Publications by authors named "Sara C Fallon"

62 Publications

Favorable postoperative outcomes for children with COVID-19 infection undergoing surgical intervention: Experience at a free-standing children's hospital.

J Pediatr Surg 2021 Jan 27. Epub 2021 Jan 27.

Michael E. DeBakey Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin Street, Suite 1210, Houston, TX 77030, United States. Electronic address:

Background: Current literature has shown that adult patients with perioperative Coronavirus Disease-2019 (COVID-19) have increased rates of postoperative morbidity and mortality. We hypothesized that children with COVID-19 have favorable postoperative outcomes compared to the reported adult experience.

Methods: We performed a retrospective cohort study for children with a confirmed preoperative COVID-19 diagnosis from April 1st, 2020 to August 15th, 2020 at a free-standing children's hospital. Primary outcomes evaluated were postoperative complications, readmissions, reoperations, and mortality within 30 days of operation. Secondary outcomes included hospital resource utilization, hospital length of stay, and postoperative oxygen support.

Results: A total of 66 children with preoperative confirmed COVID-19 were evaluated with median age of 9.5 years (interquartile range (IQR) 5-14) with 65% male and 70% Hispanic White. Sixty-five percent of patients had no comorbidities, with abdominal pain identified as the most common preoperative symptom (65%). Twenty-three percent of patients presented with no COVID-19 related symptoms. Eighty-two percent of patients had no preoperative chest imaging and 98% of patients did not receive preoperative oxygen support. General pediatric surgeons performed the majority of procedures (68%) with the most common diagnosis appendicitis (47%). Forty-one percent of patients were discharged the same day as surgery with 9% of patients utilizing postoperative intensive care unit resources and only 5% receiving postoperative invasive mechanical ventilation. Postoperative complications (7%), readmission (6%), and reoperation (6%) were infrequent, with no mortality.

Conclusion: COVID-19+ children requiring surgery have a favorable postoperative course and short-term outcomes compared to the reported adult experience.

Type Of Study: Prognosis Study.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.01.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7838581PMC
January 2021

Complications and Failure to Rescue After Inpatient Pediatric Surgery.

Ann Surg 2020 Oct 19. Epub 2020 Oct 19.

Center for Innovations in Quality, Effectiveness, and Safety Michael E DeBakey VA Medical Center.

Objective: To describe the frequency and patterns of postoperative complications and failure to rescue (FTR) after inpatient pediatric surgical procedures and to evaluate the association between number of complications and failure to rescue.

Summary And Background: FTR, or a postoperative death after a complication, is currently a nationally endorsed quality measure for adults. While it is a contributing factor to variation in mortality, relatively little is known about FTR after pediatric surgery.

Methods: Cohort study of 200,554 patients within the National Surgical Quality Improvement Program-Pediatric database (2012-2016) who underwent a high (≥1%) or low (<1%) mortality risk inpatient surgical procedures. Patients were stratified based on number of postoperative complications (0, 1, 2, or ≥3) and further categorized as having undergone either a low- or high-risk procedure. The association between the number of postoperative complications and FTR was evaluated with multivariable logistic regression.

Results: Among patients who underwent a low- (89.4%) or high-risk (10.6%) procedures, 14.0% and 12.5% had at least one postoperative complication, respectively. FTR rates after low- and high-risk procedures demonstrated step-wise increases as the number of complications accrued (e.g.: low-risk-9.2% in patients with ≥3 complications; high-risk-36.9% in patients with ≥3 complications). Relative to patients who had no complications, there was a dose-response relationship between mortality and the number of complications after low-risk (1 complication - Odds Ratio [OR] 3.34 [95% CI 2.62-4.27]; 2 - OR 10.15 [95% CI 7.40-13.92]; ≥3-27.48 [95% CI 19.06-39.62]) and high-risk operations (1 - OR 3.29 [2.61-4.16]; 2-7.24 [5.14-10.19]; ≥3-20.73 [12.62-34.04]).

Conclusions: There is a dose-response relationship between the number of postoperative complications after inpatient surgery and FTR, ever after common, 'minor' surgical procedures. These findings suggest FTR may be a potential quality measure for pediatric surgical care.
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http://dx.doi.org/10.1097/SLA.0000000000004463DOI Listing
October 2020

Outcomes After Extracorporeal Life Support Cannulation in Pediatric Patients With Trisomy 13 and Trisomy 18.

J Surg Res 2021 01 27;257:260-266. Epub 2020 Aug 27.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas; Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas. Electronic address:

Background: Indications for extracorporeal life support (ECLS) have evolved and expanded, yet its use in trisomy 13 (T13) and trisomy 18 (T18) patients remains controversial. We reviewed the experience of the Extracorporeal Life Support Organization with ECLS in these patients to inform practice at our institution.

Methods: The Extracorporeal Life Support Organization registry was queried for all patients younger than 18 y with an International Classification of Diseases, Ninth Edition/Tenth Edition code for T13 or T18 from 2000 to 2018. Basic demographics, ECLS details, and clinical outcomes were recorded. Descriptive statistics were performed.

Results: Twenty-eight patients were identified (15 with T13; 13 with T18), representing 0.06% (28 of 46,901) of pediatric ECLS cannulations. The median weight was 3.5 kg (range, 1.4-13), and age at cannulation was 52 d (range, 0 d-6.8 y). Time on ECLS ranged from 13 to 478 h (median, 114). Cardiac defects were diagnosed in 19 (68%) patients, of which 13 (46%) underwent surgical repair. Median oxygenation index pre-ECLS was 45. Venoarterial cannulations accounted for 82% of patients, whereas 14% underwent venovenous cannulation. Overall survival to hospital discharge was 46% with 86% of patients experiencing one or more complications. There were no survivors when cannulation continued past 12 d.

Conclusions: Although complications are frequent, the mortality rate in patients with T13 and T18 remains within the reported range for the general pediatric population. T13 and T18 alone should not be viewed as absolute contraindications to ECLS within the pediatric population but rather considered during the evaluation of a patient's potential candidacy.
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http://dx.doi.org/10.1016/j.jss.2020.07.036DOI Listing
January 2021

Effectiveness of a clinical pathway for pediatric complex appendicitis based on antibiotic stewardship principles.

J Pediatr Surg 2020 Jun 3;55(6):1026-1031. Epub 2020 Mar 3.

Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030. Electronic address:

Purpose: Outcomes and resource utilization were evaluated after implementing a novel complex appendicitis (CA) pathway limiting postoperative antibiotics based on clinical parameters.

Methods: Children with intraoperative CA (gangrenous, perforated, or abscess) were treated with intravenous antibiotics postoperatively until clinical criteria were met, without utilizing CBC or oral antibiotics at discharge. An interrupted time series (pre-intervention, transition, post-intervention) was used to assess outcomes. Hospital length of stay (LOS) was analyzed using segmented regression. Intra-abdominal abscess and readmission rates were analyzed using non-inferiority and multivariate logistic regression.

Results: Five hundred ten children were included with a median age of 10 [IQR7-12] years. There were no differences in postoperative LOS (slope - 0.008; p = 0.855), intra-abdominal abscess rate (5% vs. 8%; p = 0.135), or readmission rate (12% vs. 8%; p = 0.113) across time periods which remained true when adjusting for age, gender, and intraabdominal disease severity. Post-intervention outcomes were not inferior to pre-intervention, abscess rate (p = 0.002), or readmission rate (p < 0.001). Intraoperative findings of perforation (OR9.0; 95% CI1-71; p = 0.044) and perforation with abscess (OR18.2; 95% CI2-36; p = 0.005) were associated with a greater likelihood of postoperative abscess compared to gangrenous appendicitis.

Conclusion: A CA protocol based on clinical parameters is safe and effective, resulting in similar intra-abdominal abscess and readmission rates compared to more resource-intense regimens.

Level Of Evidence: III TYPE OF RESEARCH: Interrupted Time Series.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.02.045DOI Listing
June 2020

The significance of abdominal radiographs with paucity of gas in pediatric adhesive small bowel obstruction.

Am J Surg 2020 07 29;220(1):208-213. Epub 2019 Oct 29.

Department of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street, #1210, Houston, TX, 77030, USA. Electronic address:

Purpose: Management of children with adhesive small bowel obstruction (ASBO) is often based on abdominal radiographs (AXR). Our purpose was to determine the significance of paucity of gas on initial AXR.

Methods: Retrospective, single center review of children with ASBO between 2011 and 2015. Analysis included chi-square, non-parametric tests and multivariate regression.

Results: Of 207 cases, 99 were operative. Initial AXR showed paucity of gas in 41% and gaseous loops in 59%. Paucity was more common in operative patients (49% vs. 32%, p = 0.01). At operation, 71% of patients with paucity had closed loop or high-grade obstruction, compared to 29% of patients with gaseous loops (p = <0.001).

Conclusion: For children with ASBO with paucity of gas on AXR, complicated obstruction (closed loop or high-grade) should be considered. In children with high clinical suspicion of complicated obstruction, additional imaging with CT or SBFT may clarify the clinical picture.
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http://dx.doi.org/10.1016/j.amjsurg.2019.10.035DOI Listing
July 2020

Prenatal Imaging Features and Postnatal Factors Associated with Gastrointestinal Morbidity in Congenital Diaphragmatic Hernia.

Fetal Diagn Ther 2020 21;47(4):252-260. Epub 2019 Aug 21.

Texas Children's Fetal Center, Texas Children's Hospital and the Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas, USA,

Background: To perform a comprehensive assessment of postnatal gastrointestinal (GI) morbidity and determine the prenatal imaging features and postnatal factors associated with its development in patients with congenital diaphragmatic hernia (CDH).

Materials And Methods: A retrospective review was conducted of all infants evaluated for CDH at a quaternary fetal center from February 2004 to May 2017. Prenatal imaging features and postnatal variables were analyzed. GI morbidity was the primary outcome. The Mann-Whitney U test, the Kruskal-Wallis test with Dunnett's T3 post hoc analysis and logistic regression, and the χ2 test were performed when appropriate.

Results: We evaluated 256 infants; 191 (75%) underwent CDH repair and had at least 6 months of follow-up. Of this cohort, 60% had gastroesophageal reflux disease (GERD), 13% had gastroparesis, 32% received a gastrostomy tube (G-tube), and 17% needed a fundoplication. Large defect, patch repair, extracorporeal membrane oxygenation (ECMO), and prolonged use of mechanical ventilation were significantly associated with having GERD, gastroparesis, G-tube placement, and fundoplication (p < 0.05). Fetuses with stomach grades 3 and 4 were most likely to have GERD, a G-tube, and a long-term need for supplemental nutrition than fetuses with stomach grades 1 and 2 (p < 0.05).

Conclusion: Survivors of CDH with large defects, prolonged use of mechanical ventilation, or that have received ECMO may be at an increased risk for having GERD, gastroparesis, and major GI surgery. Marked stomach displacement on prenatal imaging is significantly associated with GI morbidity in left-sided CDH.
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http://dx.doi.org/10.1159/000501555DOI Listing
January 2021

High-resolution manometric guidance during laparoscopic Heller myotomy: Impact on quality of life and symptom severity for children with achalasia.

J Pediatr Surg 2019 May 5;54(5):1063-1068. Epub 2019 Feb 5.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, TX.

Background: High-resolution esophageal manometry (HREM) during laparoscopic Heller myotomy (LHM) with fundoplication for achalasia allows tailoring of myotomy length and wrap tightness. The purpose of this study is to quantify long-term postoperative symptom severity and quality of life using validated questionnaires.

Methods: Children ≤18 years with achalasia who previously underwent LHM with intraoperative HREM from 2010 to 2017 were prospectively surveyed. Eckardt Symptom Score (ESS), Achalasia Severity Questionnaire (ASQ), Pediatric Quality of Life Inventory (PedsQL), and Pediatric GERD Symptom and Quality of Life (PGSQ) questionnaires were administered. Scores for historical controls were obtained from prior survey instrument validation studies as comparison.

Results: Of 30 eligible patients, 12 (40%) completed the surveys. Mean age at time of surgery was 13 ± 3 years. Assessment was performed at least 10 months after surgery with mean time elapsed of 3.6 ± 2 years. Average premyotomy lower esophageal sphincter (LES) pressure, postmyotomy LES pressure, and postfundoplication LES pressure were 30 ± 10 mmHg, 14 ± 6 mmHg, and 18 ± 9, respectively. ESS (2.3/12), ASQ (39/100 ± 16), PGSQ (symptom: 0.6/4 ± 0.4, school: 0.4/4 ± 0.4), and overall PedsQL (82/100 ± 15) were similar to those of healthy historical controls.

Conclusion: Children with achalasia undergoing LHM with intraoperative HREM had sustained long-term symptom improvement and quality of life scores comparable to healthy patients.

Study And Level Of Evidence: Retrospective, II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.01.041DOI Listing
May 2019

Using an anonymous, resident-run reporting mechanism to track self-reported duty hours.

Am J Surg 2019 07 3;218(1):225-229. Epub 2019 Jan 3.

Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, 77030-3411, USA. Electronic address:

Background: Implementation of resident duty hour policies has resulted in a need to document work hours accurately. We compared the number of self-reported duty hour violations identified through an anonymous, resident-administered survey to that obtained from a standardized, ACGME-sanctioned electronic tracking system.

Methods: 10 cross-sectional surveys were administered to general surgery residents over five years. A resident representative collected and de-identified the data.

Results: A median of 54 residents (52% male) participated per cohort. 429 responses were received (79% response rate). 111 violations were reported through the survey, while the standardized electronic system identified 76, a trend significantly associated with PGY-level (p < 0.001) and driven by first-year residents (n = 81 versus 37, p = 0.001).

Conclusions: An anonymous, resident-run mechanism identifies significantly more self-reported violations than a standardized electronic tracking system alone. This argues for individual program evaluation of duty hour tracking mechanisms to correct systematic issues that could otherwise lead to repeated violations.
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http://dx.doi.org/10.1016/j.amjsurg.2018.12.065DOI Listing
July 2019

Congenital diaphragmatic hernia repair in patients on extracorporeal membrane oxygenation: How early can we repair?

J Pediatr Surg 2019 Jan 5;54(1):50-54. Epub 2018 Oct 5.

Baylor College of Medicine, Michael E. DeBakey Department of Surgery, Houston, TX, USA; Texas Children's Hospital, Department of Pediatric Surgery, Houston, TX, USA. Electronic address:

Background: The benefits to early repair (<72 h postcannulation) of infants with congenital diaphragmatic hernia (CDH) on extracorporeal membrane oxygenation (ECMO) are increasingly recognized. Yet it is not known if even earlier repair (<24 h) results in comparable or improved patient outcomes. The goal of this study was to compare "super-early" (<24 h) to early repair (24-72 h) of CDH patients on ECMO.

Methods: A retrospective review of infants with CDH placed on ECMO (2004-2017; n = 72) was performed. Data collected on the patients repaired while on ECMO within 72 h of cannulation (n = 33) included pre- and postnatal disease severity stratification variables and postnatal outcomes. Comparison groups were those patients repaired within 24 h of cannulation (n = 14) and those repaired between 24 and 72 h postcannulation (n = 19).

Results: Patients undergoing "super-early" (<24 h) repair had an average survival of 71.4% compared to the average survival of 59.7% in the early repair group. Pre- and postnatal variables predicting disease severity were not significantly different between the groups. Mean hospital stays, ventilator days, and cannulation days were statistically similar between the groups.

Conclusions: Repair of patients with CDH patients on ECMO at less than 24 h postcannulation achieves outcomes that are comparable to those of repair between 24 and 72 h. While the present data suggest that there is not a "too early" time point for CDH repair on ECMO, larger multicenter studies are needed to validate our findings and determine the overall benefits.

Type Of Study: Retrospective comparative study.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.10.038DOI Listing
January 2019

The surgical principles of conjoined twin separation.

Semin Perinatol 2018 10 4;42(6):386-392. Epub 2018 Oct 4.

Division of Pediatric Surgery, The Michael E. DeBakey Department of Surgery, Baylor College of Medicine and Texas Children's Hospital, 6701 Fannin, Suite 1210, Houston, TX 77019, United States. Electronic address:

The surgical management of conjoined twin separation is a complex, multidisciplinary process that requires extensive pre operative planning and organization for optimal outcomes. Identification of detailed anatomic relationships is necessary prior to the separation. The use of 3D modeling is extremely helpful for conceptualization of the operation. The principles of the separation are dependent on the type of twin, although each variant of symmetric twins has certain commonalities related to their embryology that can be considered when planning the operation. The use of tissue expansion in the pre operative planning stage is highly recommended due to known issues with closure after separation. In order to ensure a safe, successful operation, we recommend organized pre operative planning meetings with at least one simulation of the separation event with multidisciplinary involvement.
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http://dx.doi.org/10.1053/j.semperi.2018.07.013DOI Listing
October 2018

Congenital H-type tracheoesophageal fistula: A multicenter review of outcomes in a rare disease.

J Pediatr Surg 2017 Nov 11;52(11):1711-1714. Epub 2017 May 11.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6701 Fannin St. Suite 1210, Houston, TX 77030, USA. Electronic address:

Objective: To perform a multicenter review of outcomes in patients with H-type tracheoesophageal fistula (TEF) in order to better understand the incidence and causes of post-operative complications.

Background: H-type TEF without esophageal atresia (EA) is a rare anomaly with a fundamentally different management algorithm than the more common types of EA/TEF. Outcomes after surgical treatment of H-type TEF are largely unknown, but many authoritative textbooks describe a high incidence of respiratory complications.

Methods: A multicenter retrospective review of all H-type TEF patients treated at 14 tertiary children's hospital from 2002-2012 was performed. Data were systematically collected concerning associated anomalies, operative techniques, hospital course, and short and long-term outcomes. Descriptive analyses were performed.

Results: We identified 102 patients (median 9.5 per center, range 1-16) with H-type TEF. The overall survival was 97%. Most patients were repaired via the cervical approach (96%). The in-hospital complication rate, excluding vocal cord issues, was 16%; this included an 8% post-operative leak rate. Twenty-two percent failed initial extubation after repair. A total of 22% of the entire group had vocal cord abnormalities (paralysis or paresis) on laryngoscopy that were likely because of recurrent laryngeal nerve injury. Nine percent required a tracheostomy. Only 3% had a recurrent fistula, all of which were treated with reoperation.

Conclusions: There is a high rate of recurrent laryngeal nerve injury after H-type TEF repair. This underscores the need for meticulous surgical technique at the initial repair and suggests that early vocal cord evaluation should be performed for any post-operative respiratory difficulty. Routine evaluation of vocal cord function after H-type TEF repair should be considered.

The Level Of Evidence Rating: Level IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.05.002DOI Listing
November 2017

Perioperative determinants of transient hypocalcemia after pediatric total thyroidectomy.

J Pediatr Surg 2017 May 27;52(5):684-688. Epub 2017 Jan 27.

Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030. Electronic address:

Purpose: We seek to identify risk factors associated with hypocalcemia after pediatric total thyroidectomy.

Methods: We retrospectively reviewed patients younger than 21years undergoing total thyroidectomy between January 2002 and January 2016. We defined hypocalcemia as any serum calcium <8mg/dl or ionized calcium <1.0mmol/L. Perioperative risk factors were identified through multivariate logistic regression.

Results: Ninety-one children underwent total thyroidectomy. The average age was 13.7±4.4years, and 77% were female. Transient hypocalcemia was diagnosed in 34% (n=31) of patients. There was one case of permanent hypoparathyroidism. Predictors of transient hypocalcemia included age (OR 0.87, 95% CI 0.8-0.97, p=0.01), lymphadenectomy (OR 6.6, 95% CI 1.7-31.6, p=0.01), and hyperthyroidism (OR 13.3, 95% CI 1.3-1849, p=0.03). Patients with malignancy undergoing central (OR 7.1, 95% CI 1.5-33.4, p=0.01) or central plus lateral lymphadenectomy (OR 6.33, 95% CI 1.0-40.1, p=0.05) had significantly increased risk for transient hypocalcemia. Malignancy, MEN2A/B, goiter, preoperative calcium supplementation, incidental parathyroid removal, and postoperative PTH <15pg/ml were not associated with transient hypocalcemia.

Conclusions: Younger age, hyperthyroidism, and concomitant lymphadenectomy during total thyroidectomy increase risk of developing transient hypocalcemia. Malignant cases with central or central plus lateral lymphadenectomy are also at increased risk. Aggressive perioperative management of hypocalcemia should be initiated in patients with these risk factors.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.01.011DOI Listing
May 2017

Evaluating the impact of infliximab use on surgical outcomes in pediatric Crohn's disease.

J Pediatr Surg 2016 May 14;51(5):786-9. Epub 2016 Feb 14.

Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: The impact of infliximab (IFX) on surgical outcomes is poorly defined in pediatric Crohn's disease (CD). We evaluated our institution's experience with IFX on postoperative complications and surgical recurrence.

Methods: A retrospective review of children who underwent intestinal resection with primary anastomosis for CD from 1/2002 to 10/2014 was performed. Data collected included IFX use and surgical outcomes. Preoperative IFX use was within 3months of surgery.

Results: Seventy-three patients were included with median age 15years (range: 9-18). The most frequent indications for operation were obstruction (n=26) and fistulae (n=19). Nine patients (13%) had a surgical recurrence at a median of 2.3years (IQR 0.7-3.5). Twenty-two patients received preoperative IFX at median of 26days (IQR 14-46). There were 7 postoperative complications: 2 bowel obstructions, and 5 superficial wound infections. Outcomes of patients stratified by IFX were not different. When stratified by indication, refractory disease was associated with higher preoperative IFX use (IFX use 55% vs. no IFX use 28%, p=0.027). No specific indication was associated with increased reoperation rates.

Conclusion: Pediatric CD patients treated with preoperative IFX undergo intestinal resection with primary anastomosis with acceptable morbidity. The heterogeneous approach to medical management underscores the need for guidelines to direct treatment.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.02.023DOI Listing
May 2016

Outcomes after peritoneal dialysis catheter placement.

J Pediatr Surg 2016 May 11;51(5):730-3. Epub 2016 Feb 11.

Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Houston, TX; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. Electronic address:

Background: The purpose of this study was to review surgical outcomes after elective placement of peritoneal dialysis (PD) catheters in children with end-stage renal disease.

Methods: Children with PD catheters placed between February 2002 and July 2014 were retrospectively reviewed. Outcomes were catheter life, late (>30days post-op) complications (catheter malfunction, catheter malposition, infection), and re-operation rates. Comparison groups included laparoscopic versus open placement, age<2, and weight<10kg. Univariate and multivariate analysis were performed.

Results: One hundred sixteen patients had 173 catheters placed (122 open, 51 laparoscopic) with an average patient age of 9.7±6.3years. Mean catheter life was similar in the laparoscopic and open groups (581±539days versus 574±487days, p=0.938). The late complication rate was higher for open procedures (57% versus 37%, p=0.013). Children age<2 or weight<10kg had higher re-operation rates (64% versus 42%, p=0.014 and 73% versus 40%, p=0.001, respectively). Adjusted for age and weight, open technique remained a risk factor for late complications (OR 2.44, 95% CI 1.20-4.95) but not re-operation.

Discussion: Laparoscopic placement appears to reduce the rate of late complications in children who require PD dialysis catheters. Children <2years age or <10kg remain at risk for complications regardless of technique.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.02.011DOI Listing
May 2016

Feeding gastrostomy in children with complex heart disease: when is a fundoplication indicated?

Pediatr Surg Int 2016 Mar 31;32(3):285-9. Epub 2015 Dec 31.

Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital and Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Dr. Suite 1210, Houston, TX, 77030, USA.

Purpose: Malnutrition is common among children with complex heart disease (CHD). Feeding gastrostomies are often used to improve the nutritional status of such patients. Our purpose was to evaluate a cohort of children with CHD following open Stamm gastrostomy without fundoplication.

Methods: We reviewed all CHD patients who underwent feeding gastrostomy placement from 1/1/2004 to 4/7/2015. Demographic data, cardiac diagnoses, operative details, post-operative complications, and the need for GJ feeding and fundoplication were examined.

Results: Open Stamm gastrostomy was performed in 111 patients. Median age at surgery was 37 weeks (3 weeks-13.7 years); average weight was 5.3 ± 4.9 kg. Thirty-four patients (30 %) experienced a total of 37 minor complications, including tube dislodgement after stoma maturation (20), superficial surgical site infection (13), mechanical failure (3), and bleeding (1). Three patients experienced a major complication (need for return to the OR or peri-operative death <30 days). Three patients required a subsequent fundoplication. Fifty-six surviving patients (62 %) continue gastrostomy feeds, of which 7 (13 %) patients require GJ feeds.

Conclusion: Children with CHD tolerate an open Stamm gastrostomy well with minimal major complications. These results support very selective use of fundoplication in infants and children with CHD who require a feeding gastrostomy.
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http://dx.doi.org/10.1007/s00383-015-3854-1DOI Listing
March 2016

Newborn Direct or Conjugated Bilirubin Measurements As a Potential Screen for Biliary Atresia.

J Pediatr Gastroenterol Nutr 2016 06;62(6):799-803

*Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition†Department of Pathology‡Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston.

Objectives: Although screening for biliary atresia (BA) is associated with improved outcomes, no screening program currently exists in the United States. In this study, we explore the possibility of a screening strategy based on newborn direct or conjugated bilirubin (DB or CB) measurements. Our objective is to estimate testing's sensitivity and specificity for BA.

Methods: Two groups were examined retrospectively. For sensitivity calculations, a BA group consisting of infants born between January 2011 and December 2014, diagnosed with BA, and cared for at a pediatric gastroenterology referral center was examined. For specificity calculations, a non-BA group that comprised of infants born between June 2009 and August 2011 in a hospital with a policy of checking newborn bilirubin concentrations was studied.

Results: All 35 infants with newborn DB or CB measurements in the BA group had elevated concentrations, translating to a sensitivity of 100% (95% CI 87.7-100). In the non-BA group, 8936 of 9102 infants had DB concentrations within the laboratory's reference interval, translating to a specificity of 98.2% (95% CI 97.9-98.4). Three methods-calculating direct:total bilirubin ratios, using 99% reference intervals, and repeat testing-changed specificity to different degrees.

Conclusions: Newborn DB or CB measurements may have a high sensitivity and specificity for BA. Specificity can be further improved by using 99% reference intervals and/or repeat testing. Our findings can serve as the foundation for larger prospective studies, to determine whether newborn DB or CB measurements can be an effective screening strategy for BA.
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http://dx.doi.org/10.1097/MPG.0000000000001097DOI Listing
June 2016

The use of an institutional pediatric abdominal trauma protocol improves resource use.

J Trauma Acute Care Surg 2016 Jan;80(1):57-63

From the Division of Pediatric Surgery (S.C.F, A.A., B.J.N.-M.), Michael E. DeBakey Department of Surgery, and Division of Pediatric Emergency Medicine (D.D., D.C.), Department of Emergency Medicine, Baylor College of Medicine; and Trauma Services (D.D., D.C., B.J.N.-M.), Texas Children's Hospital, Houston, Texas.

Background: A novel protocol to standardize the emergency center (EC) management of abdominal trauma in children was developed and implemented at our trauma center. The purpose of this study was to evaluate whether this protocol improved patient safety by decreasing unnecessary computed tomography (CT) radiation and improved quality of care by decreasing EC length of stay (LOS) and laboratory costs.

Methods: We performed a prospective, longitudinal study of children who presented to the EC with a mechanism for abdominal trauma and received an abdominal CT scan from January 2011 to September 2014. Patients were divided into protocol periods: preimplementation (January 2011 to December 2011), Postimplementation 1 (January 2012 to August 2013), and Postimplementation 2 (September 2013 to September 2014). Outcome measures included protocol adherence, rates of clinically positive CT results, the EC LOS, and the cost of laboratory studies. χ and analysis of variance were used for statistical analysis.

Results: During the study period, 117 patients in the preimplementation, 148 patients in the Postimplementation 1, and 56 patients in the Postimplementation 2 periods were identified. Protocol adherence improved from 70% to 82% (p = 0.11) from the Postimplementation 1 to Postimplementation 2 periods. The rate of positive CT scan results increased from 23% to 31% to 46% (p = 0.003) from preimplementation to Postimplementation 1 and Postimplementation 2, respectively. When the protocol was followed, the proportion of clinically significant scans was higher than when it was not followed (31% vs. 8%, p = 0.001). The EC LOS was unchanged (median [range], 271 minutes [16-1,039 minutes] vs. 233 minutes [40-1,396 minutes], p = 0.34). The median cost of laboratory studies remained the same from preimplementation to Postimplementation 1 ($166 [$0-$454] vs. $352 [$0-$448], p = 0.29) and decreased after the second protocol revision included an emphasis on laboratory work in Postimplementation 2 ($139 [$33-$426], p = 0.005).

Conclusion: The use of an institutional abdominal trauma management algorithm is an effective method of improving resource use by decreasing unnecessary CT scan use and laboratory costs.

Level Of Evidence: Economic analysis, level IV; therapeutic/care management study, level IV.
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http://dx.doi.org/10.1097/TA.0000000000000712DOI Listing
January 2016

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis.

Pediatr Radiol 2015 Dec 18;45(13):1945-52. Epub 2015 Aug 18.

Edward B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St., MC CC470.01, Houston, TX, 77030, USA.

Background: To facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis.

Objective: The purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis.

Materials And Methods: In this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates.

Results: We identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation - only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8).

Conclusion: A scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children's hospital and stratifies risk for children based on their likelihood of appendicitis.
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http://dx.doi.org/10.1007/s00247-015-3443-4DOI Listing
December 2015

Management of traumatic duodenal hematomas in children.

J Surg Res 2015 Nov 7;199(1):126-9. Epub 2015 Apr 7.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: Duodenal hematomas from blunt abdominal trauma are uncommon in children and treatment strategies vary. We reviewed our experience with this injury at a large-volume children's hospital.

Materials And Methods: A retrospective case series was assembled from January 2003-July 2014. Data collected included demographics, clinical and radiographic characteristics, and hospital course. Patients with grade I injuries based on the American Association for the Surgery of Trauma Duodenum Injury Scale were compared with those with grade II injuries.

Results: Nineteen patients met inclusion criteria at a median age of 8.91 y (range, 1.7-17.2 y). Mechanisms of injury included direct abdominal blow or handle bar injury (n = 9), nonaccidental trauma (n = 5), falls (n = 3), and motor vehicle accident (n = 2). Ten patients had grade I hematomas and nine had grade II. Hematomas were most frequently seen in the second portion of the duodenum (n = 9). Five patients underwent a laparotomy for concerns for hollow viscus injury. No patients required operative drainage of the hematoma; however, one patient underwent percutaneous drainage. Twelve patients received parenteral nutrition (PN) for a median duration of 9 d (range, 5-14 d). Median duration of PN for grade I was 6.5 d (range, 5-8 d) versus 12 d for grade II (range, 9-14 d; P = 0.016). Complications included one readmission for concern of bowel obstruction requiring bowel rest.

Conclusions: This study suggests that duodenal hematomas can be successfully managed nonoperatively. Grade II hematomas are associated with longer duration of PN therapy and consequently longer hospital stays. These data can assist in care management planning and parental counseling for patients with traumatic duodenal hematomas.
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http://dx.doi.org/10.1016/j.jss.2015.04.015DOI Listing
November 2015

Management of appendiceal carcinoid tumors in children.

J Surg Res 2015 Oct 27;198(2):384-7. Epub 2015 Mar 27.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: Appendiceal carcinoid tumors, also know as well-differentiated neuroendocrine neoplasms, are rare lesions detected incidentally after appendectomy in children. There are limited data about the natural history of these tumors, and guidelines regarding family counseling and need for additional surgery or follow-up imaging are not established in the pediatric age group. The purpose of this study was to review our institutional experience with appendiceal carcinoid tumors to provide data that might improve management.

Methods: After institutional review board approval, the charts of all patients treated at our institution for an appendiceal carcinoid tumor between 2002 and 2014 were reviewed. Data collected included patient demographics, pathologic details, postoperative management, and follow-up information. Descriptive analyses were performed.

Results: Twenty-eight patients were identified, which represents an incidence of 0.2% of children undergoing appendectomy during that time interval. The mean age at surgery was 13.8 ± 2.1 y; 54% were females. Two patients had symptoms suspicious for carcinoid syndrome at presentation, though none had evidence of metastatic disease. The mean tumor size was 0.73 ± 0.4 cm. Five patients (18%) underwent subsequent ileocecectomy or right hemicolectomy because of pathologic findings of invasion of the mesoappendix (n = 4) or lymphovascular invasion and subserosal extension (n = 1), two of whom had residual disease in the resected specimen (one in a lymph node). No recurrences have been detected at mean follow-up of 1.8 y.

Conclusions: Appendiceal carcinoid tumors are discovered incidentally in about 0.2% of children undergoing appendectomy. Based on findings from a large contemporary series, we can conclude that these tumors are generally small and demonstrate lymphovascular invasion or mesenteric extension in fewer than 20% of cases. Prospective, multicenter studies are necessary to better define the indication for ileocecectomy and follow-up imaging protocols.
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http://dx.doi.org/10.1016/j.jss.2015.03.062DOI Listing
October 2015

Correlating surgical and pathological diagnoses in pediatric appendicitis.

J Pediatr Surg 2015 Apr 6;50(4):638-41. Epub 2014 Nov 6.

Texas Children's Hospital, Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine. Electronic address:

Background: The stratification of appendicitis into simple and complex variants has far-reaching implications. While the operative diagnosis made by the surgeon dictates clinical management, the pathologic diagnosis often differs and is frequently used for coding and reimbursement. The purpose of this study was to examine discrepancies between the operative and pathologic diagnoses with subsequent correlation to clinical outcomes.

Methods: Patients with acute appendicitis from July 2011 to July 2012 were identified. Diagnoses included simple (normal, acute, and suppurative) and complex (gangrenous and perforated). We evaluated the inter-rater reliability between pathologic and operative diagnoses in the five appendicitis categories. Clinical outcomes of deep and superficial surgical site infections were evaluated according to the pathologic and surgical diagnosis.

Results: During the study period, we identified 1166 patients with acute appendicitis. The surgeon and pathologist agreed on the specific diagnosis (acute, suppurative, gangrenous, perforated, normal) in 48% of patients (kappa 0.289, 95% CI 0.259-0.324, p=0.001). Agreement on disease severity (simple vs. complex) improved to 82%. The operative diagnosis more accurately predicted infectious complications than the pathologic diagnoses.

Conclusion: Significant discordance exists between surgical and pathologic diagnoses. While the relevance of this discordance to clinical outcomes is still not clear, a potential for incorrect hospital coding and subsequent reimbursement exists. Future quality improvement projects should focus on standardizing the surgical and pathologic diagnoses.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.11.001DOI Listing
April 2015

Performance of CT examinations in children with suspected acute appendicitis in the community setting: a need for more education.

AJR Am J Roentgenol 2015 Apr;204(4):857-60

1 Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX.

Objective: Despite a recent focus on the preferential use of ultrasound over CT for pediatric appendicitis, most children transferred from community hospitals still undergo diagnostic CT scans. The purpose of this study was to evaluate CT techniques performed for children with acute appendicitis at nonpediatric treatment centers.

Materials And Methods: All patients treated for acute appendicitis at our tertiary-care pediatric hospital from July 1, 2011, through June 30, 2012, were identified. Patient demographics, imaging modality used to diagnoses appendicitis (CT or ultrasound), location (home or referral institution), and CT technique parameters were collected. The estimated mean organ radiation dose, number of imaging phases, and use of contrast media were evaluated at home and referral institutions.

Results: During the study period, 1215 patients underwent appendectomies after imaging, with 442 (36.4%) imaged at referral facilities. Most referral patients received a diagnosis by CT (n=384, 87%), compared with 73 of 773 (9.4%) who received a diagnosis by CT at the home institution. The estimated mean (±SD) organ radiation dose was not statistically significantly different between home and referral institutions (13.5±7.3 vs 12.9±6.4 mGy; p=0.58) for single-phase examinations. Of 384 referral patients, 344 had images available for review. In total, 40% (138/344) of patients from referral centers were imaged with suboptimal CT techniques: 50 delayed phase only, 52 dual phase (eight of which were imaged twice in delayed phase), eight triple phase, and 36 without IV contrast agent.

Conclusion: CT parameters and radiation doses from single-phase examinations in children with appendicitis were similar at nonpediatric treatment centers and a tertiary care children's hospital. Future educational outreach should focus on optimizing other technical parameters.
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http://dx.doi.org/10.2214/AJR.14.12750DOI Listing
April 2015

Resource utilization after gastrostomy tube placement: defining areas of improvement for future quality improvement projects.

J Pediatr Surg 2014 Nov 8;49(11):1598-601. Epub 2014 Aug 8.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. Electronic address:

Background: Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis.

Methods: We reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30 days after discharge and 30-365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies.

Results: During the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3 months (range 0.03 months-22 years). Of the total patient population, 219 were discharged less than 30 days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30 days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31-365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%).

Conclusions: Few studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.06.015DOI Listing
November 2014

Outcomes comparing dual-lumen to multisite venovenous ECMO in the pediatric population: the Extracorporeal Life Support Registry experience.

J Pediatr Surg 2014 Oct 8;49(10):1452-7. Epub 2014 Sep 8.

Texas Children's Hospital, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX. Electronic address:

Purpose: The purpose of this study is to evaluate outcomes associated with single site dual-lumen venovenous cannulas (VVDL) and to compare them to those associated with multisite VV ECMO (VVMS) cannulation.

Methods: The Extracorporeal Life Support (ELSO) Registry was reviewed to identify all children 31days to 18years treated with venovenous ECMO from 1998 to 2011 using either VVDL or VVMS techniques. Patient demographics, cannula type, ECMO variables, complications, and patient survival were analyzed.

Results: From 1998 to 2011, 1323 children underwent venovenous ECMO. The annual utilization of VVDL cannulas has increased and recently surpassed VVMS. Fifty-four percent (n=717) of patients had VVDL cannulation. This group was significantly younger and weighed less than the VVMS group. VVDL cannulas demonstrated improved weight-adjusted flow performance than traditional cannulation. Overall survival was comparable, 64.4% and 68.6%, for VVMS and VVDL respectively. VVDL cannulas experienced higher mechanical (26.2% vs. 22.5%; p=0.004) and cardiovascular complications rates (24.4% vs. 21.7%; p=0.03) than VVMS cannulas, but when stratified by VVDL cannula type, there were no differences between wire-reinforced and non-wire reinforced cannulas.

Conclusions: VVDL cannulation has become the preferred modality for ECMO therapy in children with respiratory failure and it is mainly utilized in younger patients. The use of newer VVDL cannulas may provide improved pump flow performance without substantial additional risk.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.05.027DOI Listing
October 2014

Management of the pediatric spontaneous pneumothorax: is primary surgery the treatment of choice?

Am J Surg 2014 Oct 24;208(4):571-6. Epub 2014 Jul 24.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA.

Background: Surgery as the primary management strategy for pediatric primary spontaneous pneumothorax is controversial. This study aims to evaluate the outcomes and effectiveness of management approaches for pediatric spontaneous pneumothorax.

Methods: Outcomes of pediatric patients undergoing initial nonoperative treatment versus video-assisted thoracoscopic surgery with blebectomy and mechanical pleurodesis were compared via a retrospective review.

Results: We identified 96 patients with 108 pneumothoraces. Of 98 pneumothoraces with initial nonoperative management, 37% had surgery during their initial hospitalization for persistent air leak. Of those discharged home without video-assisted thoracoscopic surgery, 40% recurred. Initial nonoperative management resulted in more total hospital days (median: 11 vs 5 days, P < .001). No significant predictors of recurrence were identified on multivariate analysis. Sixty-three percent of all patients ultimately required surgery.

Conclusions: Fewer than 40% of primary spontaneous pneumothorax patients are definitively treated with nonoperative management. A prospective study is needed to determine whether primary surgery with blebectomy/mechanical pleurodesis is a more effective treatment strategy.
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http://dx.doi.org/10.1016/j.amjsurg.2014.06.009DOI Listing
October 2014

The management of an ectopic ovary in the inguinal canal: literature review and discussion.

Pediatr Surg Int 2014 Oct 6;30(10):1075-8. Epub 2014 Aug 6.

Division of Pediatric Surgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin, Suite 1210, Houston, TX, 77030, USA.

We report the case of a female adolescent who had an ectopic ovary in the inguinal canal without an associated hernia, a unicornuate uterus, and ipsilateral renal agenesis. The incidental discovery of the ectopic ovary and other Mullerian anomalies, as well as the surgical correction that followed, highlights important fertility considerations in children and available treatment algorithms for these rare cases.
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http://dx.doi.org/10.1007/s00383-014-3582-yDOI Listing
October 2014

Overuse of fluoroscopic gastrostomy studies in a children's hospital.

J Surg Res 2014 Aug 9;190(2):598-603. Epub 2014 May 9.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas. Electronic address:

Background: Gastrostomy tubes are often dislodged or exchanged in children. Indications for fluoroscopic examination of gastrostomy location include concern for malposition, dislodgement, leak, or gastric outlet obstruction. We hypothesized that most of the studies obtained at our institution were not ordered for one of the aforementioned indications and do not ultimately affect patient management.

Methods: All fluoroscopic gastrostomy studies performed from January 2011 to December 2012 were reviewed. Transgastric jejunostomy studies were excluded. Patient demographics, indications for the study, elapsed time since placement, imaging findings, and short-term outcomes were recorded. Chi-square analysis was used to evaluate relationships between categorical variables.

Results: During the study period, 337 patients who underwent fluoroscopic gastrostomy studies were identified; median age was 2.5 y (0.05-23.8). Sixty-two percent (208/337) of the studies were ordered in asymptomatic patients to confirm tube placement location after routine exchange or replacement. Symptomatic patients accounted for 38% of the studies. Ordering physicians were primarily nonsurgeons (72%, 242/337). Abnormal findings were observed in 4.8% (16/337) of patients, six (1.7%) of whom required an operative intervention. The 2.9% (6/208) abnormal study rate for asymptomatic patients was significantly lower than the 7.9% (10/129) rate in the patients who were evaluated for symptomatic indications (P = 0.03).

Conclusions: Most of the fluoroscopic gastrostomy studies ordered at a tertiary care center did not appear to alter patient care. Development of a standardized management algorithm based on clinical indications is necessary to decrease the number of extraneous gastrostomy studies.
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http://dx.doi.org/10.1016/j.jss.2014.05.010DOI Listing
August 2014

Management of pediatric snake bites: are we doing too much?

J Pediatr Surg 2014 Jun 10;49(6):1009-15. Epub 2014 Feb 10.

Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine. Electronic address:

Background: The optimal management of children with snake bite injuries is not well defined. The purpose of this study was to review the use of antivenom, diagnostic tests, and antibiotics in children bitten by venomous snakes in a specific geographic region (Southeast Texas).

Methods: This is a retrospective single-center review of all patients with snake bite injury from 1/2006 to 6/2012. An envenomated bite was defined as causing edema, discoloration of the skin, necrosis, or systemic effects. The severity of injury was scored using a novel 4-point scale based on initial physical examination alone.

Results: One hundred fifty-one children (mean age 8.4±4.3years) were treated for a snake bite. There were no mortalities. Lower extremity injuries were most common (60%). Most bites were from copperheads (43%). Envenomation was evident in 82% (average wound score: 2.61±0.81). The median hospital stay for admitted patients (79%) was 2days (range 1-7). Four patients required surgery for complications of the snake bite. Fifty-two children (34%) received CroFab, with one allergic reaction. 22/135 (16%) had evidence of coagulopathy. Seventy-two children (48%) received IV antibiotics.

Conclusion: Despite a high rate of envenomated bites in Southeast Texas, significant morbidity is rare. Children with an envenomation score of 1 or 2 are unlikely to be coagulopathic, suggesting that laboratory investigation should be reserved for patients with higher scores. The indications for the administration of CroFab deserve further prospective study.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.01.043DOI Listing
June 2014

Fetal MRI improves diagnostic accuracy in patients referred to a fetal center for suspected esophageal atresia.

J Pediatr Surg 2014 May 22;49(5):712-5. Epub 2014 Feb 22.

Texas Children's Fetal Center, Texas Children's Hospital, Houston, Texas; Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas. Electronic address:

Purpose: The purpose of this study was to describe prenatal imaging characteristics and outcomes of fetuses with suspected esophageal atresia (EA) in order to improve prenatal diagnosis, counseling, and management.

Methods: The medical records of all patients referred to our multidisciplinary fetal center for suspected EA from January 2003 to April 2013 were reviewed retrospectively.

Results: Thirty-three patients were referred with a prenatal diagnosis of possible EA. Following fetal center evaluation with MRI, EA was deemed unlikely in 6 (18%) fetuses. Of 27 fetuses in whom EA could not be excluded, EA was confirmed postnatally in 15 (56%), excluded in 7 (26%), and unconfirmed in 5 (3 fetal losses; 2 lost to follow-up). Imaging characteristics on fetal MRI associated with the highest positive predictive values (PPV) were an esophageal pouch (100%) and a small stomach (75%). The finding of polyhydramnios had high sensitivity (93%) but low specificity (31%) and PPV (61%) for a diagnosis of EA.

Conclusion: Prenatal imaging and fetal center evaluation correctly identify the presence or absence of esophageal atresia in 78% of patients referred on suspicion of this condition. The presence of an esophageal pouch on fetal MRI has significant predictive value for EA. These data may assist with evidence-based prenatal family counseling.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.02.053DOI Listing
May 2014

Prenatal MRI fetal lung volumes and percent liver herniation predict pulmonary morbidity in congenital diaphragmatic hernia (CDH).

J Pediatr Surg 2014 May 22;49(5):688-93. Epub 2014 Feb 22.

Texas Children's Fetal Center, Baylor College of Medicine, Houston, TX, USA; The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA. Electronic address:

Purpose: The purpose of this study was to determine whether prenatal imaging parameters are predictive of postnatal CDH-associated pulmonary morbidity.

Methods: The records of all neonates with CDH treated from 2004 to 2012 were reviewed. Patients requiring supplemental oxygen at 30 days of life (DOL) were classified as having chronic lung disease (CLD). Fetal MRI-measured observed/expected total fetal lung volume (O/E-TFLV) and percent liver herniation (%LH) were recorded. Receiver operating characteristic (ROC) curves and multivariate regression were applied to assess the prognostic value of O/E-TFLV and %LH for development of CLD.

Results: Of 172 neonates with CDH, 108 had fetal MRIs, and survival was 76%. 82% (89/108) were alive at DOL 30, 46 (52%) of whom had CLD. Neonates with CLD had lower mean O/E-TFLV (30 vs.42%; p=0.001) and higher %LH (21.3±2.8 vs.7.1±1.8%; p<0.001) compared to neonates without CLD. Using ROC analysis, the best cutoffs in predicting CLD were an O/E-TFLV<35% (AUC=0.74; p<0.001) and %LH>20% (AUC=0.78; p<0.001). On logistic regression, O/E-TFLV<35% and a %LH>20% were highly associated with indicators of long-term pulmonary sequelae. On multivariate analysis, %LH was the strongest predictor of CLD in patients with CDH (OR: 10.96, 95%CI: 2.5-48.9, p=0.002).

Conclusion: Prenatal measurement of O/E-TFLV and %LH is predictive of CDH pulmonary morbidity and can aid in establishing parental expectations of postnatal outcomes.
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http://dx.doi.org/10.1016/j.jpedsurg.2014.02.048DOI Listing
May 2014