Publications by authors named "Sara A Mansfield"

26 Publications

  • Page 1 of 1

Does epidural analgesia really enhance recovery in pediatric surgery patients?

Pediatr Surg Int 2021 Apr 8. Epub 2021 Apr 8.

Division of Anesthesiology, Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, TN, USA.

Purpose: We sought to determine the benefits of epidural anesthesia (EA) in pediatric surgical patients.

Methods: This study is a single-institution retrospective review of EA for pediatric patients undergoing thoracotomy or laparotomy from 2015 to 2020. Patients with recent or chronic opioid use were excluded. Urgent or emergent cases, patients with hemodynamic instability, or those with surgical complications that significantly impacted their post-operative course were also excluded. The primary objectives were comparison of pain scores and systemic opioid use between those patients with EA and those without EA.

Results: Epidural anesthesia was used in 151 (81.6%) laparotomies and 58 (77.3%) thoracotomies. EA use was associated with lower mean systemic opioid administration during the early post-operative period for laparotomy (POD#0-0.33 ± 0.3 oral morphine equivalents per kilogram (OME/Kg) with EA vs 0.93 ± 1.53, p < 0.001, POD#1-1.34 ± 1.79 OME/Kg with EA vs 2.61 ± 2.60, p < 0.001) and thoracotomy (POD#0-0.40 ± 0.37 OME/Kg with EA vs 0.68 ± 0.41, p = 0.008, POD#1-0.89 ± 0.86 OME/Kg with EA vs 2.02 ± 1.92, p < 0.001). There were no differences seen by POD#2. Average pain scores were significantly lower in patients with EA following laparotomy (POD#0-1.22 ± 0.99 with EA vs 1.75 ± 1.33, p = 0.008) and thoracotomy (POD#0-1.71 ± 1.13 with EA vs 2.40 ± 1.52, p = 0.04).

Conclusions: The use of EA in pediatric surgery patients was associated with lower pain scores despite lower systemic opioid requirements in the early post-operative period.
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http://dx.doi.org/10.1007/s00383-021-04897-zDOI Listing
April 2021

Implications of Tumor Characteristics and Treatment Modality on Local Recurrence and Functional Outcomes in Children with Chest Wall Sarcoma: A Pediatric Surgical Oncology Research Collaborative Study.

Ann Surg 2020 Nov 4. Epub 2020 Nov 4.

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

Objective: To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development and (3) patient-reported quality of life in children with sarcoma of the chest wall.

Summary Background Data: Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence.

Methods: A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008-2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys.

Results: The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (IQR = 1-3), and number of ribs resected did not correlate with margin status (p = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor (HR 2.24, p = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posterior rib resection (HR 8.43; p = 0.003) and increased number of ribs resected (HR 1.78; p = 0.02). Overall, patient-reported quality of life is not impaired following chest wall tumor resection.

Conclusions: Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent.
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http://dx.doi.org/10.1097/SLA.0000000000004579DOI Listing
November 2020

Vascular tumors.

Semin Pediatr Surg 2020 Oct 16;29(5):150975. Epub 2020 Sep 16.

Cancer and Hematology Center, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin Street, Houston, TX 77030, United States. Electronic address:

Vascular tumors are a rare subset of vascular anomalies. These are classified based on their malignant potential or local destruction potential. Classification has been historically difficult and treatment recommendations are based on case series. The purpose of this chapter is to review the presentation, pathologic and imaging characteristics. Treatment recommendations are summarized based on the current literature. Congenital and infantile hemangiomas are covered separately in a separate chapter in this issue.
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http://dx.doi.org/10.1016/j.sempedsurg.2020.150975DOI Listing
October 2020

Thoracoscopy vs thoracotomy for the management of metastatic osteosarcoma: A Pediatric Surgical Oncology Research Collaborative Study.

Int J Cancer 2021 Mar 31;148(5):1164-1171. Epub 2020 Aug 31.

Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA.

Complete surgical resection of pulmonary metastatic disease in patients with osteosarcoma is crucial to long-term survival. Open thoracotomy allows palpation of nodules not identified on imaging but the impact on survival is unknown. The objective of this study was to compare overall survival (OS) and pulmonary disease-free survival (DFS) in children who underwent thoracotomy vs thoracoscopic surgery for pulmonary metastasectomy. A multi-institutional collaborative group retrospectively reviewed 202 pediatric patients with osteosarcoma who underwent pulmonary metastasectomy by thoracotomy (n = 154) or thoracoscopy (n = 48). Results were analyzed by Kaplan-Meier survival estimates and multivariate Cox proportional hazard regression models. With median follow-up of 45 months, 135 (67.5%) patients had a pulmonary relapse and 95 (47%) patients were deceased. Kaplan-Meier analysis showed no significant difference in 5-year pulmonary DFS (25% vs 38%; P = .18) or OS (49% vs 42%, P = .37) between the surgical approaches of thoracotomy and thoracoscopy. In Cox regression analysis controlling for other factors impacting outcome, there was a significantly increased risk of mortality (HR 2.11; P = .027; 95% CI 1.09-4.09) but not pulmonary recurrence (HR 0.96; P = .90; 95% CI 0.52-1.79) with a thoracoscopic approach. However, in the subset analysis limited to patients with oligometastatic disease, thoracoscopy had no increased risk of mortality (HR 1.16; P = .62; 0.64-2.11). In conclusion, patients with metastatic osteosarcoma and limited pulmonary disease burden demonstrate comparable outcomes after thoracotomy and thoracoscopy for metastasectomy. While significant selection bias in these surgical cohorts limits the generalizability of the conclusions, clinical equipoise for a randomized clinical trial in patients with oligometastatic disease is supported.
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http://dx.doi.org/10.1002/ijc.33264DOI Listing
March 2021

Alternative approaches to retroperitoneal lymph node dissection for paratesticular rhabdomyosarcoma.

J Pediatr Surg 2020 Dec 1;55(12):2677-2681. Epub 2020 Apr 1.

Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN; Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN. Electronic address:

Purpose: The aim of this study was to evaluate outcomes based on surgical approach for retroperitoneal lymph node dissection (RPLND) in patients with paratesticular rhabdomyosarcoma (PT-RMS).

Methods: Patients undergoing RPLND for PT-RMS over 10 years at a single institution were retrospectively reviewed. Length of stay (LOS), complications, oral morphine equivalents per kilogram (OME/Kg), lymph node yield, and time to chemotherapy were assessed. The surgical approaches compared were: open transabdominal, open extraperitoneal, laparoscopic, and retroperitoneoscopic. For cases with lymphatic mapping, indocyanine green (ICG) was injected into the spermatic cord.

Results: Twenty patients were included: five open transabdominal, six open extraperitoneal, three laparoscopic, and six retroperitoneoscopic operations. LOS was shorter in the retroperitoneoscopic group than laparoscopic (p = 0.029) and both open groups (p < 0.001). Mean OME/kg used was lowest in the retroperitoneoscopic (0.13 ± 0.15) group compared to laparoscopic (0.68 ± 0.53, p = 0.043), open transabdominal (14.90 ± 8.87, p = 0.003), and extraperitoneal (10.11 ± 2.44, p < 0.001). Time to chemotherapy was shorter for retroperitoneoscopic patients (0.13 days ± 0.15) compared to open transabdominal (15.6 days±6.5, p = 0.005). There was no difference in lymph node yield between groups. Spermatic cord ICG demonstrated iliac lymph node avidity on near-infrared spectroscopy.

Conclusions: Minimally invasive RPLND appears to offer a faster recovery without compromising lymph node yield for patients with PT-RMS.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.03.022DOI Listing
December 2020

Optimization of percutaneous biopsy for diagnosis and pretreatment risk assessment of neuroblastoma.

Pediatr Blood Cancer 2020 05 19;67(5):e28153. Epub 2020 Feb 19.

Division of Pediatric Surgery, Department of Surgery, C. S. Mott Children's Hospital, The University of Michigan, Ann Arbor, Michigan.

Background: Image-guided percutaneous core needle biopsy (PCNB) is increasingly utilized to diagnose solid tumors. The objective of this study is to determine whether PCNB is adequate for modern biologic characterization of neuroblastoma.

Procedure: A multi-institutional retrospective study was performed by the Pediatric Surgical Oncology Research Collaborative on children with neuroblastoma at 12 institutions over a 3-year period. Data collected included demographics, clinical details, biopsy technique, complications, and adequacy of biopsies for cytogenetic markers utilized by the Children's Oncology Group for risk stratification.

Results: A total of 243 children were identified with a diagnosis of neuroblastoma: 79 (32.5%) tumor excision at diagnosis, 94 (38.7%) open incisional biopsy (IB), and 70 (28.8%) PCNB. Compared to IB, there was no significant difference in ability to accurately obtain a primary diagnosis by PCNB (95.7% vs 98.9%, P = .314) or determine MYCN copy number (92.4% vs 97.8%, P = .111). The yield for loss of heterozygosity and tumor ploidy was lower with PCNB versus IB (56.1% vs 90.9%, P < .05; and 58.0% vs. 88.5%, P < .05). Complications did not differ between groups (2.9 % vs 3.3%, P = 1.000), though the PCNB group had fewer blood transfusions and lower opioid usage. Efficacy of PCNB was improved for loss of heterozygosity when a pediatric pathologist evaluated the fresh specimen for adequacy.

Conclusions: PCNB is a less invasive alternative to open biopsy for primary diagnosis and MYCN oncogene status in patients with neuroblastoma. Our data suggest that PCNB could be optimized for complete genetic analysis by standardized protocols and real-time pathology assessment of specimen quality.
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http://dx.doi.org/10.1002/pbc.28153DOI Listing
May 2020

Ventral Abdominal Wall Defects.

Pediatr Rev 2019 Dec;40(12):627-635

Division of Pediatric Surgery, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, TN.

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http://dx.doi.org/10.1542/pir.2018-0253DOI Listing
December 2019

A Quality Improvement Intervention to Decrease Postoperative Opioid Prescriptions in Pediatric Oncology Patients.

J Pediatr Hematol Oncol 2020 05;42(4):e207-e212

Departments of Surgery.

Purpose: This quality improvement initiative aimed to minimize opioid prescribing after oncologic pediatric surgery.

Methods: Retrospective surgical data collected at a pediatric cancer hospital from July 2016 to June 2018 included hospitalization details, oral morphine equivalents prescribed, unplanned visits/calls because of pain, and parental/patient satisfaction with pain control. The quality improvement initiative promoted opioid prescription at discharge on the basis of prior inpatient requirements and education regarding nonopioid analgesia. Upon commencing this project in July 2018, we collected data prospectively.

Results: The retrospective and the prospective cohorts included 271 and 99 patients, respectively. Mean (SD) oral morphine equivalents (mg/kg) prescribed upon discharge was significantly reduced in the prospective (0.75±1.34) versus retrospective cohorts (5.48±6.94, P<0.001). The unplanned visits/calls regarding pain were 23 (retrospective, 8.5%) and 2 (prospective, 2.0%). In total, 44 patients (44.4%) received an opioid prescription at discharge in the prospective cohort, significantly fewer than retrospective cohort (251, 92.6%, P<0.001), and used a mean of 34.3 of 159.8 (21.5%) doses dispensed. Length of stay was comparable (P=0.88) between cohorts. Prospective satisfaction rate was 96.2%, leaving 3 patients (3.8%) not satisfied with their pain control regimen.

Conclusions: Dramatic reduction of opioid prescriptions after oncologic surgery can be achieved without detriment to patient satisfaction or readmissions.

Level Of Evidence: Level V.
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http://dx.doi.org/10.1097/MPH.0000000000001641DOI Listing
May 2020

Improving Quality of Chest Computed Tomography for Evaluation of Pediatric Malignancies.

Pediatr Qual Saf 2019 May-Jun;4(3):e166. Epub 2019 Jun 13.

Division of Pediatric Surgery, Department of Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio.

Introduction: Atelectasis is a problem in sedated pediatric patients undergoing cross-sectional imaging, impairing the ability to accurately interpret chest computed tomography (CT) imaging for the presence of malignancy, often leading to additional maneuvers and/or repeat imaging with additional radiation exposure.

Methods: A quality improvement team established a best-practice protocol to improve the quality of thoracic CT imaging in young patients with suspected primary or metastatic pulmonary malignancy. The specific aim was to increase the percentage of chest CT scans obtained for the evaluation of pulmonary nodules with acceptable atelectasis scores (0-1) in patients aged 0-5 years with malignancy, from a baseline of 45% to a goal of 75%.

Results: A retrospective cohort consisted of 94 patients undergoing chest CT between February 2014 and January 2015 before protocol implementation. The prospective cohort included 195 patients imaged between February 2015 and April 2018. The baseline percentage of CT scans that were scored 0 or 1 on the atelectasis scale was 44.7%, which improved to 75% with protocol implementation. The mean atelectasis score improved from 1.79 (±0.14) to 0.7 (±0.09). Sedation incidence decreased substantially from 73.2% to 26.5% during the study period.

Conclusions: Using quality improvement methodology including standardization of care, the percentage of children with atelectasis scores of 0-1 undergoing cross-sectional thoracic imaging improved from 45% to 75%. Also, eliminating the need for sedation in these patients has further improved image quality, potentially allowing for optimal detection of smaller nodules, and minimizing morbidity.
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http://dx.doi.org/10.1097/pq9.0000000000000166DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6594776PMC
June 2019

Renal Tumors in Children and Young Adults Older Than 5 Years of Age.

J Pediatr Hematol Oncol 2020 05;42(4):287-291

Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine and Nationwide Children's Hospital, Columbus, OH.

Renal masses are most common in children between ages 1 to 3 years, with less known about renal tumors in older children and young adults. The aim of this study was to review the presentation, demographics, histology, and outcomes in patients over 5 years of age with renal tumors compared with younger children. 111 renal tumors were diagnosed in patients 5 years of age and older (median, 7 y; range, 5 to 31 y) between 1950 and 2017 at a single institution. Wilms tumor (WT) was the most common histology in 84 patients (75%), followed by renal cell carcinoma in 12 patients (10.7%). Abdominal pain was the most common presenting symptom (46%) followed by hematuria (28.8%), and a palpable abdominal mass (24.3%). For WT, older children more commonly presented with advanced-stage disease (stages 3 and 4) than younger children (57.7% vs. 11.5%; P<0.001). Event-free survival (EFS) and overall survival (OS) for favorable histology WT were not different between younger and older children (OS, P=0.43; EFS, P=0.46). In this cohort, older children more frequently present with variable signs and symptoms, less common histopathologies although WT was still most frequent, and more advanced-stage disease compared with younger cohorts, but without differences in EFS or OS.
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http://dx.doi.org/10.1097/MPH.0000000000001593DOI Listing
May 2020

Cytomegalovirus immunoglobulin G titers do not predict reactivation risk in immunocompetent hosts.

J Med Virol 2019 05 11;91(5):836-844. Epub 2019 Jan 11.

Department of Surgery, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts.

Cytomegalovirus (CMV) reactivation occurs in roughly one-third of immunocompetent patients during critical illness, and is associated with worse outcomes. These outcomes have prompted consideration of early antiviral prophylaxis, but two-third of patients would receive unnecessary treatment. Tissue viral load has been associated with risk of reactivation in murine models, and recent work has suggested a relationship between immune responses to CMV and underlying viral load. We, therefore, sought to confirm the hypothesis that serum CMV-specific immunoglobulin G (IgG) correlates with tissue viral load, and might be used to predict the risk of reactivation during critical illness. We confirm that there is a good correlation between tissue viral load and serum CMV-specific IgG after laboratory infection of inbred mice. Further, we show that naturally infected outbred hosts have variable tissue viral DNA loads that do not correlate well with serum IgG. Perhaps as a consequence, CMV-specific IgG was not predictive of reactivation events in immunocompetent humans. When reactivation did occur, those with the lowest IgG levels had longer durations of reactivation, but IgG quartiles were not associated with differing peak DNAemia. Together our data suggest that CMV-specific IgG titers diverge from tissue viral loads in outbred immunocompetent hosts, and their importance for the control of reactivation events remains unclear.
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http://dx.doi.org/10.1002/jmv.25389DOI Listing
May 2019

Percutaneous cholecystostomy-tube for high-risk patients with acute cholecystitis: current practice and implications for future research.

Surg Endosc 2019 10 2;33(10):3396-3403. Epub 2019 Jan 2.

Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd floor, Columbus, OH, USA.

Background: While cholecystectomy (CCY) is the standard of care for gallstone-related acute cholecystitis, percutaneous cholecystostomy-tube (CCYT-tube) is an alternative option in patients with significant comorbid conditions. We sought to identify immediate and longitudinal hospital outcomes of patients who underwent CCYT-tube placement and determine predictors of CCYT-tube placement and eventual CCY on a national level in the US.

Methods: We identified all adults (age ≥ 18 years) with a primary diagnosis of acute calculous cholecystitis from January to November 2013 in the Nationwide Readmissions Database (NRD). The NRD allows longitudinal follow-up of a patient for one calendar year. Outcomes of patients undergoing CCY and CCYT-tube were compared. Separate univariable and multivariable regression analyses were performed to identify predictors of CCYT-tube placement and failure to undergo subsequent CCY.

Results: A total of 181,262 patients had an index hospitalization with acute cholecystitis where 178,095 (98.3%) patients underwent only CCY and 3167 (1.7%) patients were managed with CCYT-tubes. Among patients with CCYT-tube, 1196 (37.8%) underwent eventual CCY in 2013, while 1971 (62.2%) did not. One in five patients with CCYT-tube were readmitted within 30 days of hospital discharge. Multivariable analysis demonstrated that increasing age, male gender, coronary artery disease, cirrhosis, atrial fibrillation, diastolic congestive heart failure, and sepsis were associated with CCYT-tube placement. Longitudinal follow-up revealed that older age (OR 1.16, 95% CI 1.09-1.23), Elixhauser comorbidity score 3-4 (OR 1.94, 95% CI 1.03-3.63), cirrhosis (OR 3.28, 95% CI 1.59-6.79), and diastolic congestive heart failure (OR 2.47, 95% CI 1.33-4.60) were associated with failure to undergo subsequent CCY.

Conclusion: In this national survey, nearly two in three patients who receive CCYT-tube for acute cholecystitis do not get CCY during longitudinal data capture within the same calendar year. Future research needs to target novel options for drainage of the gallbladder in high-risk patient populations.
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http://dx.doi.org/10.1007/s00464-018-06634-5DOI Listing
October 2019

Surgery for Abdominal Well-Differentiated Liposarcoma.

Curr Treat Options Oncol 2018 01 16;19(1). Epub 2018 Jan 16.

Division of Surgical Oncology, Department of Surgery, The Ohio State University, N924 Doan Hall, 410 West 10th Avenue, Columbus, OH, 43210, USA.

Opinion Statement: Retroperitoneal sarcomas are rare tumors of which liposarcoma is the most common histology. Surgical resection remains the mainstay of therapy, particularly for the well-differentiated subtype. They can grow to massive size before causing symptoms or detection. Well-differentiated liposarcoma, while having a negligible metastatic rate, is fraught with a high local recurrence rate, despite a complete surgical resection. Reasons for this are not completely known but may be related to a field defect of the retroperitoneal fat creating a niche for recurrence. These tumors are classically chemo- and radio-resistant. Surgical therapy of recurrences can be challenging, but remains the treatment of choice for well-differentiated liposarcoma. In an attempt to improve on survival and recurrence rates for retroperitoneal liposarcoma, an extended resection approach has been promoted by a few groups. This involves the en bloc resection of contiguous organs that are not macroscopically involved. While this has improved local recurrence rates, benefit for overall survival has not been demonstrated. Interestingly, the improvement in local recurrence rate appeared to be driven by histology and was most improved in the well-differentiated subtype compared to historical data. However, for well-differentiated liposarcomas that are multifocal, this approach may be less useful. The application of this approach still requires further study in terms of balancing increased morbidity of extended resection against the potential for multiple surgeries for recurrence.
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http://dx.doi.org/10.1007/s11864-018-0520-6DOI Listing
January 2018

Use of quality improvement (QI) methodology to decrease length of stay (LOS) for newborns with uncomplicated gastroschisis.

J Pediatr Surg 2018 Aug 8;53(8):1578-1583. Epub 2017 Dec 8.

Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH. Electronic address:

Purpose: Gastroschisis is a congenital defect of the abdominal wall leading to considerable morbidity and long hospitalizations. The purpose of this study was to use quality improvement methodology to standardize care in the management of gastroschisis that may contribute to length of stay (LOS).

Methods: A gastroschisis quality improvement team established a best-practice protocol in order to decrease LOS in infants with uncomplicated gastroschisis. The specific aim was to decrease median LOS from a baseline of 34days. We used statistical process control charts including rational subgroup analysis to monitor LOS.

Results: From December 2008 to December 2016, 119 patients with uncomplicated gastroschisis were evaluated. Retrospective data were obtained on 25 patients prior to protocol implementation. Ninety-four patients with uncomplicated gastroschisis comprised the prospective process stage. The median LOS for this retrospective cohort was 34days (IQR: 30.5-50.5), while the median LOS for the prospective cohort following implementation of the protocol decreased to 29days (IQR: 23-43).

Conclusions: With the use of quality improvement methodology, including standardization of care and a change in surgical approach, the median LOS for newborns with uncomplicated gastroschisis at our institution decreased from 34days to 29days.

Level Of Evidence: 3.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.11.061DOI Listing
August 2018

Antiviral prophylaxis of cytomegalovirus reactivation in immune competent patients-the jury remains out.

J Thorac Dis 2017 Aug;9(8):2221-2223

Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.

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http://dx.doi.org/10.21037/jtd.2017.06.130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5594140PMC
August 2017

Laparoscopic redo fundoplication improves disease-specific and global quality of life following failed laparoscopic or open fundoplication.

Surg Endosc 2017 11 7;31(11):4649-4655. Epub 2017 Apr 7.

Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA.

Introduction: Laparoscopic fundoplication is associated with failure rates of up to 30% and redo operation rates of 5-8%. Redo fundoplication improves patient symptoms, but its impact on patient quality of life remains unclear. We hypothesized that laparoscopic redo fundoplication improves disease-specific and global quality of life in patients with recurrent symptoms following failed laparoscopic or open fundoplication.

Methods: Data for all patients undergoing a redo fundoplication between August 2009 and June 2014 were collected prospectively. Reflux symptoms and quality of life were assessed using the Gastroesophageal Reflux Symptom Scale (GERSS), the Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL), and the global quality of life Short Form-36 (SF-36) questionnaires obtained at 4 weeks and 16 months post-operatively.

Results: Forty-six patients underwent laparoscopic redo fundoplication during the study period for symptomatic hernia (n = 11), GERD (n = 18), or dysphagia (n = 17). GERSS improved from 41 at baseline to 9 at late follow-up (p < 0.001), and GERD-HRQL scores improved from 30 at baseline to 7 at late follow-up (p < 0.001). Median dysphagia scores decreased from 4.5 to 1 (p = 0.035). SF-36 scores demonstrated a significant improvement in general health (p = 0.016) and emotional well-being (p = 0.036) and a trend toward improved physical function (p = 0.068) in the post-operative period, but these improvements were not statistically significant at longer-term follow-up. Overall, 82% of patients reported satisfaction with their operation, and 96% reported that they would have the operation performed again given the benefit of hindsight.

Conclusions: While associated with long operative times and significant complications, laparoscopic redo fundoplication produces a durable improvement in reflux symptoms and disease-specific quality of life. These procedures also improve global quality of life in the short term and are associated with high patient satisfaction.
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http://dx.doi.org/10.1007/s00464-017-5528-7DOI Listing
November 2017

Timing of Breast Cancer Surgery-How Much Does It Matter?

Breast J 2017 Jul 24;23(4):444-451. Epub 2017 Jan 24.

Division of Surgical Oncology, The Ohio State University College of Medicine, Columbus, Ohio.

Timing of surgical resection after breast cancer diagnosis is dependent on a variety of factors. Lengthy delays may lead to progression; however, the impact of modest delays is less clear. The aim of this study was to evaluate the impact of surgical timing on outcomes, including disease-free survival (DFS) and nodal status (NS). The cancer registry from one academic cancer hospital was retrospectively reviewed. Time from initial biopsy to surgical resection was calculated for patients with ductal carcinoma in situ (DCIS) and stage 1 and 2 invasive carcinomas. Early (0-21 days), intermediate (22-42 days), and late (43-63 days) surgery groups were evaluated for differences in NS and DFS for each cancer stage separately. A total of 3,932 patients were identified for analysis. There were no differences in DFS noted for DCIS. For stage 1, early surgery (ES) was associated with worse DFS compared to intermediate surgery (IS) (p = 0.025). There were no significant differences between ES and late surgery (LS) (p = 0.700) or IS and LS (p = 0.065). In stage II cancers, there was a significant difference in DFS in ES compared to IS (p < 0.001) and LS (p = 0.009). There was no significant difference between IS and LS (p = 0.478). Patients were more likely to undergo immediate reconstruction (p < 0.0001 for all stages) in later time-to-surgery groups, while patients in earlier groups were more likely to undergo breast conserving surgery. There was also no significant difference in NS at time of surgery in clinical stage 1 (p = 0.321) or stage 2 disease (p = 0.571). Delays of up to 60 days were not associated with worse outcomes. This study should reassure patients and surgeons that modest delays do not adversely affect breast cancer outcomes. This allows patients time to consider treatment and reconstruction options.
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http://dx.doi.org/10.1111/tbj.12758DOI Listing
July 2017

ATM mutations for surgeons.

Fam Cancer 2017 07;16(3):407-410

Division of Surgical Oncology, Department of Surgery, The Ohio State University College of Medicine, N908 Doan Hall, 410 W 10th Ave, Columbus, OH, 43210, USA.

The ataxia-telangiectasia mutated (ATM) gene encodes a protein kinase involved in DNA repair. Heterozygotic carriers are at an increased risk of developing breast cancer. As the use of genetic testing increases, identification of at-risk patients will also increase. The aim of this study is to review two cases of heterozygous ATM mutation carriers and review the literature to clarify the cancer risks and suggested management for breast surgeons who will be intimately involved in the care of these patients.
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http://dx.doi.org/10.1007/s10689-016-9959-4DOI Listing
July 2017

Routine staging with endoscopic ultrasound in patients with obstructing esophageal cancer and dysphagia rarely impacts treatment decisions.

Surg Endosc 2017 08 18;31(8):3227-3233. Epub 2016 Nov 18.

Section of Advanced Endoscopy, Division of Gastroenterology, Hepatology and Nutrition, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, Columbus, OH, 43210, USA.

Background: Endoscopic ultrasound (EUS) has been routinely utilized for the locoregional staging of esophageal cancer. One important aspect of clinical staging has been to stratify patients to treatment with neoadjuvant chemoradiation or primary surgical therapy. We hypothesized that EUS may have a limited impact on clinical decision making in patients with dysphagia and obstructing esophageal masses.

Methods: This retrospective cohort study included all patients with esophageal adenocarcinoma undergoing esophageal EUS between July 2008 and September 2013. Dysplastic Barrett's esophagus without invasive adenocarcinoma or incomplete staging was excluded. Patient demographics, endoscopic tumor characteristics, the presence of dysphagia, sonographic staging, and post-EUS therapy were recorded. Pathologic staging for patients who underwent primary surgical therapy was also recorded. Locally advanced disease was defined as at least T3 or N1, as these patients are typically treated with neoadjuvant therapy.

Results: Two hundred sixteen patients underwent EUS for esophageal adenocarcinoma, with 147 (68.1%) patients having symptoms of dysphagia on initial presentation. Patients with dysphagia were significantly more likely to have locally advanced disease on EUS than patients without dysphagia (p < 0.0001). Additionally, 145 (67.1%) patients had a partially or completely obstructing mass on initial endoscopy, of which 136 (93.8%) were locally advanced (p < 0.0001 vs. non-obstructing lesions).

Conclusions: An overwhelming majority of patients presenting with dysphagia and/or the presence of at least partially obstructing esophageal mass at the time of esophageal cancer diagnosis had an EUS that demonstrated at least locally advanced disease. The present study supports the hypothesis that EUS may be of limited benefit for management of esophageal cancer in patients with an obstructing mass and dysphagia.
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http://dx.doi.org/10.1007/s00464-016-5351-6DOI Listing
August 2017

A case of a pseudo colonic mass causing gastrointestinal bleeding in a patient with a left ventricular assist device.

Int J Crit Illn Inj Sci 2016 Jul-Sep;6(3):153-154

Division of General Surgery, The Ohio State University, Columbus, OH 43210, USA.

There are many complications associated with the left ventricular assist devices (LVADs), including gastrointestinal bleeding (GIB). We present a case of a pseudo colonic mass visualized on colonoscopy during workup for GIB in an LVAD patient necessitating a right colectomy with final pathology negative for malignancy. A review of the literature in regards to the pathology, diagnosis, and treatment of this interesting condition is included.
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http://dx.doi.org/10.4103/2229-5151.190646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5051059PMC
October 2016

Pancreaticoduodenectomy outcomes in the pediatric, adolescent, and young adult population.

J Surg Res 2016 07 29;204(1):232-6. Epub 2016 Apr 29.

Division of Pediatric Surgery, Department of Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio. Electronic address:

Background: Pancreatic malignancy and chronic pancreatitis are rare in the pediatric, adolescent, and young adult (AYA) population, making pancreas resections an infrequent procedure in this demographic. Only case reports and small case series exist in the literature describing surgical outcomes and complications in this population. The aim of this study was to review the surgical outcomes of pediatric/AYA patients undergoing pancreaticoduodenectomy (PD) at our institution.

Methods: All pediatric/AYA adult patients (≤30 years) undergoing PD over a 15-year period (1998-2013) from a large academic institution were included. We provide adult (>30 years) data from our same institution for observational comparison. Retrospective chart review was performed to identify pertinent preoperative, perioperative, and postoperative data.

Results: Twenty-two patients with a median age of 25 years (range, 11-30 years) underwent PD. The most common postoperative histologic diagnoses were chronic pancreatitis (6, 27.3%), solid pseudopapillary neoplasm (5, 22.7%), and adenocarcinoma (4, 18.2%). Complications were 31.8% in the pediatric/AYA cohort and 58.6% in the adult cohort. The most common postoperative complication was intraabdominal abscess, which occurred in three patients (13.6%). Thirty-day mortality was 0% for pediatric/AYA patients. There were no recurrences or disease-related deaths in patients with solid pseudopapillary neoplasm. Pediatric patients with adenocarcinoma had a median survival of 10.2 mo (interquartile range, 9-21), in contrast to adults of 57.8 mo (interquartile range, 11-132).

Conclusions: This is the largest series of PD procedures reported in the pediatric/AYA population. The procedure appears to be safe, with no 30-day mortalities and an acceptable complication rate.
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http://dx.doi.org/10.1016/j.jss.2016.04.049DOI Listing
July 2016

A case of a strangulated umbilical hernia causing gangrenous appendicitis.

Int J Colorectal Dis 2016 May 6;31(5):1075-1076. Epub 2015 Oct 6.

Division of General Surgery, The Ohio State University, 395 W 12th Avenue, Columbus, OH, 43210, USA.

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http://dx.doi.org/10.1007/s00384-015-2412-6DOI Listing
May 2016

Resistant pathogens, fungi, and viruses.

Surg Clin North Am 2014 Dec 3;94(6):1195-218. Epub 2014 Oct 3.

Division of Acute Care Surgery, Trauma and Surgical Critical Care, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Lowry 2G, Boston, MA 02215, USA. Electronic address:

Although originally described in Staphylococcus aureus, resistance among bacteria has now become a race to determine which classes of bacteria will become more resistant. Availability of antibacterial agents has allowed the development of entirely new diseases caused by nonbacterial pathogens, related largely to fungi that are inherently resistant to antibacterials. This article presents the growing body of knowledge of the herpes family of viruses, and their occurrence and consequences in patients with concomitant surgical disease or critical illness. The focus is on previously immunocompetent patients, as the impact of herpes viruses in immunosuppressed patients has received thorough coverage elsewhere.
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http://dx.doi.org/10.1016/j.suc.2014.08.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4366135PMC
December 2014

Angiosarcoma and breast cancer recurrence eight years following mammosite therapy.

Breast J 2014 Nov-Dec;20(6):658-60. Epub 2014 Sep 17.

Department of General Surgery, The Ohio State University College of Medicine, Columbus, Ohio.

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http://dx.doi.org/10.1111/tbj.12337DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4467453PMC
June 2015

Acute upper gastrointestinal bleeding secondary to Kaposi sarcoma as initial presentation of HIV infection.

J Gastrointestin Liver Dis 2013 Dec;22(4):441-5

Department of Surgery, Division of Trauma, Critical Care, and Burn, The Ohio State University College of Medicine, Columbus, OH, USA;

Despite our decades of experience with Kaposi Sarcoma its true nature remains elusive. This angioproliferative disease of the vascular endothelium has a propensity to involve visceral organs in the immunocompromised population. There are four variants of the disease and each has its own pathogenesis and evolution. While the common sources of upper gastrointestinal bleeding are familiar to surgeons and critical care physicians, here we present the exceedingly rare report of upper gastrointestinal bleeding attributable to this malady, explore its successful management, and review the various forms of Kaposi Sarcoma including the strategies in regard to their management.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4097021PMC
December 2013