Publications by authors named "Yangyang R Yu"

27 Publications

  • Page 1 of 1

Preoperative resource utilization prior to minimally invasive repair of pectus excavatum.

Am J Surg 2020 Dec 31. Epub 2020 Dec 31.

Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX, 77030, USA; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX, 77030, USA. Electronic address:

Background: Preoperative testing to assess the physiologic impact of pectus excavatum is sometimes ordered to meet third-party payor preauthorization requirements. This study describes the utility of physiologic testing prior to minimally invasive repair of pectus excavatum (MIRPE).

Methods: We retrospectively reviewed patients that underwent MIRPE from 1/2012-7/2016 at two academic children's hospitals. Data collected included demographics, insurance, Haller Index (HI), pulmonary function tests (PFTs) and echocardiograms (ECHO) obtained, and preauthorization denials.

Results: A total of 360 patients (mean age 15.7 ± 2.0 years; mean HI 4.5 ± 1.5) underwent MIRPE (Hospital 1: 189, Hospital 2: 171). Commercial insurers covered 84% of patients. Hospital 1 obtained more frequent preoperative testing (PFTs: 73% vs 6%, p < 0.0001). Overall, 72% of PFTs were normal with abnormal studies limited to mild findings. Similarly, 85% of ECHOs were normal. Third-party payors more frequently denied preauthorization for MIRPE at Hospital 2 (11% vs. 5%, p = 0.03).

Conclusions: More frequent preoperative testing may decrease initial preauthorization denials for MIRPE; however, this increased utilization of resources may not be necessary as the majority of test results are normal.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.053DOI Listing
December 2020

Cost-Effectiveness Analysis of the Surgical Management of Infants Less than One Year of Age with Feeding Difficulties.

J Pediatr Surg 2020 Jan 25;55(1):187-193. Epub 2019 Oct 25.

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

Background: We compared the cost-effectiveness of the common surgical strategies for the management of infants with feeding difficulty.

Methods: Infants with feeding difficulty undergoing gastrostomy alone (GT), GT and fundoplication, or gastrojejunostomy (GJ) tube were enrolled between 2/2017 and 2/2018. A validated GERD symptom severity questionnaire (GSQ) and visual analog scale (VAS) to assess quality of life (QOL) were administered at baseline, 1 month, and every 6 months. Data collected included demographics, resource utilization, diagnostic studies, and costs. VAS scores were converted to quality adjusted life months (QALMs), and costs per QALM were compared using a decision tree model.

Results: Fifty patients initially had a GT alone (71% laparoscopically), and one had a primary GJ. Median age was 4 months (IQR 3-8 months). Median follow-up was 11 months (IQR 5-13 months). Forty-three did well with GT alone. Six (12%) required conversion from GT to GJ tube, and one required a fundoplication. Of those with GT alone, six (14%) improved significantly so that their GT was removed after a mean of 7 ± 3 months. Overall, the median GSQ score improved from 173 at baseline to 18 after 1 year (p < 0.001). VAS scores also improved from 70/100 at baseline to 85/100 at 1 year (p < 0.001). ED visits (59%), readmissions (47%), and clinic visits (88%) cost $58,091, $1,442,139, and $216,739, respectively. GJ tube had significantly higher costs for diagnostic testing compared to GT (median $8768 vs. $1007, p < 0.001). Conversion to GJ tube resulted in costs of $68,241 per QALM gained compared to GT only.

Conclusions: Most patients improved with GT alone without needing GJ tube or fundoplication. GT and GJ tube were associated with improvement in symptoms and QOL. GJ tube patients reported greater gains in QALMS but incurred higher costs. Further analysis of willingness to pay for each additional QALM will help determine the value of care.

Study And Level Of Evidence: Cost-effectiveness study, Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.09.076DOI Listing
January 2020

Accuracy of surgeon prediction of appendicitis severity in pediatric patients.

J Pediatr Surg 2019 Nov 24;54(11):2274-2278. Epub 2019 Apr 24.

The Michael E. DeBakey Department of Surgery, Baylor College of Medicine, One Baylor Plaza Suite 404D, Houston, TX 77030; Division of Pediatric Surgery, Texas Children's Hospital, 6701 Fannin Street Suite 1210, Houston, TX 77030.

Purpose: Clinical prediction of disease severity is important as one considers nonoperative management of simple appendicitis. This study assesses the accuracy of surgeons' prediction of appendicitis severity.

Methods: From February to August 2016, pediatric surgeons at a single institution were asked to predict whether patients had simple or complex appendicitis preoperatively based on clinical data, imaging, and general assessment. Receiver operating characteristic curves were generated to determine area under the curve (AUC) and optimal cutoff points of clinical findings for diagnosing simple appendicitis. Outcomes included sensitivity and specificity of variables to identify simple appendicitis. Predictions were compared to operative findings using χ. A p-value<0.05 was considered statistically significant.

Results: Of 125 cases (median age 9 years [IQR 7-13], 58% male), simple appendicitis was predicted in 77 (62%) and complex appendicitis in 48 (38%). Predictions were accurate in 59 (77%) simple cases and 45 (94%) complex cases. Although surgeon prediction was more accurate than individual imaging or clinical findings and was highly sensitive (95%) for diagnosing simple appendicitis, specificity was only 71%. Lower WBC (<15.5 × 10/μL, AUC 0.61, p = 0.05), afebrile (<100.4 °F, AUC 0.86, p < 0.01), and shorter symptom duration (≤ 1.5 days, AUC 0.71, p < 0.001) were associated with simple appendicitis. Of 18 complex cases (14%) inaccurately predicted as simple, 17 (94%) lacked diffuse tenderness, 15 (83%) were well-appearing, 11 (61%) had ultrasound findings of simple appendicitis, 11 (61%) had ≤2 days of symptoms, and 8 (44%) were afebrile (<100.4 °F).

Conclusion: While surgeon prediction of simple appendicitis is more accurate than ultrasound or clinical data alone, diagnostic accuracy is still limited.

Type Of Study: Prospective survey.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.04.007DOI Listing
November 2019

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

Bowel preparation for colostomy reversal in children.

J Pediatr Surg 2019 May 2;54(5):1045-1048. Epub 2019 Feb 2.

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

Purpose: Pediatric bowel preparation protocols used before colostomy reversal vary. The aim of this study is to determine institutional practices at our institution and evaluate the impact of bowel preparations on postoperative outcomes and hospital length of stay in children.

Methods: This was a retrospective review of children ≤18 years old undergoing colostomy reversal at Texas Children's Hospital (TCH) between 12/2013 and 8/2017. Preoperative bowel regimens and outcomes were collected and analyzed using descriptive statistics, Wilcoxon Rank-Sum and Fishers Exact tests. Continuous variables are presented as median [IQR].

Results: Sixty-one children underwent colostomy reversal. Thirty-eight (62%) did not receive a preoperative bowel preparation. The two cohorts were similar in age, gender, and race. The most common indication for colostomy was anorectal malformation for thirty-seven (61%). Time from admission to surgery (19 h [17, 23] vs 3 [2, 3]; p < 0.01) and HLOS (6 days [5, 8] vs 5 [4, 6]; p = 0.02) were both longer in the bowel preparation cohort. Complications (3 [13%] vs 5 [22%]; p = 0.12) and 90-day readmissions (3 [13%] vs 6 [16%]; p = 0.64) were similar in both cohorts.

Conclusion: Foregoing bowel preparation may have the potential to improve cost and reduce morbidity in children undergoing colostomy closure.

Level Of Evidence: III.

Study Type: Treatment study.
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http://dx.doi.org/10.1016/j.jpedsurg.2019.01.037DOI Listing
May 2019

Do Ventriculoperitoneal Shunts Increase Complications After Laparoscopic Gastrostomy in Children?

J Surg Res 2019 04 14;236:119-123. Epub 2018 Dec 14.

Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas. Electronic address:

Background: In patients requiring gastrostomies, ventriculoperitoneal (VP) shunts are a frequently encountered comorbidity. The objective of this study is to evaluate the postoperative management of children with VP shunts that undergo laparoscopic gastrostomy placement and determine their incidence of complications.

Materials And Methods: Children 18 y old or younger who underwent laparoscopic gastrostomy placement at a freestanding academic children's hospital between January 2014 and October 2016 were reviewed. Data collected included demographics, management, and outcomes. Patients were compared based on their presence of a VP shunt before laparoscopic gastrostomy. Statistical analysis was performed using chi square, Fisher's exact, and Wilcoxon rank-sum tests.

Results: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. Of these, 9% (25) had a previously placed VP shunt. In comparing patients with a VP shunt with those without a VP shunt, there was no significant difference in median age (4 versus 3 y, P = 0.92), gender (48% versus 51% males, P = 0.80), body mass index (15 versus 16, P = 0.69), preoperative diet (48% versus 47% nasogastric tube dependent, P = 0.60), or procedure time (43 versus 42 min, P = 0.37). The postoperative management of these children was similar: day of initiation of postoperative feeds (84% versus 73% on postoperative day #1, P = 0.70), method of initiation of feeds (60% versus 55% continuous, P = 0.25), and type of initial feeds (83% versus 71% Pedialyte, P = 0.24). Similarly, there was no difference in hospital length of stay, return to the emergency department, or postoperative complications within 90 d (P > 0.05).

Conclusions: Children with ventriculoperitoneal shunts do not have a higher rate of immediate complications after laparoscopic gastrostomy placement and may be managed similar to other children in the postoperative period.
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http://dx.doi.org/10.1016/j.jss.2018.10.027DOI Listing
April 2019

Use of standardized visual aids improves informed consent for appendectomy in children: A randomized control trial.

Am J Surg 2018 10 24;216(4):730-735. Epub 2018 Jul 24.

Michael E. DeBakey Department of Surgery, Pediatric Surgery Division, Texas Children's Hospital, Houston, TX, United States. Electronic address:

Background: Obtaining informed consent for surgical procedures is often compromised by patient and family educational background, complexity of the forms, and language barriers. We developed and tested a visual aid in order to improve the informed consent process for families of children with appendicitis.

Methods: Families were randomized to receive either a standard surgical consent or a standard consent plus visual aid. Univariate and multivariate analyses were performed to assess the effectiveness of adding the visual aid to the consent procedure.

Results: Parents in both cohorts were similar in age, gender and education level (p > 0.05). On multivariate analysis, visual consent had the strongest influence on parent/guardian comprehension (OR 4.0; 95%CI 2.2-7.2; p < 0.01), followed by post-secondary education (OR 2.7; 95%CI 1.5-4.9; p < 0.01), and use of external resources to look up appendicitis (OR 2.0; 95%CI 1.1-3.6; p = 0.02).

Conclusion: Visual aids improve understanding and retention of information given during the informed consent process of children with appendicitis.
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http://dx.doi.org/10.1016/j.amjsurg.2018.07.032DOI Listing
October 2018

Foley catheters are not routinely necessary in children treated with patient-controlled analgesia following perforated appendicitis.

J Pediatr Surg 2018 Oct 4;53(10):2032-2035. Epub 2018 Apr 4.

Baylor College of Medicine, Michael E. DeBakey Department of Surgery, One Baylor Plaza, Houston, TX 77030; Texas Children's Hospital, Division of Pediatric Surgery, 6701 Fannin Street, Houston, TX 77030. Electronic address:

Background: Patient-controlled analgesia (PCA) is often used in children with perforated appendicitis. To prevent urinary retention, some providers also routinely place Foley catheters. This study examines the necessity of this practice.

Methods: We retrospectively reviewed all children (≤18 years old) with perforated appendicitis and postoperative PCA from 7/2015 to 6/2016 at two academic children's hospitals. Urinary retention was defined as the inability to spontaneously void requiring straight catheterization or placement of a Foley catheter.

Results: Of 313 patients who underwent appendectomy for perforated appendicitis (Hospital 1: 175, Hospital 2: 138), 129 patients received an intraoperative Foley (Hospital 1: 22 [13%], Hospital 2: 107 [78%], p < 0.001). Age, gender, and BMI were similar between those with an intraoperative Foley and those without. There were no urinary tract infections in either group. Urinary retention rate in patients with an intraoperative Foley following removal on the inpatient unit (n = 3, 2%) and patients without an intraoperative Foley (n = 10, 5%) did not reach significance (p = 0.25). On univariate analysis, demographics, intraoperative findings, PCA specifics, postoperative abscess formation, and postoperative length of stay, were not significant risk factors for urinary retention.

Conclusions: The risk of urinary retention in this population is low despite the use of PCA. Children with perforated appendicitis do not require routine Foley catheter placement to prevent urinary retention.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.03.024DOI Listing
October 2018

Repetitive Imaging following Minimally Invasive Repair of Pectus Excavatum Is Unnecessary.

Eur J Pediatr Surg 2019 Oct 19;29(5):408-411. Epub 2018 Jun 19.

Department of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States.

Introduction:  The objective of this study was to evaluate the necessity of repeat imaging after an initial chest radiograph (CXR) following minimally invasive repair of pectus excavatum (MIRPE).

Materials And Methods:  A retrospective review was performed on patients who underwent MIRPE from January 2012 to July 2016 at two academic children's hospitals. Data collected included demographics, severity of pectus defect (Haller index [HI]), utilization of CXRs, outpatient follow-up, and clinical outcomes.

Results:  A total of 360 patients (171 at Hospital 1 and 189 at Hospital 2) underwent MIRPE. Median age was 15.6 years and 84% were males. The median HI was 4.0. Median postoperative hospital length of stay was 4.2 days and median time to bar removal was 34 months. There was significant variation in postoperative imaging between the hospitals, including frequency of immediate postoperative CXR, total number of CXRs during hospitalization, and number of postoperative outpatient CXRs prior to bar removal. However, there was no significant difference in outcomes between the hospitals, including postoperative pneumothorax, postoperative chest tube placement, and complications.

Conclusion:  These data suggest that increased repetitive imaging after an initial postoperative CXR does not affect clinical outcomes and may not be necessary after MIRPE.
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http://dx.doi.org/10.1055/s-0038-1660868DOI Listing
October 2019

Surgical outcomes in Alagille syndrome and PFIC: A single institution's 20-year experience.

J Pediatr Surg 2018 May 9;53(5):976-979. Epub 2018 Feb 9.

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

Background: Alagille Syndrome (AGS) and Progressive Familial Intrahepatic Cholestasis (PFIC) are rare pediatric biliary disorders that lead to progressive liver disease. This study reviews our experience with the surgical management of these disorders over the last 20years.

Methods: We retrospectively reviewed the records of children diagnosed with AGS or PFIC from January 1996 to December 2016. Data collected included demographics, surgical intervention (liver transplant or biliary diversion), and complications.

Results: Of 37 patients identified with these disorders, 17 patients (8 AGS,9 PFIC) underwent surgical intervention. Mean postsurgical follow-up was 6.9±4.7years. Liver transplantation was the most common procedure (n=14). Two patients who were initially thought to have biliary atresia underwent hepatoportoenterostomy, but were subsequently shown to have Alagille syndrome. Biliary diversion procedures were performed in 3 patients (external n=1, internal n=2). PFIC patients tended to be older at the time of liver transplant compared to AGS (4.3±3.9years vs. 2.4±1.1years, p=0.25). The AGS patient with external diversion had resolution of symptoms and no complications (follow-up: 12.5years). Both PFIC patients with internal diversion (conduit between gallbladder and transverse colon) had resolution of pruritus and no progression of liver disease (follow-up: 3.8 and 4.5years).

Conclusions: AGS and PFIC are rare biliary disorders in children which result in pruritus and progressive liver failure. Three patients in this series (8%) benefited from biliary diversion for control of pruritus and have not to date required transplantation for progressive liver disease. 38% underwent transplantation owing to pruritus and severe liver dysfunction.

Level Of Evidence: 2b.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.026DOI Listing
May 2018

Evaluating quality of life of extracorporeal membrane oxygenation survivors using the pediatric quality of life inventory survey.

J Pediatr Surg 2018 May 10;53(5):1060-1064. Epub 2018 Feb 10.

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

Purpose: This study assesses the impact of extracorporeal membrane oxygenation (ECMO) associated morbidities on long-term quality of life (QOL) outcomes.

Methods: A single center, retrospective review of neonatal and pediatric non-cardiac ECMO survivors from 1/2005-7/2016 was performed. The 2012 Pediatric Quality of Life Inventory™ (PedsQL™) survey was administered. Clinical outcomes and QOL scores between groups were compared.

Results: Of 74 patients eligible, 64% (35 NICU, 12 PICU) completed the survey. Mean time since ECMO was 5.5±3years. ECMO duration for venoarterial (VA) and venovenous (VV) were similar (median 9 vs. 7.5days, p=0.09). VA ECMO had higher overall complication rate (64% vs. 36%, p=0.06) and higher neurologic complication rate (52% vs. 9%, p=0.002). ECMO mode and ICU type did not impact QOL. However, patients with neurologic complications (n=15) showed a trend towards lower overall QOL (63/100±20 vs. 74/100±18, p=0.06) compared to patients without neurologic complications. A subset analysis of patients with ischemic or hemorrhagic intracranial injuries (n=13) had significantly lower overall QOL (59/100±19 vs. 75/100±18, p=0.01) compared to patients without intracranial injuries.

Conclusion: Neurologic complication following ECMO is common, associated with VA mode, and negatively impacts long-term QOL. Given these associations, when clinically feasible, VV ECMO may be considered as first line ECMO therapy.

Type Of Study: Retrospective review.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.039DOI Listing
May 2018

Injury patterns of child abuse: Experience of two Level 1 pediatric trauma centers.

J Pediatr Surg 2018 May 10;53(5):1028-1032. Epub 2018 Feb 10.

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

Purpose: This study examines non-accidental trauma (NAT) fatalities as a percentage of all injury fatalities and identifies injury patterns in NAT admissions to two level 1 pediatric trauma centers.

Methods: We reviewed all children (<5years old) treated for NAT from 2011 to 2015. Patient demographics, injury sites, and survival were obtained from both institutional trauma registries.

Results: Of 4623 trauma admissions, 557 (12%) were due to NAT. However, 43 (46%) of 93 overall trauma fatalities were due to NAT. Head injuries were the most common injuries sustained (60%) and led to the greatest increased risk of death (RR 5.1, 95% CI 2.0-12.7). Less common injuries that increased the risk of death were facial injuries (14%, RR 2.9, 95% CI 1.6-5.3), abdominal injuries (8%, RR 2.8, 95% CI 1.4-5.6), and spinal injuries (3%, RR 3.9, 95% CI 1.8-8.8). Although 76% of head injuries occurred in infants <1year, children ages 1-4years old with head injuries had a significantly higher case fatality rate (27% vs. 6%, p<0.001).

Conclusion: Child abuse accounts for a large proportion of trauma fatalities in children under 5years of age. Intracranial injuries are common in child abuse and increase the risk of death substantially. Preventing NAT in infants and young children should be a public health priority.

Type Of Study: Retrospective Review.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2018.02.043DOI Listing
May 2018

Are Foley catheters needed after minimally invasive repair of pectus excavatum?

Surgery 2018 04 1;163(4):854-856. Epub 2018 Feb 1.

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

Background: High narcotic requirements after minimally invasive repair of pectus excavatum (MIRPE) can increase the risk of urinary retention. Placement of intraoperative Foley catheters to minimize this risk is variable. This study determines the rate of urinary retention in this population to guide future practice.

Materials And Methods: We reviewed retrospectively all patients who underwent MIRPE from January 2012 to July 2016 at 2 academic children's hospitals. Data collected included demographics, BMI, severity of the pectus defect, postoperative pain management, and the incidence of urinary retention and urinary tract infection (UTI).

Results: Of 360 total patients who underwent MIRPE, 218 had an intraoperative Foley catheter. Patients with epidural pain control were more likely to receive a Foley catheter. The urinary retention rate was 34% for patients without an intraoperative Foley, and 1% in patients after removal of an intraoperatively placed Foley. Urinary retention was greater with an epidural compared with patient-controlled anesthesia (55% vs 26%, P = .002) in the no intraoperative Foley group. No urinary tract infections were identified. Epidural pain control was the only risk factor on multivariate analysis for retention in patients without an intraoperatively Foley catheter.

Conclusion: Intraoperative Foley catheters obviate urinary retention without increasing the risk of urinary tract infection after MIRPE. These results will allow surgeons to better counsel patients regarding Foley placement.
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http://dx.doi.org/10.1016/j.surg.2017.10.049DOI Listing
April 2018

Use of venovenous ECMO for neonatal and pediatric ECMO: a decade of experience at a tertiary children's hospital.

Pediatr Surg Int 2018 Mar 18;34(3):263-268. Epub 2018 Jan 18.

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

Background: Advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the pediatric population. We present the evolution and experience of pediatric VV ECMO at a tertiary care institution.

Methods: A retrospective cohort study from 01/2005 to 07/2016 was performed, comparing by cannulation mode. Survival to discharge, complications, and decannulation analyses were performed.

Results: In total, 160 patients (105 NICU, 55 PICU) required 13 ± 11 days of ECMO. VV cannulation was used primarily in 83 patients with 64% survival, while venoarterial (VA) ECMO was used in 77 patients with 54% survival. Overall, 74% of patients (n = 118) were successfully decannulated; 57% survived to discharge. VA ECMO had a higher rate of intra-cranial hemorrhage than VV (22 vs 9%, p = 0.003). Sixteen VA patients (21%) had radiographic evidence of a cerebral ischemic insult. No cardiac complications occurred with the use of dual-lumen VV cannulas. There were no differences in complications (p = 0.40) or re-operations (p = 0.85) between the VV and VA groups.

Conclusion: Dual-lumen VV ECMO can be safely performed with appropriate image guidance, is associated with a lower rate of intra-cranial hemorrhage, and may be the preferred first-line mode of ECMO support in appropriately selected NICU and PICU patients.

Level Of Evidence: II.
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http://dx.doi.org/10.1007/s00383-018-4225-5DOI Listing
March 2018

Clinical presentation of Crohn's, ulcerative colitis, and indeterminate colitis: Symptoms, extraintestinal manifestations, and disease phenotypes.

Semin Pediatr Surg 2017 Dec 5;26(6):349-355. Epub 2017 Oct 5.

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

The incidence of inflammatory bowel disease (IBD) is rising with 25% of IBD diagnosed in children under 18 years of age. The clinical presentation of IBD in children is often vague leading to initial misdiagnosis as infectious colitis or irritable bowel syndrome. When IBD is identified, overlap in histologic and endoscopic features may lead to difficulty distinguishing Crohn's disease from ulcerative colitis, resulting in a higher frequency of the diagnosis indeterminate colitis or IBD unspecified. Recognizing the common and the atypical presentation of pediatric IBD and extraintestinal manifestations will aid in expeditious referral and early diagnosis. Activity severity scoring tools and more specific classification systems for pediatric IBD direct therapeutic algorithms and allow for improved longitudinal assessment since disease severity and location have been shown to be associated with outcome.
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http://dx.doi.org/10.1053/j.sempedsurg.2017.10.003DOI Listing
December 2017

A prospective same day discharge protocol for pediatric appendicitis: Adding value to a common surgical condition.

J Pediatr Surg 2017 Oct 9. Epub 2017 Oct 9.

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

Purpose: Standardized clinical pathways for simple appendicitis decrease length of stay and result in cost savings. We performed a prospective cohort study to assess a same day discharge (SDD) protocol for children with simple appendicitis.

Methods: All children undergoing laparoscopic appendectomy for simple appendicitis after protocol implementation (February 2016 to January 2017) were assessed. Length of stay (LOS), 30-day resource utilization (ED visits and hospital readmissions), patient satisfaction, and hospital accounting costs for SDD were compared to non-SDD patients.

Results: Of 602 children treated at our institution, 185 (31%) were successfully discharged per protocol. SDD patients had longer median PACU duration (3.0 vs. 1.0h, p<0.001), but postoperative LOS (4.4 vs. 17.4h, p<0.001) and overall LOS (17.1 vs. 31.2h, p<0.001) were significantly shorter. Complication rates (1.6% vs. 3.1%), ED visits (4.3% vs. 6.0%), and readmissions (0.5% vs. 2.4%) were not significantly different for SDD compared to non-SDD patients. However, SDD decreases total cost of an appendectomy episode ($8073 vs $8424, p=0.002), and patients report high satisfaction with their hospital experience (mean 9.4 out of 10).

Conclusions: Safe and satisfactory outpatient management of pediatric simple appendicitis is achievable with appropriate patient selection. An SDD protocol can lead to significant generation of value to the healthcare system.

Level Of Evidence: Prognosis study, Level II.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.10.011DOI Listing
October 2017

Postoperative Feeding Regimens After Laparoscopic Gastrostomy Placement.

J Laparoendosc Adv Surg Tech A 2017 Nov 2;27(11):1203-1208. Epub 2017 Oct 2.

Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine , Houston, Texas.

Purpose: The objective of this study was to evaluate postoperative feeding regimens after laparoscopic gastrostomy placement and their effect on outcomes.

Methods: Children 18 years of age or younger, who underwent laparoscopic gastrostomy placement at a tertiary-care academic children's hospital between January 2014 and October 2016, were reviewed. Data collected included patient characteristics, postoperative feeding regimen, and clinical outcomes. Statistical analysis was performed using Chi-square, Fisher's exact, and Wilcoxon Rank-Sum tests.

Results: We reviewed the medical records of 270 children that underwent laparoscopic gastrostomy placement by 15 pediatric surgeons. The median age was 2.7 (interquartile range [IQR], 0.7-9.6) years, and 50% (n = 136) were male. The median body mass index was 15.5 (IQR, 14.0-17.5). Complications within 90 days included: granulation tissue (34%), leakage (17%), dislodgement (14%), and skin and soft-tissue infection (9%). Two patients returned to the operating room, 1 for a dislodged tube, and another for a volvulus within 10 days of gastrostomy tube placement. A subset analysis of outpatients that underwent elective laparoscopic gastrostomy placement showed variation in the day of initial feeds (0-2 postoperative days [POD]), method of initial feeds (continuous versus bolus) and choice of initial feeds (Pedialyte versus formula/breast milk). There was a significant difference in median hospital length of stay for early versus late initiation of feeds (POD 0: 2.1 days versus POD ≥1: 3.1 days, P < .01) without a difference in postoperative complications.

Conclusion: There is substantial variation in the postoperative feeding regimen after laparoscopic gastrostomy. Initiation of early postoperative feeds may result in decreased length of stay without increasing complications.
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http://dx.doi.org/10.1089/lap.2017.0295DOI Listing
November 2017

Perinatal diagnosis and management of oropharyngeal fetus in fetu: A case report.

J Clin Ultrasound 2018 May 26;46(4):286-291. Epub 2017 Sep 26.

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

Fetus in fetu is an extremely rare congenital anomaly. We describe the perinatal diagnosis and management of a fetus with oropharyngeal and cervical fetus in fetu. High-resolution ultrasonography with 3-dimensional rendering can identify increased risks of airway obstruction in utero. Early identification allows a multidisciplinary team to be assembled for a scheduled ex utero intrapartum treatment procedure.
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http://dx.doi.org/10.1002/jcu.22528DOI Listing
May 2018

Magnet foreign body ingestion: rare occurrence but big consequences.

J Pediatr Surg 2018 Sep 24;53(9):1815-1819. Epub 2017 Aug 24.

Division of Pediatric Surgery, Texas Children's Hospital/Baylor College of Medicine, Houston, TX, USA. Electronic address:

Purpose: To review the outcomes of magnet ingestions from two children's hospitals and develop a clinical management pathway.

Methods: Children <18years old who ingested a magnet were reviewed from 1/2011 to 6/2016 from two tertiary center children's hospitals. Demographics, symptoms, management and outcomes were analyzed.

Results: From 2011 to 2016, there were 89 magnet ingestions (50 from hospital 1 and 39 from hospital 2); 50 (56%) were males. Median age was 7.9 (4.0-12.0) years; 60 (67%) presented with multiple magnets or a magnet and a second metallic co-ingestion. Suspected locations found on imaging were: stomach (53%), small bowel (38%), colon (23%) and esophagus (3%). Only 35 patients (39%) presented with symptoms and the most common symptom was abdominal pain (33%). 42 (47%) patients underwent an intervention, in which 20 (23%) had an abdominal operation. For those undergoing abdominal surgery, an exact logistic regression model identified multiple magnets or a magnet and a second metallic object co-ingestion (OR 12.9; 95% CI, 2.4 - Infinity) and abdominal pain (OR 13.0; 95% CI, 3.2-67.8) as independent risk factors.

Conclusion: Magnets have a high risk of requiring surgical intervention for removal. Therefore, we developed a management algorithm for magnet ingestion.

Level Of Evidence: Level III.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.08.013DOI Listing
September 2018

Can the Diagnosis of Appendicitis Be Made Without a Computed Tomography Scan?

Adv Surg 2017 09 17;51(1):11-28. Epub 2017 May 17.

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

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http://dx.doi.org/10.1016/j.yasu.2017.03.002DOI Listing
September 2017

Reply to: Letter to the Editor.

J Pediatr Surg 2017 08 20;52(8):1377-1378. Epub 2017 Apr 20.

Texas Children's Hospital / Baylor College of Medicine, 6701 Fannin , Suite 1210, Houston, TX 77030. Electronic address:

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http://dx.doi.org/10.1016/j.jpedsurg.2017.04.008DOI Listing
August 2017

Time-driven activity-based costing: A dynamic value assessment model in pediatric appendicitis.

J Pediatr Surg 2017 Jun 18;52(6):1045-1049. Epub 2017 Mar 18.

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. Electronic address:

Objectives: Healthcare reform policies are emphasizing value-based healthcare delivery. We hypothesize that time-driven activity-based costing (TDABC) can be used to appraise healthcare interventions in pediatric appendicitis.

Methods: Triage-based standing delegation orders, surgical advanced practice providers, and a same-day discharge protocol were implemented to target deficiencies identified in our initial TDABC model. Post-intervention process maps for a hospital episode were created using electronic time stamp data for simple appendicitis cases during February to March 2016. Total personnel and consumable costs were determined using TDABC methodology.

Results: The post-intervention TDABC model featured 6 phases of care, 33 processes, and 19 personnel types. Our interventions reduced duration and costs in the emergency department (-41min, -$23) and pre-operative floor (-57min, -$18). While post-anesthesia care unit duration and costs increased (+224min, +$41), the same-day discharge protocol eliminated post-operative floor costs (-$306). Our model incorporating all three interventions reduced total direct costs by 11% ($2753.39 to $2447.68) and duration of hospitalization by 51% (1984min to 966min).

Conclusion: Time-driven activity-based costing can dynamically model changes in our healthcare delivery as a result of process improvement interventions. It is an effective tool to continuously assess the impact of these interventions on the value of appendicitis care.

Level Of Evidence: II, Type of study: Economic Analysis.
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http://dx.doi.org/10.1016/j.jpedsurg.2017.03.032DOI Listing
June 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

Intramural esophageal bronchogenic cyst mimicking achalasia in a toddler.

Pediatr Surg Int 2017 Jan 7;33(1):119-123. Epub 2016 Nov 7.

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

Bronchogenic cysts are congenital malformations of the tracheobronchial tree. We describe a 20-month-old male who presented with persistent non-bilious emesis; manometry and imaging were consistent with esophageal achalasia. During a planned laparoscopic Heller myotomy, an intramural bronchogenic cyst was discovered in the anterior esophagus at the level of the gastroesophageal junction and successfully resected with resolution of his symptoms.
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http://dx.doi.org/10.1007/s00383-016-3994-yDOI Listing
January 2017

Time-driven activity-based costing to identify opportunities for cost reduction in pediatric appendectomy.

J Pediatr Surg 2016 Dec 15;51(12):1962-1966. Epub 2016 Sep 15.

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. Electronic address:

Purpose: As reimbursement programs shift to value-based payment models emphasizing quality and efficient healthcare delivery, there exists a need to better understand process management to unearth true costs of patient care. We sought to identify cost-reduction opportunities in simple appendicitis management by applying a time-driven activity-based costing (TDABC) methodology to this high-volume surgical condition.

Methods: Process maps were created using medical record time stamps. Labor capacity cost rates were calculated using national median physician salaries, weighted nurse-patient ratios, and hospital cost data. Consumable costs for supplies, pharmacy, laboratory, and food were derived from the hospital general ledger.

Results: Time-driven activity-based costing resulted in precise per-minute calculation of personnel costs. Highest costs were in the operating room ($747.07), hospital floor ($388.20), and emergency department ($296.21). Major contributors to length of stay were emergency department evaluation (270min), operating room availability (395min), and post-operative monitoring (1128min). The TDABC model led to $1712.16 in personnel costs and $1041.23 in consumable costs for a total appendicitis cost of $2753.39.

Conclusion: Inefficiencies in healthcare delivery can be identified through TDABC. Triage-based standing delegation orders, advanced practice providers, and same day discharge protocols are proposed cost-reducing interventions to optimize value-based care for simple appendicitis.

Level Of Evidence: II.
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http://dx.doi.org/10.1016/j.jpedsurg.2016.09.019DOI Listing
December 2016

Complications of low-profile dorsal versus volar locking plates in the distal radius: a comparative study.

J Hand Surg Am 2011 Jul;36(7):1135-41

Beth Israel Deaconess Medical Center and the Harvard Medical School, Boston, MA 02215, USA.

Purpose: Dorsal plating of distal radius fractures with traditional 2.5-mm-thick plates is associated with extensor tendon complications. Consequently, volar locking plates have gained widespread acceptance. A new generation of 1.2- to 1.5-mm, low-profile dorsal plates was designed to minimize tendon irritation. This study examines the complication rates of low-profile dorsal plates compared with volar locking plates.

Methods: We identified patients with distal radius fractures treated between September 2002 and June 2006 by low-profile dorsal or volar locking plates. Information pertaining to 7 categories of complications (hardware discomfort and pain, tendon irritation/rupture, failure of reduction, infection, complex regional pain syndrome, stiffness, and neuropathy/hypersensitivity) was collected. Complications were defined as any postoperative plating complications requiring additional surgical intervention, whereas those that only caused patient discomfort were considered secondary problems.

Results: We included 100 patients, comprising 104 plating cases (57 dorsal, 47 volar), in this study. Overall length of follow-up was 44 ± 21 months (range, 12-80 mo). A total of 18 patients (8 dorsal, 10 volar) experienced complications, whereas 47 (25 dorsal, 22 volar) had secondary reports. Three dorsal and 4 volar patients had complete plate removals. Three dorsal and no volar plates had screw removals only. One volar plate (no dorsal plates) had a major tendon rupture (flexor pollicis longus); 3 dorsal and 3 volar plates resulted in tendon irritation complications, and 4 dorsal and 3 volar plates had secondary problems from tendon irritation. None of the above measures approached statistical significance. Volar cases were associated with significantly more neuropathic complications than dorsal cases.

Conclusions: Dorsal low-profile plates are not associated with significantly more tendon irritation or rupture complications. However, volar plating is associated with a higher rate of neuropathic complications.

Type Of Study/level Of Evidence: Therapeutic III.
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http://dx.doi.org/10.1016/j.jhsa.2011.04.004DOI Listing
July 2011

Musculoskeletal preclinical medical school education: meeting an underserved need.

J Bone Joint Surg Am 2009 Mar;91(3):733-9

Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.

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http://dx.doi.org/10.2106/JBJS.H.01305DOI Listing
March 2009