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1.
J Pediatr Surg ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32151403

RESUMO

PURPOSE: To report outcomes of sutured and sutureless closure for gastroschisis across a large multi-institutional cohort. METHODS: A retrospective study of infants with uncomplicated gastroschisis at 11 children's from 2014 to 2016 was performed. Outcomes of sutured and sutureless abdominal wall closure were compared. RESULTS: Among 315 neonates with uncomplicated gastroschisis, sutured closure was performed in 248 (79%); 212 undergoing sutured closure after silo and 36 undergoing primary sutured closure. Sutureless closure was performed in 67 (21%); 37 primary sutureless closure, 30 sutureless closure after silo placement. There was no significant difference in gestational age, gender, birth weight, total days on TPN, and time from closure to initial oral intake or goal feeds. Sutureless closure patients had less general anesthetics, ventilator use/time, time from birth to final closure, antibiotic use after closure, and surgical site/deep space infections. Subgroup analysis demonstrated primary sutureless closure had less ventilator use and anesthetics than primary sutured closure. Sutureless closure after silo led to less ventilator use/time, anesthetics, and antibiotics compared to those with sutured closure after silo. CONCLUSION: Sutureless abdominal wall closure of neonates with gastroschisis was associated with less general anesthetics, antibiotic use, surgical site/deep space infections, and decreased ventilator time. These findings support further prospective study by our group. LEVEL OF EVIDENCE: Level III.

2.
J Pediatr Surg ; 55(1): 112-116, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31699435

RESUMO

PURPOSE: Surgical training is shifting toward competency-based models that promote earlier supervised autonomy. We assessed caregiver knowledge, willingness to consent, and opinions regarding trainee autonomy in their child's operation. METHODS: At two academic children's hospitals, 100 caregivers of children aged 0-17 years completed an electronic survey in the pediatric surgery clinic (1/2018-4/2018). Knowledge, willingness to consent, and opinions of trainee involvement in their child's operation in standard and competency-based training models were assessed. McNemar's test compared willingness to consent with standard and competency-based training (p < 0.05). RESULTS: Caregivers were 75% female, 41% age 30-39 years old, and 78% white. All provider roles were correctly identified by 14% of caregivers. For routine procedures, caregivers would consent to a fellow assisting (95%) or independently operating with the attending present (78%). They would less likely consent if the attending was not in the operating room (39%) or the hospital (25%). Competency-based training improved willingness to consent, but was significant only for independence with the attending present. Most caregivers wanted to know about (81%) and be asked permission for (82%) trainee involvement in their child's operation. CONCLUSIONS: This study suggests that surgeons in academic settings must balance transparency with trainee autonomy when obtaining caregiver consent. LEVEL OF EVIDENCE: Level III.

3.
J Pediatr Surg ; 55(1): 2-17, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31761457

RESUMO

In light of APSA's 50th Anniversary, the typical Presidential Address was transformed into a "symposium" consisting of talks on the maturation of our organization to APSA 5.0 and the issues and opportunities related to its internal and external environment, especially as they apply to our pediatric surgical patients. Speakers included the President and experts in the fields of diversity, as well as inequity and poverty in the United States.

4.
J Pediatr Surg ; 55(1): 169-175, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31706614

RESUMO

PURPOSE: Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. METHODS: A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children's hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. RESULTS: Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P=0.028]. CONCLUSION: Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS. TYPE OF STUDY: Prospective pilot study LEVEL OF EVIDENCE: Level III.

5.
J Pediatr Surg ; 55(1): 29-32, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31672411

RESUMO

BACKGROUND: The practice of "cutting-away" from venoarterial extracorporeal life support (ECLS) and leaving indwelling heparinized cannulas prior to decannulation is controversial. This study aims to determine the safety and efficacy of this strategy in patients with congenital diaphragmatic hernia (CDH) who require ECLS. METHODS: A single-center retrospective review of electronic health records was performed on all patients with CDH who underwent elective ECLS decannulation between January 2014 and September 2018. Descriptive statistics are presented as medians with interquartile range. RESULTS: Seventy-three percent (19/26) of patients who underwent venoarterial ECLS for CDH were electively decannulated. After a median ECLS run of 10.7 days [6.1-19.5], patients were "cut-away" for a median of 26 h [19.8-43] prior to decannulation. One patient required re-initiation at 36 h for a pulmonary hypertensive crisis (5%). There were no major bleeding or embolic events while "cut-away", and four (21%) patients had clots removed from the cannulas without clinical sequelae. One patient was recannulated 16 days following initial decannulation. CONCLUSIONS: Our data suggests that "cutting-away" from ECLS in patients with congenital diaphragmatic hernia is safe and allows a period of observation without significant complications. This strategy may be particularly helpful in patients at risk for recannulation, but better prognostic criteria are needed. LEVEL OF EVIDENCE: Level IV. TYPE OF STUDY: Treatment Study.

6.
ASAIO J ; 66(5): 572-579, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-31294720

RESUMO

One in five children with end-stage lung failure (ESLF) die while awaiting lung transplant. No suitable animal model of ESLF exists for the development of artificial lung devices for bridging to transplant. Small lambs weighing 15.7 ± 3.1 kg (n = 5) underwent ligation of the left anterior pulmonary artery (PA) branch, and gradual occlusion of the right main PA over 48 hours. All animals remained hemodynamically stable. Over seven days of disease model conditions, they developed pulmonary hypertension (mean PA pressure 20 ± 5 vs. 33 ± 4 mm Hg), decreased perfusion (SvO2 66 ± 3 vs. 55 ± 8%) with supplemental oxygen requirement, and severe tachypneic response (45 ± 9 vs. 82 ± 23 breaths/min) (all p < 0.05). Severe right heart dysfunction developed (tricuspid annular plane systolic excursion 13 ± 3 vs. 7 ± 2 mm, fractional area change 36 ± 6 vs. 22 ± 10 mm, ejection fraction 51 ± 9 vs. 27 ± 17%, all p < 0.05) with severe tricuspid regurgitation and balloon-shaped dilation of the right ventricle. This model of pediatric ESLF reliably produces pulmonary hypertension, right heart strain, and impaired gas exchange, and will be used to develop a pediatric artificial lung.

7.
ASAIO J ; 66(4): 423-432, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31192843

RESUMO

Children with end-stage lung failure awaiting lung transplant would benefit from improvements in artificial lung technology allowing for wearable pulmonary support as a bridge-to-transplant therapy. In this work, we designed, fabricated, and tested the Pediatric MLung-a dual-inlet hollow fiber artificial lung based on concentric gating, which has a rated flow of 1 L/min, and a pressure drop of 25 mm Hg at rated flow. This device and future iterations of the current design are designed to relieve pulmonary arterial hypertension, provide pulmonary support, reduce ventilator-associated injury, and allow for more effective therapy of patients with end-stage lung disease, including bridge-to-transplant treatment.

8.
J Pediatr Surg ; 2019 Oct 25.
Artigo em Inglês | MEDLINE | ID: mdl-31672412

RESUMO

BACKGROUND: Intercostal cryoablation(IC) for pain management in children undergoing Nuss Procedure has been previously described. We evaluated postoperative outcomes following Modified Ravitch procedure for pectus disorders comparing IC to thoracic epidural(TE). MATERIALS AND METHODS: Single-center retrospective review of pediatric patients (age < 21) undergoing Modified Ravitch procedure (January 2015-March 2019) with either IC(9), or TE(20) analgesia. Primary outcome was length of stay (LOS) and secondary outcomes were inpatient opioid use (in oral morphine equivalents per kilogram; OME/kg), pain scores on each postoperative day (POD), discharge prescriptions, and complications. Pairwise comparisons made with Mann-Whitney U test or Fisher Exact test as appropriate. Two-tailed p values <0.05 were considered significant. RESULTS: Patient characteristics were similar. LOS was shorter with IC compared to TE (4 days versus 6; p < 0.006). Postoperative opioid use was not significantly different (IC: 1.5 OME/kg versus TE: 1.1; p = 0.10). There was improved pain control on POD 2 in patients who underwent IC (median pain score 3 versus 4; p < 0.0004). There was no difference in discharge prescription (IC: 3.3 OME/kg; TE: 4.8; p = 0.19) or complication rate (IC: 55.6%, TE:50%; p = 1.0). CONCLUSIONS: IC during the Modified Ravitch reduced LOS compared to TE with improved pain control starting on POD 2, with similar narcotic utilization and complication rates. LEVEL OF EVIDENCE: Treatment Study, Level III (Retrospective comparative study).

9.
Pediatrics ; 144(1)2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31164439

RESUMO

BACKGROUND: Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions. METHODS: A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy. RESULTS: Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001). CONCLUSIONS: The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.


Assuntos
Tratamentos com Preservação do Órgão , Neoplasias Ovarianas/cirurgia , Ovariectomia/estatística & dados numéricos , Medição de Risco , Adolescente , Fatores Etários , Criança , Pré-Escolar , Feminino , Hospitais Pediátricos , Humanos , Medicina , Meio-Oeste dos Estados Unidos , Neoplasias Ovarianas/patologia , Estudos Retrospectivos , Procedimentos Desnecessários , Adulto Jovem
10.
Contemp Clin Trials ; 83: 10-17, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-31254670

RESUMO

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

11.
J Pediatr Surg ; 54(6): 1138-1142, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30898401

RESUMO

PURPOSE: The purpose of this study was to evaluate the clinical presentation and operative outcomes of patients with congenital lobar emphysema (CLE) within a large multicenter research consortium. METHODS: After central reliance IRB-approval, a retrospective cohort study was performed on all operatively managed lung malformations at eleven participating children's hospitals (2009-2015). RESULTS: Fifty-three (10.5%) children with pathology-confirmed CLE were identified among 506 lung malformations. A lung mass was detected prenatally in 13 (24.5%) compared to 331 (73.1%) in non-CLE cases (p < 0.0001). Thirty-two (60.4%) CLE patients presented with respiratory symptoms at birth compared to 102 (22.7%) in non-CLE (p < 0.0001). The most common locations for CLE were the left upper (n = 24, 45.3%), right middle (n = 16, 30.2%), and right upper (n = 10, 18.9%) lobes. Eighteen (34.0%) had resection as neonates, 30 (56.6%) had surgery at 1-12 months of age, and five (9.4%) had resections after 12 months. Six (11.3%) underwent thoracoscopic excision. Median hospital length of stay was 5.0 days (interquartile range, 4.0-13.0). CONCLUSIONS: Among lung malformations, CLE is associated with several unique features, including a low prenatal detection rate, a predilection for the upper/middle lobes, and infrequent utilization of thoracoscopy. Although respiratory distress at birth is common, CLE often presents clinically in a delayed and more insidious fashion. LEVEL OF EVIDENCE: Level III.


Assuntos
Enfisema Pulmonar/congênito , Criança , Pré-Escolar , Dispneia , Humanos , Lactente , Meio-Oeste dos Estados Unidos/epidemiologia , Enfisema Pulmonar/epidemiologia , Enfisema Pulmonar/cirurgia , Anormalidades do Sistema Respiratório , Estudos Retrospectivos , Toracoscopia/estatística & dados numéricos
12.
J Pediatr Surg ; 2019 Feb 28.
Artigo em Inglês | MEDLINE | ID: mdl-30879756

RESUMO

INTRODUCTION: The purpose of this study was to develop a multi-institutional registry to characterize the demographics, management, and outcomes of a contemporary cohort of children undergoing congenital lung malformation (CLM) resection. METHODS: After central reliance IRB approval, a web-based, secure database was created to capture retrospective cohort data on pathologically-confirmed CLMs performed between 2009 and 2015 within a multi-institutional research collaborative. RESULTS: Eleven children's hospitals contributed 506 patients. Among 344 prenatally diagnosed lesions, the congenital pulmonary airway malformation volume ratio was measured in 49.1%, and fetal MRI was performed in 34.3%. One hundred thirty-four (26.7%) children had respiratory symptoms at birth. Fifty-eight (11.6%) underwent neonatal resection, 322 (64.1%) had surgery at 1-12 months, and 122 (24.3%) had operations after 12 months. The median age at resection was 6.7 months (interquartile range, 3.6-11.4). Among 230 elective lobectomies performed in asymptomatic patients, thoracoscopy was successfully utilized in 102 (44.3%), but there was substantial variation across centers. The most common lesions were congenital pulmonary airway malformation (n = 234, 47.3%) and intralobar bronchopulmonary sequestration (n = 106, 21.4%). CONCLUSION: This multicenter cohort study on operative CLMs highlights marked disease heterogeneity and substantial practice variation in preoperative evaluation and operative management. Future registry studies are planned to help establish evidence-based guidelines to optimize the care of these patients. LEVEL OF EVIDENCE: Level II.

14.
J Pediatr Surg ; 54(4): 688-692, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30224238

RESUMO

PURPOSE: Right sided aortic arch (RAA) is a rare anatomic finding in infants with esophageal atresia with or without tracheoesophageal fistula (EA/TEF). In the presence of RAA, significant controversy exists regarding optimal side for thoracotomy in repair of the EA/TEF. The purpose of this study was to characterize the incidence, demographics, surgical approach, and outcomes of patients with RAA and EA/TEF. METHODS: A multi-institutional, IRB approved, retrospective cohort study of infants with EA/TEF treated at 11 children's hospitals in the United States over a 5-year period (2009 to 2014) was performed. All patients had a minimum of one-year follow-up. RESULTS: In a cohort of 396 infants with esophageal atresia, 20 (5%) had RAA, with 18 having EA with a distal TEF and 2 with pure EA. Compared to infants with left sided arch (LAA), RAA infants had a lower median birth weight, (1.96 kg (IQR 1.54-2.65) vs. 2.57 kg (2.00-3.03), p = 0.01), earlier gestational age (34.5 weeks (IQR 32-37) vs. 37 weeks (35-39), p = 0.01), and a higher incidence of congenital heart disease (90% vs. 32%, p < 0.0001). The most common cardiac lesions in the RAA group were ventricular septal defect (7), tetralogy of Fallot (7) and vascular ring (5). Seventeen infants with RAA underwent successful EA repair, 12 (71%) via right thoracotomy and 5 (29%) through left thoracotomy. Anastomotic strictures trended toward a difference in RAA patients undergoing right thoracotomy for primary repair of their EA/TEF compared to left thoracotomy (50% vs. 0%, p = 0.1). Side of thoracotomy in RAA patients undergoing EA/TEF repair was not significantly associated with mortality, anastomotic leak, recurrent laryngeal nerve injury, recurrent fistula, or esophageal dehiscence (all p > 0.29). CONCLUSION: RAA in infants with EA/TEF is rare with an incidence of 5%. Compared to infants with EA/TEF and LAA, infants with EA/TEF and RAA are more severely ill with lower birth weight and higher rates of prematurity and complex congenital heart disease. In neonates with RAA, surgical repair of the EA/TEF is technically feasible via thoracotomy from either chest. A higher incidence of anastomotic strictures may occur with a right-sided approach. LEVEL OF EVIDENCE: Level III.


Assuntos
Atresia Esofágica/cirurgia , Toracotomia/métodos , Fístula Traqueoesofágica/cirurgia , Anel Vascular/cirurgia , Aorta Torácica/anormalidades , Aorta Torácica/cirurgia , Estudos de Coortes , Atresia Esofágica/complicações , Atresia Esofágica/epidemiologia , Esôfago/cirurgia , Feminino , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Toracotomia/efeitos adversos , Fístula Traqueoesofágica/complicações , Fístula Traqueoesofágica/epidemiologia , Estados Unidos/epidemiologia , Anel Vascular/complicações , Anel Vascular/epidemiologia
15.
J Surg Res ; 231: 217-223, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30278932

RESUMO

BACKGROUND: This study aimed to evaluate postoperative outcomes after minimally invasive repair of pectus excavatum (Nuss procedure) using video-assisted intercostal nerve cryoablation (INC) compared to thoracic epidural (TE). MATERIALS AND METHODS: We performed a single center retrospective review of pediatric patients who underwent Nuss procedure with INC (n = 19) or TE (n = 13) from April 2015 to August 2017. Preoperative, intraoperative, and postoperative characteristics were collected. The primary outcome was length of stay (LOS) and secondary outcomes were intravenous and oral opioid use, pain scores, and complications. Opioids were converted to oral morphine milligram equivalents per kilogram (oral morphine equivalent [OME]/kg). Mann-Whitney U test was used for continuous and chi-squared analysis for categorical variables. RESULTS: There were no significant differences in patient characteristics, except Haller Index (INC: median [interquartile range] 4.3 [3.6-4.9]; TE: 3.2 [2.8-4.0]; P = 0.03). LOS was shorter with INC (INC: 3 [3-4] days; TE: 6 [5-7] days; P < 0.001). Opioid use was higher intraoperatively (INC: 1.08 [0.87-1.37] OME/kg; TE: 0.46 [0.37-0.67] OME/kg; P = 0.002) and unchanged postoperatively (INC: 1.78 [1.26-3.77] OME/kg; TE: 1.82 [1.05-3.37] OME/kg; P = 0.80), and prescription doses were lower at discharge in INC (INC: 30 [30-40] doses; TE: 42 [40-60] doses; P = 0.005). There was no significant difference in postoperative complications (INC: 42.1%; TE: 53.9%; P = 0.51). CONCLUSIONS: INC during Nuss procedure reduced LOS, shifting postoperative opioid use earlier during admission. This may reflect the need for improved early pain control until INC takes effect. Prospective evaluation after INC is needed to characterize long-term pain medication requirements.


Assuntos
Analgesia Epidural/estatística & dados numéricos , Criocirurgia/estatística & dados numéricos , Tórax em Funil/cirurgia , Nervos Intercostais/cirurgia , Dor Pós-Operatória/prevenção & controle , Adolescente , Analgésicos Opioides/administração & dosagem , Feminino , Humanos , Masculino , Michigan/epidemiologia , Procedimentos Cirúrgicos Minimamente Invasivos , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Cirurgia Vídeoassistida
16.
Pediatr Surg Int ; 34(7): 755-761, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29808282

RESUMO

INTRODUCTION: For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program. METHODS: After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program. RESULTS: Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons. CONCLUSION: This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/métodos , Agendamento de Consultas , Procedimentos Cirúrgicos Ambulatórios/normas , Atitude do Pessoal de Saúde , Criança , Circuncisão Masculina/métodos , Feminino , Hérnia Inguinal/cirurgia , Hérnia Umbilical/cirurgia , Herniorrafia , Humanos , Masculino , Satisfação do Paciente , Estudos Retrospectivos , Dermatopatias/cirurgia , Hidrocele Testicular/cirurgia , Fatores de Tempo
17.
J Pediatr Surg ; 53(7): 1301-1304, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29459043

RESUMO

BACKGROUND: Neurologic complications are common, and amongst the most devastating complications in pediatric patients undergoing extracorporeal life support (ECLS). Carotid artery cannulation (CAN) has been associated with an increase in these complications, thereby shaping practices to avoid this approach in most pediatric patients in which other cannulation approaches are viable. METHODS: A retrospective review of children (0-18years) in the ELSO database was undertaken from 1989 through 2013. Multivariate logistic regression analysis of rates of stroke and other neurologic complications based on cannulation technique was undertaken, adjusting for patient factors including age, underlying disease process, and severity of illness. RESULTS: A total of 30,282 ECLS runs were found in the database. CAN was associated with higher rates of stroke (5.15% vs 3.74%) and overall neurologic complications. However, when correcting for patient factors, including age, underlying disease process, and support type, CAN was not associated with an increased rate of neurologic complications or stroke (p>0.05 for both). CONCLUSION: When correcting for patient related factors CAN is not associated with an increase in stroke or neurologic compilcations. CAN should be re-examined as a cannulation technique for older pediatric patients. LEVEL OF EVIDENCE: III.


Assuntos
Cateterismo/efeitos adversos , Oxigenação por Membrana Extracorpórea/métodos , Acidente Vascular Cerebral/etiologia , Adolescente , Fatores Etários , Cateterismo/métodos , Criança , Pré-Escolar , Bases de Dados Factuais , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Humanos , Lactente , Recém-Nascido , Modelos Logísticos , Masculino , Doenças do Sistema Nervoso/epidemiologia , Doenças do Sistema Nervoso/etiologia , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia
18.
J Pediatr Surg ; 53(3): 477-482, 2018 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-29103786

RESUMO

BACKGROUND AND OBJECTIVES: Sarcopenia, defined as reduced muscle mass, is typically assessed by CT scans, which are infrequently performed in children. Using MRI to measure sarcopenia, we determined the association with postoperative complications after colectomy for ulcerative colitis (UC). METHODS: Clinical and preoperative MRI data for 13-18-year-old UC patients who underwent colectomy were retrospectively reviewed. Bilateral paraspinous muscle area (PSMA) and psoas muscle area (PMA) at L3 vertebra were measured and averaged. Composite complications were infection, wound dehiscence, postoperative leak/abscess, prolonged ileus, pulmonary embolism, venous thromboembolism, or readmission. RESULTS: Twenty-nine patients with average age 15.9±1.36years and weight 61.5±19.8kg had a preoperative MRI. The 18/29(62%) with complications had significantly reduced PSMA (4.71±1.44 vs 5.64±1.38cm2, p=0.04) and PMA (7.16±2.60 vs 8.93±2.44, p=0.04). When stratified and compared to highest PSMA, patients with lowest PSMA had increased complication rates (88% vs 29%, p=0.04). There were no differences in age, BMI, albumin, CRP, ESR, or preoperative steroid or anti-TNFα use. Odds of complication in the lowest tertile were 25.0-fold higher than the highest tertile (p=0.04, 95% CI=1.2-520.73). CONCLUSION: This is the first study to show low PSMA on MRI is associated with complications and increased hospital stay after colectomy in children with UC. LEVELS OF EVIDENCE: Level III retrospective comparative study.


Assuntos
Colectomia , Colite Ulcerativa/cirurgia , Músculos Paraespinais/patologia , Complicações Pós-Operatórias/etiologia , Sarcopenia/complicações , Adolescente , Criança , Colite Ulcerativa/complicações , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Vértebras Lombares , Imagem por Ressonância Magnética , Masculino , Músculos Paraespinais/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , Sarcopenia/diagnóstico por imagem , Sarcopenia/patologia , Resultado do Tratamento
19.
J Laparoendosc Adv Surg Tech A ; 28(2): 223-228, 2018 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29261090

RESUMO

INTRODUCTION: Interestingly, the pediatric and adult surgeons perform vastly different operations in similar patient populations. Little is known about long-term recurrence and quality of life (QOL) in adolescents and young adults undergoing inguinal hernia repair. We evaluated long-term patient-centered outcomes in this population to determine the optimal operative approach. METHODS: The medical records of patients 12-25 years old at the time of a primary inguinal hernia repair at our institution from 2000 to 2016 were retrospectively reviewed. Patients then completed a phone survey of their postoperative courses and QOL. Outcomes of high ligation performed by pediatric surgeons were compared to those of mesh repairs by adult general surgeons. The primary outcome was recurrence. Secondary outcomes included time to recurrence, postoperative complications, and patient-centered outcomes. A Cox regression analysis was used to determine associations for recurrence. RESULTS: Of 213 patients identified, 143 (67.1%) were repaired by adult surgeons and 70 (32.9%) repaired by pediatric surgeons. Overall recurrence rate for the entire cohort was 5.7% with a median time to recurrence of 3.5 years (interquartile range 120-2155 days). High ligation and mesh repairs had similar rates of recurrence (6.3 versus 5.8, P = .57) and postoperative complications (17% versus 16%, P = .45). 101/213 (47%) patients completed the phone survey. Of those surveyed, 20% reported postoperative pain, 10% had residual numbness and tingling, and 10% of patients complained of intermittent bulging. Overall, a survey comparison showed no differences among subgroups. CONCLUSIONS: In adolescents and young adults, the long-term recurrence rate after inguinal hernia repair is ∼6% with time to recurrence approaching 4 years. Outcomes of high ligation and mesh repair are similar, highlighting the need for individualized approaches for this unique population.


Assuntos
Hérnia Inguinal/cirurgia , Herniorrafia/métodos , Ligadura/métodos , Telas Cirúrgicas/efeitos adversos , Adolescente , Adulto , Criança , Feminino , Herniorrafia/efeitos adversos , Humanos , Ligadura/efeitos adversos , Masculino , Avaliação de Resultados da Assistência ao Paciente , Complicações Pós-Operatórias/epidemiologia , Qualidade de Vida , Recidiva , Estudos Retrospectivos , Resultado do Tratamento , Adulto Jovem
20.
J Pediatr Surg ; 53(4): 629-634, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29173775

RESUMO

PURPOSE: For the last seven years, our institution has repaired infants with CDH that require ECMO early after cannulation. Prior to that, we attempted to decannulate before repair, but repaired on ECMO if we were unable to wean after two weeks. This study compares those strategies. METHODS: From 2002 to 2016, 65 infants with CDH required ECMO. 67.7% were repaired on ECMO, and 27.7% were repaired after decannulation. Data were compared between patients repaired ≤5days after cannulation ("early protocol", n=30) and >5days after cannulation or after de-cannulation ("late protocol", n=35). We used Cox regression to assess differences in outcomes between groups. RESULTS: Survival for the early and late protocol groups was 43.3% and 68.8%, respectively (p=0.0485). For patients that were successfully decannulated before repair, survival was 94.4%. Moreover, the early repair protocol was associated with prolongation of ECMO (16.8±7.4 vs. 12.6±6.8days, p=0.0216). After multivariate regression, the early repair protocol was an independent predictor of both mortality (HR=3.48, 95% CI=1.28-9.45, p=0.015) and days on ECMO (IRR=1.39, 95% CI=1.07-1.79, p=0.012). All bleeding occurred in patients repaired on ECMO (29.5%, 13/44). CONCLUSIONS: Our data suggest that protocolized CDH repair early after ECMO cannulation may be associated with increased mortality and prolongation of ECMO. However, early repair is not necessarily harmful for those patients who would otherwise be unable to wean from ECMO before repair. Further work is needed to better move towards individualized patient care. TYPE OF STUDY: Treatment Study. LEVEL OF EVIDENCE: Level III.


Assuntos
Oxigenação por Membrana Extracorpórea/métodos , Hérnias Diafragmáticas Congênitas/cirurgia , Herniorrafia/métodos , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Retrospectivos , Resultado do Tratamento
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