Publications by authors named "Sanjeev Dutta"

66 Publications

Ten-year experience with laparoscopic pedicled omental flap for cerebral revascularization in patients with Moyamoya disease.

J Pediatr Surg 2022 Jan 31. Epub 2022 Jan 31.

Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 730 Welch Rd, Stanford, Palo Alto, CA 94304, United States. Electronic address:

Background: The omental flap has numerous extraperitoneal applications in reconstruction and revascularization given its favorable immunologic and angiogenic properties. In patients with Moyamoya disease, cerebral revascularization using a pedicled omental flap has proven to be a viable option following direct revascularization procedures. Historically, harvesting omentum involved laparotomy with the associated risk of complications; herein we describe outcomes from a 10-year experience of laparoscopic harvesting of pedicled omental flap for cerebral revascularization in Moyamoya patients.

Methods: A retrospective chart review was performed of all patients with Moyamoya disease who underwent laparoscopic omental cerebral transposition between 2011 and 2021. Intraoperative and postoperative complications, length of stay (LOS), and outcomes at follow-up were analyzed.

Results: Twenty-one patients underwent the procedure during the study period. Three intraoperative complications occurred (one segmental transverse colectomy for mesenteric injury, one converted to omental free flap, and one requiring micro anastomosis). Average overall LOS was 6 ± 6 days, with 3 ± 3.5 days in the ICU (mean±SD). Following discharge, complications included epigastric incisional hernia at the graft fascial exit site, recurrent neck pain at subcutaneous tunneling site, and partial scalp necrosis. One patient required subsequent direct bypass seven months after the initial procedure owing to the progression of the disease. All other patients had partial or complete resolution of symptoms.

Conclusion: Our retrospective observational study indicates that laparoscopic pedicled omental flap mobilization and transposition is a safe and effective method of indirect cerebral revascularization in patients with Moyamoya disease.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1016/j.jpedsurg.2022.01.023DOI Listing
January 2022

Correction to: Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report.

BMC Pediatr 2019 May 28;19(1):172. Epub 2019 May 28.

Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Always Building M116, MC: 5733, Stanford, CA, 94305, USA.

Following publication of the original article [1], the authors reported error on the images/figures used which also resulted in un-sequential order. The updated figures and captions are provided below.
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http://dx.doi.org/10.1186/s12887-019-1507-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6537416PMC
May 2019

Delayed appearance of mature ganglia in an infant with an atypical presentation of total colonic and small bowel aganglionosis: a case report.

BMC Pediatr 2019 04 5;19(1):93. Epub 2019 Apr 5.

Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway Building M116, MC: 5733, Stanford, CA, 94305, USA.

Background: Total colonic and small bowel aganglionosis (TCSA) occurs in less than 1% of all Hirschsprung's disease patients. Currently, the mainstay of treatment is surgery. However, in patients with TCSA, functional outcomes are often poor. A characteristic transition zone in TCSA can be difficult to identify which may complicate surgery and may often require multiple operations.

Case Presentation: We present the case of a male infant who was diagnosed with biopsy-proven total colonic aganglionosis with extensive small bowel involvement as a neonate. The patient was diverted at one month of age based on leveling biopsies at 10 cm from the Ligament of Treitz. At 7 months of age, during stoma revision for a prolapsed stoma, intra-operative peristalsis was observed in nearly the entire length of the previously aganglionic bowel, and subsequent biopsies demonstrated the appearance of mature ganglion cells in a previously aganglionic segment.

Conclusions: TCSA remains a major challenge for pediatric surgeons. Our case introduces new controversy to our understanding of aganglionosis. Our observations warrant further research into the possibility of post-natal ganglion maturation and encourage surgeons to consider a more conservative surgical approach.
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http://dx.doi.org/10.1186/s12887-019-1456-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449943PMC
April 2019

Endoscopic Excision of Benign Facial Masses in Children: A Review of Outcomes.

J Laparoendosc Adv Surg Tech A 2018 May 15;28(5):617-621. Epub 2018 Feb 15.

2 Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center , Stanford, California.

Purpose: Benign masses of the eyebrow and forehead are common in pediatric patients and can result in facial asymmetry, discomfort, or super-infection. Excision is classically conducted via an incision directly over the mass, which can produce sub-optimal cosmesis. Recently, an endoscopic approach using pediatric brow-lift equipment has been adopted. We reviewed our center's experience with endoscopic removal of benign facial lesions and compared these cases with an equivalent series of open cases.

Materials And Methods: A retrospective chart review was conducted to identify pediatric cases of endoscopic and open removal of benign eyebrow or forehead lesions at our institution from 2009 to 2016. Clinical and cosmetic outcomes were reviewed.

Results: A total of 40 endoscopic and 25 open cases of excision of benign facial lesions in children were identified. For the patients who underwent endoscopic excision, the majority (85%) presented with a cyst located at the eyebrow. Histologic examination revealed 36 dermoid cysts (90%), 2 epidermal cysts, and 2 pilomatrixomas. Of the 36 cases with post-operative follow-up, 32 patients (89%) had an uncomplicated recovery with good cosmesis. Two patients had an eyebrow droop that resolved without intervention. One patient had localized numbness overlying the site, but no motor deficits. One patient presented with a recurrent dermoid cyst that required open resection. For the patients who underwent open excision, the majority (52%) had dermoid cysts located at the eyebrow. Of the 22 cases with follow-up, 20 of the patients had an uncomplicated recovery (90%). Comparing the rate of complications, there was no statistically significant difference between the two groups (P = 1.0).

Conclusion: Endoscopic excision of benign forehead and eyebrow lesions in pediatric patients is feasible and yields excellent cosmetic results. When compared with open excision, complication rates are similar between both approaches and a facial scar can be avoided with an endoscopic approach.
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http://dx.doi.org/10.1089/lap.2017.0168DOI Listing
May 2018

Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial.

J Am Coll Surg 2017 Jun 6;224(6):1091-1096.e1. Epub 2017 Mar 6.

Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, CA. Electronic address:

Background: Sutureless gastroschisis repair involves covering the abdominal wall defect with the umbilical cord or a synthetic dressing to allow closure by secondary intention. No randomized studies have described the outcomes of this technique. Our objective was to prospectively compare short-term outcomes of sutureless vs sutured closure in a randomized fashion.

Study Design: We recruited patients who presented with gastroschisis between 2009 and 2014 and were randomized into either sutureless or sutured treatment groups. Patients with complicated gastroschisis (stricture, perforation, and ischemia) were excluded. Predefined ventilation, feeding, and dressing change protocols were instituted. Primary outcomes were time to extubation and time to full feeds. Secondary outcomes included time to discharge and rate of complications. Data were analyzed using Fisher's exact or t-tests using a p value ≤ 0.05. Factors associated with increased time to discharge were estimated using multivariate analyses.

Results: Thirty-nine patients were enrolled, 19 to sutureless and 20 to sutured repair. There was no statistical difference in time to extubation (sutureless 1.89 vs sutured 3.15 days; p = 0.061). The sutureless group had a significant increase in mean time to full feeds (45.1 vs 27.8 days; p = 0.031) and mean time to discharge (49.3 vs 31.4 days; p = 0.016). Complication rates were similar in both groups. Multivariate regression modeling showed that an increase in time to discharge was independently associated with sutureless repair, feeding complications, and sepsis.

Conclusions: Sutureless repair of uncomplicated gastroschisis can be performed safely, however, it is associated with a significant increase in time to full feeds and time to discharge.
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http://dx.doi.org/10.1016/j.jamcollsurg.2017.02.014DOI Listing
June 2017

The Use of Laparoscopy Simulation to Explore Gender Differences in Resident Surgical Confidence.

Obstet Gynecol Int 2017 19;2017:1945801. Epub 2017 Jan 19.

Department of Obstetrics and Gynecology, University Hospitals Case Medical Center, Cleveland, OH, USA.

The objective of this study was to determine whether female surgical residents underestimate their surgical abilities relative to males on a standardized test of laparoscopic skill. Twenty-six male and female general surgery residents and 25 female obstetrics and gynecology residents at two academic centers were asked to predict their score prior to undergoing the Fundamentals of Laparoscopic Surgery standardized skills exam. Actual and predicted score as well as delta values (predicted score minus actual score) were compared between residents. Multivariate linear regression was used to determine variables associated with predicted score, actual score, and delta scores. There was no difference in actual score based on residency or gender. Predicted scores, however, were significantly lower in female versus male general surgery residents (25.8 ± 13.3 versus 56.0 ± 16.0; < 0.01) and in female obstetrics and gynecology residents versus male general surgery residents (mean difference 20.9, 95% CI 11.6-34.8; < 0.01). Male residents more accurately predicted their scores while female residents significantly underestimated their scores. Gender differences in estimating surgical ability exist that do not reflect actual differences in performance. This finding needs to be considered when structuring mentorship in surgical training programs.
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http://dx.doi.org/10.1155/2017/1945801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5288545PMC
January 2017

Hematologic outcomes after total splenectomy and partial splenectomy for congenital hemolytic anemia.

J Pediatr Surg 2016 Jan 23;51(1):122-7. Epub 2015 Oct 23.

University of Michigan, Ann Arbor, MI, United States.

Purpose: The purpose of this study was to define the hematologic response to total splenectomy (TS) or partial splenectomy (PS) in children with hereditary spherocytosis (HS) or sickle cell disease (SCD).

Methods: The Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium registry collected hematologic outcomes of children with CHA undergoing TS or PS to 1 year after surgery. Using random effects mixed modeling, we evaluated the association of operative type with change in hemoglobin, reticulocyte counts, and bilirubin. We also compared laparoscopic to open splenectomy.

Results: The analysis included 130 children, with 62.3% (n=81) undergoing TS. For children with HS, all hematologic measures improved after TS, including a 4.1g/dl increase in hemoglobin. Hematologic parameters also improved after PS, although the response was less robust (hemoglobin increase 2.4 g/dl, p<0.001). For children with SCD, there was no change in hemoglobin. Laparoscopy was not associated with differences in hematologic outcomes compared to open. TS and laparoscopy were associated with shorter length of stay.

Conclusion: Children with HS have an excellent hematologic response after TS or PS, although the hematologic response is more robust following TS. Children with SCD have smaller changes in their hematologic parameters. These data offer guidance to families and clinicians considering TS or PS.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5083068PMC
http://dx.doi.org/10.1016/j.jpedsurg.2015.10.028DOI Listing
January 2016

Laparoscopic harvesting of omental pedicle flap for cerebral revascularization in children with moyamoya disease.

J Pediatr Surg 2016 Apr 19;51(4):592-7. Epub 2015 Oct 19.

Division of Pediatric Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, CA. Electronic address:

Introduction: An abundance of angiogenic and immunologic factors makes the omentum an ideal tissue for reconstruction and revascularization of a variety of extraperitoneal wounds and defects. Omental harvesting was historically performed through a large laparotomy and subcutaneous tunneling to the site of disease. Several complications of the open procedure including abdominal wound infection, fascial dehiscence, ventral hernia, and postoperative ileus have been described. The use of laparoscopy to harvest the omentum has the potential to reduce such complications. We describe the surgical technique and outcomes of a series of patients undergoing laparoscopic pedicled omental flap mobilization for cerebral revascularization in moyamoya disease.

Methods: A retrospective chart review of all patients undergoing laparoscopic omental cerebral transposition for moyamoya disease between 2011 and 2014 was performed. Clinical indication, surgical technique, operative times, complications, and outcomes at follow-up were reviewed.

Results: A total of 7 children underwent the procedure. The general surgery team performed laparoscopic omental mobilization, extraperitonealization, and subcutaneous tunneling, while the neurosurgical team performed craniotomy and cerebral application of the graft. The patients were followed postoperatively with clinic visits and angiography. There was one intraoperative complication (colon injury) and one postoperative complication (intermittent omental hernia at fascial defect for pedicle). All patients had partial to complete symptomatic resolution and demonstrated adequate intracranial revascularization on angiography.

Conclusion: Laparoscopic omental pedicle flap mobilization and subcutaneous transposition is feasible in children who require salvage cerebral revascularization for moyamoya disease. The procedure should be considered for other conditions requiring extraperitoneal revascularization.
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http://dx.doi.org/10.1016/j.jpedsurg.2015.10.048DOI Listing
April 2016

Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac.

J Pediatr Surg 2015 Oct 26;50(10):1767-71. Epub 2015 Jun 26.

Division of Pediatric Surgery, Lucile Packard Children's Hospital, Department of Surgery, Stanford University School of Medicine, Stanford, CA. Electronic address:

Background: Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair.

Methods: After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up.

Results: Median follow-up was 24 months (range 2-52 months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients.

Demographics: mean age 29.5 months (range 1-192 months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously).

Conclusion: Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates.
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http://dx.doi.org/10.1016/j.jpedsurg.2015.06.006DOI Listing
October 2015

AKI in hospitalized children: comparing the pRIFLE, AKIN, and KDIGO definitions.

Clin J Am Soc Nephrol 2015 Apr 3;10(4):554-61. Epub 2015 Feb 3.

Center for Acute Care Nephrology, Cincinnati Children's Hospital, Cincinnati, Ohio.

Background And Objectives: Although several standardized definitions for AKI have been developed, no consensus exists regarding which to use in children. This study applied the Pediatric RIFLE (pRIFLE), AKI Network (AKIN), and Kidney Disease Improving Global Outcomes (KDIGO) criteria to an anonymized cohort of hospitalizations extracted from the electronic medical record to compare AKI incidence and outcomes in intensive care unit (ICU) and non-ICU pediatric populations.

Design, Setting, Participants, & Measurements: Observational, electronic medical record-enabled study of 14,795 hospitalizations at the Lucile Packard Children's Hospital between 2006 and 2010. AKI and AKI severity stage were defined by the pRIFLE, AKIN, and KDIGO definitions according to creatinine change criteria; urine output criteria were not used. The incidences of AKI and each AKI stage were calculated for each classification system. All-cause, in-hospital mortality and total hospital length of stay (LOS) were compared at each subsequent AKI stage by Fisher exact and Kolmogorov-Smirnov tests, respectively.

Results: AKI incidences across the cohort according to pRIFLE, AKIN, and KDIGO were 51.1%, 37.3%, and 40.3%. Mortality was higher among patients with AKI across all definitions (pRIFLE, 2.3%; AKIN, 2.7%; KDIGO, 2.5%; P<0.001 versus no AKI [0.8%-1.0%]). Within the ICU, pRIFLE, AKIN, and KDIGO demonstrated progressively higher mortality at each AKI severity stage; AKI was not associated with mortality outside the ICU by any definition. Both in and outside the ICU, AKI was associated with significantly higher LOS at each AKI severity stage across all three definitions (P<0.001). Definitions resulted in differences in diagnosis and staging of AKI; staging agreement ranged from 76.7% to 92.5%.

Conclusions: Application of the three definitions led to differences in AKI incidence and staging. AKI was associated with greater mortality and LOS in the ICU and greater LOS outside the ICU. All three definitions demonstrated excellent interstage discrimination. While each definition offers advantages, these results underscore the need to adopt a single, universal AKI definition.
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http://dx.doi.org/10.2215/CJN.01900214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4386245PMC
April 2015

Quantitative measurement of fixation stability during RareBit perimetry and Humphrey visual field testing.

J Glaucoma 2015 Feb;24(2):100-4

*Department of Ophthalmology, Byers Eye Institute at Stanford University †Department of Pediatric Surgery, Stanford University School of Medicine, Palo Alto, CA.

Purpose: To compare fixation stability and fixation loss between the Humphrey Field Analyzer (HVF, static fixation target) and the RareBit computer-based perimeter (RBP, kinetic fixation target) during visual field testing.

Methods: Fourteen healthy volunteer subjects wore an ASL Mobile Gaze Tracker as they completed HVF 10-2 and RareBit central field tests in a random order. Fixation stability, defined as the average distance from the fixation target to the subject's gaze location, was calculated using data from the processed video capture. Fixation loss, defined as eye closure or a deviation of >20 degrees from the fixation target, was also measured. All subjects were surveyed regarding test preference.

Results: Use of the RBP kinetic target was associated with 18% improved fixation stability compared with the HVF static target (P=0.02). Nine of 14 study subjects demonstrated better fixation with RBP compared with HVF. Subjects demonstrated decreased fixation loss during RBP (0.9 s) compared with HVF (10.0 s) (P=0.002). Eighty-six percent of study subjects preferred RBP over HVF.

Conclusions: Use of the RBP kinetic fixation target is associated with consistent fixation stability and decreased fixation loss compared with the HVF static target. This improvement in fixation stability may result from decreased perception interference (Ganzfeld, Troxler, and binocular rivalry effects), and may help account for the greater comfort reported with RBP compared with HVF.
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http://dx.doi.org/10.1097/IJG.0b013e31829d9b41DOI Listing
February 2015

Clinical outcomes of splenectomy in children: report of the splenectomy in congenital hemolytic anemia registry.

Am J Hematol 2015 Mar 24;90(3):187-92. Epub 2014 Nov 24.

Duke University Medical Center, Durham, North Carolina.

The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005 to 2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 g/dl, 52 week 12.8 ± 1.6 g/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.
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http://dx.doi.org/10.1002/ajh.23888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4333061PMC
March 2015

Effect of very early skin to skin contact on success at breastfeeding and preventing early hypothermia in neonates.

Indian J Public Health 2014 Jan-Mar;58(1):22-6

Clinical Assistant, Department of Pediatrics, Fortis Escorts Hospital and Research Centre, Faridabad, Haryana, India.

Context: Birth and immediate postpartum period pose many challenges for the newborn. The neonatal mortality rates are high in India, whereas the breastfeeding rates are still low. Hence, need exists for a simple and easily applicable intervention, which may counter these challenges.

Aims: The present study was undertaken to evaluate the effects of very early skin-to-skin contact (SSC), in term babies with their mothers, on success of breastfeeding and neonatal well-being.

Settings And Design: Randomized control trial conducted over 2 years' period in a tertiary care hospital.

Materials And Methods: Healthy babies delivered normally were included. Very early SSC between mothers and their newborns was initiated in the study group. We studied effective suckling (using modified infant breastfeeding assessment tool [IBFAT]), breastfeeding status at 6 weeks, maternal satisfaction, thermal regulation, baby's weight and morbidity.

Statistical Analysis: T-test, Pearson Chi-square test and non-parametric Mann-Whitney test were used through relevant Windows SPSS software version 16.0.

Results: We observed that SSC contributed to better suckling competence as measured by IBFAT score (P < 0.0001). More babies in the SSC group were exclusively breastfed at first follow-up visit (P = 0.002) and at 6 weeks (P < 0.0001). SSC led to higher maternal satisfaction rates, better temperature gain in immediate post-partum period, lesser weight loss was at discharge and at first follow-up (all P < 0.0001) and lesser morbidity than the study group (P = 0.006).

Conclusion: Very early SSC is an effective intervention that improves baby's suckling competence, maternal satisfaction, breastfeeding rates and temperature control and weight patterns.
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http://dx.doi.org/10.4103/0019-557X.128160DOI Listing
May 2014

Less invasive pedicled omental-cranial transposition in pediatric patients with moyamoya disease and failed prior revascularization.

Neurosurgery 2014 Mar;10 Suppl 1:1-14

*Department of Neurosurgery and Stanford Stroke Center, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California; ‡Department of Pediatric Surgery, Stanford University School of Medicine and Lucile Packard Children's Hospital, Stanford, California.

Background: Patients with moyamoya disease and progressive neurological deterioration despite previous revascularization pose a major treatment challenge. Many have exhausted typical sources for bypass or have ischemia in areas that are difficult to reach with an indirect pedicled flap. Omental-cranial transposition has been an effective, but sparingly used technique because of its associated morbidity.

Objective: We have refined a laparoscopic method of harvesting an omental flap that preserves its gastroepiploic arterial supply.

Methods: The pedicled omentum can be lengthened as needed by dividing it between the vascular arcades. It is transposed to the brain via skip incisions. The flap can be trimmed or stretched to cover ischemic areas of the brain. The cranial exposure is performed in parallel with pediatric surgeons. We performed this technique in 3 pediatric patients with moyamoya disease (aged 5-12 years) with previous superficial temporal artery to middle cerebral artery bypasses and progressive ischemic symptoms. In 1 patient, we transposed omentum to both hemispheres.

Results: Blood loss ranged from 75 to 250 mL. After surgery, patients immediately tolerated a diet and were discharged in 3 to 5 days. The ischemic symptoms of all 3 children resolved within 3 months postoperatively. Magnetic resonance imaging at 1 year showed improved perfusion and no new infarcts. Angiography showed excellent revascularization of targeted areas and patency of the donor gastroepiploic artery.

Conclusion: Laparoscopic omental harvest for cranial-omental transposition can be performed efficiently and safely. Patients with moyamoya disease appear to tolerate this technique much better than laparotomy. With this method, we can achieve excellent angiographic revascularization and resolution of ischemic symptoms.
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http://dx.doi.org/10.1227/NEU.0000000000000119DOI Listing
March 2014

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

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

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

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

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

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

Conclusions: Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
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http://dx.doi.org/10.1016/j.jamcollsurg.2013.01.054DOI Listing
May 2013

Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol).

J Pediatr Surg 2012 Jul;47(7):1472-5

Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA 94305, USA.

Background/purpose: Chest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction.

Methods: A retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up).

Results: Five patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years).

Conclusion: Biologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.
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http://dx.doi.org/10.1016/j.jpedsurg.2012.05.002DOI Listing
July 2012

Intestinal malrotation and catastrophic volvulus in infancy.

J Emerg Med 2012 Jul 9;43(1):e49-51. Epub 2012 Feb 9.

Department of Pediatrics, Division of Neonatology, University of California, San Francisco, San Francisco, California, USA.

Background: Intestinal malrotation in the newborn is usually diagnosed after signs of intestinal obstruction, such as bilious emesis, and corrected with the Ladd procedure.

Objectives: The objective of this report is to describe the presentation of severe cases of midgut volvulus presenting in infancy, and to discuss the characteristics of these cases.

Case Report: We performed a 7-year review at our institution and present two cases of catastrophic midgut volvulus presenting in the post-neonatal period, ending in death soon after the onset of symptoms. These two patients also had significant laboratory abnormalities compared to patients with more typical presentations resulting in favorable outcomes.

Conclusions: Although most cases of intestinal malrotation in infancy can be treated successfully, in some circumstances, patients' symptoms may not be detected early enough for effective treatment, and therefore may result in catastrophic midgut volvulus and death.
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http://dx.doi.org/10.1016/j.jemermed.2011.06.135DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351570PMC
July 2012

Single-site umbilical laparoscopic splenectomy.

Semin Pediatr Surg 2011 Nov;20(4):212-8

Department of Surgery, Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford University School of Medicine, Palo Alto, California 94305, USA.

Laparoscopic splenectomy was first described in children in 1993. Since then, it has become a commonly performed procedure in children because of reduced discomfort and hospitalization and significantly improved cosmesis compared with the open approach. With the advent of single-site laparoscopic surgery, it is only natural that this approach be used for splenectomy. This article will describe the reasons that the single-site approach might be useful for splenectomy and also the technique used at the author's institution. Moreover, a brief review of the current literature in children will be presented.
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http://dx.doi.org/10.1053/j.sempedsurg.2011.05.005DOI Listing
November 2011

A modification of the laparoscopic transcutaneous inguinal hernia repair to achieve transfixation ligature of the hernia sac.

J Pediatr Surg 2011 Aug;46(8):1658-64

Department of Surgery, Stanford University, Palo Alto, CA 94305, USA.

Background/purpose: The proposed benefits of laparoscopic inguinal hernia repair in the pediatric population include less postoperative pain, smaller scars, and easier access to the contralateral groin. This is countered by slightly higher recurrence rates reported in some series. These differences are attributable to variation in the laparoscopic technique, surgeon experience, and certain anatomic features. We describe a modification of the laparoscopic-assisted transcutaneous hernia repair that achieves transfixation ligature of the hernia sac and that may further reduce recurrence.

Methods: Institutional review board approval was obtained, and a retrospective chart review of all patients undergoing repair of symptomatic hernias using this new technique was carried out. Data collection included demographics, laterality of hernia, operative time, recurrence rate, and complications.

Results: Twenty-one patients (age 1-144 months) underwent hernia repair between October 2009 and October 2010 using a novel technique of transcutaneous transfixation ligature of the neck of the hernia sac. The mean operative time was 18 minutes (8-35 minutes). Follow-up was from 1 to 12 months. There was no intraoperative or postoperative complication and no recurrences to date.

Conclusion: The technique described is a modification of the existing laparoscopic-assisted transcutaneous inguinal hernia repair that more closely approximates the criterion standard open repair. The technique addresses some prevailing concerns with the initially described method of transcutaneous repair, and short-term outcomes are positive. Long-term outcomes remain to be defined.
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http://dx.doi.org/10.1016/j.jpedsurg.2011.03.022DOI Listing
August 2011

Guidelines for innovation in pediatric surgery.

J Laparoendosc Adv Surg Tech A 2011 May 28;21(4):371-4. Epub 2011 Mar 28.

Department of Surgery, Stanford University School of Medicine, Palo Alto, California 94305, USA.

Surgical innovation involves the conceptualization, research, and translation of a novel idea into a viable procedure or device. The technological advancements made within the field of pediatric surgery over the last century have led to major improvements in patient care and outcomes. There has, however, been a parallel increase in the complexity of the regulatory bodies governing research and device implementation. This article briefly outlines the history of innovation in pediatric surgery, describes the existing regulatory bodies governing surgical research and device development (i.e., Department of Health and Human Services, Food and Drug Administration), and offers a set of guidelines for the pediatric surgeon planning to incorporate a new procedure or device into clinical practice.
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http://dx.doi.org/10.1089/lap.2010.0342DOI Listing
May 2011

Seasonal variation of hypertrophic pyloric stenosis: a population-based study.

Pediatr Surg Int 2011 Jul 4;27(7):689-93. Epub 2011 Feb 4.

Division of Pediatric Surgery, King Fahad Hospital, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.

Introduction: Seasonal variation in the incidence of hypertrophic pyloric stenosis (HPS) has been long debated. The goal of this study was to determine if seasonal variation exists in the incidence of pyloric stenosis.

Methods: A population-based cohort consisted of all infants in the province of Ontario, Canada with HPS from 1993 to 2000. The incidence of HPS per season was adjusted by birth rate and expressed as number of pyloromyotomies per 100,000 infants less than 12 months of age. One-way analysis of variance was used to compare HPS incidence between seasons. Further time series and spectral analysis were performed to examine for seasonal variation.

Results: There were 1,777 infants included in the population-based cohort. June was the month with the highest rate of HPS. The highest rate of pyloromyotomy occurred in the summer 14.92 and the lowest in the winter 10.73, this difference was statistically significant (p = 0.01). Spectral analysis showed that June was the month with the highest rate and February had the lowest rates p = 0.0014.

Conclusion: Hypertrophic pyloric stenosis more commonly presents in the summer. Seasonal variation suggests a possible etiological role for environmental factors.
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http://dx.doi.org/10.1007/s00383-011-2857-9DOI Listing
July 2011

Institutional experience with laparoscopic partial splenectomy for hereditary spherocytosis.

J Pediatr Surg 2010 Aug;45(8):1682-6

Division of Pediatric Surgery, Department of Surgery, Lucile Packard Children's Hospital, Stanford University, Stanford, CA 94305-5733, USA.

Background/purpose: Moderate to severe hereditary spherocytosis (HS) is treated with splenectomy. However, total splenectomy leads to decreased immunologic function with the risk of overwhelming postsplenectomy sepsis. Splenic preservation is postulated as a method to avoid this potentially fatal complication. Although mainly performed through laparotomy, we report our experience with a laparoscopic approach to partial splenectomy for HS.

Methods: A retrospective review was conducted on 9 laparoscopic partial splenectomies performed for HS at our institution. Follow-up was from 1 to 3.5 years. Data included preoperative and postoperative hemoglobin, absolute reticulocyte count, splenic size, operative time, complications, and length of stay.

Results: All patients successfully underwent laparoscopic partial splenectomy with a radiologically determined upper-pole remnant of 10% to 30% and preservation of the blood supply through the upper short gastric arteries. The mean preoperative spleen length was 13 cm. Mean hospital stay was 3.6 days (range, 1-6 days). There was 1 intraoperative complication (a small bowel tear during spleen extraction) and 2 minor postoperative complications (ileus and wound infection). One patient underwent completion total splenectomy 2 years after partial splenectomy.

Conclusion: Laparoscopic partial splenectomy is a feasible and effective procedure that addresses the hematologic consequences of HS while retaining a portion of functional spleen, in addition to conferring the advantages of laparoscopy.
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http://dx.doi.org/10.1016/j.jpedsurg.2010.01.037DOI Listing
August 2010

Early, intermediate, and late effects of a surgical skills "boot camp" on an objective structured assessment of technical skills: a randomized controlled study.

J Am Coll Surg 2010 Jun;210(6):984-9

Department of Surgery, Stanford University Medical Center, 780 Welch Road, Stanford, CA 94024, USA.

Background: Surgical interns enter residency with variable technical abilities and many feel unprepared to perform necessary procedures. We hypothesized that interns exposed to a preinternship intensive surgical skills curriculum would demonstrate improved competency over unexposed colleagues on a test of surgical skills and that this effect would persist throughout internship.

Study Design: We designed a 3-day intensive skills "boot camp" with simulation-based training on 10 topics. Interns were randomized to an intervention group (boot camp) or a control group (no boot camp). All interns completed a survey including demographic information, previous experience, and comfort with basic surgical skills. Both groups completed a clinical skills assessment focused on 4 topics: chest tube insertion, central line placement, wound closure, and the Fundamentals of Laparoscopic Surgery peg transfer task. We assessed both groups immediately (month 0), early postcurriculum (month 1), and late postcurriculum (month 6).

Results: Fifteen participants were in the intervention group and 13 were in the control group. Before boot camp, mean comfort levels were similar for the groups. All participants had minimal prior experience. Competency for chest tube insertion and central line placement were considerably higher for the boot camp group at months 0 and 1, although much of this difference disappeared by month 6. There was no substantial difference between the 2 groups in the Fundamentals of Laparoscopic Surgery peg transfer and wound closure skills.

Conclusions: A surgical skills boot camp accelerates the learning curve for interns in basic surgical skills as measured by a technical skills examination for some skills, although these improvements diminished over time. This can augment traditional training and translate into fewer patient errors.
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http://dx.doi.org/10.1016/j.jamcollsurg.2010.03.006DOI Listing
June 2010

Stealth surgery: subcutaneous endoscopic excision of benign lesions of the trunk and lower extremity.

J Pediatr Surg 2010 Apr;45(4):840-4

Division of Pediatric Surgery, Department of Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA 94305, USA.

Background: Benign subcutaneous lesions of the trunk are typically excised through overlying skin incisions, which can result in permanent, potentially disfiguring scars. We previously reported our experience with transaxillary subcutaneous endoscopic approach for removal of benign lesions of the neck. Here we report a similar approach for removing benign lesions of the trunk and lower extremity.

Methods: A retrospective review was conducted on 4 consecutive subcutaneous endoscopic procedures for benign truncal and lower extremity lesions from November 2006 to October 2008. The lesions included an anterior chest wall epidermal inclusion cyst, anterior midsternal dermoid cyst, left posterior chest wall giant lipoma, and a lipoma extending from the right gluteal crease onto the thigh. Outcome measures included need for conversion, cosmetic outcome, and complications.

Results: All procedures were successfully completed using the endoscopic approach without conversion to open excision. There were no intraoperative complications. Postoperative complications included a 1 cm seroma at cyst site, axillary port site wound infection, and punctate dermal thinning secondary to adherent dermoid cyst, all resolved by 2 weeks postoperatively. All wounds healed with excellent cosmetic result at 1-month follow-up.

Conclusions: A subcutaneous endoscopic approach can be applied effectively to a variety of benign lesions of the trunk and lower extremities with adequate exposure for dissection and resulting in a quick recovery. Truncal and lower extremity scarring is absent, with small scars well hidden in either the axilla or the buttock, respectively.
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http://dx.doi.org/10.1016/j.jpedsurg.2009.12.016DOI Listing
April 2010

A comparison of laparoscopic and robotic assisted suturing performance by experts and novices.

Surgery 2010 Jun 31;147(6):830-9. Epub 2009 Dec 31.

Division of Pediatric Surgery, Department of Surgery, Lucile Packard Children's Hospital, Stanford, CA, USA.

Background: Surgical robotics has been promoted as an enabling technology. This study tests the hypothesis that use of the robotic surgical system can significantly improve technical ability by comparing the performance of both experts and novices on a complex laparoscopic task and a robotically assisted task.

Methods: Laparoscopic experts (LE) with substantial laparoscopic and robotic experience (n = 9) and laparoscopic novices (LN) (n = 20) without any robotic experience performed sequentially 10 trials of a suturing task using either robotic or standard laparoscopic instrumentation fitted to the ProMIS surgical simulator. Objective performance metrics provided by ProMIS (total task time, instrument pathlength, and smoothness) and an assessment of learning curves were analyzed.

Results: Compared with LNs, the LEs demonstrated significantly better performance on all assessment measures. Within the LE group, there was no difference in smoothness (328 +/- 159 vs 355 +/- 174; P = .09) between robot-assisted and standard laparoscopic tasks. An improvement was noted in total task time (113 +/- 41 vs 132 +/- 55 sec; P < .05) and instrument pathlengths (371 +/- 163 vs 645 +/- 269 cm; P < .05) when using the robot. This advantage in terms of total task time, however, was lost among the LEs by the last 3 trials (114 +/- 40 vs 118 +/- 49 s; P = .84), while instrument pathlength remained better consistently throughout all the trials. For the LNs, performance was significantly better in the robotic trials on all 3 measures throughout all the trials.

Conclusion: The ProMIS surgical simulator was able to distinguish between skill levels (expert versus novice) on robotic suturing tasks, suggesting that the ProMIS is a valid tool for measuring skill in robot-assisted surgery. For all the ProMIS metrics, novices demonstrated consistently better performance on a suturing task using robotics as compared to a standard laparoscopic setup. This effect was less evident for experts who demonstrated improvements only in their economy of movement (pathlength), but not in the speed or smoothness of performance. Robotics eliminated the early learning curve for novices, which was present when they used standard laparoscopic tools. Overall, this study suggests that, when performing complex tasks such as knot tying, surgical robotics is most useful for inexperienced laparoscopists who experience an early and persistent enabling effect. For experts, robotics is most useful for improving economy of motion, which may have implications for the highly complex procedures in limited workspaces (eg, prostatectomy).
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http://dx.doi.org/10.1016/j.surg.2009.11.002DOI Listing
June 2010

Outcomes of sutureless gastroschisis closure.

J Pediatr Surg 2009 Oct;44(10):1947-51

Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA 94305-5733, USA.

Introduction: A new technique of gastroschisis closure in which the defect is covered with sterile dressings and allowed to granulate without suture repair was first described in 2004. Little is known about the outcomes of this technique. This study evaluated short-term outcomes from the largest series of sutureless gastroschisis closures.

Methods And Patients: A retrospective case control study of 26 patients undergoing sutureless closure between 2006 and 2008 was compared to a historical control group of 20 patients with suture closure of the abdominal fascia between 2004 and 2006. Four major outcomes were assessed: (1) time spent on ventilator, (2) time to initiating enteral feeds, (3) time to discharge from the neonatal intensive care unit, and (4) rate of complications.

Results: In multivariate analysis, sutureless closure of gastroschisis defects independently reduced the time to extubation as compared to traditional closure (5.0 vs 12.1 days, P = .025). There was no difference in time to full enteral feeds (16.8 vs 21.4 days, P = .15) or time to discharge (34.8 vs 49.7 days, P = .22) with sutureless closure. The need for silo reduction independently increased the time to extubation (odds ratio, 4.2; P = .002) and time to enteral feeds (odds ratio, 5.2; P < .001). Small umbilical hernias were seen in all patients.

Conclusion: Sutureless closure of uncomplicated gastroschisis is a safe technique that reduces length of intubation and does not significantly alter the time required to reach full enteral feeds or hospital discharge.
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http://dx.doi.org/10.1016/j.jpedsurg.2009.03.027DOI Listing
October 2009

Early experience with single incision laparoscopic surgery: eliminating the scar from abdominal operations.

Authors:
Sanjeev Dutta

J Pediatr Surg 2009 Sep;44(9):1741-5

Division of Pediatric Surgery, Department of Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA 94305, USA.

Purpose: Single incision laproscopic surgery (SILS) involves performing abdominal operations with laparoscopic instruments placed through a single, small umbilical incision. The primary goal is to avoid visible scarring. This is the first report of SILS cholecystectomy in children and the first report in the literature of SILS splenectomy.

Methods: A retrospective chart review was performed in 20 consecutive inpatient SILS procedures (13 males, 7 females; ages 2-17 years) from May to December 2008. Outcome measures included need for conversion, operative time, time to oral analgesia, length of hospitalization, cosmetic outcome, and complications.

Results: There were 4 total splenectomies, 3 cholecystectomies, 2 combined splenectomy/cholecystectomies, and 11 appendectomies performed. All procedures were completed successfully without need for conversion to standard laparoscopy or open surgery. Mean operative time was 90 minutes for splenectomy, 68 minutes for cholecystectomy, 165 minutes for combined splenectomy/cholecystectomy, and 33 minutes for appendectomy. Mean hospital stay was 1 day for appendectomy, 1 day for cholecystectomy, and 2.5 days for splenectomy. One splenectomy patient received 1 U packed red blood cell transfusion. All appendectomy patients were converted to oral analgesia within 24 hours and splenectomy patients within 48 hours. All families were very pleased with the cosmetic outcome.

Conclusion: Single incision laparoscopic surgery is feasible for a variety of pediatric general surgical conditions, allowing for scarless abdominal operations. This early experience suggests that outcomes are comparable to standard laparoscopic surgery but with improved cosmesis, however, a larger series is necessary to confirm these findings and to determine if there are any benefits in pain or recovery. Surgeons performing SILS should have a firm foundation of advanced minimal access surgical skills and a cautious, gradated approach to attempting the various procedures. Technological refinements will further enable SILS.
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http://dx.doi.org/10.1016/j.jpedsurg.2008.12.024DOI Listing
September 2009

Short- and long-term outcomes of necrotizing enterocolitis in infants with congenital heart disease.

Pediatrics 2009 May;123(5):e901-6

Divisions of Pediatric Surgery, Lucile Packard Children's Hospital and Stanford School of Medicine, Stanford University, Stanford, California 94304, USA.

Objective: Congenital heart disease is a significant risk factor for necrotizing enterocolitis in the term infant. We compared the short- and long-term necrotizing enterocolitis-specific outcomes of infants with congenital heart disease with those of neonates without congenital heart disease.

Patients And Methods: A retrospective study of 202 patients with necrotizing enterocolitis treated at our center from May 1999 to August 2007 was conducted. Infants with necrotizing enterocolitis were grouped according to the presence (n = 76) or absence (n = 126) of congenital heart disease. Demographic and necrotizing enterocolitis-specific outcomes were recorded. The groups were compared by nonparametric and chi(2) analyses. Univariate and multivariate odds ratios were determined for each outcome.

Results: The average birth weight and gestational age of the 2 groups were not significantly different. The initial necrotizing enterocolitis severity, as determined by Bell stage, was less for necrotizing enterocolitis subjects with congenital heart disease compared with those without congenital heart disease. When controlling for birth weight and gestational age, the congenital heart disease group had decreased risk of perforation, need for a bowel operation, strictures, need for a stoma, sepsis, and short bowel syndrome compared with the non-congenital heart disease group. Although not statistically significant, subjects with congenital heart disease had a trend toward decreased risk of death from necrotizing enterocolitis, recurrent necrotizing enterocolitis, and need for peritoneal drainage.

Conclusions: Infants with congenital heart disease and necrotizing enterocolitis have decreased risk of major short- and long-term negative outcomes associated with necrotizing enterocolitis compared with neonates without congenital heart disease. Differences in initial severity, range of age at diagnosis, and prognoses between subjects with necrotizing enterocolitis with and without cardiac disease suggest that necrotizing enterocolitis in the cardiac patient is a distinct disease process and should be labeled cardiogenic necrotizing enterocolitis.
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http://dx.doi.org/10.1542/peds.2008-3216DOI Listing
May 2009

Neonatal malrotation with midgut volvulus mimicking duodenal atresia.

AJR Am J Roentgenol 2009 May;192(5):1269-71

Department of Pediatric Radiology, University of Arizona Health Sciences Center, 1501 N Campbell Avenue, Tucson, AZ 85724-5067, USA.

Objective: The purpose of this study was to describe the clinical, imaging, and surgical findings in the cases of four neonates with radiographic findings suggesting duodenal atresia (double-bubble sign) who were subsequently found to have malrotation with midgut volvulus.

Conclusion: When the surgical treatment of a patient with the double-bubble sign is to be delayed, an upper gastrointestinal radiographic or ultrasound study is needed to evaluate for malrotation with midgut volvulus.
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http://dx.doi.org/10.2214/AJR.08.2132DOI Listing
May 2009

"Stealth surgery": transaxillary subcutaneous endoscopic excision of benign neck lesions.

J Pediatr Surg 2008 Nov;43(11):2070-4

Department of Surgery, Division of Pediatric Surgery, Lucile Packard Children's Hospital, Stanford University, CA 94305-5733, USA.

Background: Benign neck lesions are traditionally removed through an overlying incision. The resultant scar can be aesthetically displeasing. We previously reported our experience with a transaxillary subcutaneous endoscopic approach for management of torticollis. We now report a similar technique for removal of benign lesions of the neck.

Methods: The study uses a retrospective review of 5 elective transaxillary endoscopic procedures from March to December 2006. The lesions included an enlarged cervical lymph node, thyroglossal duct cyst, dermoid cyst, ectopic dilated neck vein, and a parathyroid adenoma. Outcome measures included need for conversion, cosmetic outcome, and complications.

Results: All procedures were successfully completed using the endoscopic approach. Postoperative pain was controlled with acetaminophen, and all patients were discharged from the hospital the same day. There were no intraoperative complications. The patient who had a thyroglossal cyst removed developed a postoperative seroma that resolved spontaneously. All families were pleased with the cosmetic results.

Conclusions: A transaxillary subcutaneous endoscopic approach can be applied effectively to a variety of benign lesions of the neck, allowing adequate exposure for dissection, and resulting in a quick recovery. Neck scarring is absent, with small scars well hidden in the axilla.
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http://dx.doi.org/10.1016/j.jpedsurg.2008.03.031DOI Listing
November 2008
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