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Anbarasu CR, Mehl SC, Sun RC, Portuondo JI, Espinoza AF, Whitlock RS, Shah SR, Rodriguez JR, Nuchtern JG, Minifee PK, Le LD, Stafford SJ, Milewicz AL, Mazziotti MV. Variations in Nuss Procedure Operative Techniques and Complications: A Retrospective Review. Eur J Pediatr Surg 2022; 32:357-362. [PMID: 34560787 DOI: 10.1055/s-0041-1735164] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The Nuss procedure is the most common and preferred operative correction of pectus excavatum. Surgeon preference and patient factors can result in variations in Nuss procedure technique. We hypothesize that certain techniques are associated with increased risk of complications. MATERIALS AND METHODS We performed a single-center retrospective review of Nuss operations from 2016 to 2020. Variations in intraoperative techniques included sternal elevator (SE) use, number of bars placed, and usage of bilateral stabilizing sutures. Patient demographics, intraoperative data, and postoperative outcomes were reported as median with interquartile ranges or percentages. Statistical significance (p < 0.05) was determined with Wilcoxon's rank-sum and chi-square tests. Multivariate analysis was performed to control for introduction of intercostal nerve cryoablation and surgeon volume, and reported as odds ratio with 95% confidence interval. RESULTS Two hundred and sixty-five patients were identified. Patients repaired with two bars were older with a larger Haller index (HI). Patient demographics were not significantly different for SE or stabilizing suture use. Placement of two bars was associated with significantly increased risk of readmission. Similarly, SE use was associated with increased risk of pleural effusion and readmission. Finally, the use of bilateral stabilizing sutures resulted in less frequent slipped bars without statistical significance. CONCLUSION Older patients with a larger HI were more likely to need two bars placed to repair pectus excavatum. Placement of multiple bars and SE use are associated with significantly higher odds of certain complications.
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Affiliation(s)
- Centura R Anbarasu
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States
| | - Steven C Mehl
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Raphael C Sun
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Jorge I Portuondo
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Andres F Espinoza
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Richard S Whitlock
- Department of Surgery, Baylor College of Medicine, Houston, Texas, United States.,Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Sohail R Shah
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - J Ruben Rodriguez
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Jed G Nuchtern
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Paul K Minifee
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Louis D Le
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Shawn J Stafford
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Allen L Milewicz
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
| | - Mark V Mazziotti
- Division of Pediatric Surgery, Texas Children's Hospital, Houston, Texas, United States
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Shen Q, Chen Y, Peng C, Pang W, Wang Z, Wu D, Wang K, Huang X. Liver stiffness measurement predicts the difficulty of Kasai procedure in biliary atresia: a single center retrospective analysis of 199 patients. BMC Pediatr 2019; 19:465. [PMID: 31779592 PMCID: PMC6883583 DOI: 10.1186/s12887-019-1846-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/21/2019] [Indexed: 11/10/2022] Open
Abstract
Background Kasai procedure is the standard initial treatment of infants with biliary atresia. The key to perform a successful surgery is to accurately remove the fibrous portal plate near the liver hilum. Yet how to estimate surgical difficulty pre-operatively remains unclear. This study aims to design an algorithm that predicts the difficulty of Kasai procedure using liver stiffness measurement (LSM). Methods One hundred ninety-nine patients were included from April 2012 to December 2016. The patients were all surgically diagnosed with biliary atresia. Group A comprised of patients with porta hepatis retraction (the angle between the plane of the fibrous porta plate and the plane of the medial liver closest to the plate was equal to or smaller than 90°), group B comprised of patients without porta hepatis retraction (the angle between the plane of the fibrous porta plate and the plane of the medial liver closest to the plate was greater than 90°). Liver function measurements and LSM were measured for all patients within three days before surgery. Results Our study included 19 cases in group A (9 males, 10 females) and 180 cases in group B (87 males, 93 females). LSM had statistical differences between the two groups, 28.10(14.90) kPa VS 10.89(7.10) kPa, P = 0.000. There was a significant relationship between LSM and operative age, TBA, AST, GGT (P = 0.000, 0.003, 0.003, 0.012, correlation coefficient = 0.323, 0.213, 0.207, 0.179). The AUROC of LSM was 0.919. When the cutoff value was 15.15 kPa(OR = 3.989; P = 0.000), the sensitivity, specificity, PPV, NPV and diagnostic accuracy were 0.947, 0.750, 0.285, 0.992 and 0.768, respectively. When the value was 23.75 kPa(OR = 3.483; P = 0.000), the sensitivity, specificity, PPV, NPV and diagnostic accuracy were 0.631, 0.950, 0.571, 0.960 and 0.919, respectively. Conclusions LSM can be used to predict the difficulty in dissecting fibrous portal plate, and in turn, the difficulty of Kasai procedure. LSM > 23.75 kPa suggests a more complicated surgery.
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Affiliation(s)
- Qiulong Shen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Yajun Chen
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China.
| | - Chunhui Peng
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Wenbo Pang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Zengmeng Wang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Dongyang Wu
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Kai Wang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
| | - Xinjie Huang
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, No.56 Nanlishi St, Xicheng District, Beijing, 100045, China
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Wang Y, Zhang Y, Wang H, Wang T, Xia S, Chen W, Li B. Learning Curve Analysis of Open Kasai Portoenterostomy for Biliary Atresia. J Surg Res 2019; 239:38-43. [PMID: 30798170 DOI: 10.1016/j.jss.2019.01.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 12/10/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Open Kasai portoenterostomy (KPE) remains the mainstay of treatment for biliary atresia (BA) even in the era of minimally invasive surgery and is generally considered to be technically challenging. This study describes the learning curve (LC) of open KPE and its effect on outcomes. MATERIALS AND METHODS In our center, the caseload of BA was relatively low with average annual caseload below five in the past, and open KPE was started in the early 2000s. This study retrospectively enrolled the first 35 consecutive children undergoing open KPE for BA by the same surgeon in our center between June 2003 and April 2014. The LC was evaluated using the cumulative sum (CUSUM) method for operative time (OT). RESULTS The CUSUM LC of OT, which peaked at the 23rd case, was best modeled as a second-order polynomial with equation CUSUM (min) = -0.8851 × case number2 + 33.54 × case number -45.978 (R2 = 0.7287). The LC consisted of two distinct phases: phase 1 (the initial 23 cases), representing the initial learning phase and phase 2 (the remaining 12 cases), representing acquisition of technical competency. Preoperative parameters were comparable between the two phases (each P > 0.05). Of note, OT and estimated blood loss significantly decreased in phase 2 compared with phase 1 (P < 0.001; P < 0.001, respectively). Furthermore, the rates of early jaundice clearance and 2-y native liver survival significantly increased in phase 2 (P = 0.032; P = 0.034, respectively). CONCLUSIONS The two phases identified by CUSUM analysis of OT represents characteristic stages of LC for open KPE of the surgeon in our center. It is possible for surgeons to achieve competency of this demanding technique in centers with relatively low caseload of BA and late start of KPE.
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Affiliation(s)
- Yujiao Wang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China.
| | - Yuanyuan Zhang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Hui Wang
- Department of Public Health, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Ting Wang
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Shunlin Xia
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Weibing Chen
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China
| | - Bing Li
- Department of Pediatric Surgery, Huai'an Women and Children's Hospital, Huai'an, Jiang Su, China.
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