Publications by authors named "Wendy Jo Svetanoff"

35 Publications

IMPPACT (Intravenous Monotherapy for Postoperative Perforated Appendicitis in Children Trial): Randomized Clinical Trial of Monotherapy versus Multi-drug Antibiotic Therapy.

Ann Surg 2021 Jun 16. Epub 2021 Jun 16.

Division of Pediatric Surgery, Phoenix Children's Hospital, Phoenix, Arizona University of Arizona College of Public Health, Phoenix, Arizona Division of Pediatric Surgery, The Children's Mercy Hospital, Kansas City, Missouri.

Background: Perforated appendicitis is the most common cause of intraabdominal abscess (IAA) in children. The optimal postoperative antibiotic regimen to reduce IAA has evolved in the last decade from triple-drug to 2-drug therapy (CM). Recent retrospective studies show decreased infectious complications with monotherapy PT. To date prospective comparative data are lacking. Therefore, a prospective randomized trial comparing PT versus CM was conducted.

Methods: A multi-institutional prospective randomized trial was performed in children with perforated appendicitis comparing postoperative antibiotic regimens PT or CM. The primary outcome was 30-day postoperative IAA formation. Perforation was strictly defined as a hole in the appendix or fecalith in the abdomen, documented with intraoperative photographs.

Results: One hundred sixty-two patients were enrolled during the study period. No differences in age, weight, or duration of presenting symptoms were identified. In addition, length of stay, duration of intravenous antibiotic treatment, discharge oral antibiotic treatment, and antibiotic-related complications did not differ between groups. Compared to the CM group, the PT group had significantly lower IAA rate [6.1% vs 23.8%, odd ratio (OR) 4.80, P = 0.002], lower postoperative computed tomography imaging rate (13.9% vs 29.3%, OR 2.57, P = 0.030), and fewer emergency room visits (8.8% vs 26.4%, OR 3.73, P = 0.022). Multivariate logistic regression analysis found the use of CM versus PT (OR 9.21, P = 0.021) to be the most significant predictor for developing IAA.

Conclusions: In children with perforated appendicitis, postoperative monotherapy with PT is superior to standard 2-drug therapy with CM and does not increase antibiotic-related complications or antibiotic exposure duration.
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http://dx.doi.org/10.1097/SLA.0000000000005006DOI Listing
June 2021

Psychosocial factors affecting quality of life in patients with anorectal malformation and Hirschsprung disease-a qualitative systematic review.

J Pediatr Surg 2021 May 21. Epub 2021 May 21.

Comprehensive Colorectal Center, Children's Mercy-Kansas City, Kansas City, MO, United States; Department of Surgery, Children's Mercy Hospital Kansas City, MO, United States; University of Missouri-Kansas City School of Medicine, United States. Electronic address:

Introduction: Little is known about psychosocial and behavioral factors that impact the quality of life of patient's with anorectal malformations (ARM) and Hirschsprung disease (HSCR). We aimed to highlight the psychosocial, emotional, and behavioral themes that affect these patients.

Methods: A qualitative literature review of articles published between 1980 and 2019 was performed. Articles that reported quality of life (QoL) measures not directly related to bowel function and incorporated data on patients aged 0-21 years old were included. Data were separated based on distinct developmental time points.

Results: In the neonatal period, parents relayed uncertainty about the future and feeling overwhelmed by lack of social support. Difficulties with anxiety, peer rejection, and behavioral problems were noted in primary grades, while adolescents experienced low self-confidence, poor body image, and depression. Young adults expressed hesitancy to engage in romantic relationships or sexual activity. Lack of long-term follow-up, an incomplete transition to adult healthcare, and lack of psychology services leave young adults without guidance to manage a chronic condition.

Conclusion: Multiple psychosocial stressors are present in the lives of ARM and HSCR patients. Provision of developmentally matched medical, psychological, and community-based supports for ARM and HSCR patients and their families can lead to improved QoL.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.05.004DOI Listing
May 2021

Neonatal Renal Failure in the Setting of Anorectal Malformation: A Case Report and Literature Review.

Cureus 2021 May 12;13(5):e14984. Epub 2021 May 12.

Pediatric Surgery, University of Missouri Kansas City School of Medicine, Kansas City, USA.

Anorectal malformations (ARMs) can occur in isolation or in association with other anomalies, most commonly those of the genitourinary systems. Morbidity and mortality are highest among patients who develop end-stage renal disease (ESRD) either from severe congenital anomalies (dysplastic kidneys) or from repeated infections in those who have vesicoureteral reflux or persistent recto-urinary fistulas. We describe our management strategy for a patient born with an ARM and bilateral dysplastic kidneys to highlight the nuances and complex decision-making considerations required in taking care of this complex patient population. Our patient is a male twin born at 32 weeks' gestational age who was found to have bilateral dysplastic kidneys on prenatal ultrasound. On initial examination, an imperforate anus was identified along with a severe urethral stricture. Full workup also revealed sacral dysgenesis and confirmation of the dysplastic kidneys. On day of life 3, a laparoscopic diverting sigmoid colostomy was performed; urologic evaluation confirmed the severe urethral stricture, which required dilation to place an 8F council tip catheter. Due to his small size, peritoneal dialysis could not be initiated until five weeks of age. As full volumes could not be reached with peritoneal dialysis, he was soon transitioned to continuous renal replacement therapy. At five months of age, a laparoscopic-assisted posterior sagittal anorectoplasty (PSARP) was performed. As his urethral stricture had worsened, a suprapubic catheter had been placed for bladder decompression. Reversal of his colostomy was performed 15 days after PSARP. Unfortunately, the patient required three further surgical interventions due to abdominal wall and inguinal hernias contributing to filling and emptying dysfunction when utilizing peritoneal dialysis. He is currently 16 months of age and remains inpatient due to intermittent hemodialysis requirements along with autocycling of his peritoneal dialysis. He is working on developmental milestones, can pull to a stand, and is currently being evaluated for kidney transplantation. The development of ESRD in a neonate or infant with an ARM is rare and can be due to congenital dysplasia or agenesis of bilateral kidneys. While peritoneal dialysis is the preferred approach, catheter dysfunction can result from intra-abdominal adhesions or inadequate fluid removal from inguinal or abdominal wall hernias that form in the setting of increased intra-abdominal pressure required for peritoneal dialysis. Close collaboration is required between pediatric surgeons, nephrologists, and urologists to facilitate colonic and urologic reconstruction and manage catheter-related complications.
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http://dx.doi.org/10.7759/cureus.14984DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8194500PMC
May 2021

Leveraging Collaboration in Pediatric Multidisciplinary Colorectal Care Using a Telehealth Platform.

Am Surg 2021 Jun 9:31348211023428. Epub 2021 Jun 9.

Comprehensive Colorectal Center, 4204Children's Mercy Hospital, University of Missouri Kansas City, Kansas City, MO, USA.

Purpose: Pediatric colorectal problems often require complex multidisciplinary care (MDC), which has been affected by the SARS-CoV-2-2019 (COVID-19) pandemic. We describe our utilization and implementation of telehealth (TH) for pediatric colorectal surgery MDC visits and collate patient satisfaction using TH compared to in-person (IP) visits.

Methods: Implementation of a single-institution MDC TH platform to perform patient visits on February 1, 2020 was studied. Following 6 months of implementation, TH visits' characteristics were compared with IP visits in the 3 months before implementation by patient volume, length of clinic visits, and patient satisfaction survey results.

Results: Before implementation, 152 (100%) of clinic visits were IP. During the implementation, 87 (37.7%) were TH visits. Seventy-four (49%) were MDC visits, 17 (23%) of these using the TH platform. Each TH visit's median length was 25 minutes (IQR 15-30), while the median length of IP visits was 45 minutes (IQR 30-45). Pre-implementation satisfaction scores were 88.6% positive, while satisfaction scores after implementation were 96.8% positive. None of the patients who utilized the TH platform had an unplanned hospital admission within 24 hours of being seen.

Conclusion: Our experience demonstrates that the TH platform can provide an efficient avenue for established patients and families to receive highly complex multidisciplinary follow-up care. High levels of patient satisfaction indicated that TH should become part of the routine care plan for patients who require long-term or consistent follow-up.
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http://dx.doi.org/10.1177/00031348211023428DOI Listing
June 2021

Debunking the Myth on Surgical Site Infection: In Reply to Spruce.

J Am Coll Surg 2021 Jul 15;233(1):159-161. Epub 2021 May 15.

Kansas City, MO.

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http://dx.doi.org/10.1016/j.jamcollsurg.2021.04.004DOI Listing
July 2021

Evolution, lessons learned, and contemporary outcomes of esophageal replacement with jejunum for children.

Surgery 2021 Jul 1;170(1):114-125. Epub 2021 Apr 1.

Department of General Surgery, Boston Children's Hospital, MA. Electronic address:

Background: The jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes.

Methods: The study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010-2015) and contemporary cohorts (2016-2019).

Results: Fifty-five patients, 58% male, median age 4 years (interquartile range 2.4-8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P = .01), intensive care unit (22 vs 13 days; P = .03), and hospital stay (50 vs 27 days; P = .004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P = .78), anastomotic stricture resection (7% vs 10%; P = .74), and need for reoperation (57% vs 46%; P = .48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P = .007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P = .04).

Conclusion: We have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition.
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http://dx.doi.org/10.1016/j.surg.2021.01.036DOI Listing
July 2021

Contemporary outcomes of the Foker process and evolution of treatment algorithms for long-gap Esophageal Atresia.

J Pediatr Surg 2021 Feb 26. Epub 2021 Feb 26.

Boston Children's Hospital, Department of General Surgery; Johns Hopkins All Children's Hospital, Department of Surgery.

Background: Esophageal growth using the Foker process (FP) for long-gap esophageal atresia (LGEA) has evolved over time.

Methods: Contemporary LGEA patients treated from 2014-2020 were compared to historical controls (2005 to <2014).

Results: 102 contemporary LGEA patients (type A 50%, B 18%, C 32%; 36% prior anastomotic attempt; 20 with esophagostomy) underwent either primary repair (n=23), jejunal interposition (JI; n = 14), or Foker process (FP; n = 65; 49 primary [p], 16 rescue [r]). The contemporary p-FP cohort experienced significantly fewer leaks on traction (4% vs 22%), bone fractures (2% vs 22%), anastomotic leak (12% vs 37%), and Foker failure (FP→JI; 0% vs 15%), when compared to historical p-FP patients (n = 27), all p ≤ 0.01. Patients who underwent a completely (n = 11) or partially (n = 11) minimally invasive FP experienced fewer median days paralyzed (0 vs 8 vs 17) and intubated (9 vs 15 vs 25) compared to open FP patients, respectively (all p ≤ 0.03), with equivalent leak rates (18% vs 9% vs 26%, p = 0.47). At one-year post-FP, most patients (62%) are predominantly orally fed.

Conclusion: With continued experience and technical refinements, the Foker process has evolved with improved outcomes, less morbidity and maximal esophageal preservation.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.054DOI Listing
February 2021

A single institution experience with Laparoscopic Hernia repair in 791 children.

J Pediatr Surg 2021 Jun 23;56(6):1185-1189. Epub 2021 Feb 23.

Department of Surgery, Children's Mercy, Kansas City, USA; University of Missouri-Kansas City School of Medicine, Kansas City, USA. Electronic address:

Introduction: There are many described technique to performing laparoscopic inguinal hernia repair in children. We describe our outcomes using a percutaneous internal ring suturing technique.

Methods: A retrospective review of patients under 18 years old who underwent repair between January 2014 - March 2019 was performed. A percutaneous internal ring suturing technique, involving hydro-dissection of the peritoneum, percutaneous suture passage, and cauterization of the peritoneum in the sac prior to high ligation, was used. p < 0.05 was considered significant during the analysis.

Results: 791 patients were included. The median age at operation was 1.9 years (IQR 0.37, 5.82). The median operative time for a unilateral repair was 21 min (IQR 16, 28), while the median time for a bilateral repair was 30.5 min (IQR 23, 41). In total, 3 patients required conversion to an open procedure (0.4%), 4 (0.6%) experienced post-operative bleeding, 9 (1.2%) developed a wound infection, and iatrogenic ascent of testis occurred in 10 (1.3%) patients. Twenty patients (2.5%) developed a recurrent hernia. All but two were re-repaired laparoscopically.

Conclusions: The use of percutaneous internal ring suturing for laparoscopic repair of inguinal hernias in the pediatric population is safe and effective with a low rate of complications and recurrence.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.02.021DOI Listing
June 2021

Post-operative enterocolitis in Hirschsprung's disease: response to a Letter to the Editor.

Pediatr Surg Int 2021 Apr 16;37(4):527-528. Epub 2021 Feb 16.

Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.

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http://dx.doi.org/10.1007/s00383-021-04866-6DOI Listing
April 2021

Long-term outcomes and satisfaction rates after costal cartilage resection for slipping Rib syndrome.

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

Department of Pediatric Surgery, Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108, USA. Electronic address:

Purpose: Slipping rib syndrome (SRS) is a challenging and underdiagnosed condition. We previously demonstrated the efficacy of costal cartilage resection for SRS and now report long-term follow-up of our updated cohort.

Methods: Retrospective chart review with prospective telephone follow-up was performed for 30 previously analyzed patients and 22 new patients to elucidate risk factors for recurrence, discuss preoperative experience, current symptoms, postoperative course, and satisfaction.

Results: From 2006-2020, 49 patients met inclusion criteria and underwent 67 operations. Eleven underwent re-operation for recurrence, with median time of 1.6 years [1.2, 2.6]. Median age of symptom onset was 13 years [11,14] while median age at diagnosis was 15.4 years [14, 16.7]. 29/49 (59%) patients were contacted, with median follow-up of 4.5 years [2.1, 5.7]. Twenty-one patients (72%) reported complete cure, 20 (69%) reported satisfaction 10/10, with 83% rating their satisfaction >7/10. Eleven patients (38%) were offered opioids for pain control prior to surgical evaluation. Patients with recurrence had residual or fused cartilage, hypermobile bony ribs, or both, at re-excision.

Conclusions: Costal cartilage resection is an effective treatment for SRS with high satisfaction rates and an appropriate consideration for patients who fail conservative management.

Level Of Evidence: Level IV; Case series with no comparison groups.
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http://dx.doi.org/10.1016/j.jpedsurg.2021.01.034DOI Listing
January 2021

Colostomy Takedown: Ischemic Complication following Anorectal Malformation Surgery.

Case Rep Surg 2021 12;2021:8870631. Epub 2021 Jan 12.

Comprehensive Colorectal Center, Department of Surgery, Children's Mercy Kansas City, Kansas City, MO 64108, USA.

Introduction: Anorectal malformations (ARM) are complex disorders that often require staged reconstructions. We present a case and imaging findings of a child who developed issues following colostomy closure due to segmental colonic ischemia. . A 3-year-old female with Currarino syndrome presented with abdominal distention, blood-flecked stools, and prolonged cecostomy flush time. For her anorectal malformation, a colostomy was initially placed. A new colostomy was created at posterior sagittal anorectoplasty (PSARP) to allow the distal rectum to reach the anus without tension. Differentials for her presenting symptoms included a mislocation of the anus, stenosis at the anoplasty site, stricture within the colon, or sacral mass from Currarino syndrome, causing obstructive symptoms. Workup at our hospital included an anorectal exam under anesthesia (EUA), which showed a well-located anus with without stenosis at the anoplasty site, and an antegrade contrast study revealed a featureless descending colon with a 3-4 mm stricture in the distal transverse colon at the site of the previous colostomy, without an obstructing presacral mass. To alleviate this obstruction, the child underwent removal of the chronically ischemic descending colon and a redo-PSARP, where the distal transverse colon was brought down to the anus. She is now able to successfully perform antegrade flushes.

Conclusion: Patients who have had prior surgeries for ARM repair are at a higher risk of complications, including strictures or ischemic complications at areas of previous surgery or colostomy placement. A thorough preoperative workup, including contrast studies, can alert the surgeon to these potential pitfalls.
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http://dx.doi.org/10.1155/2021/8870631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7817294PMC
January 2021

Debunking the Myth: What You Really Need to Know about Clothing, Electronic Devices, and Surgical Site Infection.

J Am Coll Surg 2021 Mar 13;232(3):320-331.e7. Epub 2021 Jan 13.

Department of General and Thoracic Surgery, Children's Mercy Hospital, Kansas City, MO; University of Missouri-Kansas City (UMKC) School of Medicine, Kansas City, MO. Electronic address:

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http://dx.doi.org/10.1016/j.jamcollsurg.2020.11.032DOI Listing
March 2021

Impact of an institution-designed algorithm for the management of dislodged gastrostomy tubes.

J Pediatr Surg 2020 Dec 24. Epub 2020 Dec 24.

Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States; University of Missouri-Kansas City School of Medicine, 2411 Holmes Street, Kansas City, MO 64108, United States. Electronic address:

Background: Gastrostomy tube (GT) dislodgement is a common reason for emergency department (ED) visits. We aim to assess the efficacy of our institution's algorithm in reducing surgical consultation and GT contrast studies for replacement of dislodged GT and to examine the need for operation before and after algorithm implementation.

Methods: A retrospective review was performed between March 2017-February 2018 (prealgorithm) and March 2018-December 2018 (postalgorithm) for patients <18 years presenting to the ED with GT dislodgement. Demographics and outcomes were analyzed.

Results: A total of 433 visits among 279 patients were included, 200 (46.2%) pre and 233 (53.8%) postalgorithm implementation. Median ED LOS was 2.1 h (IQR 1.4, 3.0). Surgery was consulted in 92 visits (21.3%) and a contrast study obtained in 287 (66.3%). The GT was replaced by ED providers in 363 visits (83.8%) and by surgery in 70 (16.2%). Surgical consultation increased postalgorithm (16.5% vs. 25.3%; p = 0.03). Six (1.4%) patients required reoperation, with 5 occurring postalgorithm, p = 0.22. For GTs placed < 8 weeks prior to the dislodgment, there were no differences in surgical consultations, contrast studies performed, or need for reoperation pre and postalgorithm.

Conclusion: An algorithm for replacement of dislodged GT is usable, effective, and increased surgical team involvement without significant changes in patient outcomes. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.12.009DOI Listing
December 2020

Prophylactic negative vacuum therapy of high-risk esophageal anastomoses in pediatric patients.

J Pediatr Surg 2021 May 13;56(5):944-950. Epub 2020 Dec 13.

Division of Gastroenterology, Hepatology and Nutrition; Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States.

Background: Esophageal anastomoses are at risk for leak or stricture. Negative pressure vacuum-assisted closure (VAC) therapy is used to treat leak. We hypothesized that a prophylactic VAC (pEVAC) at the time of new anastomosis may lead to fewer leaks and strictures.

Methods: Single center retrospective case-control study of patients undergoing high-risk esophageal anastomoses between July 2015 and January 2019. Outcomes of leak and long-term anastomotic failure (refractory stricture requiring surgery) were compared between groups.

Results: Sixteen patients had a pEVAC placed during LGEA repair (N = 10) or stricture resection (N = 6). Of pEVAC cases, 3 (N = 1 Foker, N = 2 stricture resections) experienced leak (18.8%). In comparison, leak occurred in 9/41 (22%) Foker patients and in 1/20 (5%) stricture resections without pEVAC, all p > 0.05. Long-term anastomotic failure was more common in the pEVAC cohort versus controls (56.3% versus 11.5%, p < 0.001).

Conclusions: Prophylactic EVAC placement does not appear to reduce leak and is associated with significantly greater odds of long-term anastomotic failure. Further device refinement could improve its potential role in prophylaxis of high-risk anastomoses, but future research is needed to better understand optimal patient selection, device design, and duration of pEVAC therapy.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.12.002DOI Listing
May 2021

The left-sided repair: An alternative approach for difficult esophageal atresia repair.

J Pediatr Surg 2021 May 13;56(5):938-943. Epub 2020 Nov 13.

Department of General Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States; Department of Surgery, Johns Hopkins All Children's Hospital, 601 5th St S, Ste306, St. Petersburg, FL 33701, United States. Electronic address:

Purpose: We describe a left-sided approach for long gap esophageal atresia (LGEA) repair in patients who have a large leftward upper pouch and no significant tracheomalacia, or as a salvage strategy after prior failed right-sided repairs.

Methods: Retrospective review of patients who underwent repair via traction induced growth (Foker procedure [FP]) from 2014 to 2019 was performed. Surgical technique and post-operative outcomes were evaluated.

Results: Of 47 LGEA patients, 18 (38%) were approached via the left side - 94% had a left aortic arch, and 22% had prior attempts at a right-sided anastomosis. More left-sided patients underwent minimally invasive repair (39% vs 7%, p = 0.007) and internal traction (50% vs 10%, p = 0.002) compared to right-sided patients. On multivariate analysis, internal traction was associated with a decreased length of paralysis (p<0.01); length of intubation and hospital stay were similar between groups. Anastomotic leak (17% vs 20%, p = 0.80) and stricture resection (6% vs 24%, p = 0.12) rates were similar. No left-sided FP patient required additional surgery for tracheomalacia, while six right-sided patients required intervention.

Conclusion: Left-sided FP can be considered for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.11.003DOI Listing
May 2021

30 Years of Flipping the Coin-Heads or Tails?

Eur J Pediatr Surg 2020 Nov 3. Epub 2020 Nov 3.

Department of Surgery, Center for Prospective Trials, Children's Mercy Hospital, Kansas City, Missouri, United States.

Introduction:  Swallowed coins are a frequent cause of pediatric emergency department visits. Removal typically involves endoscopic retrieval under anesthesia. We describe our 30-year experience retrieving coins using a Foley catheter under fluoroscopy ("coin flip").

Materials And Methods:  Patients younger than 18 years who underwent the coin flip procedure from 1988 to 2018 were identified. Failure of fluoroscopic retrieval was followed by rigid endoscopic retrieval in the operating room. Detailed subanalysis of patients between 2011 and 2018 was also performed.

Results:  A total of 809 patients underwent the coin flip procedure between 1988 and 2018. Median age was 3.3 years; 51% were male. The mean duration from ingestion to presentation was 19.8 hours. Overall success of removal from the esophagus was 85.5%, with 76.5% of coins retrieved and 9% pushed into the stomach. All remaining coins were retrieved by endoscopy. Complication rate was 1.2% with nine minor and one major complications, a tracheal tear that required repair. In our recent cohort, successful fluoroscopic removal led to shorter hospital lengths of stay (3.2 vs. 18.1 hours,  < 0.001).

Conclusion:  Patients who present with a coin in the esophagus can be successfully managed with a coin flip, which can be performed without hospital admission, with rare complications.
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http://dx.doi.org/10.1055/s-0040-1718752DOI Listing
November 2020

Same-day discharge for pediatric laparoscopic gastrostomy.

J Pediatr Surg 2021 Jan 6;56(1):26-29. Epub 2020 Oct 6.

Children's Mercy Hospital, Kansas City, MO. Electronic address:

Background: Laparoscopic gastrostomy is a common procedure in children. We developed a same-day discharge (SDD) protocol for laparoscopic button gastrostomy.

Methods: We performed a prospective observational study of children undergoing laparoscopic button gastrostomy and were eligible for SDD from August 2017-September 2019. Patients were eligible if: 1) the family was comfortable with eliminating overnight admission and were suitable candidates for outpatient surgery (absence of major co-morbidities), 2) they were not undergoing additional procedures requiring admission, and 3) they received pre-operative education.

Results: Sixty-two patients who underwent laparoscopic button gastrostomy were eligible for SDD. The median age was 2.1 years [IQR 0.9-4.1], and the median weight was 10.5 kg [IQR 7.6-15.5]. Forty-one (66%) were previously nasogastric fed. The median operative time was 22 min [IQR 16-29]. The median time to initiation of feeds was 4.4 h [IQR 3.4-5.5]. Fifty-one (82%) were discharged the same day with a median length of stay of 9 h [IQR 7-10]. Eleven were admitted, most commonly for further teaching. Eleven SDD patients were seen in the emergency room <30 days at a median 5 days [IQR 3-12] post-operatively, primarily for mechanical complications.

Conclusion: Same-day discharge following laparoscopic gastrostomy is safe and feasible for select pediatric patients who undergo pre-operative education. The SDD pathway results in a low admission rate and relatively low ER visits.

Type Of Study: Prospective Observational Study.

Level Of Evidence: Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.09.044DOI Listing
January 2021

Are Posterior Crural Stitches Necessary in Pediatric Laparoscopic Fundoplication?

J Laparoendosc Adv Surg Tech A 2020 Dec 27;30(12):1272-1276. Epub 2020 Oct 27.

Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, USA.

Minimal esophageal mobilization during laparoscopic fundoplication decreases the rate of wrap transmigration, and previous study has shown that placement of esophageal-crural sutures does not offer any advantages in preventing wrap migration. Our aim was to determine the need for posterior crural sutures during laparoscopic fundoplication. This was a retrospective review of patients >1 month old who underwent a primary laparoscopic fundoplication from 2010 to 2019. Demographic, surgical, and outcome data were recorded. Primary outcome was transmigration of the fundoplication wrap. Analysis was performed using STATA (StataCorp, College Station, TX); value <.05 was significant. There were 181 patients included. The median age was 7.2 months (interquartile range [IQR] 3.7, 17.0) with 59% being male patients. Sixty-one (34%) patients received posterior crural stitches and 120 (66%) did not receive stitches according to staff preference. The stitch group had a median of 1 (IQR 1, 1) posterior crural stitches placed. There was no difference in the incidence of wrap migration, the number of patients requiring a workup for recurrent symptoms, or reoperation between the two groups (Table 1). A significantly higher percentage of patients in the no-stitch group underwent concurrent procedures; when controlled for this, there was no difference in the median operative time between the groups ( = .18). The placement of crural sutures, including the posterior crural suture, does not prevent wrap migration and may not be necessary for prevention of wrap herniation in pediatric fundoplication.
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http://dx.doi.org/10.1089/lap.2020.0646DOI Listing
December 2020

Inpatient management of Hirschsprung's associated enterocolitis treatment: the benefits of standardized care.

Pediatr Surg Int 2020 Dec 1;36(12):1413-1421. Epub 2020 Oct 1.

Department of Surgery, Comprehensive Colorectal Center, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO, 64108, USA.

Introduction: Patients with Hirschsprung's disease (HSCR) remain at risk of developing Hirschsprung-associated enterocolitis (HAEC) after surgical intervention. As inpatient management remains variable, our institution implemented an algorithm directed at standardizing treatment practices. This study aimed to compare the outcomes of patients pre- and post-algorithm.

Methods: A retrospective review of patients admitted for HAEC was performed; January 2017-June 2018 encompassed the pre-implementation period, and October 2018-October 2019 was the post-implementation period. Demographics and outcomes were compared between the two groups.

Results: Sixty-two episodes of HAEC occurred in 27 patients during the entire study period. Sixteen patients (59%) had more than one episode. The most common levels of the transition zone were the rectosigmoid (50%) and descending colon (27%). Following algorithm implementation, the median length of stay (2 vs. 7 days, p < 0.001), TPN duration (0 vs. 5.5 days, p < 0.001), and days to full enteral diet (6 days vs. 2 days, p < 0.001) decreased significantly. Readmission rates for recurrent enterocolitis were similar pre- and post-algorithm implementation.

Conclusion: The use of a standardized algorithm significantly decreases the length of stay and duration of intravenous antibiotic administration without increasing readmission rates, while still providing appropriate treatment for HAEC.

Level Of Evidence: III level.

Type Of Study: Retrospective comparative study.
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http://dx.doi.org/10.1007/s00383-020-04747-4DOI Listing
December 2020

Response regarding: "Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?"

J Surg Res 2020 12 8;256:701-702. Epub 2020 Sep 8.

Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri. Electronic address:

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http://dx.doi.org/10.1016/j.jss.2020.08.032DOI Listing
December 2020

Characterization of Pediatric Breast Abscesses and Optimal Treatment: A Retrospective Analysis.

J Surg Res 2021 01 25;257:195-202. Epub 2020 Aug 25.

Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri. Electronic address:

Background: Literature on pediatric breast abscesses is sparse; therefore, treatment is based on adult literature which has shifted from incision and drainage (I&D) to needle aspiration. However, children may require different treatment due to different risk factors and the presence of a developing breast bud. We sought to characterize pediatric breast abscesses and compare outcomes.

Materials And Methods: A retrospective review of patients presenting with a primary breast abscess from January 2008 to December 2018 was conducted. Primary outcome was persistent disease. Antibiotic utilization, treatment required, and risk factors for abscess and recurrence were also assessed. A follow-up survey regarding scarring, deformity, and further procedures was administered. Fisher's exact and Kruskal-Wallis tests for group comparisons and multivariable regression to determine associations with recurrence were performed.

Results: Ninety-six patients were included. The median age was 12.8 y [IQR 4.9, 14.3], 81% were women, and 51% were African-American. Most commonly, patients were treated with antibiotics alone (47%), followed by I&D (27%), and aspiration (26%). Twelve patients (13%) had persistent disease. There was no difference in demographic or clinical characteristics between those with persistent disease and those who responded to initial treatment. The success rates of primary treatment were 80% with antibiotics alone, 90% with aspiration, and 96% with I&D (P = 0.35). The median time to follow-up survey was 6.5 y [IQR 4.4, 8.5]. Four patients who underwent I&D initially reported significant scarring.

Conclusions: Treatment modality was not associated with persistent disease. A trial of antibiotics alone may be considered to minimize the risk of breast bud damage and adverse cosmetic outcomes with invasive intervention.
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http://dx.doi.org/10.1016/j.jss.2020.07.014DOI Listing
January 2021

Protocol-driven Antibiotic Treatment of Pediatric Empyema After Fibrinolysis.

Pediatr Infect Dis J 2021 01;40(1):44-48

From the Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri.

Background: The duration of antibiotic treatment after resolution of empyema in children is variable. We evaluated the efficacy and safety of a protocol-driven antibiotic regimen aimed to decrease antibiotic duration following treatment with fibrinolysis.

Methods: Our institutional protocol consisted of 7 further days of antibiotics upon removal of the thoracostomy tube, with the patient being afebrile, off supplemental oxygen, and having negative cultures. A prospective observational study was then performed between September 2014 and March 2019. Empyema recurrence and antibiotic-related complications were recorded. Results were compared with previously published data from the preprotocol era.

Results: A total of 37 patients were included. Mean total duration of antibiotics decreased from 26 ± 6.5 days in the preprotocol group to 22 ± 9.7 days in the postprotocol group (P = 0.004). This resulted in a significant decrease in hospital stay from the preprotocol cohort to the postprotocol cohort, respectively (9.3 ± 4.8 d versus 6.8 ± 3.1 d, P = 0.003). Sixty-two percentage of the patients were intended to treat according to the protocol, with a 50% adherence rate. Patients in which the protocol was followed had an average of 2.8 fewer days of antibiotics after discharge (P = 0.004), although overall duration was not statistically different. Significantly fewer antibiotic-related complications were noted after protocol initiation. There was no difference in empyema recurrence or readmissions.

Conclusions: Institution of a protocol-driven approach to antibiotic duration following resolution of pleural space disease may reduce antibiotic duration and complications without reducing efficacy.
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http://dx.doi.org/10.1097/INF.0000000000002872DOI Listing
January 2021

Intra-abdominal Abscess After Appendectomy-Are Drains Necessary in All Patients?

J Surg Res 2020 10 12;254:384-389. Epub 2020 Jun 12.

Department of Surgery, Children's Mercy, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri. Electronic address:

Background: Research has shown that patients who develop a postoperative intra-abdominal abscess (PIAA) after appendectomy have a greater number of health care visits with drain placement. Our institution developed an algorithm to limit drain placement for only abscesses with a size >20 cm. We sought to determine the adherence to and effectiveness of this algorithm.

Methods: This prospective observational study included patients aged 2-18 y old who developed a PIAA from September 2017 to June 2019. Outcomes were compared between patients with a small or large abscess. Analysis was performed in STATA; P < 0.05 was significant.

Results: Thirty patients were included. The median age was 10.6 y (7, 11.7); 60% were men, and 60% were Caucasian. The median duration of symptoms before diagnosis of appendicitis was 3 d (2, 6). Thirteen patients (43%) were diagnosed with a PIAA while still inpatient, and 17 (57%) were readmitted at a later date. After algorithm implementation, 95% (n = 19) of patients with a large abscess had aspiration ± drain placement, whereas 30% (n = 3) with a small abscess underwent drainage. Length of stay after abscess diagnosis, total duration of antibiotics, and number of health care visits were the same between groups. One patient with a small abscess required reoperation for an obstruction, whereas one patient with a large abscess that was drained was readmitted for a recurrent abscess.

Conclusions: Small PIAA can be successfully managed without intervention. Our proposed algorithm can assist in determining which patients can be treated with antibiotics alone.
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http://dx.doi.org/10.1016/j.jss.2020.05.016DOI Listing
October 2020

Optimization of Pediatric Bowel Management Using an Antegrade Enema Troubleshooting Algorithm.

J Surg Res 2020 10 29;254:247-254. Epub 2020 May 29.

Department of Surgery, Children's Mercy Hospital, Kansas City, MO. Electronic address:

Background: A successful flush is the ability to flush through the appendicostomy or cecostomy channel, empty the flush through the colon, and achieve fecal cleanliness. We evaluated our experience with patients who were having flush difficulties based on a designed algorithm.

Methods: Eight patients with flush difficulties were initially evaluated. Based on the need for additional surgery versus changes in bowel management therapy (BMT), we developed an algorithm to guide future management. The algorithm divided flush issues into before, during, and after flushing. Children aged <20 y who presented with flush issues from September 2018 to August 2019 were evaluated to determine our algorithm's efficacy. Specific outcomes analyzed included changes in BMT versus need for additional surgery.

Results: After algorithm creation, 29 patients were evaluated for flush issues. The median age was 8.4 y (interquartile range: 6, 14); 66% (n = 19) were men. Underlying diagnoses included anorectal malformations (n = 17), functional constipation (n = 7), Hirschsprung's disease (n = 2), spina bifida (n = 2), and prune belly (n = 1). A total of 35 flush issues/complaints were noted: 29% before the flush, 9% during the flush, and 63% after the flush. Eighty percent of issues before the flush required surgical intervention, wherease 92% of issues during or after the flush were managed with changes in BMT.

Conclusions: Most flush issues respond to changes in BMT. This algorithm can help delineate which types of flush issues would benefit from surgical intervention and what problems might be present if patients are not responding to changes in their flush regimen.
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http://dx.doi.org/10.1016/j.jss.2020.04.033DOI Listing
October 2020

When to consider a posterolateral descending aortopexy in addition to a posterior tracheopexy for the surgical treatment of symptomatic tracheobronchomalacia.

J Pediatr Surg 2020 Dec 3;55(12):2682-2689. Epub 2020 May 3.

Department of Surgery, Boston Children's Hospital, Boston, MA. Electronic address:

Purposes: The descending thoracic aorta typically crosses posterior to the left mainstem bronchus (LMSB). We sought to evaluate patient factors that may lead one to consider a posterolateral descending thoracic aortopexy (PLDA) in addition to a posterior tracheopexy (PT) in the surgical treatment of symptomatic tracheobronchomalacia (TBM) that involves the LMSB.

Methods: Retrospective review of patients who underwent PT with or without PLDA between 2012 and 2017. Severity and extent of TBM were assessed using dynamic tracheobronchoscopy. Aortic positioning compared to the anterior border of the spine (ABS) at the level of the left mainstem bronchus was identified on computed tomography (CT). Factors associated with performing a PLDA were evaluated with logistic regression.

Results: Of 188 patients who underwent a PT, 70 (37%) also had a PLDA performed. On multivariate analysis, >50% LMSB compression on bronchoscopy (OR 8.06, p < 0.001), >50% of the aortic diameter anterior to the ABS (OR 2.06, p = 0.05), and more recent year of surgery (OR 1.61, p = 0.003) were associated with performing a PLDA.

Conclusion: When performing a PT, a PLDA should be considered for patients who have >50% LMSB compression on dynamic bronchoscopy, and in those with a descending thoracic aorta located >50% anterior to the ABS.

Level Of Evidence: III TYPE OF STUDY: Retrospective comparative study.
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http://dx.doi.org/10.1016/j.jpedsurg.2020.04.018DOI Listing
December 2020

Same-Day Discharge and Quality of Life for Primary Laparoscopic Rectopexy for Rectal Prolapse in Children: A 10-Year Experience.

J Laparoendosc Adv Surg Tech A 2020 Jun 21;30(6):679-684. Epub 2020 Apr 21.

Department of Pediatric Surgery, Children's Mercy-Kansas City, Kansas City, Missouri, USA.

Rectal prolapse (RP) in pediatric patients may require surgical intervention. Varying surgical approaches and heterogenous patient populations have resulted in difficulty defining surgical outcomes and superiority of technique. We sought to review our surgical and self-reported outcomes of patients who underwent laparoscopic rectopexy for idiopathic RP. Records of children <18 years who underwent primary laparoscopic rectopexy between March 2009 and March 2019 were retrospectively reviewed. Patients with redo rectopexy were excluded. Demographics, pre- and postoperative treatment, and outcome data were collected and reported using descriptive statistics. Qualitative analysis of a quality of life (QoL) questionnaire administered to patients and parents 2-10 years postoperatively was performed. Fifteen patients were included. Median age at surgery was 5 years (interquartile range [IQR] 3, 12.5); 60% were male and median weight was 22 kg (IQR 16.4, 39.2). Median length of stay was 6 hours (IQR 4, 22) with 9 (60%) discharged the same day. Perioperatively, 73% were on laxative for constipation, whereas only 33% were on laxative therapy at 6 months postrectopexy. Median follow-up was 19 months (IQR 8, 39). Three patients (20%) suffered recurrent RP (2 required redo rectopexy), and 2 patients self-limited urinary retention. Respondents to the QoL questionnaire indicated improvement in symptoms after surgery. No patient reported fecal incontinence, smearing, or leakage of stool. Laparoscopic rectopexy is a safe minimally invasive approach for children with idiopathic RP that offers high patient satisfaction with same-day discharge, early recovery, and low recurrence.
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http://dx.doi.org/10.1089/lap.2020.0050DOI Listing
June 2020

Declining frequency of thoracoscopic decortication for empyema - redefining failure after fibrinolysis.

J Pediatr Surg 2020 Nov 10;55(11):2352-2355. Epub 2020 Jan 10.

Department of Surgery, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; School of Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA. Electronic address:

Background: Primary fibrinolysis for pediatric empyema has become standard of care at our institution. Early study of our protocol revealed a 16% thoracoscopic decortication rate after primary fibrinolysis. We now report the frequency with which children progress to operation with maturation of the protocol.

Methods: A database of patients diagnosed with empyema between September 2014 and March 2019 was examined. Patients who underwent tissue plasminogen activator (tPA) therapy with or without subsequent video-assisted thoracoscopic (VATS) decortication were included. Patients with additional indications for tube thoracostomy or VATS were excluded.

Results: Forty-eight patients were included. Median age was 4.5 years [IQR 2-9.3]. Median length of stay (LOS) was 8 days [IQR 6-11]. No patients underwent primary VATS. Median days with a chest tube was 5 [IQR 5-6] and median number of doses of tPA was 3 [IQR 3-3]. Seven patients (14.6%) had a chest tube replaced without undergoing VATS. The VATS rate was 4.2% in the first half of this study but 0% in the last 33 months.

Conclusion: Thoracoscopic decortication is rarely necessary in children with empyema. Raising the threshold for surgical intervention and utilizing further nonoperative measures can avoid an operation in most children without increasing in-hospital length of stay.

Level Of Evidence: IV.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.12.023DOI Listing
November 2020

Laparoscopic Ladd Procedure for the Management of Malrotation and Volvulus.

J Laparoendosc Adv Surg Tech A 2020 Feb 31;30(2):210-215. Epub 2019 Dec 31.

Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri.

While laparoscopic Ladd procedure is commonly performed in patients with asymptomatic malrotation, a paucity of data exists on children with volvulus or with low weight (≤3 kg). Our purpose was to evaluate the safety and efficacy of the laparoscopic Ladd procedure in these complex patient populations. A retrospective review of patients undergoing operation for malrotation from 2008 to 2018 was performed. Specific subgroup analysis was performed comparing outcomes after open and laparoscopic approaches in patients presenting with acute volvulus or in low-weight (<3 kg) patients. Out of 110 patients, 38 (35%) presented with volvulus and 72 (65%) without volvulus. In patients with volvulus, 16 (42%) underwent laparoscopy and 22 (58%) had an open procedure. More patients in the open group had a preoperative diagnosis of volvulus (63.6% vs. 12.5%,  = .002). Operative time was longer in the laparoscopic group (87 vs. 61 minutes,  = .029), with 7 patients being converted to an open procedure (44%). Days to regular diet, hospital length of stay, and recurrent volvulus were similar between groups. In patients weighting <3 kg, 10 patients underwent laparoscopy and 10 patients had an open procedure. Demographics, operative time, postoperative outcomes, and complications were similar between groups. One person in the laparoscopic group was converted to open. Laparoscopic management of malrotation, even in the presence of volvulus and low patient weight, is safe and effective, with low rates of recurrent volvulus. If exposure is suboptimal, conversion to open in patients with volvulus should be considered.
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http://dx.doi.org/10.1089/lap.2019.0602DOI Listing
February 2020

Great vessel anomalies and their impact on the surgical treatment of tracheobronchomalacia.

J Pediatr Surg 2020 Jul 6;55(7):1302-1308. Epub 2019 Aug 6.

Department of Surgery, Boston Children's Hospital. Electronic address:

Background: Tracheobronchial compression (TBC) from great vessel anomalies (GVA) can contribute to tracheobronchomalacia (TBM) symptoms. The frequency, impact on symptoms and optimal management of GVA in these patients, with or without a history of esophageal atresia (EA), are still unclear.

Study Design: Patients who underwent surgery for TBM/ TBC between 2001 and 2017 were reviewed. Demographics, type of GVA, and operative interventions were collected. The frequency and treatment modalities of GVA between EA and non-EA patients were compared.

Results: Overall, 209 patients met criteria; 120 (57.4%) patients had at least one GVA, including double aortic arches (n = 4, 1.9%), right aortic arches (n = 14, 6.7%), aberrant right subclavian arteries (n = 15, 7.2%), and innominate artery compression (n = 71, 34.0%). Non-EA patients were more likely to have surgery later in life (29.5 months versus 16 months, p = 0.0002), double aortic arch (p = 0.0174), right aortic arch (p < 0.0001), and undergo vascular reconstruction concurrently with their airway procedure (25% vs 8.4%, p = 0.002). Vessel reconstruction was performed in 25 patients; six required cardiac bypass.

Conclusion: The frequency of GVA in patients with symptomatic airway collapse is substantial. Multidisciplinary evaluation is imperative for operative planning as many require complex reconstruction and collaboration with cardiac surgery, particularly patients without a history of EA.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.08.001DOI Listing
July 2020