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Hom J, Lam SHF, Delaney KM, Koos JA, Kunkov S. Vomiting, Pyloric Mass, and Point-of-Care Ultrasound: Diagnostic Test Accuracy for Hypertrophic Pyloric Stenosis-A Meta-Analysis. J Emerg Med 2023; 65:e427-e431. [PMID: 37722950 DOI: 10.1016/j.jemermed.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 03/01/2023] [Accepted: 06/13/2023] [Indexed: 09/20/2023]
Abstract
BACKGROUND Hypertrophic pyloric stenosis is a common cause of nonbilious vomiting in infants younger than 6 months. Its history, physical examination, and point-of-care ultrasound (POCUS) have not been compared for their diagnostic test accuracy. OBJECTIVE The aim of this systematic review was to quantify and compare the diagnostic test accuracy of a history of vomiting, a pyloric mass on palpation, and POCUS. METHODS We performed three searches of the literature from 1977 to March 2022. We evaluated bias using the QUADAS-2 (Quality Assessment Tool for Diagnostic Accuracy-2) tool. We performed a bivariate analysis. RESULTS From 5369 citations, we identified 14 studies meeting our inclusion criteria. We quantified three diagnostic elements: POCUS, a pyloric mass on palpation, and vomiting. We identified five studies that analyzed POCUS, which included 329 patients. POCUS had a sensitivity of 97.7% (95% confidence interval (CI) 93.1-99.3%) and a specificity of 94.1% (95% CI 88.7-97.1%) for detecting pyloric stenosis. We identified six studies that analyzed the presence of a pyloric mass, which included 628 patients. The palpation of a pyloric mass had a sensitivity of 73.5% (95% CI 62.6-82.1%) and a specificity of 97.5% (95% CI 93.8-99.0%). We identified four studies that analyzed vomiting, which included 355 patients. Vomiting had a sensitivity of 91.3% (95% CI 82.1-96.0) and a specificity of 60.8% (95% CI 8.5-96.3). Both POCUS and palpation of a pyloric mass had a high positive likelihood ratio (LR+: 17 and 33, respectively). The LR+ for vomiting was 5.0. CONCLUSIONS Both POCUS and palpable mass had high specificity and positive LR, whereas vomiting provided the lowest diagnostic test measures.
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Affiliation(s)
- Jeffrey Hom
- Department of Pediatrics, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York; Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York.
| | - Samuel H F Lam
- Department of Emergency Medicine, Sutter Medical Center, Sacramento, California
| | - Kristen M Delaney
- Department of Pediatrics, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
| | - Jessica A Koos
- Health Science Library, Stony Brook University, Stony Brook, New York
| | - Sergey Kunkov
- Department of Pediatrics, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York; Department of Emergency Medicine, Renaissance School of Medicine, Stony Brook University, Stony Brook, New York
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Lovasik BP, Srinivasan JK, Pettitt BJ. "The Most Satisfactory Procedure in the Field of Pediatric Surgery": The History of Hypertrophic Pyloric Stenosis. Am Surg 2023; 89:3716-3720. [PMID: 37144475 DOI: 10.1177/00031348231175108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
This historical retrospective explores the history of hypertrophic pyloric stenosis from its initial observations to the first surgical approaches to modern understandings of pathogenesis. The important work of Hirschsprung, Fredet, and Ramstedt remains a foundational part of management for this complex condition.
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Infantile hypertrophic pyloric stenosis: maternal diabetes and perinatal exposure to non-macrolide antibiotics. J Perinatol 2023; 43:465-469. [PMID: 36702873 DOI: 10.1038/s41372-023-01619-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/07/2023] [Accepted: 01/17/2023] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Infant exposure to macrolide antibiotics is a risk factor for infantile hypertrophic pyloric stenosis (IHPS). The aim of the study was to establish whether perinatal exposure to non-macrolide antibiotics was a risk factor for IHPS. STUDY DESIGN A retrospective matched case-control study was performed using a database including all children born at Soroka University Medical Centre between 2006 and 2018. Cases and controls were compared using Student T-test and multiple logistic regression. RESULT Of 189 461 children in the database, 63 infants were diagnosed with IHPS and underwent pyloromyotomy. There was no association between non-macrolide antibiotic exposure and IHPS. Maternal diabetes (DM) had an adjusted odds ratio for infants developing IHPS of 4.53 (p = 0.004). CONCLUSION The lack of association between exposure to non-macrolide antibiotics and IHPS suggests a quality unique to macrolides. An association between DM and IHPS may suggest elevated levels of IGF-1 have a role.
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Environmental exposure in the etiology of infantile hypertrophic pyloric stenosis: a systematic review and meta-analysis. Pediatr Surg Int 2022; 38:951-961. [PMID: 35441884 DOI: 10.1007/s00383-022-05128-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate the occupational and environmental factors in the etiology of infantile hypertrophic pyloric stenosis (IHPS). METHODS Protocol was drafted according to the PRISMA guidelines and registered on PROSPERO (CRD42020152460). A search for a combination of terms related to IHPS, fetus and neonates, and environmental exposure was performed for studies published between 2000 and 2020 in the EMBASE, Pubmed, and MEDLINE databases. RESULTS Overall, 2203 abstracts were identified and 829 were screened. The full text of the selected articles (N = 98) was assessed for eligibility. Fifteen studies were included in quantitative synthesis. IHPS risk was significantly lower in black and Hispanic mothers than in white mothers [OR 0.47 (95% CI 0.44-0.51, p < 0.001), OR 0.85 (95% CI 0.77-0.94, p = 0.002), respectively]. Lower maternal education level and maternal smoking were risk factor for IHPS. We further observed a non-significant association between maternal folic acid usage and IHPS risk. Data were insufficient to evaluate occupational exposure. CONCLUSION This review provides an understanding of the role of environmental exposures in IHPS etiology. Lower maternal educational level, maternal smoking, and white ethnicity are associated with a significantly increased risk of IHPS, while folic acid use seems non-significantly associated with IHPS risk. LEVEL OF EVIDENCE III.
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The Safety and Effectiveness of Laparoscopic Pyloromyotomy Using 3-mm Electrocautery Hook versus Open Surgery for Treatment of Hypertrophic Pyloric Stenosis in Infants. CHILDREN-BASEL 2021; 8:children8080701. [PMID: 34438592 PMCID: PMC8392573 DOI: 10.3390/children8080701] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 08/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND The standard of treatment for infants with hypertrophic pyloric stenosis is still pyloromyotomy. Recently, in most of the pediatric surgery centers laparoscopic pyloromyotomy has become popular. The aim of the present study is to compare the outcomes of treatment in infants with hypertrophic pyloric stenosis between traditional open approach and laparoscopic pyloromyotomy using 3-mm electrocautery hook. METHODS A total of 125 infants, 104 (83.2%) males, with median age 33 (interquartile range, IQR 24, 40) days, who underwent pyloromyotomy because of hypertrophic pyloric stenosis, between 2005 and 2021, were included in the retrospective study. Of that number 61 (48.8%) infants were allocated to the open group and 64 (51.2%) to the laparoscopic group. The groups were compared in regards to time to oral intake, duration of surgery, the type and rate of complications, rate of reoperations, frequency of vomiting after surgery, and the length of hospital stay. RESULTS No differences were found with regards to baseline characteristics between two investigated groups. Laparoscopic approach was associated with significantly better outcomes compared to open approach: shorter duration of surgery (35 min (IQR 30, 45) vs. 45 min (40, 57.5); p = 0.00008), shorter time to oral intake (6 h (IQR 4, 8) vs. 22 h (13.5, 24); p < 0.00001), lower frequency of postoperative vomiting (n = 10 (15.6%) vs. n = 19 (31.1%)), and shorter length of postoperative hospital stay (3 days (IQR 2, 3) vs. 6 days (4.5, 8); p < 0.00001). In regards to complications and reoperation rates, both were lower in the laparoscopic pyloromyotomy group but the differences were not statistically significant (p = 0.157 and p = 0.113, respectively). The most common complication in both groups was mucosal perforation (open group, n = 3 (4.9%); laparoscopic group, n = 2 (3.1%)) followed by wound infection in open group, n = 3 (4.9%). No cases of wound infection were recorded in the laparoscopic group. CONCLUSION Open and laparoscopic pyloromyotomy are equally safe and effective in treatment of hypertrophic pyloric stenosis. Laparoscopic technique is associated with faster recovery, shorter duration of surgery and shorter duration of hospital stay.
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Zampieri N, Corato V, Scirè G, Camoglio FS. Hypertrophic Pyloric Stenosis: 10 Years' Experience with Standard Open and Laparoscopic Approach. Pediatr Gastroenterol Hepatol Nutr 2021; 24:265-272. [PMID: 34046329 PMCID: PMC8128778 DOI: 10.5223/pghn.2021.24.3.265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/21/2020] [Accepted: 02/02/2021] [Indexed: 11/21/2022] Open
Abstract
PURPOSE Hypertrophic pyloric stenosis (HPS) is the most common cause of gastric obstruction in newborns. Extra-mucosal pyloromyotomy can be performed through a small laparotomy or laparoscopy. The aim of this study was to compare the two surgical techniques. We also analyzed the incidence of HPS in infants in the last 10 years in relation to the demographic trend of our province. METHODS We analyzed all the cases of HPS treated at our Unit between January 2010 and December 2019. The data were obtained from operating systems. Data about the demographic trends, in particular, the number of births and the population residing in the province of Verona from 2010 to 2019, were also retrieved. RESULTS During the study period, 60 patients were treated for HPS and met the inclusion criteria. Of these, 56 males and 4 females with an average age of 38±14 days at surgery were included. No differences were found in terms of the duration of surgery, post-operative complications, duration of hospitalization, and weight at the time of surgery. The only statistically significant data was the chlorine level in cases with and without post-operative vomiting (97±3.5 vs. 102±3.3 mmol/L, p<0.05). There was a lower incidence of HPS from 2014 to 2019; however, there was no significant evidence regarding the correlation between this and the reduced birth rate recorded in the province of Verona during the same period. CONCLUSION Although laparoscopic pyloromyotomy is a highly complex procedure, it is a feasible alternative to the classic open technique.
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Affiliation(s)
- Nicola Zampieri
- Department of Surgery, Dentistry, Paediatrics and Gynecology, Woman and Child Hospital; Division of Pediatric Surgery, University of Verona, Verona, Italy
| | - Valentina Corato
- Department of Surgery, Dentistry, Paediatrics and Gynecology, Woman and Child Hospital; Division of Pediatric Surgery, University of Verona, Verona, Italy
| | - Gabriella Scirè
- Department of Surgery, Dentistry, Paediatrics and Gynecology, Woman and Child Hospital; Division of Pediatric Surgery, University of Verona, Verona, Italy
| | - Francesco Saverio Camoglio
- Department of Surgery, Dentistry, Paediatrics and Gynecology, Woman and Child Hospital; Division of Pediatric Surgery, University of Verona, Verona, Italy
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Protocol: A systematic review and meta-analysis of the role of fetal and infantile environmental exposure in etiopathogenesis of infantile hypertrophic pyloric stenosis. PLoS One 2021; 16:e0247003. [PMID: 33592043 PMCID: PMC7886114 DOI: 10.1371/journal.pone.0247003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 01/27/2021] [Indexed: 01/10/2023] Open
Abstract
Infantile hypertrophic pyloric stenosis (IHPS) is one of the hallmark pediatric surgical diseases. However, its etiology remains incompletely understood. By systematically reviewing the literature, we aim to clarify the effect of the effect of occupational and environmental factors and role of nitric oxide (NO) metabolism in the etiopathogenesis of IHPS. The systematic review is drafted with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement (PRISMA) and the Meta-analysis of Observational Studies in Epidemiology (MOOSE). Systematic literature search will be performed for the period 2000 (Jan) to 2020 (Dec) in the databases: MEDLINE, EMBASE, PubMed. The systematic search will cover the literature in English and Turkish language and will be limited to studies on human subjects. Four investigators will independently search the databases (MEDLINE, EMBASE, PubMed) according to the defined search strategy. The full-text of the selected articles will be screened independently by four reviewers, against the inclusion criteria. Descriptive data will be extracted from each study regarding: study details, methods, participants, outcomes and calculations of association for potential further statistical analysis. If meta-analysis could not be undertaken, systematic approach to analyzing the findings of included multiple studies will be described. Heterogeneity will be assessed by quantifying the inconsistency across studies using I2 statistic. Statistical analysis will be performed using Comprehensive Meta-Analysis Version 3.0 software. The p values lower than 0.05 will be considered statistically significant for all analyses.
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Abstract
CLINICAL/METHODICAL ISSUE Acute, non-traumatic abdominal pain is one of the main reasons for medical consultation in pediatric patients. Knowledge of different diseases and their age dependence is essential for correct diagnosis and treatment. STANDARD RADIOLOGICAL METHODS Ultrasonography is the imaging method of choice. X‑ray is only used in case of emergency, e. g., suspected perforation. METHODICAL INNOVATIONS Contrast-enhanced ultrasonography (CEUS) and elastography complement ultrasonography. PERFORMANCE Magnetic resonance imaging is of increasing relevance for differential diagnosis of unclear sonographic results. PRACTICAL RECOMMENDATIONS The primary imaging modality in pediatric patients is ultrasonography. Cross-sectional imaging should only be used in cases of unclear sonographic findings.
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Affiliation(s)
- P C Krüger
- Sektion Pädiatrische Radiologie, Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland
| | - H J Mentzel
- Sektion Pädiatrische Radiologie, Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Jena, Am Klinikum 1, 07747, Jena, Deutschland.
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Pogorelić Z, Čagalj IČ, Žitko V, Nevešćanin A, Krželj V. Late-Onset Hypertrophic Pyloric Stenosis in a 14-Weeks-Old Full Term Male Infant. ACTA MEDICA (HRADEC KRÁLOVÉ) 2019; 62:82-84. [PMID: 31362816 DOI: 10.14712/18059694.2019.108] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Hypertrophic pyloric stenosis is the most common cause of gastric outlet obstruction in infants, and classically presents at 2 to 6 weeks of age. Delayed presentation is an extremely rare occurrence after early infancy. CASE REPORT A 14-weeks-old full term male infant presented with non-bilious vomiting, dehydration and hypocloremic metabolic alkalosis. Abdominal ultrasonography revealed tubular mass 20 mm in lenght. Because of unusual age, diagnosis was confirmed with upper gastrointestinal contrast study. Laparoscopic pyloromyotomy was performed. After surgery the child was free of symptoms, had gained weight, and was tolerating a regular diet. Message: Despite the age hypertrophic pyloric stenosis should be kept in mind in any child who presents with non-bilious vomiting.
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Affiliation(s)
- Zenon Pogorelić
- Department of Pediatric Surgery, University Hospital of Split, Split, Croatia. .,University of Split, School of Medicine, Split, Croatia.
| | - Ivana Čulo Čagalj
- Department of Pediatrics, University Hospital of Split, Split, Croatia
| | - Vanda Žitko
- Department of Pediatrics, University Hospital of Split, Split, Croatia
| | - Ana Nevešćanin
- Department of Anesthesiology, Reanimatology and Intensive Care, University Hospital of Split, Split, Croatia
| | - Vjekoslav Krželj
- Department of Pediatrics, University Hospital of Split, Split, Croatia.,University of Split, School of Medicine, Split, Croatia
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Kapoor R, Kancherla V, Cao Y, Oleson J, Suhl J, Canfield MA, Druschel CM, Kirby RS, Meyer RE, Romitti PA. Prevalence and descriptive epidemiology of infantile hypertrophic pyloric stenosis in the United States: A multistate, population-based retrospective study, 1999-2010. Birth Defects Res 2018; 111:159-169. [PMID: 30549250 DOI: 10.1002/bdr2.1439] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 10/12/2018] [Accepted: 10/15/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Antecedents for infantile hypertrophic pyloric stenosis (IHPS) vary across studies; therefore, we conducted a multistate, population-based retrospective study of the prevalence and descriptive epidemiology of IHPS in the United States (US). METHODS Data for IHPS cases (n = 29,554) delivered from 1999-2010 and enumerated from 11 US population-based birth defect surveillance programs, along with data for live births (n = 14,707,418) delivered within the same birth period and jurisdictions, were analyzed using Poisson regression to estimate IHPS prevalence per 10,000 live births. Additional data on deliveries from 1999-2005 from seven of these programs were analyzed using multivariable logistic regression to estimate adjusted prevalence ratios (aPR)s and 95% confidence intervals (CI)s for selected infant and parental characteristics. RESULTS Overall, IHPS prevalence from 1999-2010 was 20.09 (95% CI = 19.87, 20.32) per 10,000 live births, with statistically significant increases from 2003-2006 and decreases from 2007-2010. Compared to their respective referents, aPRs were higher in magnitude for males, preterm births, and multiple births, but lower for birth weights <2,500 g. The aPRs for all cases increased with decreasing parental age, maternal education, and maternal parity, but decreased for parental race/ethnicity other than non-Hispanic White. Estimates restricted to isolated cases or stratified by infant sex were similar to those for all cases. CONCLUSIONS This study covers one of the largest samples and longest temporal period examined for IHPS in the US. Similar to findings reported in Europe, estimates suggest that IHPS prevalence has decreased recently in the US. Additional analyses supported associations with several infant and parental characteristics.
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Affiliation(s)
- Renuka Kapoor
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Vijaya Kancherla
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yanyan Cao
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Jacob Oleson
- Department of Biostatistics, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Jonathan Suhl
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa
| | - Mark A Canfield
- Birth Defects Epidemiology and Surveillance Branch, Texas Department of State Health Services, Austin, Texas
| | - Charlotte M Druschel
- Department of Epidemiology and Biostatistics, University of Albany School of Public Health, State University of New York, New York, New York
| | - Russell S Kirby
- Department of Community and Family Health, College of Public Health, University of South Florida, Florida
| | - Robert E Meyer
- Birth Defects Monitoring Program, Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, North Carolina.,Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul A Romitti
- Department of Epidemiology, College of Public Health, The University of Iowa, Iowa City, Iowa.,Department of Biostatistics, College of Public Health, The University of Iowa, Iowa City, Iowa
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Impact of a multimedia teaching tool on parental anxiety and knowledge during the informed consent process. Pediatr Surg Int 2018; 34:1345-1352. [PMID: 30255353 DOI: 10.1007/s00383-018-4352-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2018] [Indexed: 12/16/2022]
Abstract
PURPOSE Before performing a surgical procedure, informed consent (IC) is obtained. Parents may exhibit anxiety and/or a desire for more knowledge during the IC process for their child. The purpose of this study was to measure the impact of a multimedia intervention (MMI) versus conventional discussion on parental understanding and anxiety during the IC process for infants undergoing surgery for hypertrophic pyloric stenosis. METHODS A time-interrupted series design was employed over a 9-month period. In the first phase, conventional discussion for IC was performed. In the second phase, a MMI was utilized. In both phases, anxiety scores and post-consent knowledge tests were collected. RESULTS 31 participants were included in the study, 17 in the conventional consent and 14 in the MMI phase. Parental anxiety around the IC discussion was measured. There was a significant decrease in anxiety noted with use of the MMI (p = 0.046) but no significant difference in knowledge (p = 0.84). CONCLUSION The MMI significantly reduced parental anxiety during the IC process. Providers may consider applying this type of MMI to other surgical procedures. Securing IC in a manner that improves knowledge and decreases anxiety may improve long-term understanding and parental satisfaction with the health care process.
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Johncilla M, Yantiss RK. Malformations, choristomas, and hamartomas of the gastrointestinal tract and pancreas. Semin Diagn Pathol 2018; 36:24-38. [PMID: 30482417 DOI: 10.1053/j.semdp.2018.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Congenital and hamartomatous lesions of the gastrointestinal tract cause diagnostic challenges for surgical pathologists. Many of these are merely histologic curiosities, whereas others have substantial clinical implications because they herald cancer syndromes or associated anomalies. Although a comprehensive discussion of all developmental abnormalities that can occur in the gastrointestinal tract is beyond the scope of a single manuscript, some entities are more likely to be encountered by surgical pathologists, have important clinical consequences, or pose diagnostic difficulties. The purpose of this review is to discuss the more common malformations and choristomas, as well as hamartomatous lesions that may be clinically important due to their risk for cancer development, frequent associations with heritable cancer syndromes and other anomalies, or potential to simulate other entities.
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Affiliation(s)
- Melanie Johncilla
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Rhonda K Yantiss
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
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