly used at MTC and ATC (P = 0.001). MTC and ATC were more likely to transfuse than PTC (P = 0.002). MTC and ATC OM rates were lower in children aged ≤12 than in children aged >12 (P < 0.001). Splenectomy rate was 1.5% at PTC, 8.4% at MTC, and 14.4% at ATC (P < 0.001). In OM group, PTC patients had a higher ISS (P = 0.018) and spleen AIS (P = 0.048) than both MTC and ATC. The proportion of patients treated by NOM at ATC increased during the 5-year period studied (P = 0.015). Treatment at MTC or ATC increased the risk for OM by 3.89 and 5.36 times respectively (P < 0.001).

Conclusions: PTCs still outperform ATCs in NOM success rates despite higher ISS and splenic injury grades. From 2011 to 2015, ATC OM rates dropped from 17% to 12.4% suggesting increased adoption of the APSA guidelines. Further educational initiatives may help augment this trend.

Level Of Evidence: II TYPE OF STUDY: Retrospective.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.01.001DOI Listing
September 2020

Systematic Review of Disparities in Care and Outcomes in Pediatric Appendectomy.

J Surg Res 2020 05 6;249:42-49. Epub 2020 Jan 6.

Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. Electronic address:

Background: The impact of social, racial, and economic inequities on health and surgical outcomes for children is poorly described.

Methods: A systematic review using search terms related to disparities in care of pediatric appendicitis identified 20 titles and narrowed to 11 full texts. Nine retrospective studies were analyzed, representing 350,408 cases treated across the United States from 1983 to 2010. Outcomes included length of stay (LOS), appendiceal perforation rate (AP), laparoscopic versus open approach, and rate of misdiagnosis.

Results: The most frequently reported outcomes were LOS (six of nine studies) and AP (six of nine studies). AP was higher for young children (48% for <6 versus 25% for >10), those in rural settings (42% versus 26% in urban settings), and patients receiving care at children's hospitals (35% versus 22% at nonchildren's hospitals). Longer LOS was associated with young age in three studies (2-5 d for age <10 y versus 1-3 d for age >11 y), race in four studies (1.5-3 d for African American children versus 1-2 d for other races), and lower family income in two studies (2-4 d versus 1-3 d for highest income). Inequitable use of laparoscopy, time to surgery, and rates of misdiagnosis were also reported to be associated with age and race.

Conclusions: Although limited, the existing literature suggests that social, racial, and economic inequalities impact management and outcomes in pediatric appendicitis. More studies are needed to better describe and mitigate disparities in the surgical care of children.
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http://dx.doi.org/10.1016/j.jss.2019.12.018DOI Listing
May 2020

Predictors and Outcomes of Laparoscopy in Pediatric Trauma Patients: A Retrospective Cohort Study.

J Laparoendosc Adv Surg Tech A 2019 Dec 5;29(12):1598-1604. Epub 2019 Nov 5.

Department of Surgery, University at Buffalo, State University of New York Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York.

Laparoscopy has been shown to offer a safe alternative to laparotomy in hemodynamically stable pediatric trauma patients. Our purpose was to identify factors predictive of this approach and examine surgical outcomes. This is a retrospective cohort study using the ACS Pediatric Trauma Quality Improvement Program to examine pediatric patients who underwent exploration for blunt or penetrating abdominal trauma in 2014 and 2015. Patients with contraindications to laparoscopy were excluded. Multivariable modeling identified predictors of a laparoscopic approach. Secondary analysis assessed differences in outcomes and resource utilization between laparoscopy and laparotomy groups. A total of 160 patients met inclusion criteria. Patients undergoing surgery in the northeastern (odds ratio [OR]: 2.25, 95% confidence interval [CI]: 1.26-4.03,  = .006) and western (OR: 2.03, 95% CI: 1.06-3.88,  = .032) U.S. regions had over two times greater odds of undergoing laparoscopy as those treated in the south. Patients injured by a firearm were significantly less likely to undergo laparoscopy than those suffering blunt injury (OR: 0.27, 95% CI: 0.13-0.55,  < .001). After adjustment, patients explored laparoscopically in comparison with those through laparotomy had decreased average length of stay (LOS) (mean difference [MD]: 2.55 days, 95% CI: 1.19-3.90,  < .001) and number of intensive care unit (ICU) days (MD: 1.13 days, 95% CI: 0.28-1.98,  = .01). Trauma laparoscopy may decrease LOS and ICU days in select pediatric patients requiring abdominal exploration; however, laparoscopy is not uniformly practiced in the United States. Targeted education and protocols for initial use of laparoscopy should be incorporated into hospitals treating this group to minimize morbidity and resource utilization.
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http://dx.doi.org/10.1089/lap.2019.0322DOI Listing
December 2019

Risk Factors for Inpatient Mortality in Patients Born with Gastroschisis in the United States.

Am J Perinatol 2021 01 14;38(1):60-64. Epub 2019 Aug 14.

Department of Pediatric Surgery, John R. Oishei Children's Hospital, Buffalo, New York.

Objective: This study aimed to characterize risk factors for inpatient mortality in patients born with gastroschisis in a contemporary cohort.

Study Design: This was a retrospective cohort study of infants born with gastroschisis using the Kids' Inpatient Database 2016. Simple descriptive statistics were used to characterize the patients by demographics, and illness severity was estimated using the All-Patient Refined Diagnosis-Related Groups classification. Variables associated with an increased risk of mortality on univariate analysis were incorporated into a multivariable logistic regression model to generate adjusted odds ratios (aORs) for mortality.

Results: An estimated 1,990 patient with gastroschisis were born in 2016, with a 3.7% mortality rate during the initial hospitalization. Multivariable logistic regression demonstrated the following variables to be associated with an increased risk of inpatient mortality: black or Asian race compared with white (aOR: 2.6, 95% confidence interval [CI]: 1.1-6.1,  = 0.03 and aOR: 4.1, 95% CI: 1.3-13.3,  = 0.02, respectively), whereas private health insurance compared with government (aOR: 0.2; 95% CI: 0.2-0.8;  = 0.007) and exurban domicile compared with urban (aOR: 0.5; 95% CI: 0.2-0.9;  = 0.04) appeared to be associated with a decreased risk of inpatient mortality.

Conclusion: Inpatient mortality for neonates with gastroschisis is relatively low. Even after correcting for illness severity, race, health insurance status, and domicile appear to play a role in mortality disparities. Opportunities may exist to further decrease mortality in at-risk populations.
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http://dx.doi.org/10.1055/s-0039-1694732DOI Listing
January 2021

Association of perioperative red blood cell transfusion with postoperative venous thromboembolism in pediatric patients: A propensity score matched analysis.

Pediatr Blood Cancer 2019 10 12;66(10):e27919. Epub 2019 Jul 12.

Department of Pediatric Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.

Objective: To examine the association between perioperative red blood cell (RBC) transfusion and postoperative venous thromboembolism (VTE) in pediatric surgical patients.

Methods: Retrospective cohort study using the National Surgical Quality Improvement Project Pediatric, a validated registry of 118 United States children's hospitals. Patients under 19 years of age undergoing a surgical procedure between 2012 and 2017 were included, with the main exposure being RBC transfusion in the perioperative period (48 hours prior to operation to 72 hours after operation). The primary 30-day outcome of interest was a postoperative VTE requiring therapy. Risk-adjusted odds ratios (aOR) were calculated using multiple logistic regression. Subgroup analyses were performed across multiple surgical specialties. Sensitivity analyses were performed after (a) imputation for missing variables and (b) propensity score matching.

Results: During the study years, 482 867 pediatric patients (56.7% male; median age, 6 years [interquartile range, 1-12 years]) underwent an operation. Of these, 30 879 (6.4%) received at least one perioperative RBC transfusion. Postoperative VTE requiring therapy occurred in 618 patients (0.13%). After adjustment for multiple risk factors, perioperative RBC transfusion was associated with an increased risk of VTE (aOR 2.4; 95% CI, 1.9-3.0). The increased VTE risk persisted after imputation of missing demographic and clinical data as well as after 1:1 propensity score matching (29 811 matched pairs, aOR 2.2; 95% CI, 1.7-2.8).

Conclusions: Perioperative RBC transfusion is associated with an increased, albeit still very low, risk of postoperative VTE in pediatric patients. Patients receiving blood in the perioperative period may benefit from additional monitoring or VTE prophylaxis.
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http://dx.doi.org/10.1002/pbc.27919DOI Listing
October 2019

Provider education decreases opioid prescribing after pediatric umbilical hernia repair.

J Pediatr Surg 2020 Jul 11;55(7):1319-1323. Epub 2019 May 11.

Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL. Electronic address:

Purpose: To improve opioid stewardship for umbilical hernia repair in children.

Methods: An educational intervention was conducted at 9 centers with 79 surgeons. The intervention highlighted the importance of opioid stewardship, demonstrated practice variation, provided prescribing guidelines, encouraged non-opioid analgesics, and encouraged limiting doses/strength if opioids were prescribed. Three to six months of pre-intervention and 3 months of post-intervention prescribing practices for umbilical hernia repair were compared.

Results: A total of 343 patients were identified in the pre-intervention cohort and 346 in the post-intervention cohort. The percent of patients receiving opioids at discharge decreased from 75.8% pre-intervention to 44.6% (p < 0.001) post-intervention. After adjusting for age, sex, umbilicoplasty, and hospital site, the odds ratio for opioid prescribing in the post- versus the pre-intervention period was 0.27 (95% CI = 0.18-0.39, p < 0.001). Among patients receiving opioids, the number of doses prescribed decreased after the intervention (adjusted mean 14.3 to 10.4, p < 0.001). However, the morphine equivalents/kg/dose did not significantly decrease (adjusted mean 0.14 to 0.13, p = 0.20). There were no differences in returns to emergency departments or hospital readmissions between the pre- and post-intervention cohorts.

Conclusions: Opioid stewardship can be improved after pediatric umbilical hernia repair using a low-fidelity educational intervention.

Type Of Study: Retrospective cohort study.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.04.035DOI Listing
July 2020
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