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Peramsetty NR, Fung T, Zhang A, Saliba C, Blewett C, Miyata S, Herman R. Recurrent Ileocolic Intussusception With the Appendix as the Pathologic Lead Point in Children: A Report of Two Cases and Review of Literature. Cureus 2024; 16:e61120. [PMID: 38919204 PMCID: PMC11198737 DOI: 10.7759/cureus.61120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/27/2024] Open
Abstract
Ileocolic intussusception is a consideration in young pediatric patients with acute abdominal pain. Meckel's diverticulum is the most common pathologic lead point for intussusception in children and the appendix acting as the lead point is rare. In addition, management guidelines for recurrent ileocolic intussusception (RICI) are lacking. We present two cases of RICI in which the pathological lead point was the appendix. The first patient, a two-year-old with no medical history, had intermittent abdominal pain and non-bloody vomiting for a month. Ultrasound revealed ileocolic intussusception, successfully managed with pneumatic reduction. However, symptoms recurred and a repeat ultrasound showed partial intussusception of the appendix into the cecum. Laparoscopic reduction and appendectomy were then performed. Symptomatic intussusception recurred, and a second laparoscopic reduction with stump appendectomy resolved all symptoms. The second patient, a three-year-old with no medical history, had colicky abdominal pain for 24 hours. Ultrasound revealed ileocolic intussusception that was pneumatically reduced. As pain recurred, laparoscopic reduction and appendectomy were performed, revealing ileocolic intussusception with a dilated appendix as the pathologic lead point. Recurrent ileocolic intussusception (RICI) with the appendix as the lead point is common, but RICI with the appendix as the lead point is rare. These cases demonstrate the role of the appendix as a pathologic lead point, and a review of the literature supports the need for surgical reduction. While enema reduction is the first line for recurrent intussusception, surgical reduction is preferred when a pathological lead point is suspected.
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Affiliation(s)
- Nikita R Peramsetty
- Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, USA
| | - Tiffany Fung
- Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, USA
| | - Andi Zhang
- Pediatric Surgery, Saint Louis University School of Medicine, St. Louis, USA
| | - Christian Saliba
- Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, USA
| | - Christopher Blewett
- Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, USA
| | - Shin Miyata
- Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, USA
| | - Richard Herman
- Pediatric Surgery, SSM Health Cardinal Glennon Children's Hospital, Saint Louis, USA
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Morris E, Marschke B, Bashrum B, Dhanasekara CS, Siddiqui A, Tucker A, Dissanaike S. Should We Perform Incidental Appendectomy in Trauma Patients Undergoing Laparotomy? Am Surg 2022:31348221109458. [PMID: 35706388 DOI: 10.1177/00031348221109458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Incidental appendectomy (IA) is sometimes performed in patients undergoing abdominal operations to prevent subsequent development of appendicitis. Patients who undergo laparotomy for major abdominal trauma are at high risk of developing dense adhesions, increasing the risk of future operations. Therefore, there is a potential benefit to IA for patients undergoing trauma laparotomy. We performed a retrospective review of patients who underwent IA during laparotomy for abdominal trauma at a Level 1 trauma center between January 2010, and June 2020. Twenty-three patients underwent IA; they tended to be young (33.7 ± 18.9 years) and male (87%) with 12 penetrating and 11 blunt injuries. Regarding indications, 13 had no documented intra-operative abnormalities of the appendix, 6 patients had a fecalith, and 3 had trauma to the appendix. One patient's appendix was adhered to the peritoneum and one patient had unusual anatomic location. Only one patient developed an appendiceal stump leak after IA.
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Affiliation(s)
- Erin Morris
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Brianna Marschke
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Bryan Bashrum
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | | | - Arham Siddiqui
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Amber Tucker
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
| | - Sharmila Dissanaike
- Department of Surgery, 12343Texas Tech University Health Science Center, Lubbock, TX, USA
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Yan J, Shen Q, Peng C, Pang W, Chen Y. Colocolic Intussusception in Children: A Case Series and Review of the Literature. Front Surg 2022; 9:873624. [PMID: 35465438 PMCID: PMC9018986 DOI: 10.3389/fsurg.2022.873624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundColocolic intussusception is a rare subtype of intussusception mostly caused by juvenile polyps. The treatment of colocolic intussusception caused by other pathologic lead points in children remains poorly understood.MethodA systematic literature review was performed between January 2000 and June 2021 to characterize the comprehensive treatment of colocolic intussusception in children. This report also included patients admitted to our center between January 2010 and June 2021 who were not previously reported in the literature.ResultsWe identified 27 patients in 20 studies in addition to 17 patients from our center for a total of 44 patients (median age, 4.4 years; 52.3% male). The lead point was identified in 40 patients (40/44, 90.9%). The most common lead point was juvenile polyps (19/44, 43.2%). A therapeutic enema was performed in 15 patients with colocolic intussusception caused by juvenile polyps and was successful in 9 patients (9/15, 60.0%). Colonoscopic polypectomy was subsequently performed in 8 patients and was successful in 7 patients (7/8, 87.5%). The other patient had undergone laparoscopic exploration, and no abnormality was found. Subsequently, the patient underwent open surgery. The patients with colocolic intussusception caused by other pathologic lead points almost underwent surgical treatment (15/21, 71.4%), including 13 open surgeries and 2 laparoscopic surgeries.ConclusionA therapeutic enema followed by colonoscopic polypectomy is feasible to treat colocolic intussusception caused by juvenile polyps unless the patient has bowel perforation; however, surgery is sometimes needed. For patients with colocolic intussusception caused by other pathologic lead points, open surgery remains the primary treatment.
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Affiliation(s)
- Jiayu Yan
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Qiulong Shen
- Department of Emergency Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Chunhui Peng
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Wenbo Pang
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Yajun Chen
- Department of General Surgery, National Center for Children's Health, Beijing Children's Hospital, Capital Medical University, Beijing, China
- *Correspondence: Yajun Chen
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Liu T, Wu Y, Xu W, Liu J, Sheng Q, Lv Z. A retrospective study about incidental appendectomy during the laparoscopic treatment of intussusception. Front Pediatr 2022; 10:966839. [PMID: 36147812 PMCID: PMC9485678 DOI: 10.3389/fped.2022.966839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 08/15/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE We aim to see incidental appendectomy (IA) was worth or not during the laparoscopic treatment of intussusception. METHODS This study included forty-eight patients who underwent a laparoscopic procedure for idiopathic intussusception without intestinal resection between April 2014 and April 2021. The Chi-square or Fisher's exact tests for categorical variables and the Student t-test for continuous variables were used to analyze and compare patient characteristics. RESULTS IA was performed on 63% (30/48) of patients after surgical reduction, while 18 (37%), did not. Patients who underwent IA had a higher total cost (16,618 ± 2,174 vs.14,301 ± 5,206, P = 0.036), and a longer mean operation duration (59 ± 19 vs.45 ± 21, P = 0.025). The distribution of the PO time, length of hospital stay, PCs, and RI did not differ significantly. The histopathological evaluation of the 30 resected appendices revealed five (17%) with signs of acute inflammation, 20 (66%) with chronic signs of inflammation, and five (17%) with inconspicuous appendices. CONCLUSION IA is linked to a longer average operation time and a higher total cost. There is insufficient evidence to recommend IA during laparoscopic intussusception treatment. The risks and benefits of IA need further study.
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Affiliation(s)
- Tao Liu
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yibo Wu
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weijue Xu
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jiangbin Liu
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qingfeng Sheng
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhibao Lv
- Department of General Surgery, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Gadgade BD, Radhakrishna V, Kumar N. Factors Associated with a Failed Nonoperative Reduction of Intussusception in Children. J Indian Assoc Pediatr Surg 2021; 26:421-426. [PMID: 34912140 PMCID: PMC8637975 DOI: 10.4103/jiaps.jiaps_297_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 10/11/2020] [Accepted: 10/28/2020] [Indexed: 11/17/2022] Open
Abstract
Aims: The aim of this study was to evaluate the factors associated with the failure of nonoperative reduction of intussusception in children. Methods: A retrospective study was conducted in a tertiary care pediatric surgery hospital. The children admitted to the department of pediatric surgery between November 2013 and February 2020 with the diagnosis of Intussusception were included. Results: A total of 106 (67%) children underwent pneumatic reduction. Eighty-nine (84%) children had a successful reduction. A higher rate of failed reduction was found in children who presented at or after 48 h of the onset of symptoms (P = 0.03) and abdominal distension at presentation (P < 0.002). On multiple logistic regression analysis, the children presenting at or after 48 h of the onset of symptoms (odds ratio [OR] = 11.3; P = 0.039) and abdominal distension at presentation (OR = 4.46; P = 0.021) were found to be associated with increased risk of failure of nonoperative reduction. The variables age <1 year, weight <10 kg, pain abdomen, vomiting, bilious vomiting, fever, bleeding per rectum, and palpable mass were not associated with the failed nonoperative reduction. The variables, presentation at or after 48 h of the onset of symptoms (OR = 2.812; P = 0.045) and abdominal distension at presentation (OR = 8.758; P = 0.000) were found to be associated with an increased need for surgery. Conclusion: The risk factors for failed nonoperative reduction of intussusception include a presentation at or after 48 h of the onset of symptoms and the presence of abdominal distension at presentation. The delayed presentation was associated with the increased need for surgery and increased chances of intestinal nonviability.
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Affiliation(s)
- Bahubali Deepak Gadgade
- Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Veerabhadra Radhakrishna
- Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Nitin Kumar
- Department of Paediatric Surgery, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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Chen X, Chen Q, Wang X, Gao Z. Clinical characteristics of recurrent intussusception: A single-center retrospective study. J Pediatr Surg 2021; 56:1831-1834. [PMID: 33896613 DOI: 10.1016/j.jpedsurg.2021.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/16/2021] [Accepted: 03/17/2021] [Indexed: 01/24/2023]
Abstract
PURPOSE we attempted to summarize the clinical characteristics of recurrent intussusception through a large sample size retrospective study. METHODS 5778 patients who were diagnosed with intussusception and treated in our hospital between January 2014 and December 2018 were reviewed. RESULTS the overall recurrence rate was 20.0%, with the recurrence frequency ranged from 1 to 17 episodes and the recurrence interval ranged from 0 to 5 years. 80.0% (926/1158) patients had only 1 to 2 episodes of recurrence. Most of the patients (88.3%) relapsed within 1 year after successful reduction, among which 616 patients (53.2%) relapsed within 3 days. The recurrence rate of intussusception was the lowest when the age was less than 1 year, increased and kept high level in patients aged from 1 to 5 years old, then decreased after 5 years. The pathologic lead point (PLP) proportion of recurrence group was higher than that of non-recurrence group (2.2% VS 1.2%, P = 0.005). CONCLUSIONS the overall recurrence rate was 20.0%. Most of the patients had only 1 to 2 episodes of recurrence and relapsed within 1 year after successful reduction. Age and PLP were risk factors for intussusception recurrence.
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Affiliation(s)
- Xiaoli Chen
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, 57 Zhugan Street, Xiacheng District, Hangzhou, Zhejiang, China.
| | - Qingjiang Chen
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiang Wang
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Zhigang Gao
- Department of General Surgery, The Children's Hospital, National Clinical Research Center for Child Health, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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Capparelli MA, Ayarzabal VH, Halac ET, Questa HA, Minetto MJ, Cervio G, Barrenechea ME. Preoperative risk factors for the early failure of the Kasai portoenterostomy in patients with biliary atresia. Pediatr Surg Int 2021; 37:1183-1189. [PMID: 34057595 DOI: 10.1007/s00383-021-04933-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 01/11/2023]
Abstract
PURPOSE Biliary atresia is managed surgically by the Kasai portoenterostomy (KP). It has been reported by some groups that the outcomes of patients who have an early failed KP requiring a liver transplant (LTx) within the first year of life are worse than the outcomes of patients who undergo a primary LTx. The aim of this study was to identify preoperative parameters that could help predict what patients are at risk for the early failure of the procedure. MATERIALS AND METHODS We conducted a retrospective chart review of all patients who underwent a KP between January 2008 and May 2018. The following preoperative parameters were analyzed: age at KP, anatomical variant of the biliary atresia, degree of liver fibrosis, CMV status, and PELD score. The main outcome of the study was the early failure of the KP (EF-K), which was defined as the need for LTx before 1 year of age, or BA-related death before 1 year of age. Second, we analyzed the risk factors associated with death without LTx within the first year of life. RESULTS A total of 58 patients were included in the analysis. The native liver survival (NLS) was 56.5% and 48% at 1 and 5 years post KP, respectively. Overall survival (OS) was 79% and 76% at 1 and 5 years post KP, respectively. Early failure of KP occurred in 23 (39.7%) patients. OS in this group was 47% and 40% at 1 and 5 years, respectively. On the contrary, the OS of the remaining 35 (60.3%) patients was 100% at 1 and 5 years (P < 0.0001). When we compared all preoperative parameters, the only predictor of EF-K was the PELD score. When we analyzed the cases in the EF-K group who died without LTx, we found that the significant predictors were the cystic variant, a degree of liver fibrosis >4, and the PELD score. Nevertheless, on multivariate analysis, only PELD score was found as a statistically significant variable. CONCLUSION Due to bad prognosis found in EF-K patients, we believe that it could be reasonable to offer them a primary LTx. PELD score was found to be the strongest preoperative parameter that allows predicting which patient will likely have an early failed KP. Further prospective and multicenter studies are needed to reinforce these results.
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Affiliation(s)
- Mauro Ariel Capparelli
- Division of General Surgery, J. P. Garrahan Hospital, Combate de los Pozos 1881, C 1245 AAM, Buenos Aires, Argentina.
| | - Victor Hugo Ayarzabal
- Division of General Surgery, J. P. Garrahan Hospital, Combate de los Pozos 1881, C 1245 AAM, Buenos Aires, Argentina
| | - Esteban Tomas Halac
- Division of Liver Transplant, J. P. Garrahan Hospital, Buenos Aires, Argentina
| | - Horacio Alberto Questa
- Division of General Surgery, J. P. Garrahan Hospital, Combate de los Pozos 1881, C 1245 AAM, Buenos Aires, Argentina
| | - Maria Julia Minetto
- Division of Liver Transplant, J. P. Garrahan Hospital, Buenos Aires, Argentina
| | - Guillermo Cervio
- Division of Liver Transplant, J. P. Garrahan Hospital, Buenos Aires, Argentina
| | - Marcelo Eugenio Barrenechea
- Division of General Surgery, J. P. Garrahan Hospital, Combate de los Pozos 1881, C 1245 AAM, Buenos Aires, Argentina
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Kelley-Quon LI, Arthur LG, Williams RF, Goldin AB, St. Peter SD, Beres AL, Hu YY, Renaud EJ, Ricca R, Slidell MB, Taylor A, Smith CA, Miniati D, Sola JE, Valusek P, Berman L, Raval MV, Gosain A, Dellinger MB, Sømme S, Downard CD, McAteer JP, Kawaguchi A. Management of intussusception in children: A systematic review. J Pediatr Surg 2021; 56:587-596. [PMID: 33158508 PMCID: PMC7920908 DOI: 10.1016/j.jpedsurg.2020.09.055] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 08/30/2020] [Accepted: 09/24/2020] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The goal of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee was to develop recommendations for the management of ileocolic intussusception in children. METHODS The ClinicalTrials.gov, Embase, PubMed, and Scopus databases were queried for literature from January 1988 through December 2018. Search terms were designed to address the following topics in intussusception: prophylactic antibiotic use, repeated enema reductions, outpatient management, and use of minimally invasive techniques for children with intussusception. The Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines were followed. Consensus recommendations were derived based on the best available evidence. RESULTS A total of 83 articles were analyzed and included for review. Prophylactic antibiotic use does not decrease complications after radiologic reduction. Repeated enema reductions may be attempted when clinically appropriate. Patients can be safely observed in the emergency department following enema reduction of ileocolic intussusception, avoiding hospital admission. Laparoscopic reduction is often successful. CONCLUSIONS Regarding intussusception in hemodynamically stable children without critical illness, pre-reduction antibiotics are unnecessary, non-operative outpatient management should be maximized, and minimally invasive techniques may be used to avoid laparotomy. LEVEL OF EVIDENCE Level 3-5 (mainly level 3-4) TYPE OF STUDY: Systematic Review of level 1-4 studies.
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Affiliation(s)
- Lorraine I. Kelley-Quon
- Division of Pediatric Surgery, Children’s Hospital Los Angeles and the Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California,Department of Preventive Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - L. Grier Arthur
- Division of Pediatric Surgery, St. Christopher’s Hospital for Children, Philadelphia, PA
| | - Regan F. Williams
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN
| | - Adam B. Goldin
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | | | - Alana L. Beres
- Division of Pediatric General, Thoracic and Fetal Surgery, University of California, Davis, CA
| | - Yue-Yung Hu
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Elizabeth J. Renaud
- Alpert Medical School at Brown University, Hasbro Children’s Hospital, Providence, RI
| | - Robert Ricca
- Division of Pediatric Surgery, Naval Medical Center Portsmouth, Portsmouth, Virginia
| | - Mark B. Slidell
- Section of Pediatric Surgery, The University of Chicago Medicine, Comer Children’s Hospital, Chicago, Illinois
| | - Amy Taylor
- Texas Medical Center Library, Houston, TX
| | - Caitlin A. Smith
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Doug Miniati
- Division of Pediatric Surgery, Kaiser Permanente Roseville Women and Children’s Center, Roseville, California
| | - Juan E. Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Patricia Valusek
- Pediatric Surgical Associates, Ltd., Children’s Minnesota, Minneapolis, MN
| | - Loren Berman
- Division of Pediatric surgery, Department of Surgery, Nemours-AI DuPont Hospital for Children and Sidney Kimmel Medical College at Thomas Jefferson University, Wilmington, DE
| | - Mehul V. Raval
- Division of Pediatric Surgery, Ann & Robert H. Lurie Children’s Hospital, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ankush Gosain
- Division of Pediatric Surgery, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, TN,Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN
| | - Matthew B. Dellinger
- Division of Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Stig Sømme
- Division of Pediatric Surgery, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Cynthia D. Downard
- Division of Pediatric Surgery, Hiram C. Polk, Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | | | - Akemi Kawaguchi
- Department of Pediatric Surgery, University of Texas McGovern Medical School and Children’s Memorial Hermann Hospital, Houston, TX
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