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Huerta CT, Saberi RA, Lynn R, Ramsey WA, Gilna GP, Parreco JP, Sola JE, Perez EA, Thorson CM. Outcomes after Ladd Procedures for Intestinal Malrotation in Newborns with Heterotaxy Syndrome. J Pediatr Surg 2023; 58:1095-1100. [PMID: 36941169 DOI: 10.1016/j.jpedsurg.2023.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 02/09/2023] [Indexed: 02/19/2023]
Abstract
PURPOSE Intestinal malrotation may be asymptomatic in patients with heterotaxy syndrome (HS), and whether these newborns benefit from prophylactic Ladd procedures is unknown. This study sought to uncover nationwide outcomes of newborns with HS receiving Ladd procedures. METHODS Newborns with malrotation were identified from the Nationwide Readmission Database (2010-2014) and stratified into those with and without HS utilizing ICD-9CM codes for situs inversus (759.3), asplenia or polysplenia (759.0), and/or dextrocardia (746.87). Outcomes were analyzed using standard statistical tests. RESULTS 4797 newborns with malrotation were identified, of which 16% had HS. Ladd procedures were performed in 70% overall and more common in those without heterotaxy (73% vs. 56% HS). Ladd procedures in newborns with heterotaxy were associated with higher complications compared to those without HS including surgical site reopening (8% vs. 1%), sepsis (9% vs. 2%), infections (19% vs. 11%), venous thrombosis (9% vs. 1%), and prolonged mechanical ventilation (39% vs. 22%), all p < 0.001. HS newborns were less frequently readmitted with bowel obstructions (0% vs. 4% without HS, p < 0.001) with no readmissions for volvulus in either group. CONCLUSION Ladd procedures in newborns with heterotaxy were associated with increased complications and cost without differences in rates of volvulus and bowel obstruction on readmission. TYPE OF STUDY Retrospective Comparative. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Carlos Theodore Huerta
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Rebecca A Saberi
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Royi Lynn
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - Walter A Ramsey
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Gareth P Gilna
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Joshua P Parreco
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Juan E Sola
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Eduardo A Perez
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Chad M Thorson
- DeWitt Daughtry Family Department of Surgery, Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.
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Impact of gastrointestinal comorbidities in patients with right and left atrial isomerism. Cardiol Young 2022; 32:1053-1060. [PMID: 34470692 DOI: 10.1017/s1047951121003620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND AIM Heterotaxy syndrome, being right atrial isomerism (RAI) or left atrial isomerism (LAI), often presents with Congenital Heart Disease (CHD). Intestinal abnormalities, including malrotation are common. We assessed the spectrum of gut abnormalities and their impact on medium-term outcome in a cohort of patients with fetal and postnatal diagnoses of heterotaxy syndrome. METHODS We reviewed the cardiology records of heterotaxy syndrome patients from two centres, regarding the presence of CHD, time for cardiac intervention, presence of gastrointestinal abnormalities, and type/time of surgery. A questionnaire about gastrointestinal status was sent to patients <18 years old. Kaplan-Meier curves were derived for survival data and freedom from intervention. RESULTS Data were included for 182 patients (49 RAI and 133 LAI) of 247 identified. Questionnaires were sent to 77 families and 47 replied. CHD was present in all RAI and 61.7% of LAI cases. Thirty-eight patients had abdominal surgery (20.9%), similar for RAI and LAI (20.4% versus 21%, p> 0.99): Ladd procedure in 17 (44.7%), non-Ladd in 12 (31.5%), and both procedures in 9 (23.7%). Ten-year freedom from Ladd procedure for all was 86% for the whole cohort (RAI = 87%; LAI = 85%, p = 0.98). Freedom from any gastrointestinal surgery at 10 years was 79% for the whole cohort (RAI = 77%; LAI = 80%, p = 0.54). Ten-year freedom from cardiac surgery was 31% for the whole cohort (RAI = 6%; LAI = 43%, p < 0.0001). CONCLUSIONS In our cohort, one in five patients required abdominal surgery, mostly in their first year of life, similar for RAI and LAI. Between 1 and 10 years of follow-up, the impact of gastrointestinal abnormalities on outcome was minimal. Medium term survival was related to CHD.
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Malrotation is not associated with adverse outcomes after cardiac surgery in patients with heterotaxy syndrome. J Pediatr Surg 2018; 53:1494-1498. [PMID: 29453132 DOI: 10.1016/j.jpedsurg.2018.01.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 12/18/2017] [Accepted: 01/15/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Patients with heterotaxy syndrome (HS) often have asymptomatic malrotation. There is a lack of consensus regarding the management of these patients, particularly in patients with complex congenital heart disease (CHD). We sought to describe the prevalence of malrotation and incidence of volvulus in a population of patients with complex CHD and to identify the impact of malrotation on morbidity and mortality following cardiac surgery. METHODS We performed a retrospective review of all patients with HS and complex CHD who required cardiac surgery in the first year of life at a single center between October 1995 and September 2015. Malrotation was diagnosed by abdominal imaging or by direct inspection during abdominal surgery. Demographic data was collected along with details of hospitalization following cardiac and GI surgeries. Descriptive analysis along with appropriate hypothesis testing was conducted to evaluate the results. RESULTS We identified 49 patients with HS, 42 with single ventricle anatomy and 7 with biventricular anatomy. Of the 49 patients, 29 (59%) were diagnosed with malrotation, 6 (12%) had normal intestinal rotation, and 14 (29%) had no evaluation of intestinal rotation. The prevalence of malrotation in the population who underwent abdominal imaging was 29 out of 35 (83%). There was no difference in survival following cardiac surgery between patients with malrotation and those with unknown or normal intestinal anatomy. Comparing patients with malrotation and patients with normal or unknown intestinal rotation, there was also no difference in surrogate markers of morbidity. Of the 29 patients with known malrotation, only 2 patients (7%) underwent therapeutic Ladd procedures and 19 (65%) underwent prophylactic Ladd procedures. CONCLUSIONS We conclude that the outcomes following cardiac surgery for patients with HS are not impacted by the presence of malrotation. Furthermore, we also found that the incidence of volvulus in the studied group is low. Given these findings, and the understanding that patients with HS and significant CHD are frequently tenuous and high risk surgical candidates, we do not believe performing prophylactic Ladd procedures is warranted. LEVEL OF EVIDENCE III.
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Landisch RM, Loomba RS, Salazar JH, Buelow MW, Frommelt M, Anderson RH, Wagner AJ. Is isomerism a risk factor for intestinal volvulus? J Pediatr Surg 2018; 53:1118-1122. [PMID: 29605269 DOI: 10.1016/j.jpedsurg.2018.02.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Accepted: 02/27/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Isomerism, or heterotaxy syndrome, affects many organ systems anatomically and functionally. Intestinal malrotation is common in patients with isomerism. Despite a low reported risk of volvulus, some physicians perform routine screening and prophylactic Ladd procedures on asymptomatic patients with isomerism who are found to have intestinal malrotation. The primary aim of this study was to determine if isomerism is an independent risk factor for volvulus. METHODS Kid's Inpatient Database data from 1997 to 2012 was utilized for this study. Characteristics of admissions with and without isomerism were compared with a particular focus on intestinal malrotation, volvulus, and Ladd procedure. A logistic regression was conducted to determine independent risk factors for volvulus with respect to isomerism. RESULTS 15,962,403 inpatient admissions were included in the analysis, of which 7970 (0.05%) patients had isomerism, and 6 patients (0.1%) developed volvulus. Isomerism was associated with a 52-fold increase in the odds of intestinal malrotation by univariate analysis. Of 251 with isomerism and intestinal malrotation, only 2.4% experienced volvulus. Logistic regression demonstrated that isomerism was not an independent risk factor for volvulus. CONCLUSION Isomerism is associated with an increased risk of intestinal malrotation but is not an independent risk factor for volvulus. TYPE OF STUDY Prognosis study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Rachel M Landisch
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Surgery, Milwaukee, WI.
| | - Rohit S Loomba
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Cardiology, Milwaukee, WI
| | - Jose H Salazar
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Surgery, Milwaukee, WI
| | - Matthew W Buelow
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Cardiology, Milwaukee, WI
| | - Michele Frommelt
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Cardiology, Milwaukee, WI
| | - Robert H Anderson
- Institute of Genetics, Newcastle University, Division of Pediatric Cardiology, Newcastle Upon Tyne, United Kingdom
| | - Amy J Wagner
- Children's Hospital of Wisconsin/Medical College of Wisconsin, Division of Pediatric Surgery, Milwaukee, WI
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Buca DIP, Khalil A, Rizzo G, Familiari A, Di Giovanni S, Liberati M, Murgano D, Ricciardulli A, Fanfani F, Scambia G, D'Antonio F. Outcome of prenatally diagnosed fetal heterotaxy: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2018; 51:323-330. [PMID: 28603940 DOI: 10.1002/uog.17546] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/22/2017] [Accepted: 06/02/2017] [Indexed: 02/05/2023]
Abstract
OBJECTIVES The main aim of this systematic review was to evaluate the prevalence and type of associated anomalies in fetuses with heterotaxy diagnosed prenatally on ultrasound; the perinatal outcome of these fetuses was also studied. METHODS An electronic search of MEDLINE, EMBASE and CINAHL databases was performed. Only studies reporting the prenatal diagnosis of isomerism were included. Outcomes observed included associated cardiac and extracardiac anomalies, fetal arrhythmia, abnormal karyotype, type of surgical repair and perinatal mortality. The analysis was stratified according to the type of heterotaxy syndrome (left (LAI) or right (RAI) atrial isomerism). Meta-analyses of proportions were used to combine data. Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for cohort studies. RESULTS Sixteen studies (647 fetuses) were included in the analysis. Atrioventricular septal defect was the most common associated major cardiac anomaly found both in fetuses with LAI (pooled proportion (PP), 59.3% (95% CI, 44.0-73.7%)), with obstructive lesions of the right outflow tract occurring in 35.5% of these cases, and in fetuses with RAI (PP, 72.9% (95% CI, 60.4-83.7%)). Fetal arrhythmias occurred in 36.7% (95% CI, 26.9-47.2%) of cases with LAI and were mainly represented by complete atrioventricular block, while this finding was uncommon in cases with RAI (PP, 1.3% (95% CI, 0.2-3.2%)). Abnormal stomach and liver position were found, respectively, in 59.4% (95% CI, 38.1-79.0%) and 32.5% (95% CI, 11.9-57.6%) of cases with LAI, and in 54.5% (95% CI, 38.5-70.1%) and 45.9% (95% CI, 11.3-83.0%) of cases with RAI, while intestinal malrotation was detected in 14.2% (95% CI, 2.5-33.1%) of LAI and 27.1% (95% CI, 7.9-52.0%) of RAI cases. Hydrops developed in 11.8% (95% CI, 2.9-25.6%) of fetuses diagnosed prenatally with LAI. Biventricular repair was accomplished in 78.2% (95% CI, 64.3-89.4%) of cases with LAI, while univentricular repair or palliation was needed in 17.0% (95% CI, 9.7-25.9%); death during or after surgery occurred in 26.8% (95% CI, 4.6-58.7%) of LAI cases. Most children with RAI had univentricular repair and 27.8% (95% CI, 15.5-42.1%) died during or after surgery. CONCLUSIONS Fetal heterotaxy is associated with a high prevalence of cardiac and extracardiac anomalies. Approximately one quarter of fetuses with heterotaxy died during or after surgery. Abnormal heart rhythm, especially heart block, is common in fetuses with LAI, while this finding is uncommon in RAI. Biventricular repair was common in LAI while univentricular repair was required in the majority of children affected by RAI. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D I P Buca
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - A Khalil
- St George's, University of London & St George's University Hospitals NHS Foundation Trust Molecular and Clinical Sciences Research Institute, London, UK
| | - G Rizzo
- Department of Obstetrics and Gynaecology, Università di Roma Tor Vergata, Rome, Italy
| | - A Familiari
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy
| | - S Di Giovanni
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - M Liberati
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - D Murgano
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - A Ricciardulli
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - F Fanfani
- Department of Obstetrics and Gynaecology, SS. Annunziata Hospital, G. D'Annunzio University of Chieti-Pescara, Chieti, Italy
| | - G Scambia
- Department of Obstetrics and Gynaecology, Catholic University of the Sacred Heart, Rome, Italy
| | - F D'Antonio
- Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynaecology, University Hospital of Northern Norway, Tromsø, Norway
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Is Screening of Intestinal Foregut Anatomy in Heterotaxy Patients Really Necessary?: A Systematic Review in Search of the Evidence. Ann Surg 2017; 264:1156-1161. [PMID: 26704743 DOI: 10.1097/sla.0000000000001563] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE (1) Is screening of intestinal rotational anatomy obligatory in "asymptomatic" patients with heterotaxy? (2) Does detection of an anomaly warrant surgical correction? SUMMARY OF BACKGROUND DATA Heterotaxy is an abnormal arrangement of thoraco-abdominal viscera across a left-to-right axis. Intestinal rotational anomalies are frequent among patients with heterotaxy, but debate exists as to whether they are benign in nature, requiring careful observation alone, or if surgical correction is warranted to prevent obstruction or midgut volvulus. METHODS A systematic review [according to PRISMA guidelines] was conducted using CINAHL, EMBASE, Medline, and Cochrane Databases. Article quality was assessed using MINORS criteria. Conference proceedings and unpublished data were screened additionally. RESULTS Nineteen studies met the eligibility criteria but reporting was adequate for 9. All were observational studies. These included a total of 414 patients managed expectantly, that is, "asymptomatic patients" in whom no intestinal rotation screening was undertaken (group A), 191 cases in whom screening was performed routinely (group B), and 92 patients considered "symptomatic" of potential rotational anomalies and therefore underwent imaging or laparotomy (group C). In group A, 1 patient developed symptoms attributable to malrotation in whom laparotomy confirmed the diagnosis (0.24%). Among groups B and C, 151 had Ladd's operations (53%) and 14 cases of malrotation with obstruction or volvulus were described (4.9%), of which 2 "symptomatic patients" died before laparotomy. Overall surgical complication rate was 17% with 30-day mortality rate of 2.6% to 4.6%. CONCLUSION The evidence base for screening "asymptomatic" patients is weak especially considering the life-limiting comorbidities.
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Putnam LR, Anderson KT, Tsao K, Kao LS, Lugo JA, Lally KP, Kawaguchi AL. The impact of cardiac risk factors on short-term outcomes for children undergoing a Ladd procedure. J Pediatr Surg 2017; 52:390-394. [PMID: 27894758 DOI: 10.1016/j.jpedsurg.2016.09.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 09/29/2016] [Accepted: 09/29/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND/PURPOSE The purpose of this study was to describe the outcomes of children with and without congenital heart disease who undergo a Ladd procedure. METHODS The 2012-2014 National Surgical Quality Improvement Program Pediatric (NSQIP-P) data were queried for patients undergoing a Ladd procedure. Utilizing NSQIP-P definitions, patients were categorized into four cardiac risk groups (none, minor, major, severe) based on severity of cardiac anomalies, previous cardiac procedure(s), and ongoing cardiac dysfunction. Ladd procedures were elective/non-elective. Outcomes included length of stay, adverse events, and mortality. RESULTS 878 patients underwent Ladd procedures. 633 (72%) patients had no cardiac risk factors and 84 (10%), 109 (12%), and 52 (6%) had minor, major, and severe cardiac risk factors, respectively. Children with congenital heart disease experienced increased morbidity and mortality and longer hospital stays (all p<0.05). Elective Ladd procedures were associated with similar morbidity but shorter length of stay and lower mortality than non-elective procedures. Older age at time of operation was associated with fewer adverse events. CONCLUSIONS Although overall mortality remains low, children with higher risk cardiac disease experience increased morbidity and mortality when undergoing a Ladd procedure. Older age at the time of the Ladd procedure was associated with improved outcomes in children.
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Affiliation(s)
- Luke R Putnam
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Kathryn T Anderson
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - KuoJen Tsao
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Lillian S Kao
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of General Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.252, Houston, TX 77030, USA
| | - Jane A Lugo
- Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Kevin P Lally
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA
| | - Akemi L Kawaguchi
- Center for Surgical Trials and Evidence-based Practice, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.248, Houston, TX 77030, USA; Department of Pediatric Surgery, McGovern Medical School at The University of Texas Health Science Center at Houston, 6431 Fannin Street, MSB 5.258, Houston, TX 77030, USA; Children's Memorial Hermann Hospital, 6411 Fannin Street, Houston, TX 77030, USA.
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Characteristics of Hospitalizations for the Glenn Procedure in Those With Isomerism Compared to Those Without. Pediatr Cardiol 2016; 37:1409-1415. [PMID: 27393478 DOI: 10.1007/s00246-016-1449-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
Abstract
Isomerism, also known as heterotaxy, is a unique clinical entity in which there are mirror imaged findings in the thoracic. In the abdomen, the arrangement of organs can be random. The anatomic findings also have functional consequences. Isomerism has been known to increase morbidity and mortality in those with functionally univentricular hearts. The aim of this study was to determine the impact of isomerism on the Glenn hospitalization. Data from the 1997 to 2012 Kids' Inpatient Database were utilized for this cross-sectional study. Admissions during which a Glenn procedure was done were identified. Next, these admissions were separated into those with and without isomerism. Admission characteristics were then compared in a univariate fashion as well as by regression analysis. Length of hospitalization, cost of hospitalization, extracorporeal membrane oxygenation, and inpatient mortality were the outcomes of interest. A total of 4959 admissions with a Glenn procedure were identified. Of these, 450 were associated with isomerism. The median age at which the Glenn procedure was done was 10 and 13 months in those without and with isomerism, respectively. Neither univariate nor regression analysis demonstrated any significant difference in length of hospitalization, cost of hospitalization, need for extracorporeal membrane oxygenation, and inpatient mortality between those with and without isomerism. Isomerism does not impact the characteristics of the Glenn hospitalization. Those with isomerism did tend to be older when they underwent the Glenn procedure.
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Piggott KD, George G, Fakioglu H, Blanco C, Narasimhulu SS, Pourmoghadam K, Munroe H, Decampli W. Single institution experience with the Ladd’s procedure in patients with heterotaxy and stage I palliated single-ventricle. World J Clin Pediatr 2016; 5:319-324. [PMID: 27610349 PMCID: PMC4978626 DOI: 10.5409/wjcp.v5.i3.319] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 04/01/2016] [Accepted: 06/03/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate and describe our current institutional management protocol for single-ventricle patients who must undergo a Ladd’s procedure.
METHODS: We retrospectively reviewed the charts of all patients from January 2005 to March 2014 who were diagnosed with heterotaxy syndrome and an associated intestinal rotation anomaly who carried a cardiac diagnosis of functional single ventricle and were status post stage I palliation. A total of 8 patients with a history of stage I single-ventricle palliation underwent Ladd’s procedure during this time period. We reviewed each patients chart to determine if significant intraoperative or post-operative morbidity or mortality occurred. We also described our protocolized management of these patients in the cardiac intensive care unit, which included pre-operative labs, echocardiography, milrinone infusion, as well as protocolized fluid administration and anticoagulation regimines. We also reviewed the literature to determine the reported morbidity and mortality associated with the Ladd’s procedure in this particular cardiac physiology and if other institutions have reported protocolized care of these patients.
RESULTS: A total of 8 patients were identified to have heterotaxy with an intestinal rotation anomaly and single-ventricle heart disease that was status post single ventricle palliation. Six of these patients were palliated with a Blaylock-Taussig shunt, one of whom underwent a Norwood procedure. The two other patients were palliated with a stent, which was placed in the ductus arteriosus. These eight patients all underwent elective Ladd’s procedure at the time of gastrostomy tube placement. Per our protocol, all patients remained on aspirin prior to surgery and had no period where they were without anticoagulation. All patients remained on milrinone during and after the procedure and received fluid administration upon arrival to the cardiac intensive care unit to account for losses. All 8 patients experienced no intraoperative or post-operative complications. All patients survived to discharge. One patient presented to the emergency room two months after discharge in cardiac arrest and died due to bowel obstruction and perforation.
CONCLUSION: Protocolized intensive care management may have contributed to favorable outcomes following Ladd’s procedure at our institution.
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Tan YW, Khalil A, Kakade M, Carvalho JS, Bradley S, Cleeve S, Giuliani S. Screening and Treatment of Intestinal Rotational Abnormalities in Heterotaxy: A Systematic Review and Meta-Analysis. J Pediatr 2016; 171:153-62.e1-3. [PMID: 26868865 DOI: 10.1016/j.jpeds.2015.12.074] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/20/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess the role of screening and prophylactic surgery for intestinal rotational abnormalities (IRAs) in asymptomatic patients with heterotaxy. STUDY DESIGN PubMed, Embase, and Cinahl were searched electronically to determine the overall incidence of IRAs in heterotaxy; the detection rate of IRAs associated with screening; the incidence of midgut volvulus in patients without screening; and the incidence of morbidity and mortality after prophylactic and emergency Ladd procedures. Relevant data were computed with a meta-analysis of proportions. Between-study heterogeneity was assessed with the I(2) statistic. RESULTS From 276 papers identified, 24 studies with a total of 1433 patients with heterotaxy were included for systematic review. No randomized study was identified. True incidence of IRA in heterotaxy could not be ascertained through meta-analysis. In patients who underwent screening, the incidence of IRA was 58%. Acute midgut volvulus occurred in 5.8% of those who did not undergo screening. Postoperative mortality after Ladd procedure mainly was associated with cardiac insufficiency, and overall it was significantly greater in the emergency group compared with the prophylactic group (18% vs 5.6%). The complication rate also was greater in case of emergency vs prophylactic abdominal surgery (27% vs 16%); adhesional small bowel obstruction was the most common complication overall (6%). CONCLUSION The screen-detected incidences of IRA and acute midgut volvulus were significantly greater in heterotaxy than the normal population. Prophylactic Ladd procedure was associated with less morbidity and mortality compared with emergency surgery. A long-term prospective randomized trial is needed to define the indication for screening and prophylactic treatment of IRA in heterotaxy.
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Affiliation(s)
- Yew-Wei Tan
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, Division of Developmental Science, St George's University of London, London, United Kingdom
| | - Madhavi Kakade
- Department of Pediatric and Neonatal Surgery, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Julene S Carvalho
- Fetal Medicine Unit, Division of Developmental Science, St George's University of London, London, United Kingdom; Department of Pediatric Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Sarah Bradley
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Stewart Cleeve
- Department of Pediatric and Neonatal Surgery, Royal London Hospital, London, United Kingdom
| | - Stefano Giuliani
- Department of Pediatric and Neonatal Surgery, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom.
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Aurégan C, Donciu V, Millischer AE, Khen-Dunlop N, Deloison B, Sonigo P, Magny JF. [Prenatal discovery of Joubert syndrome associated with small bowel volvulus]. Arch Pediatr 2016; 23:301-6. [PMID: 26850151 DOI: 10.1016/j.arcped.2015.12.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 12/15/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
Joubert syndrome and prenatal volvulus are difficult to diagnose during pregnancy. Joubert syndrome and related diseases should be considered in case of prenatal abnormal features of the fourth ventricle. Small bowel volvulus is also a surgical emergency because of the risk of intestinal necrosis before or after delivery. This type of condition justifies the transfer of pregnant women to a specialized hospital where the newborn may receive appropriate care. We report the case of a 31-week and 4-day gestational-age fetus in whom intrauterine growth retardation and small-bowel volvulus were diagnosed. Additional imaging revealed associated Joubert syndrome. This highlights the need for regular ultrasound monitoring during pregnancy and the comanagement of obstetricians and pediatricians to provide appropriate care before and after delivery.
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Affiliation(s)
- C Aurégan
- Service des urgences pédiatriques, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France.
| | - V Donciu
- Service de radiopédiatrie, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - A-E Millischer
- Service de radiopédiatrie, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - N Khen-Dunlop
- Service de chirurgie viscérale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - B Deloison
- Service de gynécologie obstétrique, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - P Sonigo
- Service de radiopédiatrie, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
| | - J-F Magny
- Service de néonatalogie, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75743 Paris cedex 15, France
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12
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Loomba R, Shah PH, Anderson RH, Arora Y. Radiologic Considerations in Heterotaxy: The Need for Detailed Anatomic Evaluation. Cureus 2016; 8:e470. [PMID: 26973805 PMCID: PMC4771576 DOI: 10.7759/cureus.470] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
So-called "heterotaxy" is a laterality defect characterized by isomerism of the thoracic organs and random arrangement of the abdominal organs. These findings go beyond anatomic curiosity and have functional implications. It is, thus, of the utmost importance to be able to properly identify these findings. Radiologic studies can be invaluable in determining anomalies in the central nervous, pulmonary, cardiovascular, gastrointestinal, genitourinary, and immunologic systems in patients with isomerism. Here, we review findings associated with isomerism and their importance in the setting of isomerism with the aim of ensuring that radiologists effectively describe findings in these patients and that cardiologists understand the wide variety of congenital malformations that may be present.
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Affiliation(s)
- Rohit Loomba
- Department of Cardiology, Children's Hospital of Wisconsin
| | - Parinda H Shah
- Department of Radiology, Advocate Illinois Masonic Medical Center
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13
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Cullis PS, Siminas S, Salim A, Johnson R, Losty PD. Heterotaxy and intestinal rotation anomalies: 20 years experience at a UK regional paediatric surgery centre. Pediatr Surg Int 2015; 31:1127-31. [PMID: 26243388 DOI: 10.1007/s00383-015-3755-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The association of heterotaxy with intestinal rotation anomalies is well described. However debate exists with regard optimal management notably should 'asymptomatic' bowel rotation anomalies undergo operation? The present study therefore sought to determine: (1) the risk(s) of volvulus in patients diagnosed with heterotaxy and (2) define morbidity associated with operation for 'asymptomatic' anomalies in a fragile patient cohort with co-existent congenital heart disease. METHODS Medical case record reviews of ALL heterotaxy patients born during January 1993-December 2013 and attending a UK paediatric centre were analyzed. RESULTS Of a total of 92 patients, 16 (17.4%) cases underwent foregut imaging studies. Three examinations were performed in 'symptomatic' patients. Twelve studies reported 'abnormal anatomy' with only five patients undergoing surgical correction. No complication(s) were recorded after Ladd's operation to correct defects. A single fatality occurred within 30 days postoperatively from cardiac failure. In 87 patients in whom Ladd's operation was not undertaken, no single patient developed intestinal volvulus (median length of follow-up 27.2 months, total 446.1 person years). CONCLUSION This study strongly supports a 'watchful waiting' policy for heterotaxy patients. Many children who ultimately die from heart disease may avoid unnecessary abdominal surgery.
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Affiliation(s)
- Paul S Cullis
- Department of Surgical Paediatrics, The Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
| | - Sotirios Siminas
- Department of Paediatric Surgery, Royal Manchester Children's Hospital, Manchester, UK
| | - Adeline Salim
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Robert Johnson
- Department of Paediatric Cardiology, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK
| | - Paul D Losty
- Department of Paediatric Surgery, Alder Hey Childrens Hospital NHS Foundation Trust, Liverpool, UK. .,Institute of Child Health, University of Liverpool, Liverpool, UK.
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Landisch R, Abdel-Hafeez AH, Massoumi R, Christensen M, Shillingford A, Wagner AJ. Observation versus prophylactic Ladd procedure for asymptomatic intestinal rotational abnormalities in heterotaxy syndrome: A systematic review. J Pediatr Surg 2015; 50:1971-4. [PMID: 26358665 DOI: 10.1016/j.jpedsurg.2015.08.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 07/27/2015] [Accepted: 08/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The management of intestinal rotational abnormalities (IRA) in heterotaxy syndrome (HS) remains inconsistent. Because of the high incidence of malrotation in HS, screening of asymptomatic patients is standard of care in some institutions. The Ladd procedure is the treatment for malrotation, and has been reported to have high complication rates in HS patients. METHODS We performed a systematic review of publications describing IRA in pediatric HS patients from January 1993 to present. The incidence of volvulus on surgical exploration was determined. Perioperative and long-term outcomes were analyzed to determine complication and mortality rates. RESULTS Eleven retrospective studies describing 649 HS patients were identified. Of all patients with HS, 27% (176/649) underwent Ladd procedure. Only 1.2% (8/649) of HS patients included had volvulus. Postoperative complications occurred in 25 patients (14%), including a 10% incidence of small bowel obstruction. Perioperative and overall mortality rates after Ladd procedure were 3% and 21%, respectively. Six studies described mesenteric width, reporting 43% to have narrow mesentery. CONCLUSION The Ladd procedure is not without significant morbidity and mortality in heterotaxy patients. Further prospective studies should investigate predictors of mesenteric width to spare the unnecessary morbidity of surgery in patients who are at low risk for volvulus.
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Affiliation(s)
- Rachel Landisch
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | | | - Roxanne Massoumi
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Melissa Christensen
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Amanda Shillingford
- Division of Pediatric Cardiology, Medical College of Wisconsin, Milwaukee, WI 53226.
| | - Amy J Wagner
- Division of Pediatric Surgery, Medical College of Wisconsin, Milwaukee, WI 53226.
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Graziano K, Islam S, Dasgupta R, Lopez ME, Austin M, Chen LE, Goldin A, Downard CD, Renaud E, Abdullah F. Asymptomatic malrotation: Diagnosis and surgical management: An American Pediatric Surgical Association outcomes and evidence based practice committee systematic review. J Pediatr Surg 2015. [PMID: 26205079 DOI: 10.1016/j.jpedsurg.2015.06.019] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Patients with malrotation, or an intestinal rotation abnormality (IRA), can experience serious adverse events. Increasingly, asymptomatic patients are being diagnosed with malrotation incidentally. Patients with symptomatic malrotation require surgery in an urgent or semiurgent manner to address their symptoms. The treatment of asymptomatic or incidentally discovered malrotation remains controversial. METHODS Data were compiled from a broad search of Medline, Cochrane, Embase and Web of Science from January 1980 through January 2013 for five questions regarding asymptomatic malrotation. RESULTS There is minimal evidence to support screening asymptomatic patients. Consideration may be given to operate on asymptomatic patients who are younger in age, while observation may be appropriate in the older patient. If reliably diagnosed, atypical malrotation with a broad-based mesentery and malposition of the duodenum can be observed. Regarding diagnostic imaging, the standard of care for diagnosis remains the upper gastrointestinal contrast study (UGI), ultrasound may be useful for screening. A laparoscopic approach is safe for diagnosis and treatment of rotational abnormalities. Laparoscopy can aid in determining whether a patient has true malrotation with a narrow mesenteric stalk, has nonrotation and minimal risk for volvulus, or has atypical anatomy with malposition of the duodenum. It is reasonable to delay Ladd procedures until after palliation on patients with severe congenital heart disease. Observation can be considered with extensive education for family and caregivers and close clinical follow-up. CONCLUSIONS There is a lack of quality data to guide the management of patients with asymptomatic malrotation. Multicenter and prospective data should be collected to better assess the risk profile for this complex group of patients. A multidisciplinary approach involving surgery, cardiology, critical care and the patient's caregivers can help guide a watchful waiting management plan in individual cases.
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Affiliation(s)
- Kathleen Graziano
- Division of Pediatric General Surgery, Phoenix Children's Hospital, Phoenix, AZ.
| | - Saleem Islam
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, OH
| | - Monica E Lopez
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Mary Austin
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center; Department of Pediatric Surgery, University of Texas Medical School, Houston, TX
| | - Li Ern Chen
- Department of Surgery, Baylor University Medical Center, Dallas, TX
| | - Adam Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children's Hospital; Department of Surgery, University of Washington, Seattle, WA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD; Department of Surgery, University of Louisville, Louisville, KY
| | - Elizabeth Renaud
- Division of Pediatric Surgery, Department of Surgery, Albany Medical Center, Albany, NY
| | - Fizan Abdullah
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
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16
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Abstract
PURPOSE OF REVIEW At present, there is a debate as to the management of malrotation in pediatric patients. This review highlights recent literature including the role of laparoscopy, and the management of asymptomatic patients with and without congenital cardiac disease. RECENT FINDINGS Symptomatic patients are still recommended to undergo open Ladd's procedure. Laparoscopic Ladd's procedure in asymptomatic patients confers a shorter time to tolerating feeds, shorter length of stay, and a decreased rate of bowel obstruction and other complications. It may, however, carry a higher risk of postoperative volvulus. Diagnostic laparoscopy is recommended in asymptomatic patients in whom the diagnosis is uncertain on upper gastrointestinal imaging. Asymptomatic patients with congenital heart disease may be managed with initial observation or operation, based upon individualized risk benefit assessment. If an elective Ladd's procedure is performed, it should take place after palliative cardiac operations have resulted in stable cardiac function. Screening upper gastrointestinal studies in heterotaxy patients may be unnecessary as the reported rates of volvulus in recent studies are low. SUMMARY Laparoscopic Ladd's procedure may be an acceptable alternative to an open procedure for asymptomatic patients. Observation of asymptomatic patients with congenital cardiac disease is a reasonable alternative in selected patients.
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17
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Heterotaxy syndrome infants are at risk for early shunt failure after Ladd procedure. Ann Thorac Surg 2015; 99:918-25. [PMID: 25595831 DOI: 10.1016/j.athoracsur.2014.09.077] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Revised: 09/19/2014] [Accepted: 09/23/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cardiac-specific risks and complications after a Ladd procedure in patients with heterotaxy syndrome (HS) and intestinal rotational anomalies (IRA) are unknown. We sought to (1) describe rates of hospital mortality and early systemic-to-pulmonary (S-P) artery shunt failure after the Ladd procedure in patients with HS and (2) explore risk factors associated with early shunt failure in patients with HS with single ventricle (SV). METHODS This retrospective study included all Ladd procedures performed from January 1999 to December 2012 in patients with HS at a single center. Risk factors investigated for early S-P artery shunt failure included birth weight, gestational age, sex, age at and timing of Ladd procedure relative to cardiac operations, and shunt type. RESULTS Ladd procedure was performed on 54 infants with HS and congenital heart disease. Hospital mortality for the entire cohort was 5.6% (3 of 54 patients). Early shunt failure occurred in 19% (4 of 21) of HS infants with SV. Mean preoperative blood urea nitrogen (BUN) levels were higher in HS infants with early shunt failure (20 versus 12.5 mg/dL; p = 0.054). CONCLUSIONS Patients with SV and HS with S-P artery shunts are at risk for early shunt failure after a Ladd procedure. A higher mean preoperative BUN level is noted in patients with HS and early shunt failure. Careful risk-benefit analysis is indicated before recommending routine elective Ladd procedures in patients with HS.
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18
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Sulkowski JP, Cooper JN, Duggan EM, Balci O, Anandalwar S, Blakely ML, Heiss K, Rangel SJ, Minneci PC, Deans KJ. Early versus delayed surgical correction of malrotation in children with critical congenital heart disease. J Pediatr Surg 2015; 50:86-91. [PMID: 25598100 PMCID: PMC4298705 DOI: 10.1016/j.jpedsurg.2014.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 10/06/2014] [Indexed: 10/24/2022]
Abstract
PURPOSE The purpose of this study was to compare outcomes between early and delayed surgical correction of malrotation in children with critical congenital heart disease (CHD). METHODS Patients with CHD who underwent cardiac surgery by 1 year of age and had malrotation diagnosed during their initial admission at 34 hospitals contributing to the Pediatric Health Information System in 2004-2009 were included. Ladd's procedures performed during the first admission were considered early correction, and those at a subsequent admission were considered delayed. Interhospital variability in the proportion of patients undergoing delayed correction was assessed, and outcomes were compared between the groups. RESULTS Of the 324 patients identified, 85.2% underwent early correction. Significant variability existed in the proportion of patients undergoing delayed correction across hospitals (p<0.0001). Baseline characteristics, including severity of CHD, were similar between the groups. In the delayed group, 27% of patients underwent a Ladd's procedure during an urgent or emergent admission, but none had volvulus or underwent intestinal resection. Rates of mortality and readmission within 1 year of malrotation diagnosis were similar in both groups. Chart validation confirmed 100% accuracy of diagnosis and treatment group assignment. CONCLUSIONS In patients with critical CHD, delayed operative intervention for malrotation without volvulus may be a reasonable alternative.
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Affiliation(s)
- Jason P Sulkowski
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer N Cooper
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Eileen M Duggan
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Ozlem Balci
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Seema Anandalwar
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Martin L Blakely
- Department of Pediatric Surgery, Monroe Carell Jr Children's Hospital, Nashville, TN
| | - Kurt Heiss
- Department of Pediatric Surgery, Children's Hospital of Atlanta, Atlanta, GA
| | - Shawn J Rangel
- Department of Pediatric Surgery, Children's Hospital Boston, Boston, MA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH
| | - Katherine J Deans
- Center for Surgical Outcomes Research, Department of Surgery and the Research Institute, Nationwide Children's Hospital, Columbus, OH, USA.
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