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

OBJECTIVE: To determine the impact of tumor characteristics and treatment approach on (1) local recurrence, (2) scoliosis development, and (3) patient-reported quality of life in children with sarcoma of the chest wall. SUMMARY OF BACKGROUND DATA: Children with chest wall sarcoma require multimodal therapy including chemotherapy, surgery, and/or radiation. Despite aggressive therapy which places them at risk for functional impairment and scoliosis, these patients are also at significant risk for local recurrence. METHODS: A multi-institutional review of 175 children (median age 13 years) with chest wall sarcoma treated at seventeen Pediatric Surgical Oncology Research Collaborative institutions between 2008 and 2017 was performed. Patient-reported quality of life was assessed prospectively using PROMIS surveys. RESULTS: The most common diagnoses were Ewing sarcoma (67%) and osteosarcoma (9%). Surgical resection was performed in 85% and radiation in 55%. A median of 2 ribs were resected (interquartile range = 1-3), and number of ribs resected did not correlate with margin status ( P = 0.36). Local recurrence occurred in 23% and margin status was the only predictive factor(HR 2.24, P = 0.039). With a median follow-up of 5 years, 13% developed scoliosis (median Cobb angle 26) and 5% required corrective spine surgery. Scoliosis was associated with posteriorrib resection (HR 8.43; P= 0.003) and increased number of ribs resected (HR 1.78; P = 0.02). Overall, patient-reported quality of life is not impaired after chest wall tumor resection. CONCLUSIONS: Local recurrence occurs in one-quarter of children with chest wall sarcoma and is independent of tumor type. Scoliosis occurs in 13% of patients, but patient-reported quality of life is excellent.

Trends in robotic surgery utilization across tertiary children's hospitals in the United States.

BACKGROUND: A growing number of tertiary children's hospitals are utilizing robotic surgical technology. We sought to characterize national trends in pediatric surgical robotic case utilization and related drivers. METHODS: Pediatric urology and pediatric surgery (abdominal and thoracic) procedures, performed from January 2010 to December 2019 across 19 U.S. tertiary care children's hospitals, were identified using the Pediatric Health Information System (PHIS). Trends in robot utilization were evaluated by surgical subspecialty, procedure type, and number of individual operating surgeons. RESULTS: Increases were noted in the overall numbers of pediatric surgery (1.3% per quarter, p = 0.005) and urology robotic procedures (2.0% per quarter, p < 0.001), as well as the numbers of pediatric surgeons (7.5% per year, p < 0.001) and pediatric urologists (7.8% per year, p < 0.001) operating robotically. Biliary system and spleen surgery were the most common robotic pediatric surgery procedures (45.5%) and had stable utilization over time (- 0.8% per quarter, 95% CI - 2.3-0.8). Robotic foregut surgery showed the most rapid growth in utilization (2.1% per quarter, 95% CI 0.7-3.6, p = 0.004) in pediatric surgery, while mediastinal/thoracic surgery demonstrated a decrease in utilization (- 4.6%, 95% CI - 7.9-1.2, p = 0.008). Renal pelvis/ureter surgery was the most common robotic urologic procedure (55.8%) and also demonstrated the fastest growth utilization (2.2% per quarter, 95% CI 1.5-2.9, p < 0.001) in urology. CONCLUSIONS: Utilization of robotic-assisted surgery in pediatric surgery and pediatric urology has increased both in case volume and the number of operating surgeons, with foregut and renal pelvis/ureter surgery responsible for the areas of greatest growth.

Outcomes of Head and Neck Free Tissue Transfer in Renal Failure Patients.

OBJECTIVE: To assess if there is increased risk of free flap failure in renal failure patients undergoing head and neck reconstruction. We seek to primarily assess free flap outcomes based on stages of chronic kidney disease (CKD) and secondarily determine increased risk for postoperative complications. METHODS: Retrospective chart review was performed at five tertiary care centers. Patients were identified that had undergone microvascular free flap reconstruction of the head and neck with diagnosis of renal failure, classified as Stage 3 CKD or higher. Demographic data was collected. Outcomes in the postoperative period were examined. RESULTS: Seventy-three patients met inclusion criteria. The average patient age was 69 years with a male predominance (n = 48). The majority of patients had CKD Stage 3 (n = 52). Overall flap failure rate was 12.33% (n = 9, CKD stage 3 = 7.69%, CKD stage 4 = 30%, CKD stage 5 = 18%). There was an increased risk of flap failure on multivariate analysis for CKD stage 4/5 patients when compared to CKD 3 patients (p = 0.0095). When compared to matched controls, there was an increased risk of flap failure in CKD patients (p = 0.01) as well as an increased risk of overall complications (p < 0.0001). CONCLUSIONS: Patients with CKD undergoing head and neck reconstruction are at a higher risk of flap failure and overall complications. When comparing CKD stages there may be increased risk of flap failure in later stages of CKD compared to CKD 3. Appropriate patient counseling is recommended pre-operatively in this patient population with consideration for regional flaps in the appropriate patient. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:688-694, 2024.

Optimizing Innervation in Radial Forearm Phalloplasty: Consider the Posterior Antebrachial Cutaneous Nerve.

SUMMARY: One goal of an ideal phallic reconstruction is achieving tactile and erogenous sensation. Traditionally, the most common flap used in phalloplasty has been the radial forearm flap, where the medial and lateral antebrachial cutaneous nerves are coapted to meet this goal. The purpose of this article is to draw attention to the lesser-known posterior antebrachial cutaneous nerve (PABC) as an alternative or additional nerve for coaptation that innervates a majority of the shaft, where sensation is most desired. The presence, anatomical location, and territory of innervation of the antebrachial cutaneous nerves were assessed in a series of 12 consecutive in vivo radial forearm phalloplasties. A literature review was conducted to establish which nerves have traditionally been used for sensory reinnervation of the phallus. The PABC was the first nerve encountered on the radial border of the flap lying on the fascia in the interval between the brachioradialis and extensor carpi radials longus. The posterior and lateral antebrachial cutaneous nerves innervated the phallic shaft, whereas the anterior branch of the medial antebrachial cutaneous nerve innervated the phallic urethra. There were no articles in our review that used PABC for nerve coaptation in radial forearm phalloplasty. The skin innervated by the PABC represents a significant portion of the phallic shaft when using the standard template for radial forearm phalloplasty. Despite this, its use is not described in the literature. The authors introduce the PABC as an alternative or additional nerve for coaptation in radial forearm phalloplasty.

Mucoepidermoid Carcinomas of the Larynx.

OBJECTIVES: Discussions regarding the specific management and outcomes for laryngeal MEC are limited to very small, single-institution case series. To look further into the diagnosis and management of these uncommon non-squamous cell carcinomas of the larynx, we present 3 recent cases of laryngeal MEC treated at our institution. METHODS: Patients at a tertiary hospital treated for MEC between October 2019 and December 2020 were retrospectively identified. Chart review, imaging analysis, and histologic slide creation were completed for all patients. RESULTS: We identified and treated 2 patients with high-grade supraglottic and 1 patient with intermediate-grade glottic MEC. These patients presented to our clinic with a primary complaint of either gradual, worsening dysphonia, dysphagia, or both. All patients underwent laryngovideostroboscopy as well as panendoscopy with directed submucosal biopsy, which was consistent with MEC. MRI was performed in 2 of the cases further elucidating the extent of submucosal spread. PET-CT was performed in all 3 cases, and none demonstrated evidence of regional or distal metastases. Surgically, high-grade MEC lesions were treated with a total laryngectomy. The intermediate MEC lesion was managed with a supracricoid partial laryngectomy (SCPL). Surgical margins were free of tumor in all cases with no nodal metastases by modified radical neck dissection. Radiation therapy was offered to both high-grade MEC patients and declined by one. Radiation was not recommended to the patient with intermediate-grade MEC as we believed that the risk of additional treatment outweighed the benefit. CONCLUSION: We believe that MEC of the larynx should be considered in patients with atypical submucosal laryngeal masses. Laryngovideostroboscopy, MRI, and PET imaging may be valuable in determining the extent of the lesions and planning appropriate surgery. Postoperative radiation therapy should be considered a per tumor grade in other more studied sites, as there is no data on efficacy in laryngeal MEC.

Assessing opioid administration in pediatric burn patients with nonsurgical management.

BACKGROUND: Despite the vast literature studying the opioid crisis, sparse data describe this in the pediatric burn population. This study sought to assess patient-level characteristics and their potential effects on opioid administration in nonsurgical pediatric burn inpatients. METHODS: Admitted burn patients from 2013 to 2018 with nonsurgical management at an American Burn Association (ABA) verified pediatric burn center were retrospectively identified. Morphine milligram equivalents by weight (MME/kg) per admission were evaluated through a multiple loglinear regression with race, sex, age, total body surface area burned (TBSA), and burn depth as predictors. Simple linear regression was used to evaluate the temporal trend of median opioid utilization. RESULTS: A total of 806 patients (55% White, 35% Black, 5% Hispanic, 5% Other) were included. In an adjusted analysis, no differences in opioid administration were seen by sex, burn degree, or for Blacks and Hispanics when compared with Whites. Increased MME/kg was associated with older age (10-18 years; p<0.0001) and larger burns (>5% TBSA burned; p<0.0001). From 2013 to 2018, median MME/kg per admission declined significantly (2013:0.21, 2018:0.09; p=0.0103). CONCLUSIONS: Nonsurgical burn patients who were older and presented with larger TBSA experienced marked increases in opioid utilization. Overall, opioid administration decreased over time.

Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial.

IMPORTANCE: Although opioids are an important component of pain management for children recovering from surgery, postoperative opioid prescribing has contributed to the current opioid crisis in the United States because these medications are often prescribed in excess and are rarely properly disposed. One potential strategy to combat opioid misuse is to remove excess postoperative opioids from circulation by providing patients with drug disposal products that enable safe disposal of opioids in the home garbage. OBJECTIVE: To determine whether the provision of a drug disposal bag increases proper opioid disposal among the families of pediatric patients undergoing ambulatory surgery. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial enrolled 202 parents or guardians of children 1 to 17 years of age who underwent otolaryngologic or urologic surgery at the outpatient surgery centers of a tertiary children's hospital in Columbus, Ohio, from June to December 2018 and who received an opioid prescription prior to discharge. INTERVENTIONS: Families randomized to intervention were provided a drug disposal bag containing activated charcoal and instructions for use plus standard postoperative discharge instructions on opioid use, storage, and disposal. Families in standard care arm received standard postoperative discharge instructions only. All participants completed a baseline survey and a follow-up survey 2 to 4 weeks postoperatively. MAIN OUTCOMES AND MEASURES: Primary outcome was proper opioid disposal, defined as disposal using a drug disposal bag or a disposal method recommended by the US Food and Drug Administration. RESULTS: Of 202 parents or guardians enrolled, 181 completed follow-up (92 in intervention arm and 89 in standard care arm). Most patients in both groups were white (75 [73.5%] vs 79 [80.6%]) and male (63 [61.2%] vs 54 [54.6%]), and the median (interquartile range) age was 6 (5-9) years in the intervention arm and 7 (6-10) years in the standard care arm. For intention-to-treat analyses, 92 families receiving a disposal bag and 89 families not receiving a disposal bag were included. Among them, 66 families (71.7%) randomized to receive a disposal bag reported properly disposing of their child's opioids, whereas 50 parents (56.2%) who did not receive a disposal bag reported proper opioid disposal (difference in proportions, 15.5%; 95% CI, 1.7%-29.3%; P = .03). Among only those families who filled an opioid prescription and had leftover opioids after resolution of their child's pain, 66 of 77 parents or guardians (85.7%) who had received a disposal bag and 50 of 77 parents or guardians (64.9%) who had received standard care reported properly disposing of their child's opioids (difference in proportions, 20.8%; 95% CI, 7.6%-34.0%). CONCLUSIONS AND RELEVANCE: Results of this study indicated that providing drug disposal bags to families of children receiving postoperative opioids increased the likelihood of excess opioid disposal. Greater availability of disposal products may complement ongoing prescribing reduction efforts aimed at decreasing opioid misuse. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03575377.