Publications by authors named "Ronald B Hirschl"

145 Publications

Ultrasound-guided pediatric inguinal hernia repair.

J Pediatr Surg 2021 Mar 11. Epub 2021 Mar 11.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA 48109; Department of Interventional Radiology, Michigan Medicine, Ann Arbor MI USA 48109. Electronic address:

Purpose: Inguinal hernias are amongst the most common surgical conditions in children. Typically, these repairs are performed through an open or laparoscopic approach, using a high ligation of the hernia sac. The use of ultrasound has been described in identifying and evaluating hernia contents in children. Our goal was to determine if ultrasound guidance could be used to perform a high ligation of the hernia sac in pediatric patients.

Methods: Following IRB approval, a retrospective review of all female patients at a single center undergoing ultrasound guided inguinal hernia repair between 2017 and 2018 was performed. Pre-operative characteristics, intra-operative outcomes, and post-operative outcomes were all evaluated. Laparoscopy was used to evaluate the repair and evaluate for a contralateral hernia. Male patients did not undergo ultrasound inguinal hernia repair to avoid damage to the vas deferens and vessels.

Results: A total of 10 patients with 13 hernias total were found during the study period. A total of one patient was converted to a laparoscopic repair. No patients were found to have an inappropriate repair or a missed contralateral hernia, and there were no vascular injuries or injuries to surrounding structures. No patients had a hernia recurrence during the study period.

Conclusion: This study demonstrates the safety and feasibility of ultrasound guided inguinal hernia repairs in female pediatric patients. Further study is needed to compare these repairs to existing techniques, evaluate for recurrences over time, and evaluate if these repairs can be performed without general anesthetic in some patients.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.053DOI Listing
March 2021

Pleuropulmonary Blastoma in Pediatric Lung Lesions.

Pediatrics 2021 Mar 24. Epub 2021 Mar 24.

Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Background: Pediatric lung lesions are a group of mostly benign pulmonary anomalies with a broad spectrum of clinical disease and histopathology. Our objective was to evaluate the characteristics of children undergoing resection of a primary lung lesion and to identify preoperative risk factors for malignancy.

Methods: A retrospective cohort study was conducted by using an operative database of 521 primary lung lesions managed at 11 children's hospitals in the United States. Multivariable logistic regression was used to examine the relationship between preoperative characteristics and risk of malignancy, including pleuropulmonary blastoma (PPB).

Results: None of the 344 prenatally diagnosed lesions had malignant pathology ( < .0001). Among 177 children without a history of prenatal detection, 15 (8.7%) were classified as having a malignant tumor (type 1 PPB, = 11; other PPB, = 3; adenocarcinoma, = 1) at a median age of 20.7 months (interquartile range, 7.9-58.1). Malignancy was associated with the DICER1 mutation in 8 (57%) PPB cases. No malignant lesion had a systemic feeding vessel ( = .0427). The sensitivity of preoperative chest computed tomography (CT) for detecting malignant pathology was 33.3% (95% confidence interval [CI]: 15.2-58.3). Multivariable logistic regression revealed that increased suspicion of malignancy by CT and bilateral disease were significant predictors of malignant pathology (odds ratios of 42.15 [95% CI, 7.43-340.3; < .0001] and 42.03 [95% CI, 3.51-995.6; = .0041], respectively).

Conclusions: In pediatric lung masses initially diagnosed after birth, the risk of PPB approached 10%. These results strongly caution against routine nonoperative management in this patient population. DICER1 testing may be helpful given the poor sensitivity of CT for identifying malignant pathology.
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http://dx.doi.org/10.1542/peds.2020-028357DOI Listing
March 2021

Central line placement at ECMO decannulation: A missed opportunity.

J Pediatr Surg 2021 Feb 25. Epub 2021 Feb 25.

Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI 48109, USA.

Introduction: ECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation.

Methods: A single-institution retrospective study of patients undergoing open neck decannulation from 2015 to 2019. Patients were divided into two groups:  ≤ 28-days and > 28-days.

Results: Of 65 patients, 31% had a CVL placed at decannulation. Sepsis and pneumonia were the most common indications for ECMO in the older-group compared to CDH in neonates. The most common indications for CVL were hemodialysis (45%), monitoring (25%), and access (25%). 89% of neonates had an access line placed, whereas 73% of the older group received hemodialysis catheters. Median CRRT requirement was 20 days. 85% of lines were functional at time of removal or death. None were removed for infection. 40% of the patients not receiving a CVL at decannulation required one within 30 days.

Conclusion: 69% of patients did not have a CVL placed at decannulation, however 40% required a CVL within 30 days. Most lines placed at decannulation remained functional and none were removed for infection. Decannulation removes the circuit as a route for vascular access, but it also presents an opportunity to safely place an essential CVL.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.050DOI Listing
February 2021

Does the timing of pouch creation in 2-stage operations for pediatric patients with ulcerative colitis matter?

J Pediatr Surg 2021 Feb 20. Epub 2021 Feb 20.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's Hospital, 1500 E. Hospital Dr, Ann Arbor, MI 48109, USA; Susan B. Meister Child Health Evaluation and Research Center, Michigan Medicine, Ann Arbor, MI 48109, USA. Electronic address:

Introduction: Children with fulminant ulcerative colitis(UC) traditionally undergo 2-stage operations: restorative-proctocolectomy(RP/IPAA) and ileostomy followed by ostomy closure. In the biologic era, surgeons have modified their strategy: initial subtotal-colectomy/diversion, followed by RP/IPAA without diversion. Yet, evidence on efficacy and functional outcomes with the "modified 2-stage" approach is limited in children. We sought to compare the timing of pouch creation in 2-stage operations to determine outcomes.

Methods: This is a retrospective study of children with UC undergoing either a traditional 2-stage RP/IPAA or modified 2-stage RP/IPAA between 2010 and 2019. Complications (leak, stricture, wound-infection) were recorded at 90-days and 1 year from 2nd operation.

Results: N = 57 (Traditional n = 40, Modified n = 17). Median time to surgery from consultation was shorter in the modified-group (7 vs.25 days, p = 0.01). Preoperatively, the modified-group had lower albumin(p = 0.01), higher CRP(p = 0.01), and more frequently took biologics within 90-daysp=0.001). After re-establishing intestinal continuity, stricture requiring dilation was higher in the traditional-group (59% vs.18%, p = 0.008). No difference in pouch leak (p = 0.38), bowel obstruction(p = 0.35), loperamide dose(p = 0.21), or incontinence(p = 0.38) was observed.

Conclusion: Delaying pouch creation to the second operation without a protective ileostomy as a modified 2-stage is safe in a sicker and more acute pediatric population.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.023DOI Listing
February 2021

Switching to centrifugal pumps may decrease hemolysis rates among pediatric ECMO patients.

Perfusion 2021 Jan 18:267659120982572. Epub 2021 Jan 18.

Division of Pediatric Surgery, Mott Children's Hospital, Ann Arbor, MI, USA.

Recent advances in ECLS technology have led to the adoption of centrifugal pumps for the majority of patients worldwide. Despite several advantages of centrifugal pumps, they remain controversial because a number of studies have shown increased rates of hemolysis. The aim of this study was to assess the impact of transitioning from roller to centrifugal pumps on hemolysis rates at our center. A retrospective analysis of all pediatric ECMO patients at a single center between 2005 and 2017 was undertaken. Hemolysis was defined as a plasma free hemoglobin >50 mg/dL. Multivariable logistic regression was performed correcting for several factors to determine risk factors for hemolysis and analyze outcomes among patients with hemolysis. Significant findings were those with  < 0.05. A total of 590 patients were identified during the study period. Multivariable logistic regression for risk factors for hemolysis showed roller pumps (OR 1.92, CI 1.11-3.33) and ECMO duration (OR 1.002 per hour, CI 1.00-1.01) to be significant factors. Rates of hemolysis significantly improved following conversion from roller to centrifugal pumps, with significantly lower rates of hemolysis in 2012, 2015, 2016, and 2017 when compared to the historical average with roller pumps from 2005 to 2009 (34.7%). Additionally, hemolysis was associated with an increased risk of death (OR 3.59, CI 2.05-6.29) when correcting for other factors. These data suggest decreasing rates of hemolysis with centrifugal pumps compared to roller pumps. Since hemolysis was also associated with increased risk of death, these data support the switch from roller to centrifugal pumps at ECMO centers.
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http://dx.doi.org/10.1177/0267659120982572DOI Listing
January 2021

Pediatric and neonatal extracorporeal life support: current state and continuing evolution.

Pediatr Surg Int 2021 Jan 1;37(1):17-35. Epub 2021 Jan 1.

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

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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http://dx.doi.org/10.1007/s00383-020-04800-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7775668PMC
January 2021

Fetal Risk Stratification and Outcomes in Children with Prenatally Diagnosed Lung Malformations: Results from a Multi-Institutional Research Collaborative.

Ann Surg 2020 Nov 17. Epub 2020 Nov 17.

Division of Pediatric Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

Objective: To assess current clinical outcomes in children with prenatally diagnosed congenital lung malformations (CLMs) and to identify prenatal characteristics associated with adverse outcomes.

Summary Background Data: Despite a wide spectrum of clinical disease, the identification of fetal CLM subgroups at increased risk for hydrops and respiratory compromise at delivery have not been well defined.

Methods: A retrospective cohort study was conducted using an operative database of prenatally diagnosed CLMs managed at eleven children's hospitals from 2009-2016. Statistical analyses were performed using non-parametric bivariate or multivariable logistic regression.

Results: Three hundred forty-four children were analyzed. Fifteen (5.5%) fetuses were managed with maternal steroids in the setting of hydrops, and prenatal surgical intervention was uncommon (1.7%). Seventy-five (21.8%) had respiratory symptoms at birth, and 34 (10.0%) required neonatal lung resection. Congenital pulmonary airway malformation volume ratio (CVR) measurements were recorded in 169 (49.1%) cases and were significantly associated with perinatal outcome, including hydrops, respiratory distress at birth, need for supplemental oxygen, neonatal ventilator use, and neonatal resection (p < 0.001). An initial CVR ≤ 1.4 was significantly correlated with a reduced risk for hydrops [area under the curve (AUC), 0.93; 95% confidence interval (CI), 0.87-1.00]. A maximum CVR < 0.9 (AUC, 0.72; 95% CI, 0.67-0.85) was associated with a low risk for respiratory symptoms at birth.

Conclusion: In this large, multi-institutional study, an initial CVR ≤ 1.4 identifies fetuses at very low risk for hydrops, and a maximum CVR < 0.9 is associated with asymptomatic disease at birth. These findings represent an opportunity for standardization and quality improvement for prenatal counseling and delivery planning.
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http://dx.doi.org/10.1097/SLA.0000000000004566DOI Listing
November 2020

Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula.

J Pediatr Surg 2021 Jan 6;56(1):47-54. Epub 2020 Oct 6.

Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI. Electronic address:

Background/purpose: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF).

Methods: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively.

Results: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029).

Conclusions: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes.

Level Of Evidence: Level II.

Type Of Study: Treatment Study.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.09.049DOI Listing
January 2021

Predicting lethal pulmonary hypoplasia in congenital diaphragmatic hernia (CDH): Institutional experience combined with CDH registry outcomes.

J Pediatr Surg 2020 Dec 15;55(12):2618-2624. Epub 2020 Aug 15.

University of Michigan, Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, Pediatric Surgery, 1540 E. Hospital Dr., Ann Arbor, MI 48109-4211, USA. Electronic address:

Background: The Severe Pulmonary Hypoplasia and Evaluation for Resuscitative Efforts (SPHERE) protocol was developed to attempt to identify CDH patients with likely lethal pulmonary hypoplasia. We present our experience with this protocol and utilize the CDH Registry to critically assess the protocol.

Methods: SPHERE patients identified based on prenatal imaging (10/2009-1/2018) were offered ECMO if meeting postnatal physiologic criteria, while others received comfort measures. Within the CDH Registry, patients with suspected severe CDH were identified and separated into "passed" (lowest pCO2 ≤100) versus "failed" (lowest pCO2 >100) groups.

Results: Of 23 SPHERE patients, 57% (13/23) passed criteria for ECMO and survival was 46% (6/13) in that cohort. Of 4912 patients in the CDH Registry, 265 met criteria. There was no difference in survival rates between those that "passed" (122/227; 54%) versus "failed" (18/38; 47%). However, the latter had longer ECMO runs and more required ventilator/ECMO support at 30 days. Amongst survivors, the "failed" group had longer hospital stays and more frequently required tube feeds at discharge.

Conclusions: The SPHERE protocol did not predict mortality in the CDH Registry. However, our data suggest resource utilization is significant when unable to reach pCO2 ≤100 despite resuscitation. Morbidity remains high in this group.

Level Of Evidence: Level III ANNOTATION OF CHANGES: Institutional Review Board Approval at University of Michigan (HUM00031524 and HUM00044010) TYPE OF STUDY: Retrospective Review.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.08.010DOI Listing
December 2020

Efficacy of Early Pleurectomy for Severe Congenital Chylothorax.

J Surg Res 2020 12 11;256:433-438. Epub 2020 Aug 11.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan.

Background: Severe congenital chylothorax (SCC) may result in respiratory failure, malnutrition, immunodeficiency, and sepsis. Although typically managed with bowel rest, parenteral nutrition, and octreotide, persistent chylothoraces require surgical management. At our institution, a pleurectomy, unilateral or bilateral, in combination with mechanical pleurodesis and thoracic duct ligation is performed for SCC, and we describe our approach and outcomes.

Materials And Methods: We reviewed over 15-year period neonatal patients with SCC managed surgically with pleurectomy after medical therapy was unsuccessful. Patients were divided into two groups: those who underwent pleurectomy within 28 d of diagnosis (early group) and those who underwent pleurectomy after 28 d (late group). Resolution of chylothorax was defined by the absence of clinical symptoms as well as absent or minimal pleural effusion on chest X-ray.

Results: Of 40 patients diagnosed with SCC over the study period, 15 underwent pleurectomy, eight early [mean time to operation = 20 (IQR 17, 23) d] and 7 late [59 (42, 75) d, P = 0.001]. Overall survival was 67% (10 of 15). Seven of 8 (88%) neonates who underwent early pleurectomy survived versus 3 of 7 (43%) who underwent late pleurectomy (P = 0.07). Length of stay was lower in the early group than the late group [73 (57, 79) versus 102 (109, 213) d, P = 0.05]. All patients who survived to discharge had resolution of their chylothorax.

Conclusions: Pleurectomy with mechanical pleurodesis and thoracic duct ligation is effective in the management of severe congenital chylothorax. When performed earlier, pleurectomy for severe congenital chylothorax may be associated with improved survival and shorter hospital length of stay.
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http://dx.doi.org/10.1016/j.jss.2020.07.005DOI Listing
December 2020

Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis.

JAMA 2020 08;324(6):581-593

Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio.

Importance: Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery.

Objective: To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis.

Design, Setting, And Participants: Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study.

Interventions: Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698).

Main Outcomes And Measures: The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments.

Results: Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference.

Conclusion And Relevance: Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.

Trial Registration: ClinicalTrials.gov Identifier: NCT02271932.
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http://dx.doi.org/10.1001/jama.2020.10888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7385674PMC
August 2020

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

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

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

Purpose: To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort.

Methods: A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared.

Results: Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo.

Conclusion: Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.02.017DOI Listing
November 2020

APSA 5.0: Saving even more lifetimes the Jay and Margie Grosfeld presidential symposium.

J Pediatr Surg 2020 Jan 21;55(1):2-17. Epub 2019 Nov 21.

In light of APSA's 50th Anniversary, the typical Presidential Address was transformed into a "symposium" consisting of talks on the maturation of our organization to APSA 5.0 and the issues and opportunities related to its internal and external environment, especially as they apply to our pediatric surgical patients. Speakers included the President and experts in the fields of diversity, as well as inequity and poverty in the United States.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.10.004DOI Listing
January 2020

Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation.

J Pediatr Surg 2020 Jan 24;55(1):169-175. Epub 2019 Oct 24.

Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ.

Purpose: Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery.

Methods: A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion.

Results: Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028].

Conclusion: Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS.

Type Of Study: Prospective pilot study LEVEL OF EVIDENCE: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.043DOI Listing
January 2020

Caregiver knowledge, opinion, and willingness to consent to trainee involvement in pediatric surgical care.

J Pediatr Surg 2020 Jan 5;55(1):112-116. Epub 2019 Nov 5.

Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI.

Purpose: Surgical training is shifting toward competency-based models that promote earlier supervised autonomy. We assessed caregiver knowledge, willingness to consent, and opinions regarding trainee autonomy in their child's operation.

Methods: At two academic children's hospitals, 100 caregivers of children aged 0-17 years completed an electronic survey in the pediatric surgery clinic (1/2018-4/2018). Knowledge, willingness to consent, and opinions of trainee involvement in their child's operation in standard and competency-based training models were assessed. McNemar's test compared willingness to consent with standard and competency-based training (p < 0.05).

Results: Caregivers were 75% female, 41% age 30-39 years old, and 78% white. All provider roles were correctly identified by 14% of caregivers. For routine procedures, caregivers would consent to a fellow assisting (95%) or independently operating with the attending present (78%). They would less likely consent if the attending was not in the operating room (39%) or the hospital (25%). Competency-based training improved willingness to consent, but was significant only for independence with the attending present. Most caregivers wanted to know about (81%) and be asked permission for (82%) trainee involvement in their child's operation.

Conclusions: This study suggests that surgeons in academic settings must balance transparency with trainee autonomy when obtaining caregiver consent.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.064DOI Listing
January 2020

Use of cryoanalgesia for pain management for the modified ravitch procedure in children.

J Pediatr Surg 2020 Jul 25;55(7):1381-1384. Epub 2019 Oct 25.

Pediatric Surgery Section, University of Michigan, Ann Arbor, MI, 48109, USA. Electronic address:

Background: Intercostal cryoablation(IC) for pain management in children undergoing Nuss Procedure has been previously described. We evaluated postoperative outcomes following Modified Ravitch procedure for pectus disorders comparing IC to thoracic epidural(TE).

Materials And Methods: Single-center retrospective review of pediatric patients (age < 21) undergoing Modified Ravitch procedure (January 2015-March 2019) with either IC(9), or TE(20) analgesia. Primary outcome was length of stay (LOS) and secondary outcomes were inpatient opioid use (in oral morphine equivalents per kilogram; OME/kg), pain scores on each postoperative day (POD), discharge prescriptions, and complications. Pairwise comparisons made with Mann-Whitney U test or Fisher Exact test as appropriate. Two-tailed p values <0.05 were considered significant.

Results: Patient characteristics were similar. LOS was shorter with IC compared to TE (4 days versus 6; p < 0.006). Postoperative opioid use was not significantly different (IC: 1.5 OME/kg versus TE: 1.1; p = 0.10). There was improved pain control on POD 2 in patients who underwent IC (median pain score 3 versus 4; p < 0.0004). There was no difference in discharge prescription (IC: 3.3 OME/kg; TE: 4.8; p = 0.19) or complication rate (IC: 55.6%, TE:50%; p = 1.0).

Conclusions: IC during the Modified Ravitch reduced LOS compared to TE with improved pain control starting on POD 2, with similar narcotic utilization and complication rates.

Level Of Evidence: Treatment Study, Level III (Retrospective comparative study).
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.016DOI Listing
July 2020

Safety of delayed decannulation of venoarterial cannulas in patients with congenital diaphragmatic hernia.

J Pediatr Surg 2020 Jan 25;55(1):29-32. Epub 2019 Oct 25.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI. Electronic address:

Background: The practice of "cutting-away" from venoarterial extracorporeal life support (ECLS) and leaving indwelling heparinized cannulas prior to decannulation is controversial. This study aims to determine the safety and efficacy of this strategy in patients with congenital diaphragmatic hernia (CDH) who require ECLS.

Methods: A single-center retrospective review of electronic health records was performed on all patients with CDH who underwent elective ECLS decannulation between January 2014 and September 2018. Descriptive statistics are presented as medians with interquartile range.

Results: Seventy-three percent (19/26) of patients who underwent venoarterial ECLS for CDH were electively decannulated. After a median ECLS run of 10.7 days [6.1-19.5], patients were "cut-away" for a median of 26 h [19.8-43] prior to decannulation. One patient required re-initiation at 36 h for a pulmonary hypertensive crisis (5%). There were no major bleeding or embolic events while "cut-away", and four (21%) patients had clots removed from the cannulas without clinical sequelae. One patient was recannulated 16 days following initial decannulation.

Conclusions: Our data suggests that "cutting-away" from ECLS in patients with congenital diaphragmatic hernia is safe and allows a period of observation without significant complications. This strategy may be particularly helpful in patients at risk for recannulation, but better prognostic criteria are needed.

Level Of Evidence: Level IV.

Type Of Study: Treatment Study.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.070DOI Listing
January 2020

A Model of Pediatric End-Stage Lung Failure in Small Lambs <20 kg.

ASAIO J 2020 05;66(5):572-579

From the Extracorporeal Life Support Laboratory, Department of Surgery.

One in five children with end-stage lung failure (ESLF) die while awaiting lung transplant. No suitable animal model of ESLF exists for the development of artificial lung devices for bridging to transplant. Small lambs weighing 15.7 ± 3.1 kg (n = 5) underwent ligation of the left anterior pulmonary artery (PA) branch, and gradual occlusion of the right main PA over 48 hours. All animals remained hemodynamically stable. Over seven days of disease model conditions, they developed pulmonary hypertension (mean PA pressure 20 ± 5 vs. 33 ± 4 mm Hg), decreased perfusion (SvO2 66 ± 3 vs. 55 ± 8%) with supplemental oxygen requirement, and severe tachypneic response (45 ± 9 vs. 82 ± 23 breaths/min) (all p < 0.05). Severe right heart dysfunction developed (tricuspid annular plane systolic excursion 13 ± 3 vs. 7 ± 2 mm, fractional area change 36 ± 6 vs. 22 ± 10 mm, ejection fraction 51 ± 9 vs. 27 ± 17%, all p < 0.05) with severe tricuspid regurgitation and balloon-shaped dilation of the right ventricle. This model of pediatric ESLF reliably produces pulmonary hypertension, right heart strain, and impaired gas exchange, and will be used to develop a pediatric artificial lung.
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http://dx.doi.org/10.1097/MAT.0000000000001017DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851459PMC
May 2020

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale.

Contemp Clin Trials 2019 08 26;83:10-17. Epub 2019 Jun 26.

Center for Surgical Outcomes Research, The Research Institute, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA; Department of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, USA.

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.
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http://dx.doi.org/10.1016/j.cct.2019.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073001PMC
August 2019

Low-Resistance, Concentric-Gated Pediatric Artificial Lung for End-Stage Lung Failure.

ASAIO J 2020 04;66(4):423-432

From the Extracorporeal Life Support Laboratory, Department of Surgery, University of Michigan, Ann Arbor, Michigan.

Children with end-stage lung failure awaiting lung transplant would benefit from improvements in artificial lung technology allowing for wearable pulmonary support as a bridge-to-transplant therapy. In this work, we designed, fabricated, and tested the Pediatric MLung-a dual-inlet hollow fiber artificial lung based on concentric gating, which has a rated flow of 1 L/min, and a pressure drop of 25 mm Hg at rated flow. This device and future iterations of the current design are designed to relieve pulmonary arterial hypertension, provide pulmonary support, reduce ventilator-associated injury, and allow for more effective therapy of patients with end-stage lung disease, including bridge-to-transplant treatment.
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http://dx.doi.org/10.1097/MAT.0000000000001018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7293821PMC
April 2020

Factors Associated With Management of Pediatric Ovarian Neoplasms.

Pediatrics 2019 07 4;144(1). Epub 2019 Jun 4.

Division of Pediatric Surgery, Department of Surgery and the Research Institute and

Background: Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.

Methods: A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.

Results: Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty ( = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status ( = .02), preoperative suspicion for malignancy ( < .0001), larger lesion size ( < .0001), and presence of solid components ( < .0001). Preoperative findings independently associated with malignancy included increasing size ( < .0001), solid components ( = .003), and age ( < .0001).

Conclusions: The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.
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http://dx.doi.org/10.1542/peds.2018-2537DOI Listing
July 2019

Current operative management of congenital lobar emphysema in children: A report from the Midwest Pediatric Surgery Consortium.

J Pediatr Surg 2019 Jun 1;54(6):1138-1142. Epub 2019 Mar 1.

Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA.

Purpose: The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium.

Methods: After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015).

Results: Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0).

Conclusions: Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.02.043DOI Listing
June 2019

Development of a multi-institutional registry for children with operative congenital lung malformations.

J Pediatr Surg 2020 Jul 28;55(7):1313-1318. Epub 2019 Feb 28.

Section of Pediatric Surgery, Department of Surgery, University of Michigan and Michigan Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Ann Arbor, MI, USA.

Introduction: The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection.

Methods: After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative.

Results: Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%).

Conclusion: This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.01.058DOI Listing
July 2020

Neural monitoring during H-type tracheoesophageal fistula division: A way to decrease recurrent laryngeal nerve injury?

J Pediatr Surg 2019 Aug 31;54(8):1711-1714. Epub 2018 Oct 31.

Division of Pediatric Surgery, Hiram C. Polk, Jr., M.D. Department of Surgery, University of Louisville, Louisville, KY.

Isolated tracheoesophageal fistula (TEF) is a rare condition with a previously reported high incidence of vocal cord paresis. A technique using recurrent laryngeal nerve monitoring is described as a strategy to potentially minimize the risk of vocal cord dysfunction in this patient population.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.10.059DOI Listing
August 2019

Comparing outcomes with thoracic epidural and intercostal nerve cryoablation after Nuss procedure.

J Surg Res 2018 11 21;231:217-223. Epub 2018 Jun 21.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan.

Background: This study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE).

Materials And Methods: We performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (n = 19) or TE (n = 13) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables.

Results: There were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; P = 0.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; P < 0.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; P = 0.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; P = 0.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; P = 0.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; P = 0.51).

Conclusions: INC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.
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http://dx.doi.org/10.1016/j.jss.2018.05.048DOI Listing
November 2018

Infants with esophageal atresia and right aortic arch: Characteristics and outcomes from the Midwest Pediatric Surgery Consortium.

J Pediatr Surg 2019 Apr 21;54(4):688-692. Epub 2018 Aug 21.

Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI.

Purpose: Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF.

Methods: A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up.

Results: In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p < 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p > 0.29).

Conclusion: RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.08.002DOI Listing
April 2019

Clinic-day surgery for children: a patient and staff perspective.

Pediatr Surg Int 2018 Jul 28;34(7):755-761. Epub 2018 May 28.

Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, C.S. Mott Children's Hospital, Ann Arbor, MI, 48109, USA.

Introduction: For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program.

Methods: After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program.

Results: Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons.

Conclusion: This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.
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http://dx.doi.org/10.1007/s00383-018-4288-3DOI Listing
July 2018

Is there a best approach for extracorporeal life support cannulation: a review of the extracorporeal life support organization.

J Pediatr Surg 2018 Jul 31;53(7):1301-1304. Epub 2018 Jan 31.

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

Background: Neurologic complications are common, and amongst the most devastating complications in pediatric patients undergoing extracorporeal life support (ECLS). Carotid artery cannulation (CAN) has been associated with an increase in these complications, thereby shaping practices to avoid this approach in most pediatric patients in which other cannulation approaches are viable.

Methods: A retrospective review of children (0-18years) in the ELSO database was undertaken from 1989 through 2013. Multivariate logistic regression analysis of rates of stroke and other neurologic complications based on cannulation technique was undertaken, adjusting for patient factors including age, underlying disease process, and severity of illness.

Results: A total of 30,282 ECLS runs were found in the database. CAN was associated with higher rates of stroke (5.15% vs 3.74%) and overall neurologic complications. However, when correcting for patient factors, including age, underlying disease process, and support type, CAN was not associated with an increased rate of neurologic complications or stroke (p>0.05 for both).

Conclusion: When correcting for patient related factors CAN is not associated with an increase in stroke or neurologic compilcations. CAN should be re-examined as a cannulation technique for older pediatric patients.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.01.015DOI Listing
July 2018

Outcomes of Adolescent and Young Adults Receiving High Ligation and Mesh Repairs: A 16-Year Experience.

J Laparoendosc Adv Surg Tech A 2018 Feb 20;28(2):223-228. Epub 2017 Dec 20.

1 Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan , Ann Arbor, Michigan.

Introduction: Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. Little is known about long-term recurrence and quality of life (QOL) in adolescents and young adults undergoing inguinal hernia repair. We evaluated long-term patient-centered outcomes in this population to determine the optimal operative approach.

Methods: The medical records of patients 12-25 years old at the time of a primary inguinal hernia repair at our institution from 2000 to 2016 were retrospectively reviewed. Patients then completed a phone survey of their postoperative courses and QOL. Outcomes of high ligation performed by pediatric surgeons were compared to those of mesh repairs by adult general surgeons. The primary outcome was recurrence. Secondary outcomes included time to recurrence, postoperative complications, and patient-centered outcomes. A Cox regression analysis was used to determine associations for recurrence.

Results: Of 213 patients identified, 143 (67.1%) were repaired by adult surgeons and 70 (32.9%) repaired by pediatric surgeons. Overall recurrence rate for the entire cohort was 5.7% with a median time to recurrence of 3.5 years (interquartile range 120-2155 days). High ligation and mesh repairs had similar rates of recurrence (6.3 versus 5.8, P = .57) and postoperative complications (17% versus 16%, P = .45). 101/213 (47%) patients completed the phone survey. Of those surveyed, 20% reported postoperative pain, 10% had residual numbness and tingling, and 10% of patients complained of intermittent bulging. Overall, a survey comparison showed no differences among subgroups.

Conclusions: In adolescents and young adults, the long-term recurrence rate after inguinal hernia repair is ∼6% with time to recurrence approaching 4 years. Outcomes of high ligation and mesh repair are similar, highlighting the need for individualized approaches for this unique population.
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http://dx.doi.org/10.1089/lap.2017.0511DOI Listing
February 2018

Comparison of early versus delayed strategies for repair of congenital diaphragmatic hernia on extracorporeal membrane oxygenation.

J Pediatr Surg 2018 Apr 22;53(4):629-634. Epub 2017 Nov 22.

Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, 1540 E. Hospital Dr., Ann Arbor, MI. Electronic address:

Purpose: For the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies.

Methods: From 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤5days after cannulation ("early protocol", n=30) and >5days after cannulation or after de-cannulation ("late protocol", n=35). We used Cox regression to assess differences in outcomes between groups.

Results: Survival for the early and late protocol groups was 43.3% and 68.8%, respectively (p=0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8±7.4 vs. 12.6±6.8days, p=0.0216). After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR=3.48, 95% CI=1.28-9.45, p=0.015) and days on ECMO (IRR=1.39, 95% CI=1.07-1.79, p=0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44).

Conclusions: Our data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care.

Type Of Study: Treatment Study.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.10.056DOI Listing
April 2018