RESUMO
Surgical palliative care (PC) facilitates communication between surgeons and patients/family about prognosis, symptom control, and therapeutic goals. Surgical critical care (SCC) fellows are at the forefront of the intensive care team; thus, we aim to assess previous and ongoing experiences in delivering PC by surveying fellows at a large academic center. Seventeen surveys were completed in which 59% of fellows reported no previous PC education. Six fellows (35%) reported participating in goals of care/end-of-life (GOC/EOL) discussions "a few times a year" during residency, while 41% responded the same for transitioning patients to comfort-focused care (CFC). When asked if respondents felt comfortable facilitating GOC/EOL discussions prior to fellowship, 7 (41%) answered "disagree" or "strongly disagree." Most fellows reported that more training in navigating GOC/EOL discussions (88%) and transitioning patients to CFC (76%) is needed. This assessment demonstrates variability in fellows' prior PC exposure and a strong desire for more structured training.
Assuntos
Centros Médicos Acadêmicos , Cuidados Críticos , Bolsas de Estudo , Avaliação das Necessidades , Cuidados Paliativos , Humanos , Inquéritos e Questionários , Educação de Pós-Graduação em Medicina/métodos , Internato e Residência , Feminino , Cirurgia Geral/educação , Masculino , Cirurgia de Cuidados CríticosRESUMO
INTRODUCTION: ECMO is a support modality for refractory critical illness. This study reviews the incidence and utility of central venous line (CVL) placement at pediatric ECMO decannulation. METHODS: A single-institution retrospective study of patients undergoing open neck decannulation from 2015 to 2019. Patients were divided into two groups: ≤ 28-days and > 28-days. RESULTS: Of 65 patients, 31% had a CVL placed at decannulation. Sepsis and pneumonia were the most common indications for ECMO in the older-group compared to CDH in neonates. The most common indications for CVL were hemodialysis (45%), monitoring (25%), and access (25%). 89% of neonates had an access line placed, whereas 73% of the older group received hemodialysis catheters. Median CRRT requirement was 20 days. 85% of lines were functional at time of removal or death. None were removed for infection. 40% of the patients not receiving a CVL at decannulation required one within 30 days. CONCLUSION: 69% of patients did not have a CVL placed at decannulation, however 40% required a CVL within 30 days. Most lines placed at decannulation remained functional and none were removed for infection. Decannulation removes the circuit as a route for vascular access, but it also presents an opportunity to safely place an essential CVL.
Assuntos
Cateterismo Venoso Central , Oxigenação por Membrana Extracorpórea , Criança , Estado Terminal , Humanos , Incidência , Recém-Nascido , Estudos RetrospectivosRESUMO
Surgical trainees are expected to demonstrate family-centered care. However, it is unclear if residents know how to address psychosocial issues of pediatric patients and their families. Our aim was to evaluate surgical trainees' knowledge of family dynamics. Over a six-month period, trainees (n = 16) were surveyed regarding their comfort and familiarity with the psychosocial aspects of patient care and family dynamics. Residents recorded their comfort level with managing various behaviors using a Likert scale, and indicated which family issues they felt least prepared to handle. Most trainees lacked knowledge of family adjustment phases (50%), relational triangles (78%), developmental stages of families (40%), ambiguous loss (75%), ABCX model of family stress (100%), and the SPIKES model (88%). Excluding anxiety and sadness, almost half of residents felt unprepared for dealing with a variety of challenging behaviors. Finally, trainees were least comfortable with breaking bad news. A Family Dynamics curriculum could potentially increase resident management skills and improve patient care.
Assuntos
Competência Clínica/normas , Cirurgia Geral/educação , Internato e Residência/normas , Relações Profissional-Família , California , Comunicação , Currículo , Saúde da Família/educação , Humanos , Assistência ao Paciente/normasRESUMO
BACKGROUND: The Big Five framework examines five factors that represent a description of human personality. These factors correlate with success measures and job satisfaction. The Big Five Inventory is a 44-item instrument designed to measure the Big Five framework. Our aim was to document the distribution of Big Five personality traits among Pediatric Surgery fellowship applicants, compare with community norms, surgical residents, between genders, and correlate to the fellowship match results. MATERIALS AND METHODS: Forty Pediatric Surgery fellowship applicants at a university hospital completed the Big Five Inventory during the interview process. It was analyzed and compared with general surgery residents' results and community norms. The data were compared regarding gender and match results. Continuous variables were compared by unpaired t-tests and Mann-Whitney tests. A P value <0.05 was considered significant. RESULTS: The 40 applicants were equally divided between male and female. When compared with general surgery residents and community norms, applicants of both genders scored higher on agreeableness (P < 0.01), conscientiousness (P < 0.01), and emotional stability (P < 0.01). Applicants scored higher on openness when compared with surgical residents (P < 0.01). Male applicants scored higher on emotional stability than females (P = 0.026). Matched applicants scored higher for conscientiousness than unmatched applicants (P = 0.016). CONCLUSIONS: Pediatric Surgery fellowship applicants expressed higher levels of desirable professional traits compared with general surgery residents and community norms. Male applicants demonstrated higher emotional stability than females. Conscientiousness was higher in matching applicants. This first reported experience with personality testing in Pediatric Surgery fellow selection demonstrated potential utility in applicant matching.
Assuntos
Testes de Personalidade/estatística & dados numéricos , Feminino , Humanos , Masculino , Pediatria/estatística & dados numéricos , Especialidades Cirúrgicas/estatística & dados numéricosRESUMO
AIM: The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity. MATERIALS AND METHODS: Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data. RESULTS: Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01). CONCLUSIONS: Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability. TYPE OF STUDY: Prospective study. LEVEL OF EVIDENCE: Level II.
Assuntos
Competência Clínica , Bolsas de Estudo , Laparoscopia/educação , Pediatria/educação , Técnicas de Sutura/educação , Adulto , Criança , Humanos , Internato e Residência , Estudos Prospectivos , Técnicas de Sutura/instrumentaçãoRESUMO
BACKGROUND/PURPOSE: Lean Six Sigma (LSS) is a process improvement methodology that utilizes a collaborative team effort to improve performance by systematically identifying root causes of problems. Our objective was to determine whether application of LSS could improve efficiency when applied simultaneously to all services of an academic children's hospital. METHODS: In our tertiary academic medical center, a multidisciplinary committee was formed, and the entire perioperative process was mapped, using fishbone diagrams, Pareto analysis, and other process improvement tools. Results for Children's Hospital scheduled main operating room (OR) cases were analyzed, where the surgical attending followed themselves. RESULTS: Six hundred twelve cases were included in the seven Children's Hospital operating rooms (OR) over a 6-month period. Turnover Time (interval between patient OR departure and arrival of the subsequent patient) decreased from a median 41min in the baseline period to 32min in the intervention period (p<0.0001). Turnaround Time (interval between surgical dressing application and subsequent surgical incision) decreased from a median 81.5min in the baseline period to 71min in the intervention period (p<0.0001). CONCLUSION: These results demonstrate that a coordinated multidisciplinary process improvement redesign can significantly improve efficiency in an academic Children's Hospital without preselecting specific services, removing surgical residents, or incorporating new personnel or technology. STUDY TYPE: Prospective comparative study, Level II.
Assuntos
Centros Médicos Acadêmicos/organização & administração , Eficiência Organizacional/normas , Hospitais Pediátricos/organização & administração , Salas Cirúrgicas/organização & administração , Assistência Perioperatória/normas , Melhoria de Qualidade/organização & administração , Gestão da Qualidade Total , Centros Médicos Acadêmicos/estatística & dados numéricos , California , Criança , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Salas Cirúrgicas/estatística & dados numéricos , Assistência Perioperatória/estatística & dados numéricos , Avaliação de Processos em Cuidados de Saúde , Estudos Prospectivos , Melhoria de Qualidade/estatística & dados numéricos , Fatores de TempoRESUMO
PURPOSE: The aim was to review the respiratory failure causes and outcomes of infants with omphalocele or gastroschisis receiving ECMO and reported to the Extracorporeal Life Support Organization (ELSO). METHODS: Gastroschisis and omphalocele infants supported with ECMO and reported to the ELSO Registry between 1992 and 2015 were retrospectively reviewed. Clinical variables, diagnosis of respiratory failure (pulmonary hypertension (PHN), congenital heart defects (CHD), congenital diaphragmatic hernia (CDH), and sepsis), and outcomes were recorded. Univariate analysis was performed using Student's t-test for continuous or Fisher's exact test for categorical variables. RESULTS: Fifty-two infants with gastroschisis (41) (79%) or omphalocele (11) (21%) were identified. The survival to discharge rate of 51% for gastroschisis remained stable and was significantly higher (P=0.05). The overall mortality rate for omphalocele was 82%. Omphalocele had significantly more PHN (P<0.01), CDH (P<0.01), and multiple anomalies (P=0.04) had significantly more sepsis (P=0.02), and none had a CDH. CONCLUSION: Infants with gastroschisis requiring ECMO support have significantly better survival than omphaloceles, and respiratory failure is significantly associated with sepsis. The majority of omphalocele infants die despite ECMO, and respiratory failure is associated PHN and CDH. The association of omphalocele, PHN, and CDH merits further investigation. STUDY TYPE AND EVIDENCE LEVEL: Retrospective comparative study of Registry Database, Level 3.
Assuntos
Oxigenação por Membrana Extracorpórea , Gastrosquise/complicações , Hérnia Umbilical/complicações , Insuficiência Respiratória/terapia , Feminino , Gastrosquise/mortalidade , Hérnia Umbilical/mortalidade , Humanos , Lactente , Recém-Nascido , Masculino , Sistema de Registros , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do TratamentoRESUMO
AIM: The purpose of this study was to document the incidence and pattern of cervical spine (c-spine) injuries in children below 36months with inflicted trauma. METHODS: An IRB approved, prospective cohort study was performed between July 2011 and January 2016. Inclusion criteria were: age below 36months, loss of consciousness after inflicted trauma, and one initial head computed tomography finding: a subdural, intraventricular, intraparenchymal, subarachnoid hemorrhage, diffuse axonal injury, hypoxic injury, or cerebral edema. A protocol of brain and neck magnetic resonance imaging and angiography was obtained within 48h. Variables were compared by t-test and Fisher-exact test. RESULTS: There were 53 children (median age: five months; range: 1-35months), 38 males (71.7%), of which seven died (13.2%). C-spine injury was identified in 8 (15.1%): ligamentous injury (2), vertebral artery shear injury (1), atlantooccipital dissociation (AOD) (1), cord injury with cord epidural hematoma (2), and isolated cord epidural hematoma (2). Retinal hemorrhages (p=0.02), shaking (p=0.04), lower Glasgow coma score (GCS) (p=0.01), brain infarcts (p=0.01), and hypoxic/ischemic injury (p=0.01) were associated with c-spine injury. One with AOD died. Six had significant disability. CONCLUSION: For small children with inflicted trauma, the c-spine injury incidence is 15.1%. The injury pattern includes retinal hemorrhages, shaking, lower GCS, and brain injury. Evaluation of shaken infants should include c-spine imaging. LEVEL OF EVIDENCE: Level 2 A- This is a prospective cohort study with complete follow-up to hospital discharge or death. In all cases, inflicted trauma was confirmed. Owing to the nature of child abuse, the precise time of injury is not known. All children underwent a strict imaging protocol on arrival to hospital that was supervised on a prospective basis.
Assuntos
Vértebras Cervicais/lesões , Maus-Tratos Infantis/diagnóstico , Imageamento por Ressonância Magnética , Traumatismo Múltiplo/diagnóstico por imagem , Traumatismos da Medula Espinal/diagnóstico por imagem , Traumatismos da Coluna Vertebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X , California/epidemiologia , Vértebras Cervicais/diagnóstico por imagem , Maus-Tratos Infantis/mortalidade , Maus-Tratos Infantis/estatística & dados numéricos , Pré-Escolar , Traumatismos Craniocerebrais/diagnóstico por imagem , Traumatismos Craniocerebrais/epidemiologia , Traumatismos Craniocerebrais/etiologia , Feminino , Seguimentos , Humanos , Incidência , Lactente , Angiografia por Ressonância Magnética , Masculino , Traumatismo Múltiplo/epidemiologia , Traumatismo Múltiplo/etiologia , Estudos Prospectivos , Traumatismos da Medula Espinal/epidemiologia , Traumatismos da Medula Espinal/etiologia , Traumatismos da Coluna Vertebral/epidemiologia , Traumatismos da Coluna Vertebral/etiologia , Taxa de SobrevidaRESUMO
Lymphatic malformations (LMs) are vascular anomalies thought to arise from dysregulated lymphangiogenesis. These lesions impose a significant burden of disease on affected individuals. LM pathobiology is poorly understood, hindering the development of effective treatments. In the present studies, immunostaining of LM tissues revealed that endothelial cells lining aberrant lymphatic vessels and cells in the surrounding stroma expressed the stem cell marker, CD133, and the lymphatic endothelial protein, podoplanin. Isolated patient-derived CD133+ LM cells expressed stem cell genes (NANOG, Oct4), circulating endothelial cell precursor proteins (CD90, CD146, c-Kit, VEGFR-2), and lymphatic endothelial proteins (podoplanin, VEGFR-3). Consistent with a progenitor cell identity, CD133+ LM cells were multipotent and could be differentiated into fat, bone, smooth muscle, and lymphatic endothelial cells in vitro. CD133+ cells were compared to CD133- cells isolated from LM fluids. CD133- LM cells had lower expression of stem cell genes, but expressed circulating endothelial precursor proteins and high levels of lymphatic endothelial proteins, VE-cadherin, CD31, podoplanin, VEGFR-3 and Prox1. CD133- LM cells were not multipotent, consistent with a differentiated lymphatic endothelial cell phenotype. In a mouse xenograft model, CD133+ LM cells differentiated into lymphatic endothelial cells that formed irregularly dilated lymphatic channels, phenocopying human LMs. In vivo, CD133+ LM cells acquired expression of differentiated lymphatic endothelial cell proteins, podoplanin, LYVE1, Prox1, and VEGFR-3, comparable to expression found in LM patient tissues. Taken together, these data identify a novel LM progenitor cell population that differentiates to form the abnormal lymphatic structures characteristic of these lesions, recapitulating the human LM phenotype. This LM progenitor cell population may contribute to the clinically refractory behavior of LMs.
Assuntos
Diferenciação Celular , Células Progenitoras Endoteliais/citologia , Vasos Linfáticos/anormalidades , Adolescente , Animais , Antígenos CD/genética , Antígenos CD/metabolismo , Caderinas/genética , Caderinas/metabolismo , Linhagem Celular Tumoral , Células Cultivadas , Criança , Pré-Escolar , Células Progenitoras Endoteliais/metabolismo , Células Progenitoras Endoteliais/transplante , Proteínas de Homeodomínio/genética , Proteínas de Homeodomínio/metabolismo , Humanos , Lactente , Vasos Linfáticos/citologia , Vasos Linfáticos/metabolismo , Glicoproteínas de Membrana/genética , Glicoproteínas de Membrana/metabolismo , Células-Tronco Mesenquimais/citologia , Células-Tronco Mesenquimais/metabolismo , Camundongos , Camundongos Endogâmicos C57BL , Proteína Homeobox Nanog , Fator 3 de Transcrição de Octâmero/genética , Fator 3 de Transcrição de Octâmero/metabolismo , Proteínas Supressoras de Tumor/genética , Proteínas Supressoras de Tumor/metabolismo , Receptor 3 de Fatores de Crescimento do Endotélio Vascular/genética , Receptor 3 de Fatores de Crescimento do Endotélio Vascular/metabolismo , Proteínas de Transporte Vesicular/genética , Proteínas de Transporte Vesicular/metabolismoRESUMO
PURPOSE: Over the last 15 years thoracoscopic lobectomy for congenital and acquired lesions has become an accepted modality in pediatric thoracic surgery. There is still debate about the need to perform a complete lobectomy for some of these lesions, and some advocate observation rather than resection, despite possible long-term complications of untreated lesions. High-resolution computed tomography (CT) scans and physical findings at the time of surgery, along with new advanced techniques, now allow for discrete partial anatomic resections, which may preserve normal lung. This study evaluates the feasibility and early results using these techniques in selected cases. PATIENTS AND METHODS: With institutional review board approval, the records of all patients undergoing thoracoscopic lung resection were reviewed. From January 2006 to December 2012, 23 patients, ranging from 1 month to 16 years of age and weighing 3.8-42 kg, underwent thoracoscopy for planned resection. Pathology was congenital cystic lung disease in 19 patients, bronchiectasis in 3 patients, and arteriovenous malformation in 1 patient. In each case findings on CT scan and at the time of surgery warranted consideration of lung-preserving surgery. Procedures were performed through three ports using single lung ventilation and CO2 insufflation to achieve lung collapse. The LigaSure™ device (Covidien, Norwalk, CT) was the primary instrument used to seal and divide the lung parenchyma and seal vessels. RESULTS: All procedures were completed successfully thoracoscopically. An anatomic segmental resection was achieved in 22 of 23 cases. Operative time ranged from 30 to 300 minutes (mean, 120 minutes). Segmental resections included the left upper lobe apical/posterior (n=4), lingula (n=3), left lower lobe superior (n=5), medial or posterior basal (n=3), right middle lobe medial (n=1), right upper lobe apical (n=1), right lower lobe superior (n=4), and posterior basal (n=2). Two patients had more than one segment excised. Chest tubes were left in for 24 hours in 16 cases, 48 hours in 4 cases, and 5 days in 1 case. Hospital stay ranged from 1 to 6 days (mean, 2 days). Follow-up CT scans obtained at 1-6 years (mean, 28 months) show no residual disease in 20 of 21 patients. One patient underwent a nonanatomic resection and had evidence of recurrent congenital pulmonary airway malformation at the 4-year follow-up. This patient underwent a secondary thoracoscopic resection. CONCLUSIONS: Thoracoscopic lung-conserving therapy is technically feasible and safe in infants and children. The magnification provided by a thoracoscopic approach makes identification of segmental anatomic planes easier, aiding in safe dissection and resection. Anatomic resection appears to be associated with a low morbidity. It may be appropriate in the case of bilateral or extensive disease or in cases where the diseased tissue is clearly limited to an anatomic segment. Continued long-term follow-up is needed.
Assuntos
Pneumopatias/congênito , Pneumopatias/cirurgia , Tratamentos com Preservação do Órgão/métodos , Toracoscopia/métodos , Adolescente , Tubos Torácicos , Criança , Pré-Escolar , Estudos de Viabilidade , Feminino , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Pneumopatias/diagnóstico por imagem , Masculino , Duração da Cirurgia , Recidiva , Tomografia Computadorizada por Raios X , Resultado do TratamentoRESUMO
PURPOSE: Lung-to-head ratio (LHR) has been used for antenatal evaluation of infants with congenital diaphragmatic hernia (CDH). We hypothesized that LHR was predictive of acute and chronic pulmonary hypertension in infants with CDH. METHODS: Echocardiograms on all inborn infants with CDH (December 2001-March 2011) were reviewed. Echocardiograms at 1 and 3 months post-repair and most recent follow-up were assessed for presence of pulmonary hypertension (PAH). LHR, gestational age, birth weight, extracorporeal membrane oxygenation (ECMO), and death rate were obtained. Bivariate and multivariate analyses were performed. RESULTS: 106 infants with CDH had LHR obtained at median 28 weeks gestation (median LHR=1.25 [range 0.4-5.3]). Median follow-up was 26.6 months (range 4.6-97.5). The long-term incidence of pulmonary hypertension was 16%. LHR was significantly associated with pulmonary hypertension at one month (p=0.0001) but not at 3 months (p=0.22) or long-term (p=0.54). LHR was predictive of ECMO use (p=0.01) and death (p=0.001). CONCLUSIONS: The overall incidence of PAH in infants with CDH decreases over time. Prenatal LHR predicts PAH at one month but not long-term in infants with CDH. The ability for LHR to predict PAH at one month but not long term may suggest remodeling of the pulmonary vasculature over time.
Assuntos
Cabeça/embriologia , Hérnias Diafragmáticas Congênitas , Hipertensão Pulmonar/diagnóstico , Pulmão/embriologia , Ultrassonografia Pré-Natal , Doença Aguda , Criança , Pré-Escolar , Doença Crônica , Feminino , Seguimentos , Cabeça/diagnóstico por imagem , Hérnia Diafragmática/complicações , Hérnia Diafragmática/diagnóstico por imagem , Hérnia Diafragmática/mortalidade , Hérnia Diafragmática/cirurgia , Herniorrafia , Humanos , Hipertensão Pulmonar/diagnóstico por imagem , Hipertensão Pulmonar/epidemiologia , Hipertensão Pulmonar/etiologia , Incidência , Lactente , Recém-Nascido , Modelos Logísticos , Pulmão/diagnóstico por imagem , Análise Multivariada , Gravidez , Prognóstico , Estudos RetrospectivosRESUMO
PURPOSE: To assess the efficacy and accuracy of ultrasonography (US) and selective computed tomography (CT) in the diagnosis of acute appendicitis in children. METHODS: A retrospective review of all ultrasound evaluations for appendicitis from July 1, 2003, to June 30, 2010, was conducted at two urban pediatric centers. Beginning in 2003, a multi-disciplinary diagnostic protocol was implemented to reduce radiation exposure employing US as the initial imaging modality followed by CT for non-diagnostic US studies in patients with an equivocal clinical presentation. The imaging, operative findings, and pathology of 802 patients (365 females, 437 males, age less than 18 years) with suspected appendicitis were reviewed. The sensitivity, specificity, predictive value, and negative appendectomy rate of the protocol were analyzed. A telephone survey was conducted of patients discharged without a diagnosis of appendicitis to evaluate the missed appendicitis rate. RESULTS: Of the 601 pediatric appendectomies performed, a total of 275 (46%) were diagnosed by protocol. The selective protocol had a sensitivity of 94.2%, specificity of 97.5%, positive predictive value of 95.2%, and negative predictive value of 97.0%. The negative appendectomy rate was 1.82%, and the missed appendicitis rate was 0%. No patient discharged after only ultrasound evaluation without undergoing surgery reported missed appendicitis on the survey (41.7% response rate). Protocol use increased from 6.7% to 88.3%. US was the sole imaging modality in 630 of all 802 patients (78.6%). CONCLUSIONS: US followed by selective CT for the diagnosis of acute appendicitis is useful and accurate. This has important implications in the reduction of childhood radiation exposure.
Assuntos
Apendicite/diagnóstico por imagem , Doses de Radiação , Tomografia Computadorizada por Raios X/métodos , Ultrassonografia Doppler/métodos , Dor Abdominal/diagnóstico , Dor Abdominal/etiologia , Adolescente , Fatores Etários , Apendicectomia/métodos , Apendicectomia/estatística & dados numéricos , Apendicite/cirurgia , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Hospitais Pediátricos , Humanos , Masculino , Seleção de Pacientes , Proteção Radiológica , Estudos Retrospectivos , Medição de Risco , Tomografia Computadorizada por Raios X/efeitos adversos , Ultrassonografia Doppler/efeitos adversos , Estados Unidos , População UrbanaRESUMO
Infants with tracheoesophageal fistulas may present with complex cardiac disease that may obviate or disrupt a safe operative repair. Here we present a case of an infant who developed cardiac instability during esophageal atresia repair, precluding formal anastomosis after approximation of the distal and proximal esophageal segments. Postoperatively, anastomosis of the esophagus was achieved using an image-guided technique with subsequent dilation. This approach may provide an alternative approach for establishment of esophageal continuity in patients who are high-risk operative candidates.