Publications by authors named "Kenneth S Azarow"

41 Publications

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion.

JAMA Surg 2021 Jan;156(1):76-90

Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, California.

Importance: Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

Objective: To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

Evidence Review: Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

Findings: Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

Conclusions And Relevance: These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.
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January 2021

Significant practice variability exists in the prevention of venous thromboembolism in injured children: results from a joint survey of the Pediatric Trauma Society and the Trauma Center Association of America.

Pediatr Surg Int 2020 Jul 2;36(7):809-815. Epub 2020 Jun 2.

Division of Pediatric Surgery, Department of Surgery, Oregon Health and Science University, Portland, OR, USA.

Background/purpose: The purpose of this study was to characterize current practices to prevent venous thromboembolism (VTE) in children and measure adherence to recent joint consensus guidelines from the Pediatric Trauma Society and Eastern Association for the Surgery of Trauma (PTS/EAST).

Methods: An 18-question survey was sent to the membership of PTS and the Trauma Center Association of American. Responses were compared with Chi-square test.

Results: One hundred twenty-nine members completed the survey. Most respondents were from academic (84.5%), Level 1 pediatric (62.0%) trauma centers. Criteria for VTE prophylaxis varied between hospitals with freestanding pediatric trauma centers significantly more likely to stratify children by risk factors than adult trauma centers (p = 0.020). While awareness of PTS/EAST guidelines (58.7% overall) was not statistically different between hospital types (44% freestanding adult, 52% freestanding pediatric, 71% combined adult pediatric, p = 0.131), self-reported adherence to these guidelines was uniformly low at 37.2% for all respondents. Lastly, in three clinical scenarios, respondents chose VTE screening and prophylaxis plans in accordance with a prospective application of PTS/EAST guidelines 55.0% correctly.

Conclusion: Currently no consensus regarding the prevention of VTE in pediatric trauma exists. Prospective application of PTS/EAST guidelines has been limited, likely due to poor quality of evidence and a reliance on post-injury metrics. Results of this survey suggest that further investigation is needed to more clearly define the risk of VTE in children, evaluate, and prospectively validate alternative scoring systems for VTE prevention in injured children.

Level Of Evidence: N/A-Survey.
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July 2020

Perspectives on Pediatric Appendicitis and Appendectomy During the Severe Acute Respiratory Syndrome Coronavirus 2 Pandemic.

J Laparoendosc Adv Surg Tech A 2020 04 1;30(4):356-357. Epub 2020 Apr 1.

Department of Surgery, Oregon Health & Science University, Portland, Oregon.

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April 2020

Minimizing variance in pediatric surgical care through implementation of a perioperative colon bundle: A multi-institution retrospective cohort study.

J Pediatr Surg 2020 Oct 25;55(10):2035-2041. Epub 2020 Jan 25.

Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.

Background: Employing an institutional initiative to minimize variance in pediatric surgical care, we implemented a set of perioperative bundled interventions for all colorectal procedures to reduce surgical site infections (SSIs).

Methods: Implementation of a standard colon bundle at two children's hospitals began in December 2014. Subjects who underwent a colorectal procedure during the study period were analyzed. Demographics, outcomes, and complications were compared with Wilcoxon Rank-Sum, Chi-square and Fisher exact tests, as appropriate. Multivariable logistic regression was performed to assess the influence of time period (independent of protocol implementation) on the rate of subsequent infection.

Results: One hundred and forty-five patients were identified (preprotocol=68, postprotocol= 77). Gender, diagnosis, procedure performed and wound classification were similar between groups. Superficial SSIs (21% vs. 8%, p=0.031) and readmission (16% vs. 4%, p=0.021) were significantly decreased following implementation of a colon bundle. Median hospital days, cost, reoperation, intraabdominal abscess, and anastomotic leak were unchanged before and after protocol implementation (all p > 0.05). Multivariable logistic regression found time period to be independent of SSIs (OR: 0.810, 95% CI: 0.576-1.140).

Conclusion: Implementation of a standard pediatric perioperative colon bundle can reduce superficial SSIs. Larger prospective studies are needed to evaluate the impact of colon bundles in reducing complications, hospital stay and cost.

Level Of Evidence: III - Retrospective cohort study.
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October 2020

Conservative management of urachal anomalies.

J Pediatr Surg 2019 May 14;54(5):1054-1058. Epub 2019 Feb 14.

Department of Pediatric Surgery, Children's Hospital and Medical Center, Omaha, NE; Department of Surgery, University of Nebraska College of Medicine, Omaha, NE. Electronic address:

Purpose: The purpose of this study was to evaluate trends in management of urachal anomalies at our institution and the safety of nonoperative care.

Methods: Based on our experience managing urachal remnants from 2000 to 2010 (reported in 2012), we adopted a more conservative approach, including preoperative antibiotic use, refraining from using voiding cystourethrograms (VCUG), postponing surgery until at least six months of age, and considering nonoperative management. A retrospective analysis of urachal anomaly cases was conducted (2011-2016) to assess trends in practice. Charts indicating anomalies of the urachus were pulled and trends in management (nonoperative versus surgical treatment), VCUG and antibiotic use, and outcomes were reviewed.

Results: Data from 2000-2010 and 2013-2016 were compared. Our findings indicate care has shifted towards nonoperative management. A smaller proportion of patients from 2013-2016 was treated surgically compared to 2000-2010. Patients receiving nonoperative treatment exhibited lower rates of complication relative to surgically managed cases. VCUGs were eliminated as a diagnostic tool for evaluating urachal anomalies. Prophylactic preoperative antibiotic use was standardized. No patients with a known urachal remnant presented later with an abscess or sepsis.

Conclusions: We find that a shift towards nonoperative treatment of urachal anomalies did not adversely affect overall outcomes. We recommend observing minimally symptomatic patients, especially those under six months old.

Study Type: Performance improvement.

Level Of Evidence: Level IV.
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May 2019

Analysis of Gender-based Differences in Surgery Faculty Compensation, Promotion, and Retention: Establishing Equity.

Ann Surg 2018 09;268(3):479-487

Department of Surgery, Oregon Health & Science University, Portland, OR.

Objectives: The objectives of this study were to evaluate gender-based differences in faculty salaries before and after implementation of a university-wide objective compensation plan, Faculty First (FF), in alignment with Association of American Medical Colleges regional median salary (AAMC-WRMS). Gender-based differences in promotion and retention were also assessed.

Summary Background Data: Previous studies demonstrate that female faculty within surgery are compensated less than male counterparts are and have decreased representation in higher academic ranks and leadership positions.

Methods: At a single institution, surgery faculty salaries and work relative value units (wRVUs) were reviewed from 2009 to 2017, and time to promotion and retention were reviewed from 1998 to 2007. In 2015, FF supplanted specialty-specific compensation plans. Salaries and wRVUs relative to AAMC-WRMS, time to promotion, and retention were compared between genders.

Results: Female faculty (N = 24) were compensated significantly less than males were (N = 62) before FF (P = 0.004). Female faculty compensation significantly increased after FF (P < 0.001). After FF, female and male faculty compensation was similar (P = 0.32). Average time to promotion for female (N = 29) and male faculty (N = 82) was similar for promotion to associate professor (P = 0.49) and to full professor (P = 0.37). Promotion was associated with significantly higher retention for both genders (P < 0.001). The median time of departure was similar between female and male faculty (P = 0.73).

Conclusions: A university-wide objective compensation plan increased faculty salaries to the AAMC western region median, allowing correction of gender-based salary inequity. Time to promotion and retention was similar between female and male faculty.
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September 2018

Minimizing variance in Care of Pediatric Blunt Solid Organ Injury through Utilization of a hemodynamic-driven protocol: a multi-institution study.

J Pediatr Surg 2017 Dec 4;52(12):2026-2030. Epub 2017 Sep 4.

Division of Pediatric Surgery, Doernbecher Children's Hospital, Oregon Health Science University, Portland, OR; Division of Pediatric Surgery, Randall Children's Hospital at Legacy Emanuel, Portland, OR. Electronic address:

Background: An expedited recovery protocol for management of pediatric blunt solid organ injury (spleen, liver, and kidney) was instituted across two Level 1 Trauma Centers, managed by nine pediatric surgeons within three hospital systems.

Methods: Data were collected for 18months on consecutive patients after protocol implementation. Patient demographics (including grade of injury), surgeon compliance, National Surgical Quality Improvement Program (NSQIP) complications, direct hospital cost, length of stay, time in the ICU, phlebotomy, and re-admission were compared to an 18-month control period immediately preceding study initiation.

Results: A total of 106 patients were treated (control=55, protocol=51). Demographics were similar among groups, and compliance was 78%. Hospital stay (4.6 vs. 3.5days, p=0.04), ICU stay (1.9 vs. 1.0days, p=0.02), and total phlebotomy (7.7 vs. 5.3 draws, p=0.007) were significantly less in the protocol group. A decrease in direct hospital costs was also observed ($11,965 vs. $8795, p=0.09). Complication rates (1.8% vs. 3.9%, p=0.86, no deaths) were similar.

Conclusions: An expedited, hemodynamic-driven, pediatric solid organ injury protocol is achievable across hospital systems and surgeons. Through implementation we maintained quality while impacting length of stay, ICU utilization, phlebotomy, and cost. Future protocols should work to further limit resource utilization.

Type Of Study: Retrospective cohort study.

Level Of Evidence: Level II.
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December 2017

Performance improvement and patient safety program-guided quality improvement initiatives can significantly reduce computed tomography imaging in pediatric trauma patients.

J Trauma Acute Care Surg 2016 08;81(2):278-84

From the Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery (C.R.C., J.D.Y., L.E.E., P.E.B., P.M.K.B., M.A.S., J.M.W.), Oregon Health & Science University, Portland, Oregon; Division of Pediatric Surgery, Department of Surgery (K.S.A., M.A.J.), Oregon Health & Science University, Portland, Oregon; Doernbecher Children's Hospital, Randall Children's Hospital (M.A.J.), Oregon Health & Science University, Portland, Oregon.

Background: Morbidity and mortality of cervical spine (C-spine) injury in pediatric trauma patients are high, necessitating quick and accurate diagnosis. Best practices emphasize minimizing radiation exposure through decreased reliance on computed tomography (CT), instead using clinical assessment, physical examination, and alternate imaging techniques. We implemented an institutional performance improvement and patient safety (PIPS) program initiative for C-spine clearance in 2010 because of high rates of CT scans among pediatric trauma patients.

Methods: A retrospective review of pediatric trauma patients, aged 0 years to 14 years, in the pre- and post-PIPS implementation periods was conducted. Rates of C-spine CT, overall CT, other imaging modalities, radiation exposure, patient characteristics, and injury severity were compared, and compliance with PIPS protocol was reviewed.

Results: Patient characteristics and injury severity were similar before and after PIPS implementation. C-spine CT rates decreased significantly between groups (30% vs. 13%, p < 0.001), whereas C-spine plain x-ray rates increased significantly (7% vs. 25%, p < 0.001). There was no difference in C-spine magnetic resonance imaging between groups (12% vs. 10%, p = 0.11). In 2007, 71% of patients received a CT scan for any reason. However, the overall CT rate decreased significantly between groups (60% vs. 45%, p < 0.001). There was an estimated 22% decrease in lifetime attributable risk (LAR) for any cancer due to ionizing imaging exposure in males and 38% decrease in females between the pre- and post-PIPS groups. There was a 54% decrease in LAR for thyroid cancer in males and females between groups; 2014 compliance with the protocol was excellent (82-90% per quarter).

Conclusions: Performance improvement and patient safety program-generated protocol can significantly decrease ionizing radiation exposure. We demonstrate that a simple protocol focused on C-spine imaging has high compliance, decreased C-spine CT scans, and decreased LAR for thyroid cancer. A secondary benefit is a reduction in total CT imaging, with an associated decrease in LAR for all cancers.

Level Of Evidence: Therapeutic study, level IV; diagnostic study, level III.
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August 2016

Understanding the Operative Experience of the Practicing Pediatric Surgeon: Implications for Training and Maintaining Competency.

JAMA Surg 2016 08;151(8):735-41

Department of Surgery, University of Michigan Health System, Ann Arbor.

Importance: The number of practicing pediatric surgeons has increased rapidly in the past 4 decades, without a significant increase in the incidence of rare diseases specific to the field. Maintenance of competency in the index procedures for these rare diseases is essential to the future of the profession.

Objective: To describe the demographic characteristics and operative experiences of practicing pediatric surgeons using Pediatric Surgery Board recertification case log data.

Design, Setting, And Participants: We performed a retrospective review of 5 years of pediatric surgery certification renewal applications submitted to the Pediatric Surgery Board between 2009 and 2013. A surgeon's location was defined by population as urban, large rural, small rural, or isolated. Case log data were examined to determine case volume by category and type of procedures. Surgeons were categorized according to recertification at 10, 20, or 30 years.

Main Outcome And Measure: Number of index cases during the preceding year.

Results: Of 308 recertifying pediatric surgeons, 249 (80.8%) were men, and 143 (46.4%) were 46 to 55 years of age. Most of the pediatric surgeons (304 of 308 [98.7%]) practiced in urban areas (ie, with a population >50 000 people). All recertifying applicants were clinically active. An appendectomy was the most commonly performed procedure (with a mean [SD] number of 49.3 [35.0] procedures per year), nonoperative trauma management came in second (with 20.0 [33.0] procedures per year), and inguinal hernia repair for children younger than 6 months of age came in third (with 14.7 [13.8] procedures per year). In 6 of 10 "rare" pediatric surgery cases, the mean number of procedures was less than 2. Of 308 surgeons, 193 (62.7%) had performed a neuroblastoma resection, 170 (55.2%) a kidney tumor resection, and 123 (39.9%) an operation to treat biliary atresia or choledochal cyst in the preceding year. Laparoscopy was more frequently performed in the 10-year recertification group for Nissen fundoplication, appendectomy, splenectomy, gastrostomy/jejunostomy, orchidopexy, and cholecystectomy (P < .05) but not lung resection (P = .70). It was more frequently used by surgeons recertifying in the 10-year group (used in 11 375 of 14 456 procedures [78.7%]) than by surgeons recertifying in the 20-year (used in 6214 of 8712 procedures [71.3%]) or 30-year group (used in 2022 of 3805 procedures [53.1%]).

Conclusions And Relevance: Practicing pediatric surgeons receive limited exposure to index cases after training. With regard to maintaining competency in an era in which health care outcomes have become increasingly important, these results are concerning.
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August 2016

Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs.

J Trauma Acute Care Surg 2015 Dec;79(6):983-9; discussion 989-90

From the Department of Surgery (K.K.S., G.E.B., M.J.M., M.J.E.), Madigan Army Medical Center, Tacoma, Washington; and Department of Surgery (K.S.A.), Oregon Health Sciences University; and Trauma and Acute Care Surgery Service (W.L., M.J.M.), Legacy Emanuel Hospital, Portland, Oregon.

Background: The current conflict in Afghanistan has resulted in a high volume of significantly injured pediatric patients. The austere environment has demanded emphasis on prehospital interventions (PHIs) to sustain casualties during transport.

Methods: The Department of Defense Trauma Registry was queried for all pediatric patients (≤18 years) treated at Camp Bastion from 2004 to 2012. PHIs were grouped by Advanced Trauma Life Support categories into (1) airway (A)--intubation or surgical airway; 2) breathing (B)--chest tube or needle thoracostomy; and 3) circulation (C)--tourniquet or hemostatic dressing. Outcomes were assessed based on injury severity, hemodynamics, blood products and fluids, as well as mortality rates.

Results: There were 766 injured children identified with 20% requiring one or more PHIs, most commonly circulation (C, 51%) followed by airway (A, 40%) and breathing (B, 8.7%). The majority of C interventions were tourniquets (85%) and hemostatic dressings (15%). Only 38% of patients with extremity vascular injury or amputation received a C intervention, with a significant reduction in blood products and intravenous fluids associated with receiving a C PHI (both p < 0.05). A interventions consisted of endotracheal intubation for depressed mental status (Glasgow Coma Scale [GCS] score < 8). Among patients with traumatic brain injury, A interventions were associated with higher unadjusted mortality (56% vs. 20%, p < 0.01) and remained independently associated with increased mortality after multivariate adjustment (odds ratio, 5.9; p = 0.001). B interventions were uncommon and performed in only 2% of patients with no recorded adverse outcomes.

Conclusion: There is a high incidence of PHIs among pediatric patients with severe wartime injuries. The most common and effective were C PHI for hemorrhage control, which should remain a primary focus of equipment and training. A interventions were most commonly performed in the setting of severe traumatic brain injury but were associated with worse outcomes. B interventions seem safe and effective and may be underused.

Level Of Evidence: Care management/therapeutic study, level IV.
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December 2015

Trends in surgical management of urachal anomalies.

J Pediatr Surg 2015 Aug 15;50(8):1334-7. Epub 2015 May 15.

Department of Pediatric Surgery, Children's Hospital and Medical Center, Omaha, NE, 68114-4113, USA.

Purpose: We have noted an increasing frequency of diagnosed urachal anomalies. The purpose of this study is to evaluate this increase, as well as the outcomes of management at our institution over 10 years.

Methods: A retrospective analysis of urachal anomalies at our institution was performed. Inclusion criteria were Anomalies of Urachus (ICD 753.7) or Urinary Anomaly NOS (ICD 753.9) between January 2000 and December 2010. Exclusion criteria were having an asymptomatic urachal remnant incidentally excised.

Results: Eighty-five patients (49 male, 36 female) presented between 0 and 17 years of age (mean 1.5 years). Diagnoses increased from 0 in 2000 to 21 in 2010. Zero was surgically managed in 2000 while 21 were managed in 2010 (p=0.0145). Fifteen patients (17.6%) were observed with 13 (13/15, or 15.3%) resolving without complication while 2 were operated on. Average time to resolution (clinical or radiologic) was 4.9 months (Range: 0.4-12.6). A total of seventy-two patients (84.7%) underwent excision. Thirty-nine (54%) surgical cases were outpatient while 33 (46%) were admitted. Thirteen (18%) had post-operative complications. Ten (77%) of the complications were wound infections. Patients under 6 months of age accounted for 60% (6 of 10) of all wound infections and 52% (17 of 33) of hospitalizations.

Conclusions: Our experience and review of the literature suggest a high complication rate with surgical management in young patients, mostly from infections and support non-operative management of all non-infected urachal remnants in children.
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August 2015

The effort and outcomes of the Pediatric Surgery match process: Are we interviewing too many?

J Pediatr Surg 2015 Nov 20;50(11):1954-7. Epub 2015 Jun 20.

Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA.

Purpose: Increasing numbers of programs participating in the pediatric surgery match has resulted in economic and logistical issues for candidates, General Surgery residencies, and Pediatric Surgery training programs (PSTP). We sought to determine the ideal number of interviews conducted by programs based on resultant rank order lists (ROL) of matched candidates.

Methods: PSTPs received 4 online surveys regarding interview practices (2011-2012, 2014), and matched candidate ROL (2008-2010, 2012, 2014). Program directors (PD) also provided estimates regarding minimum candidate interview numbers necessary for an effective match (2011-2012, 2014). Kruskal-Wallis equality-of-populations rank tests compared ROL and interview numbers conducted. Quartile regression predicted ROL based on the interview numbers. Wilcoxon signed rank-sum tests compared the interview numbers to the minimal interview number using a matched pair. p Values<0.05 were significant.

Results: Survey response rates ranged from 85-100%. Median ROL of matched candidates (2-3.5) did not differ between programs (p=0.09) and the lowest matched ROL for any year was 10-12. Interview numbers did not affect the final candidate ROL (p=0.22). While PDs thought the minimum median interview number should be 20, the number actually conducted was significantly higher (p<0.001).

Conclusion: These data suggest that PSTPs interview excessive numbers of candidates. Programs and applicants should evaluate mechanisms to reduce interviews to limit costs and effort associated with the match.
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November 2015

Increased burden of de novo predicted deleterious variants in complex congenital diaphragmatic hernia.

Hum Mol Genet 2015 Aug 1;24(16):4764-73. Epub 2015 Jun 1.

Division of Molecular Genetics, Department of Pediatrics,

Congenital diaphragmatic hernia (CDH) is a serious birth defect that accounts for 8% of all major birth anomalies. Approximately 40% of cases occur in association with other anomalies. As sporadic complex CDH likely has a significant impact on reproductive fitness, we hypothesized that de novo variants would account for the etiology in a significant fraction of cases. We performed exome sequencing in 39 CDH trios and compared the frequency of de novo variants with 787 unaffected controls from the Simons Simplex Collection. We found no significant difference in overall frequency of de novo variants between cases and controls. However, among genes that are highly expressed during diaphragm development, there was a significant burden of likely gene disrupting (LGD) and predicted deleterious missense variants in cases (fold enrichment = 3.2, P-value = 0.003), and these genes are more likely to be haploinsufficient (P-value = 0.01) than the ones with benign missense or synonymous de novo variants in cases. After accounting for the frequency of de novo variants in the control population, we estimate that 15% of sporadic complex CDH patients are attributable to de novo LGD or deleterious missense variants. We identified several genes with predicted deleterious de novo variants that fall into common categories of genes related to transcription factors and cell migration that we believe are related to the pathogenesis of CDH. These data provide supportive evidence for novel genes in the pathogenesis of CDH associated with other anomalies and suggest that de novo variants play a significant role in complex CDH cases.
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August 2015

The association between congenital diaphragmatic hernia and undescended testes.

J Pediatr Surg 2015 May 19;50(5):744-5. Epub 2015 Feb 19.

Division of Pediatric Surgery, Department of Surgery, Shaare Zedek Medical Center, Jerusalem, Israel.

Background: Undescended testes (UDT) is a common abnormality treated by pediatric surgeons. Embryological development of the genitourinary ridge is in close proximity with the pleuroperitoneal fold. The purpose of this paper is to describe the association between congenital diaphragmatic hernia (CDH) and UDT.

Materials/methods: As part of the DHREAMS (Diaphragmatic Hernia Research and Exploration: Advancing Molecular Science) study (, all living children had tissue banked and analyzed for common genetic mutations and had a health assessment performed by telephone consultation with the parents at two years of age. The incidence of UDT was then compared to clinical and genetic findings previously identified.

Results: Sixty-five males had complete information from their 2year health assessment. Of these, twelve (18%) had a UDT repaired by the time of the 2year assessment. Of the twelve who had a repair, no child had a unilateral UDT which was contralateral to the side of the CDH. There were no differences in rate or number of mutations of any of the genes we checked as part of our study.

Conclusion: It appears that a deficiency of diaphragm tissue may affect the first or transabdominal phase of the testicular descent, leading to an increased incidence of UDT.
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May 2015

Identifying strategies to decrease infectious complications of gastroschisis repair.

J Pediatr Surg 2015 Jan 29;50(1):98-101. Epub 2014 Oct 29.

University of Nebraska Medical Center and Children's Hospital, Omaha, NE, USA. Electronic address:

Purpose: We describe the infectious complications of gastroschisis in order to identify modifiable factors to decrease these complications.

Methods: Data from 155 gastroschisis patients (2001-2013) were reviewed. Complicated gastroschisis (intestinal atresia, necrotic bowel, or perforation) were excluded, leaving 129 patients for review. Patient demographics, surgical details, postoperative infections and complications, and length of stay were reviewed. We used CDC definitions of infectious complications.

Results: The average gestational age of patients was 35.97weeks. Silos were used in 46% of patients (n=59) for an average of 7.4days. Thirty-one patients (24%) acquired an infection within the first 60days of life. Patients who developed an infection were born earlier in gestation (P=0.02), weighed less (P=0.01), required silos more often (P=0.01), and received a sutured repair (P=0.04). Length of stay of patients with an infection was longer than in patients without infection (P=0.01).

Conclusions: Infectious complications following gastroschisis repair are common. Subsets of gastroschisis patients at increased risk of infection include patients with silos, preterm delivery, low birth weight, and sutured repair. Based on our findings, our recommendation would be to carry gastroschisis patients to term and advocate against the routine use of silos, reserving their use for those cases when primary closure is not possible.
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January 2015

Morbidity and mortality associated with liver resections for primary malignancies in children.

Pediatr Surg Int 2014 May 20;30(5):493-7. Epub 2014 Mar 20.

Department of Surgery, Madigan Army Medical Center, Tacoma, WA, 98431, USA,

Purpose: Liver resection (LR) is a high-risk procedure with limited data in the pediatric surgical literature regarding short-term outcomes. Our aim was to characterize the patient population and short-term outcomes for children undergoing LR for malignancy.

Methods: We studied 126 inpatient admissions for children ≤20 years of age undergoing LR in 2009 using the Kids' Inpatient Database. Patients had a principal diagnosis of a primary hepatic malignancy and LR listed as one of the first five procedures. Transplantations were excluded. Complications were defined by ICD-9 codes. High-volume centers performed at least 5 LR.

Results: The mean age was 5.83 years. The morbidity and mortality rates were 30.7 and 3.7%, respectively. The most common causes of morbidity were digestive system complications (7.4%), anemia (7.3%), and respiratory complications (3.8%). 43.9% received a blood product transfusion. The average length of stay was 10.04 days. When compared to low-volume centers, high-volume centers increased the likelihood of a complication fourfold (P = 0.011) but had 0% mortality (P = 0.089).

Conclusion: LR remains a procedure fraught with multiple complications and a significant mortality rate. High-volume centers have a fourfold increase in likelihood of complications compared to low-volume centers and may be related to extent of hepatic resection.
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May 2014

Chronic cervical esophageal foreign bodies in children: surgical approach after unsuccessful endoscopic management.

Ann Otol Rhinol Laryngol 2014 Jan;123(1):19-24

Department of Otolaryngology-Head and Neck Surgery (Schramm, Sewell), College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska.

Objectives: We reviewed the surgical management of chronic cervical esophageal foreign bodies (CCEFBs) in a pediatric population after failed endoscopic retrieval.

Methods: A descriptive analysis via a retrospective chart review of patients with CCEFBs who failed initial endoscopic management was performed between 2008 and 2013. Details were recorded regarding presenting symptoms, time from symptom onset to diagnosis of the CCEFB, surgical approach, and complications.

Results: Three patients with CCEFBs unsuccessfully managed with endoscopy were identified. The range of ages at diagnosis was 14 months to 4.5 years. The foreign bodies (FBs) were present for at least 1 month before diagnosis (range, 1 to 10 months). Respiratory symptoms were predominant in all cases. Neck exploration with removal of the FB was performed in each case. Complications included esophageal stricture necessitating serial dilations (patient 1), left true vocal fold paresis that resolved spontaneously (patient 3), and tracheoesophageal fistula with successful endoscopic closure (patient 3). No long-term sequelae were experienced.

Conclusions: A high index of suspicion is required to recognize CCEFBs in children with respiratory distress. Although endoscopic management remains the first-line treatment, it may fail or may not be possible because of transmural FB migration. In this setting, neck exploration with FB removal is a safe and effective alternative.
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January 2014

Whole exome sequencing identifies de novo mutations in GATA6 associated with congenital diaphragmatic hernia.

J Med Genet 2014 Mar 2;51(3):197-202. Epub 2014 Jan 2.

Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York, USA.

Background: Congenital diaphragmatic hernia (CDH) is a common birth defect affecting 1 in 3000 births. It is characterised by herniation of abdominal viscera through an incompletely formed diaphragm. Although chromosomal anomalies and mutations in several genes have been implicated, the cause for most patients is unknown.

Methods: We used whole exome sequencing in two families with CDH and congenital heart disease, and identified mutations in GATA6 in both.

Results: In the first family, we identified a de novo missense mutation (c.1366C>T, p.R456C) in a sporadic CDH patient with tetralogy of Fallot. In the second, a nonsense mutation (c.712G>T, p.G238*) was identified in two siblings with CDH and a large ventricular septal defect. The G238* mutation was inherited from their mother, who was clinically affected with congenital absence of the pericardium, patent ductus arteriosus and intestinal malrotation. Deep sequencing of blood and saliva-derived DNA from the mother suggested somatic mosaicism as an explanation for her milder phenotype, with only approximately 15% mutant alleles. To determine the frequency of GATA6 mutations in CDH, we sequenced the gene in 378 patients with CDH. We identified one additional de novo mutation (c.1071delG, p.V358Cfs34*).

Conclusions: Mutations in GATA6 have been previously associated with pancreatic agenesis and congenital heart disease. We conclude that, in addition to the heart and the pancreas, GATA6 is involved in development of two additional organs, the diaphragm and the pericardium. In addition, we have shown that de novo mutations can contribute to the development of CDH, a common birth defect.
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March 2014

The increasing incidence of adolescent bariatric surgery.

J Pediatr Surg 2013 Dec;48(12):2401-7

Department of Surgery, Madigan Army Medical Center, Tacoma, WA. Electronic address:

Background: Morbid obesity continues to be a significant problem within the United States, as overweight/obesity rates are nearing 33%. Bariatric surgery has had success in treating obesity in adults and is becoming a viable treatment option for obese adolescents.

Methods: We studied 1615 inpatient admissions for children ≤20 years of age undergoing a bariatric procedure for morbid obesity in 2009 using the Kids' Inpatient Database (KID). Patients had a principal diagnosis of obesity and a bariatric procedure listed as one of their first 5 procedures. Procedures (open gastric bypass, laparoscopic gastric bypass, sleeve gastrectomy, laparoscopic gastroplasty, and laparoscopic gastric band) and complications were defined by ICD-9 codes.

Results: There were 90 open gastric bypasses, 906 laparoscopic gastric bypasses, 150 sleeve gastrectomies, 18 laparoscopic gastroplasties, and 445 laparoscopic gastric bandings. The length of stay for each procedure was 2.44, 2.20, 2.33, 1.10, and 1.02 days, respectively (P<0.001). The complication rates were 3.3%, 3.5%, 0.7%, 0.0%, 0.2%, respectively (P=0.004).

Conclusions: Bariatric surgery is an increasingly utilized option for the treatment of morbid obesity among adolescents. The procedures can be performed safely as evidenced by low complication rates. Additional long-term follow-up is necessary.
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December 2013

Multi-institutional analysis of long-term symptom resolution after cholecystectomy for biliary dyskinesia in children.

Pediatr Surg Int 2013 Dec 12;29(12):1243-7. Epub 2013 Jul 12.

Children's Mercy Hospital, Kansas City, MO, USA.

Purpose: Current literature for resolution of abdominal pain after cholecystectomy in children with biliary dyskinesia shows variable outcomes. We sought to compare early outcomes with long-term symptom resolution in children.

Methods: Telephone surveys were conducted on children who underwent cholecystectomy for biliary dyskinesia between January 2000 and January 2011 at two centers. Retrospective review was performed to obtain demographics and short-term outcomes.

Results: Charts of 105 patients' age 7.9-19 years were reviewed; 80.9 % were female. All were symptomatic with an ejection fraction (EF) <35 % or pain with cholecystokinin administration. At the postoperative visit, 76.1 % had resolution of symptoms. Fifty-six (53.3 %) patients were available for follow-up at median 3.7 (1.1-10.7) years. Of these, 34 (60.7 %) reported no ongoing abdominal pain. Of the 22 patients with persistent symptoms, satisfaction score was 7.3 ± 2.7 (scale of 1-10) and 19 (86.4 %) were glad that they had a cholecystectomy performed. EF, body mass index percentile (BMI %), and pain with cholecystokinin (CCK) were not predictive of ongoing pain at either follow-up periods.

Conclusion: Short-term symptom resolution in children undergoing cholecystectomy for biliary dyskinesia is not reflective of long-term results. Neither EF, BMI % nor pain with CCK was predictive of symptom resolution. The majority of patients with ongoing complaints do not regret cholecystectomy.
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December 2013

Variants in GATA4 are a rare cause of familial and sporadic congenital diaphragmatic hernia.

Hum Genet 2013 Mar 9;132(3):285-92. Epub 2012 Nov 9.

Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, 1150 St. Nicholas Avenue, Room 620, New York, NY 10032, USA.

Congenital diaphragmatic hernia (CDH) is characterized by incomplete formation of the diaphragm occurring as either an isolated defect or in association with other anomalies. Genetic factors including aneuploidies and copy number variants are important in the pathogenesis of many cases of CDH, but few single genes have been definitively implicated in human CDH. In this study, we used whole exome sequencing (WES) to identify a paternally inherited novel missense GATA4 variant (c.754C>T; p.R252W) in a familial case of CDH with incomplete penetrance. Phenotypic characterization of the family included magnetic resonance imaging of the chest and abdomen demonstrating asymptomatic defects in the diaphragm in the two "unaffected" missense variant carriers. Screening 96 additional CDH patients identified a de novo heterozygous GATA4 variant (c.848G>A; p.R283H) in a non-isolated CDH patient. In summary, GATA4 is implicated in both familial and sporadic CDH, and our data suggests that WES may be a powerful tool to discover rare variants for CDH.
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March 2013

De novo copy number variants are associated with congenital diaphragmatic hernia.

J Med Genet 2012 Oct;49(10):650-9

Department of Pediatrics, Columbia University Medical Center, New York, New York 10032, USA.

Background: Congenital diaphragmatic hernia (CDH) is a common birth defect with significant morbidity and mortality. Although the aetiology of CDH remains poorly understood, studies from animal models and patients with CDH suggest that genetic factors play an important role in the development of CDH. Chromosomal anomalies have been reported in CDH.

Methods: In this study, the authors investigated the frequency of chromosomal anomalies and copy number variants (CNVs) in 256 parent-child trios of CDH using clinical conventional cytogenetic and microarray analysis. The authors also selected a set of CDH related training genes to prioritise the genes in those segmental aneuploidies and identified the genes and gene sets that may contribute to the aetiology of CDH.

Results: The authors identified chromosomal anomalies in 16 patients (6.3%) of the series including three aneuploidies, two unbalanced translocation, and 11 patients with de novo CNVs ranging in size from 95 kb to 104.6 Mb. The authors prioritised the genes in the CNV segments and identified KCNA2, LMNA, CACNA1S, MYOG, HLX, LBR, AGT, GATA4, SOX7, HYLS1, FOXC1, FOXF2, PDGFA, FGF6, COL4A1, COL4A2, HOMER2, BNC1, BID, and TBX1 as genes that may be involved in diaphragm development. Gene enrichment analysis identified the most relevant gene ontology categories as those involved in tissue development (p=4.4×10(-11)) or regulation of multicellular organismal processes (p=2.8×10(-10)) and 'receptor binding' (p=8.7×10(-14)) and 'DNA binding transcription factor activity' (p=4.4×10(-10)).

Conclusions: The present findings support the role of chromosomal anomalies in CDH and provide a set of candidate genes including FOXC1, FOXF2, PDGFA, FGF6, COL4A1, COL4A2, SOX7, BNC1, BID, and TBX1 for further analysis in CDH.
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October 2012

Pediatric surgery.

Surg Clin North Am 2012 Jun 17;92(3):xvii-xix. Epub 2012 Apr 17.

University of Nebraska College of Medicine & Children's Hospital & Medical Center 8200 Dodge Street, Omaha, NE 68114, USA.

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June 2012

Long-term neurodevelopmental outcomes in children born with gastroschisis: the tiebreaker.

J Pediatr Surg 2012 Jan;47(1):125-9

Division of Pediatric Surgery, Munroe Meyer Institute, University of Nebraska Medical Center, Omaha, NE 68198, USA.

Purpose: We evaluated 2-year neurodevelopmental outcomes in children with gastroschisis.

Methods: We reviewed the records of children with gastroschisis treated between August 2001 and July 2008. Children discharged from the neonatal intensive care unit were referred to the state-sponsored Developmental Tracking Infant Progress Statewide (TIPS) program. We reviewed TIPS assessments performed before age 2 years. School districts evaluated children referred by TIPS and determined their eligibility for early intervention services. Poor outcomes were defined as scores of "failure" or "moderate/high risk" on the screening assessment or enrollment in early intervention services by 2 years. Children with gastroschisis were compared with case-matched nonsurgical, nonsyndromic children of similar gestational age and birth weight.

Results: One hundred five children were born with gastroschisis, and 46 were followed up with TIPS. There was no statistically significant difference in performance on screening assessments or in the rate of enrollment in early intervention services between the gastroschisis children and controls.

Conclusions: Children born with gastroschisis have similar 2-year neurodevelopmental outcomes as nonsurgical, nonsyndromic neonatal intensive care unit children of similar gestational age and birth weight. Both groups of children have a higher rate of enrollment in early intervention than their healthy peers. These data suggest that neurodevelopmental outcomes in gastroschisis children are delayed secondary to prematurity rather than the presence of the surgical disease.
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January 2012

Use of fresh frozen plasma in children.

Kenneth S Azarow

J Pediatr 2012 Feb 7;160(2):185-6. Epub 2011 Oct 7.

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February 2012

Pathologic changes in biliary dyskinesia.

J Pediatr Surg 2011 May;46(5):879-82

Department of Surgery, Children's Hospital and Medical Center, University of Nebraska College of Medicine, Omaha, NE, USA.

Purpose: For children with upper abdominal pain and evaluation for acalculous biliary disease, laparoscopic cholecystectomy is an accepted treatment with inconsistent outcomes. The purpose of this study was to identify predictors of outcomes.

Methods: One hundred sixty-seven children underwent laparoscopic cholecystectomy at a single children's hospital. Radiographic findings, histopathology, family history, and demographics (sex, age, height, weight, body mass index-for-age percentile) were evaluated as predictors of postoperative symptomatic resolution using a binomial probability model. The data for radiologic studies and pathologic specimens were obtained via re-review in a blinded fashion.

Results: Of 167 children, 43 (25.7%) had a preoperative diagnosis of biliary dyskinesia and 41 (95.3%) had documented follow-up. Mean follow-up was 8.4 months. Twenty-eight patients (68.3%) had symptom resolution. Ejection fraction less than or equal to 15%, pain upon cholecystokinin injection, and a family history of biliary disease were not predictors of symptomatic resolution. Nonoverweight patients (body mass index-for-age <85th percentile) were more likely to have symptom resolution than their overweight counterparts (odds ratio, 2.13). Most patients (68.3%) had a pathologic gallbladder on blinded review. However, this did not correlate with outcome.

Conclusions: Most gallbladders removed for biliary dyskinesia are pathologic. Being overweight can be considered a relative contraindication to cholecystectomy for biliary dyskinesia.
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May 2011

Mesonephric remnant with tubular function in a 15-year-old female.

J Pediatr Surg 2008 Dec;43(12):2293-6

Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA.

Congenital abnormalities of the genital or urinary tract are not uncommon and often occur together. This article discusses a unique case in which a functioning mesonephric remnant was found.
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December 2008

Pediatric trauma in an austere combat environment.

Crit Care Med 2008 Jul;36(7 Suppl):S293-6

Department of Pediatrics (PCS), Connecticut Children's Medical Center, Hartford, CT, USA.

Objective: The objective of this study was to describe the epidemiology of pediatric patients admitted with traumatic injuries to U.S. combat support hospitals and to provide insight into both critical care and noncritical care challenges this presents.

Design: The authors provide a descriptive report.

Setting: This study was conducted at seven combat support hospitals in both Iraq and Afghanistan.

Patients: Subjects were pediatric patients age <18 yrs.

Measurements And Main Results: There were 1,305 (7.1%) pediatric patients admitted to Army combat support hospitals who required 12% of all hospital bed days. The hospital length of stay was increased in pediatric patients compared with both adult coalition and noncoalition patients. Thirteen percent of all the patients who died at combat support hospitals and 11% of all transfusions and patients on mechanical ventilation were children. In-hospital mortality for pediatric patients was increased 71 of 1,305 (5.4%) compared with both adult coalition (114 of 8,567 [1.3%]) and noncoalition patients (369 of 8,511 [4.3%]) (p < .05). In-hospital mortality was increased for children <6 yrs of age compared with children 6 to 17 yrs of age, 10.7% versus 3.8%, respectively (p < .05).

Conclusions: Pediatric patients with traumatic injuries are common at deployed U.S. military medical facilities as a result of combat-related and noncombat-related injuries and have increased in-hospital mortality compared with adults. Mortality was also increased for younger compared with older children. Innovative adaptations in addition to logistic and organizational changes have potentially improved pediatric care since the early stages of both wars from 2001 to 2003. Self-improvement through coalition support of the Iraqi and Afghani medical systems is needed to permit advancement and self-reliance.
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July 2008

Pediatric care as part of the US Army medical mission in the global war on terrorism in Afghanistan and Iraq, December 2001 to December 2004.

Pediatrics 2008 Feb;121(2):261-5

Camp Taji, Iraq.

Objective: Our objective in this report was to describe the epidemiologic features of and workload associated with pediatric admissions to 12 US Army military hospitals deployed to Iraq and Afghanistan.

Methods: The Patient Administration Systems and Biostatistics Activity database was queried for all local national patients <18 years of age who were admitted to deployed Army hospitals in Afghanistan and Iraq between December 2001 and December 2004.

Results: Pediatric admissions during the study period were 1012 (4.2%) of 24,227 admissions, occupying 10% of all bed-days. The median length of stay was 4 days (interquartile range: 1-8 days). The largest proportion of children were 11 to 17 years of age (332 of 757 children; 44%), although 45 (6%) of 757 children hospitalized were <1 year of age. The majority (63%) of pediatric patients admitted required either general surgical or orthopedic procedures. The in-hospital mortality rate for all pediatric patients was 59 (5.8%) of 1012 patients, compared with 274 (4.5%) of 6077 patients for all adult non-US coalition patients.

Conclusions: Pediatric patients with injuries threatening life, limb, or eyesight are part of the primary responsibility of military medical facilities during combat and have accounted for a significant number of admissions and hospital bed-days in deployed Army hospitals in Afghanistan and Iraq. Military medical planners must continue to improve pediatric medical support, including personnel, equipment, and medications that are necessary to treat children injured during combat operations, as well as those for whom the existing host nation medical infrastructure is unable to provide care.
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February 2008

Colon and rectal injuries during Operation Iraqi Freedom: are there any changing trends in management or outcome?

Dis Colon Rectum 2007 Jun;50(6):870-7

Department of Surgery, Madigan Army Medical Center, Fort Lewis, Washington, USA.

Purpose: Despite the evolution in the management of traumatic colorectal injuries in both civilian and military settings during the previous few decades, they continue to be a source of significant morbidity and mortality. The purpose of this study was to analyze management and clinical outcomes from a cohort of patients suffering colorectal injuries.

Methods: This was a retrospective analysis of prospectively collected data from all patients injured and treated at the 31st Combat Support Hospital during Operation Iraqi Freedom from September 2003 to December 2004.

Results: From the 3,442 patients treated, 175 (5.1 percent) had colorectal injuries. Patients were predominately male (95 percent), suffered penetrating injuries (96 percent), and had a mean age of 29 (range, 4-70) years. Ninety-one percent of patients had associated injuries. Initial management included primary repair (34 percent), stoma (33 percent), resection with anastomosis (19 percent), and damage control only (14 percent). By injury location, stomas were placed more frequently with rectal or sphincter injuries 65 percent (25/40) vs. other sites (right, 19 percent (8/42); transverse, 25 percent (8/32); left, 36 percent (20/55); P < 0.01). Thirteen percent of patients eventually received stomas for failure of initial in-continuity management. Patients with colorectal injuries had a significantly increased mortality rate than those without (18 percent (31/175) vs. 8 percent (269/3267); P < 0.001) but not the subset without colorectal injuries undergoing celiotomy (18 vs.14.4 percent; P = 0.41). Rectal (odds radio, 22; P = 0.03) and transverse colon (odds radio, 17; P = 0.04) injuries were independently associated with increased mortality in multivariate regression analysis. Initial placement of stoma had an independent association with lower leak rates (odds radio, 0.06; P = 0.04).

Conclusions: Injury to the rectum or transverse colon is an independent predictor of mortality. The use of a diverting stoma varied by injury site and was associated with a decreased leak rate but demonstrated no impact on the incidence of sepsis or mortality.
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June 2007