Disparities in the Management of Pediatric Breast Masses.

INTRODUCTION: Disparities in surgical management have been documented across a range of disease processes. The objective of this study was to investigate sociodemographic disparities in young females undergoing excision of a breast mass. METHODS: A retrospective study of females aged 10-21 y who underwent surgery for a breast lesion across eleven pediatric hospitals from 2011 to 2016 was performed. Differences in patient characteristics, workup, management, and pathology by race/ethnicity, insurance status, median neighborhood income, and urbanicity were evaluated with bivariate and multivariable regression analyses. RESULTS: A total of 454 females were included, with a median age of 16 y interquartile range (IQR: 3). 44% of patients were nonHispanic (NH) Black, 40% were NH White, and 7% were Hispanic. 50% of patients had private insurance, 39% had public insurance, and 9% had other/unknown insurance status. Median neighborhood income was $49,974, and 88% of patients resided in a metropolitan area. NH Whites have 4.5 times the odds of undergoing preoperative fine needle aspiration or core needle biopsy compared to NH Blacks (CI: 2.0, 10.0). No differences in time to surgery from the initial imaging study, size of the lesion, or pathology were observed on multivariable analysis. CONCLUSIONS: We found no significant differences by race/ethnicity, insurance status, household income, or urbanicity in the time to surgery after the initial imaging study. The only significant disparity noted on multivariable analysis was NH White patients were more likely to undergo preoperative biopsy than were NH Black patients; however, the utility of biopsy in pediatric breast masses is not well established.

Management of Pediatric Breast Masses: A Multi-institutional Retrospective Cohort Study.

BACKGROUND: The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. MATERIALS AND METHODS: A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. RESULTS: Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. CONCLUSIONS: Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

Echocardiography Reveals Heart Abnormalities in Pediatric Pectus Carinatum.

BACKGROUND: Symptoms including chest pain and palpitations are commonly described by pediatric patients with pectus deformity. Cardiac anomalies are thought to be less common in patients with pectus carinatum (PC) than those in patients with pectus excavatum; however, no literature supports this presumption. Echocardiogram (echo) assesses heart structure and function. We hypothesized that a screening echo would 1) determine the relationship between symptoms and echo findings and 2) define the incidence of cardiac defects in patients with PC. MATERIALS AND METHODS: This is an institutional review board-approved retrospective review of all patients with PC who received an echo from 2015 to 2019 at a tertiary care children's hospital. Echo findings and patient-reported symptoms were collected from electronic health records. Descriptive statistics were used to assess correlation between findings. RESULTS: We identified 155 patients with PC who received an echo with complete data available for analysis. Of these, 44 (28.4%) reported chest pain and 13 (8.4%) reported palpitations. Echo results showed that five patients (3.2%) had mitral valve prolapse and 11 (7.1%) had aortic root dilation. Patient-reported symptoms were not significantly associated with abnormal echo findings. CONCLUSIONS: Chest pain and palpitations frequently occur in the PC population but may not be related to abnormal echo findings. We recommend screening echo in patients with PC regardless of symptoms.

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.

BACKGROUND/PURPOSE: Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias. METHODS: Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair. RESULTS: Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy. CONCLUSION: Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair. LEVEL OF EVIDENCE: Level III.

Acid suppression duration does not alter anastomotic stricture rates after esophageal atresia with distal tracheoesophageal fistula repair: A prospective multi-institutional cohort study.

INTRODUCTION: Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation. METHODS: A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively. RESULTS: Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p<0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p<0.01). There was no association between acid suppression duration and stricture formation. CONCLUSION: No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.

Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula.

BACKGROUND/PURPOSE: This study evaluated compliance with a multi-institutional quality improvement management protocol for Type-C esophageal atresia with distal tracheoesophageal fistula (EA/TEF). METHODS: Compliance and outcomes before and after implementation of a perioperative protocol bundle for infants undergoing Type-C EA/TEF repair were compared across 11 children's hospitals from 1/2016-1/2019. Bundle components included elimination of prosthetic material between tracheal and esophageal suture lines during repair, not leaving a transanastomotic tube at the conclusion of repair (NO-TUBE), obtaining an esophagram by postoperative-day-5, and discontinuing prophylactic antibiotics 24 h postoperatively. RESULTS: One-hundred seventy patients were included, 40% pre-protocol and 60% post-protocol. Bundle compliance increased 2.5-fold pre- to post-protocol from 17.6% to 44.1% (p < 0.001). After stratifying by institutional compliance with all bundle components, 43.5% of patients were treated at low-compliance centers (<20%), 43% at medium-compliance centers (20-80%), and 13.5% at high-compliance centers (>80%). Rates of esophageal leak, anastomotic stricture, and time to full feeds did not differ between pre- and post-protocol cohorts, though there was an inverse correlation between NO-TUBE compliance and stricture rate over time (ρ = -0.75, p = 0.029). CONCLUSIONS: Compliance with our multi-institutional management protocol increased 2.5-fold over the study period without compromising safety or time to feeds and does not support the use of transanastomotic tubes. LEVEL OF EVIDENCE: Level II. TYPE OF STUDY: Treatment Study.

Baseline preoperative physical activity for surgical patients varies from healthy population controls.

BACKGROUND: Preoperative physical activity (PA) is an important reference point to evaluate recovery, yet is not attainable for emergent surgical admissions. We investigated the validity of PA of healthy children recruited from within the same community as surgical patients and a nationally representative sample as alternative baseline PA for pediatric surgical patients. METHODS: Patients undergoing an elective operation were matched to community-recruited healthy controls (CRHC) on sex, age, and weight, and their PA was assessed using an Actigraph accelerometer. National Health and Nutrition Examination Survey (NHANES) Actigraph PA data were used as a nationally representative match for baseline PA. Surgical patients wore the accelerometer for 2 days preoperatively, CRHC for 2 days, and NHANES participants for 7 days. PA was categorized as light (LPA) or moderate vigorous (MVPA). Means were compared between the 3 groups. RESULTS: Thirty patients were matched with 80 CRHC and 3147 NHANES participants. LPA was similar between surgical patients and CRHC. However, CRHC averaged 19 min/day more MVPA than surgery patients (p = 0.04), and both groups averaged 58 min and 67 min/day higher MVPA than the matched NHANES sample, respectively (p < 0.01). CONCLUSIONS: CRHC LPA was similar to preoperative LPA in surgical patients and may be an alternative. LEVEL OF EVIDENCE: Level II.

A novel technique to measure severity of pediatric pectus excavatum using white light scanning.

BACKGROUND/PURPOSE: Computed tomography (CT) derived Haller Index (HI) remains the standard for quantifying severity in patient with pectus excavatum (PE). Optical scanning described in literature reports optimistic results and new indices that correlate with HI. This study assessed the feasibility of a handheld White Light Scanner (WLS) to obtain 3D measurements and indices of PE deformity. METHODS: From April 2015-April 2017, WLS scanning was conducted by orthotists during clinical visits. Included were children with PE up to 18 years. Analysis assessed correlation of a WLS-derived severity index, Hebal-Malas Index (HMI), with physician measured PE Depth (PED), and CT-derived HI. RESULTS: Of 195 participants, 185(94%) patients with PE were scanned and 127(69%) had complete WLS data. For 88 patients undergoing monitoring, HMI correlated with PED (r = 0.42, p = 0.004). For 39 patients with pre-operative CT, HMI demonstrated strong correlation with HI (r = 0.87, p<0.0001). CONCLUSIONS: WLS demonstrated high feasibility of scanning PE. WLS-derived HMI best correlates with HI for patients with severe pectus deformity. Our current data is suggestive that WLS is best applied for severe deformities and yet to be established for milder deformities. Future yearly WLS will provide data on deformity progression and surgical therapy. LEVEL OF EVIDENCE: IV. TYPE OF STUDY: Diagnostic Study.

Measuring the impact of surgical intervention on pediatric pectus excavatum using white light scanning.

BACKGROUND: Objective preoperative assessment of pectus excavatum (PE) deformity in patients is limited to preoperative measurement of severity using computed tomography (CT) or magnetic resonance imaging (MRI). Postoperative assessment is currently subjective as postoperative CT scans are not recommended in light of radiation exposure and high cost to families. White Light Scanning (WLS) is a novel 3D imaging modality that offers an alternative that is a quick, nonionizing, inexpensive, and safe strategy for measurement both pre- and postsurgery. Our prior investigation demonstrated the feasibility of using WLS to measure PE deformity and showed very strong correlation of a new WLS-derived PE severity index, the Hebal-Malas Index (HMI), with CT-derived HI. The purpose of this study was to demonstrate use of WLS to assess extent of correction of PE deformities after the Nuss procedure. METHODS: WLS scan data were gathered prospectively in pediatric patients with PE from 2015 to 2018. HMI was obtained from the preoperative and postoperative WLS scans. Analysis assessed the differences of preoperative and postoperative HMI. Preoperative CT-derived HI was collected from the medical record and estimated postoperative Haller Index was calculated from HMI and correlation of HMI and HI using historical data. RESULTS: A total of 71 patients received a preoperative CT scan and underwent surgery for PE. Of those, 63 (89%) received WLS preoperatively and 51 (72%) had complete preoperative and postoperative WLS data. The average postoperative decrease in the WLS-derived HMI was 0.35 (SD: 0.15) and 1.73 (SD: 1.03) in WLS-estimated HI. CONCLUSIONS: WLS is highly effective in objectively quantifying the extent of surgical correction in PE patients. LEVEL OF EVIDENCE: IV TYPE OF STUDY: Diagnostic Study.

Measuring the impact of brace intervention on pediatric pectus carinatum using white light scanning.

BACKGROUND: Evaluation of Pectus Carinatum (PC) deformity in patients undergoing bracing is limited to subjective assessment of the chest through physical exam and photography. White Light Scanning (WLS) is a novel 3D imaging modality and offers an objective alternative that is quick, inexpensive, and safe. We previously demonstrated the feasibility of using a WLS-derived proxy for Haller index, called the Hebal-Malas Index (HMI), in measuring the surgical correction of Pectus Excavatum. The purpose of this study was to demonstrate the use of WLS to measure the severity of pre- and postbracing intervention of PC deformities and assess corrected difference between the two scans. METHODS: We conducted a prospective review of preintervention WLS scans in pediatric patients with PC from 2015 to 2017. HMI was obtained from the preintervention and postintervention WLS scans. Analysis assessed the differences of pre- and postbracing intervention of measurements. RESULTS: Of 32 patients with both pre- and postbracing scans, 13 (34%) showed improvement of more than 10%, 21 (55%) showed slight improvement of 1%-10%, and 4 (11%) did not improve at follow-up. The average postbracing change in the WLS-derived HMI was 0.10 (SD:0.11). The average length of bracing days was 331.4 (SD: 127.3) with an average of 6.8 h worn per day. Compliance was defined as patient reported utilization of the brace. Patients who were compliant showed a significant improvement (p = 0.004) compared to those who were not compliant (Table 2). However, even patients with moderate compliance still improved in many instances. Change in height was a significant factor correlating with improvement. Children who grew more while wearing a brace showed greater improvement in their deformity. CONCLUSION: Using this technique, we have the ability to objectively quantify the impact of bracing on the severity of PC deformity and measure change in deformity over time. TYPE OF STUDY: Prospective study. LEVEL OF EVIDENCE: Level IV.