1
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Palm PH, Matos MC, Velazco CS. Complications following ileal pouch-anal anastomosis in pediatric ulcerative colitis. Semin Pediatr Surg 2024; 33:151405. [PMID: 38583361 DOI: 10.1016/j.sempedsurg.2024.151405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
Ileal pouch-anal anastomosis (IPAA) is the procedure of choice for reconstruction after total proctocolectomy in pediatric patients with ulcerative colitis. 30-60 % of patients undergoing IPAA will experience a postoperative complication. The primary objective of this article is to address the most common complications specific to IPAA in the pediatric population and provide an up-to-date review of their presentation, risk factors, workup, and management. We also share our preferred approaches to management and prevention of complications, where relevant. We intend to provide a concise review on the topic aimed at pediatric surgeons and healthcare providers involved in the care of this population with the goal of contributing to improved outcomes and patient quality of life.
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Affiliation(s)
- Preston H Palm
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Monique C Matos
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA
| | - Cristine S Velazco
- Division of Pediatric Surgery, Orlando Health Arnold Palmer Hospital for Children, Orlando, FL 32806, USA.
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2
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Encisco EM, Lim IIP, Velazco CS, Rosen NG, Garrison AP, Rymeski B, Frischer JS. Hirschsprung-Associated Enterocolitis at a Referral Institution: A Retrospective Review. J Pediatr Surg 2023:S0022-3468(23)00250-6. [PMID: 37221126 DOI: 10.1016/j.jpedsurg.2023.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 04/17/2023] [Indexed: 05/25/2023]
Abstract
BACKGROUND Hirschsprung-associated enterocolitis (HAEC) is the most common cause of morbidity and mortality amongst patients with Hirschsprung disease (HD); rectal Botulinum toxin (Botox) has been reported a possible prevention strategy. We aimed to evaluate our institution's historic cohort of HD patients, first to determine our incidence of HAEC and second to begin assessing the effect of Botox on HAEC incidence. METHODS Patients with HD seen at our institution between 2005 and 2019 were reviewed. Incidence of HD and frequencies of HAEC and Botox injections were tallied. Associations between initial Botox treatment or transition zone and HAEC incidence were evaluated. RESULTS We reviewed 221 patients; 200 were included for analysis. One hundred thirteen (56.5%) patients underwent primary pull-through at a median age of 24 days (IQR 91). Eighty-seven (43.5%) patients with initial ostomy had their intestinal continuity reestablished at a median of 318 days (IQR 595). Ninety-four (49.5%) experienced at least one episode of HAEC and 62 (66%) experienced multiple episodes of HAEC. Nineteen (9.6%) patients had total colonic HD and had an increased total incidence of HAEC compared to patients without total colonic HD (89% vs 44%, p < 0.001). Six (2.9%) patients received Botox injections at the time of pull-through or ostomy takedown; one experienced an episode of HAEC (versus 50.7% of the patients who were confirmed to have not received Botox injections at their surgery, p = 0.102). CONCLUSION Further prospective study on Botox's effect on Hirschsprung-associated enterocolitis is required and is the next step in our investigation. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ellen M Encisco
- Colorectal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | | | - Cristine S Velazco
- Department of Pediatric Surgery, Arnold Palmer Hospital for Children, Orlando Health, Orlando, FL, USA
| | - Nelson G Rosen
- Colorectal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Aaron P Garrison
- Colorectal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Colorectal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jason S Frischer
- Colorectal Center, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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3
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Lai K, Hargis-Villanueva A, Velazco CS, Weidler EM, Garvey EM, van Leeuwen K, Lee J. Early postoperative feeding in single-stage repair of anorectal malformation with vestibular or perineal fistula is not associated with increased wound complications. J Pediatr Surg 2023; 58:467-470. [PMID: 35934522 DOI: 10.1016/j.jpedsurg.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION The objective of this study is to assess the postoperative outcomes of single-stage repair of anorectal malformations with vestibular (VF) or perineal fistula (PF) and early initiation of postoperative feeding. METHODS A retrospective review of patients undergoing single-stage repair of isolated low anorectal malformations (VF and PF) from 2017 to 2020 was conducted. All patients underwent an anterior anoplasty with complete mobilization of the rectal fistula, or posterior sagittal anorectoplasty (PSARP), without protective colostomy. The variables examined include age, timing of postoperative feeding initiation, length of stay (LOS), and complications. RESULTS Nineteen patients with VF or PF underwent a single-stage repair. 12/19 (63%) patients were female. All 7 males and 9/12 females had a PF. The range of age at surgery was 2 days to 3 years with median age of 92 days [IQR 1,3: 9,193]. The median postoperative day for initiation of feeds was day 0 [IQR 1,3: 0,1] and median LOS was 1 day [IQR 1,3: 1,4.5]. 18/19 (95%) patients were evaluated in follow-up and there were no wound infections, wound dehiscences, or recurrent fistulas. Within 90 days postoperatively, no patients were seen in the emergency department for postoperative issues. Within 6 months, 2/19 (11%) patients required an unplanned return to the operating room for anal dilation. CONCLUSION In single-stage repair of isolated low anorectal malformations, VF and PF, early initiation of postoperative feeding is safe, results in a short length of stay, and does not lead to increased wound complications. Early enteral feeding eliminates the need for parenteral nutrition and central venous access, and their associated complications. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Krista Lai
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Angela Hargis-Villanueva
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Cristine S Velazco
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Erica M Weidler
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Erin M Garvey
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Kathleen van Leeuwen
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA
| | - Justin Lee
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Road, Phoenix, AZ 85016, USA.
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4
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Mour GK, Chang YH, Calderon E, Chang JM, Velazco CS, Jadlowiec CC, Reddy KS, Heilman RL, Mathur AK. Kidney donor profile index and post-transplant health care utilization: Implications for value of transplant care delivery. Clin Transplant 2022; 36:e14618. [PMID: 35182437 DOI: 10.1111/ctr.14618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 01/17/2022] [Accepted: 02/10/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Centers discard high kidney donor profile index (KDPI) allografts, potentially related to delayed graft function and prolonged hospital use by kidney transplant recipients (KTR). We sought to determine whether high KDPI KTRs have excess health care utilization. METHODS We conducted a retrospective cohort study from a high-volume center analyzing KTRs from January 3, 2011 to April 12, 2015 (n = 652). We measured differences in hospital use, emergency visits, and outpatient visits within the first 90 days between low (≤85%) versus high KDPI (>85%) KTRs, as well as long-term graft function and patient survival. RESULTS High (n = 107) and low KDPI (n = 545) KTRs had similar length of stay (median = 3 days, P = .66), and readmission rates at 7, 30, and 90 days after surgery (all, P > .05). High KDPI kidneys were not associated with excess utilization of the hospital, emergency services, outpatient transplant clinics, or ambulatory infusion visits on univariate or multivariate analysis (all, P > .05). Low KDPI KTRs had significantly better eGFR at 2 years (Low vs. High KDPI: 60.35 vs. 41.54 ml/min, P < .001), but similar 3-year patient and graft survival (both, P > .09). CONCLUSIONS High and low KDPI KTRs demonstrated similar 90-day risk-adjusted health care utilization, which should encourage use of high KDPI kidneys.
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Affiliation(s)
- Girish K Mour
- Division of Nephrology, Mayo Clinic, Phoenix, Arizona, USA
| | - Yu-Hui Chang
- Robert D. and Patricia E. Kern Center for the Center for the Science of Healthcare Delivery, Mayo Clinic, Phoenix, Arizona, USA
| | - Esteban Calderon
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - James M Chang
- Division of Vascular Surgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Kunam S Reddy
- Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | - Amit K Mathur
- Robert D. and Patricia E. Kern Center for the Center for the Science of Healthcare Delivery, Mayo Clinic, Phoenix, Arizona, USA.,Division of Transplant Surgery, Mayo Clinic, Phoenix, Arizona, USA
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5
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Calderon E, Chang YH, Chang JM, Velazco CS, Giorgakis E, Srinivasan A, Moss AA, Khamash H, Heilman R, Reddy KS, Mathur AK. Outcomes and Health Care Utilization After Early Hospital Dismissal in Kidney Transplantation: An Analysis of 1001 Consecutive Cases. Ann Surg 2022; 275:e511-e519. [PMID: 32516231 DOI: 10.1097/sla.0000000000003948] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To understand whether reduced lengths of stay after kidney transplantation were associated with excess health care utilization in the first 90 days or long-term graft and patient survival outcomes. BACKGROUND Reducing length of stay after kidney transplant has an unknown effect on post-transplant health care utilization. We studied this association in a cohort of 1001 consecutive kidney transplants. METHODS We retrospectively reviewed 2011-2015 data from a prospectively-maintained kidney transplant database from a single center. RESULTS A total of 1001 patients underwent kidney transplant, and were dismissed from the hospital in 3 groups: Early [≤2 days] (19.8%), Normal [3-7 days] (79.4%) and Late [>7 days] (3.8%). 34.8% of patients had living donor transplants (Early 51%, Normal 31.4%, Late 18.4%, P < 0.001). Early patients had lower delayed graft function rates (Early 19.2%, Normal 32%, Late73.7%, P = 0.001). By the hospital dismissal group, there were no differences in readmissions or emergency room visits at 30 or 90 days. Glomerular filtration rate at 12 months and rates of biopsy-proven acute rejection were also similar between groups. The timing of hospital dismissal was not associated with the risk-adjusted likelihood of readmission. Early and Normal patients had similar graft and patient survival. Late dismissal patients, who had higher rates of cardiovascular complications, had significantly higher late mortality versus Normal dismissal patients in unadjusted and risk-adjusted models. CONCLUSION Dismissing patients from the hospital 2 days after kidney transplant is safe, feasible, and improves value. It is not associated with excess health care utilization or worse short or long-term transplant outcomes.
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Affiliation(s)
| | - Yu-Hui Chang
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
| | - James M Chang
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | | | | | | | - Adyr A Moss
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Hasan Khamash
- Department of Nephrology, Mayo Clinic, Phoenix, Arizona
| | | | - Kunam S Reddy
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
| | - Amit K Mathur
- Department of Surgery, Mayo Clinic, Phoenix, Arizona
- Kern Center for the Science of Health Care Delivery, Mayo Clinic, Phoenix, Arizona
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6
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Hargis-Villanueva AE, Velazco CS, Garvey EM, van Leeuwen KD, Lee JH. Vestibular and Perineal Fistula: Outcomes of Single-stage Repair with Early Feeding and Limited Postoperative Antibiotics. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.08.672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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7
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Goddard GR, Lim IIP, Cheng YC, Velazco CS, Jenkins T, Rosen NG, Kotagal M, Garrison AP, Falcone R, Rymeski B, Frischer JS. A child presents with perianal symptoms - how often is this Crohn's disease? J Pediatr Surg 2021; 56:1618-1622. [PMID: 33280851 DOI: 10.1016/j.jpedsurg.2020.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 11/05/2020] [Accepted: 11/14/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The cumulative incidence and predictors of future diagnosis of Crohn's disease (CD) following presentation with perianal symptoms, such as anorectal abscess, fistula or fissure, is unknown. METHODS A 5-year retrospective review of children presenting with perianal symptoms without prior CD diagnosis was performed. Institutional cumulative incidence of CD was calculated to determine the risk of CD presenting with perianal symptoms. RESULTS 1140 children presented for evaluation of an anorectal abscess (n = 232), fistula (n = 49), or fissure (n = 859). Thirty-five were later diagnosed with CD, resulting in an incidence of 3%. Prognostic indicators of future CD diagnosis included increased age per every additional year (RR 1.19, 95% CI: 1.14-1.25, p < 0.001), male sex (RR 2.12, 95% CI 1.07-4.22, p = 0.024), or perianal fistula (RR 4.67, 95% CI 2.26-9.67, p = 0.022). Among those diagnosed with CD, 57% experienced and had a documented history of a CD-associated symptom prior to perianal symptom onset. Absence of symptoms resulted in delayed diagnosis (43 vs 3 days, p < 0.02). CONCLUSION Of children presenting with a perianal symptom, three percent will eventually be diagnosed with CD. At highest risk (35%) were males aged 10 years or older with a perianal fistula; which should prompt expeditious workup.
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Affiliation(s)
- Gillian R Goddard
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Irene Isabel P Lim
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States.
| | - Yu-Chia Cheng
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Cristine S Velazco
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Todd Jenkins
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Nelson G Rosen
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Meera Kotagal
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Aaron P Garrison
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Richard Falcone
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Beth Rymeski
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
| | - Jason S Frischer
- Colorectal Center, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229, United States
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8
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Velazco CS, Davila VJ, Alhajjat AM, Ostlie DJ, Garvey EM. Mentorship in pediatric surgery: A need for structure? J Pediatr Surg 2021; 56:892-899. [PMID: 33139033 DOI: 10.1016/j.jpedsurg.2020.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 08/31/2020] [Accepted: 09/21/2020] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Mentorship in surgical training is critical but differs greatly from the early apprenticeship model and often spans generations. This study evaluates the current state of and desire for structured mentorship in pediatric surgical training from the perspective of program directors (PDs) and trainees. METHODS A survey addressing demographics, presence of or desire for structured mentorship, and proposed mentoring topics was emailed to pediatric surgery PDs (n = 58) and trainees completing fellowship in 2018-2020 (n = 72). RESULTS The response rate was 38.5%. 50% of trainees were female versus 15% of PDs (p = 0.02). 19% of trainees reported having a structured mentorship program versus 26% of PDs (p = 0.72). The majority, 83%, of trainees felt a structured mentorship program is warranted versus 40% of PDs (p = 0.002). There were differing opinions between trainees and PDs regarding important components of a mentoring program. Trainees felt the following were more important: transition to practice, job negotiation, CV review, financial planning and performance review. PDs felt the following were more important: quality improvement projects and work/life balance. Both agreed academic development and job search were important. CONCLUSIONS The majority of pediatric surgery trainees desire structured mentorship programs; however, few institutions have them. Training programs and program directors warrant a response to this gap. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Cristine S Velazco
- Department of General Surgery, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Victor J Davila
- Division of Vascular Surgery, Mayo Clinic, 5777 E Mayo Blvd, Phoenix, AZ 85054
| | - Amir M Alhajjat
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Daniel J Ostlie
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - Erin M Garvey
- Division of Pediatric Surgery, Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ 85016.
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9
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Hammond JB, Flug JA, Foley BM, Bryant LA, Casey WJ, Velazco CS, Rebecca AM. A Newly Described, Highly Prevalent Arterial Pedicle Perfuses Both Gracilis and Profunda Artery Perforator Flap Tissues: An Angiographic Study of the Medial Thigh. J Reconstr Microsurg 2019; 36:177-181. [DOI: 10.1055/s-0039-1698438] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Abstract
Background Novel secondary flap options are paramount for patients who are not candidates for common reconstructive methods. The purpose of this study is to identify the prevalence of single arterial pedicle supplying both the gracilis muscle and medial thigh tissue carried in a profunda artery perforator (PAP) flap. Such a pedicle could allow the creation of a chimeric gracilis and PAP flap with a single-arterial anastomosis.
Methods We conducted a retrospective review of 157 lower extremity computed tomography (CT) angiograms to assess the vasculature of the thigh soft tissues. Imaging evaluation was supervised by a board-certified musculoskeletal radiologist.
Results Prevalence of a single-arterial pedicle to a gracilis and PAP flap in each patient was 59% (31% within the right leg and 28% in the left leg). Furthermore, 16% of patients had a common arterial pedicle in both lower extremities.
Conclusion Existence of a single-arterial pedicle to both the gracilis muscle and PAP flap tissues is frequently present in most patients in at least one lower extremity. This chimeric flap configuration could serve as a reconstructive avenue for patients, particularly those who have exhausted other more common flap options. Screening angiography is warranted in patients looking for this anatomic variation to establish its presence.
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Affiliation(s)
| | | | | | - Lyndsey A. Bryant
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | - William J. Casey
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
| | | | - Alanna M. Rebecca
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, Phoenix, Arizona
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10
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Webb C, Day R, Velazco CS, Pockaj BA, Gray RJ, Stucky CC, Young-Fadok T, Wasif N. Implementation of an Enhanced Recovery After Surgery (ERAS) Program is Associated with Improved Outcomes in Patients Undergoing Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy. Ann Surg Oncol 2019; 27:303-312. [PMID: 31605328 DOI: 10.1245/s10434-019-07900-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has been associated with increased postoperative complications and a prolonged length of stay (LOS). We report on our experience following implementation of an Enhanced Recovery After Surgery (ERAS) program for CRS and HIPEC. METHODS Patients were divided into pre- and post-ERAS groups. Modifications in the ERAS group included routine use of transversus abdominis plane blocks, intra- and postoperative fluid restriction, and minimizing the use of narcotics, drains, and nasogastric tubes. RESULTS Of a total of 130 procedures, 49 (38%) were in the pre-ERAS group and 81 (62%) were in the ERAS group. Mean LOS was reduced from 10.3 ± 8.9 days to 6.9 ± 5.0 days (p = 0.007) and the rate of grade III/IV complications was reduced from 24 to 15% (p = 0.243) following ERAS implementation. The ERAS group received less intravenous fluid during hospitalization (19.2 ± 18.7 L vs. 32.8 ± 32.5 L, p = 0.003) and used less opioids than the pre-ERAS group (median of 159.7 mg of oral morphine equivalents vs. 272.6 mg). There were no significant changes in the rates of 30-day readmission or acute kidney injury between the two groups (p = non-significant). On multivariable analyses, ERAS was significantly associated with a reduction in LOS (- 2.89 days, 95% CI - 4.84 to - 0.94) and complication rates (odds ratio 0.22, 95% CI 0.08-0.57). CONCLUSIONS Implementation of an ERAS program for CRS and HIPEC is associated with a reduction in overall intravenous fluids, postoperative narcotic use, complication rates, and LOS.
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Affiliation(s)
- Christopher Webb
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Ryan Day
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Cristine S Velazco
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Richard J Gray
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Chee-Chee Stucky
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tonia Young-Fadok
- Department of Surgery, Division of Colorectal Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Nabil Wasif
- Department of Surgery, Division of Surgical Oncology, Mayo Clinic Arizona, Phoenix, AZ, USA.
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11
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Linnaus ME, Sheaffer WW, Ali-Mucheru MN, Velazco CS, Neville M, Gray RJ. The Opioid Crisis and Surgeons: National Survey of Prescribing Patterns and the Influence of Motivators, Experience, and Gender. Am J Surg 2019; 217:1116-1120. [DOI: 10.1016/j.amjsurg.2018.11.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 10/31/2018] [Accepted: 11/15/2018] [Indexed: 01/21/2023]
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12
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Peña A, Han GR, Velazco CS, Rappaport DE. Blunt Thigh Trauma and a Pulsatile Mass: An Unusual Case of Pseudoaneurysm of the Medial Geniculate Artery. J Emerg Med 2019; 57:100-101. [PMID: 31003814 DOI: 10.1016/j.jemermed.2019.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/05/2019] [Accepted: 02/17/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Austin Peña
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, Arizona; Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Ga-Ram Han
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, Arizona; Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Cristine S Velazco
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, Arizona; Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
| | - Douglas E Rappaport
- Department of Emergency Medicine, Mayo Clinic Hospital, Phoenix, Arizona; Department of Surgery, Mayo Clinic Hospital, Phoenix, Arizona
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13
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Jaroszewski DE, Velazco CS, Pulivarthi VSKK, Arsanjani R, Obermeyer RJ. Cardiopulmonary Function in Thoracic Wall Deformities: What Do We Really Know? Eur J Pediatr Surg 2018; 28:327-346. [PMID: 30103240 DOI: 10.1055/s-0038-1668130] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Patients with pectus excavatum (PE) frequently present with complaints of exercise intolerance and cardiopulmonary symptoms. There continues to be controversy regarding the physiologic benefits of repair. The aim of this review is to summarize and discuss recent data regarding the cardiopulmonary effects of PE deformity and the evidence for improvement obtained after surgical repair including (1) a greater efficiency of breathing (chest wall mechanics), (2) improvement in pulmonary restrictive deficits, (3) an increase in cardiac chamber size and output, with improved cardiac strain and strain rate, and (4) improvement in exercise capacity.
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Affiliation(s)
- Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, United States
| | - Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic, Phoenix, Arizona, United States
| | | | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, Arizona, United States
| | - Robert J Obermeyer
- Department of Pediatric Surgery, Children's Hospital of the King's Daughters, Norfolk, Virginia, United States
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14
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Donato BB, Linnaus ME, Velazco CS, McMahon LE, Towbin R, Notrica DM. Severe pectus excavatum with tracheal compression presenting with chronic cough. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Abstract
Minimally invasive repair of pectus excavatum has been successfully modified for use in adult patients. Many patients present in adulthood with progression of symptoms as the chest wall becomes less compliant with age. A thorough workup is completed including echocardiogram and chest CT to evaluate for anatomic abnormalities. Cardiopulmonary exercise testing is done to quantify the physiologic impact. Modifications of the original Nuss procedure required to allow for successful adult repair include the use of forced sternal elevation, the use of multiple bars, medial bar fixation, and interspace support to prevent bar rotation and migration. Occasionally, fractures may occur that require an open procedure and osteotomy or cartilage resection and hybrid approach incorporating the principals of intrathoracic support and osteotomy with bar stabilization.
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Affiliation(s)
- Cristine S Velazco
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic Arizona, Phoenix, AZ, United States
| | - Dawn E Jaroszewski
- Department of Cardiovascular and Thoracic Surgery, Mayo Clinic Arizona, Phoenix, AZ, United States.
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Fullerton BS, Velazco CS, Hong CR, Carey AN, Jaksic T. High Rates of Positive Severe Combined Immunodeficiency Screening Among Newborns with Severe Intestinal Failure. JPEN J Parenter Enteral Nutr 2017; 42:239-246. [PMID: 29505141 DOI: 10.1002/jpen.1013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 08/22/2017] [Accepted: 09/07/2017] [Indexed: 11/12/2022]
Abstract
PURPOSE Severe combined immunodeficiency (SCID) screening by T-cell receptor excision circles (TREC) has been part of Massachusetts routine newborn screening since 2009. Tetratricopeptide repeat domain 7A gene (TTC7A) mutations responsible for hereditary multiple intestinal atresia with combined immunodeficiency (MIA-CID) were also recently identified. We reviewed newborn SCID screening among infants with intestinal failure and correlated results with patient characteristics and outcomes. METHODS Records of infants with severe intestinal failure and available newborn screen results treated at a single center 2009-2016 were reviewed retrospectively. Patients with 1 or more positive SCID screens (<252 TREC copies/μL) were compared with those without positive screens. TREC copies/μL were compared with population norms. RESULTS Of 70 included infants, 34% had newborn screens with TREC <252 copies/μL, compared with 0.3% of the general population; TREC levels for the cohort were lower than the general population (p<0.001). Of those with positive screens, 42% had prior or subsequent negative screening, 8% had no further workup, and 50% had flow cytometry showing: severe T-cell lymphopenia (absolute CD3+ <1500 cells/mcL) in 8, 3 of whom had TTC7A mutation-associated MIA-CID. Four had CD3+ >1500 cells/mcL. MIA-CID patients had the lowest serum citrulline in the cohort; 4 of the 8 patients with CD3+ <1500 cells/mcL on flow cytometry had newborn screening notable for severe hypocitrullinemia (<3 μM). CONCLUSION Infants with intestinal failure have lower TREC copies/μL than the general population; one-third had levels concerning for SCID, and 11% were diagnosed with severe T-cell lymphopenia. The clinical implications and etiology of this phenomenon remain unknown, but may be related to hypocitrullinemia.
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Affiliation(s)
- Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Alexandra N Carey
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.,Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA, USA.,Department of Surgery, Boston Children's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Velazco CS, Fullerton BS, Brazzo JA, Hong CR, Jaksic T, Barnewolt CE. Radiographic measurement of intestinal length among children with short bowel syndrome: Retrospective determination remains problematic. J Pediatr Surg 2017; 52:1921-1924. [PMID: 28987713 DOI: 10.1016/j.jpedsurg.2017.08.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022]
Abstract
PURPOSE Small bowel length is the most reliable predictor of enteral independence in pediatric short bowel syndrome. Retrospectively measured bowel lengths on upper GI with small bowel follow-through (UGI/SBFT) were compared to operative measurements. METHODS A pediatric radiologist and surgical trainees blinded to operative measurements retrospectively analyzed UGI/SBFT studies using the digital radiography curved measurement tool. Children with SBS and severe intestinal failure (parenteral nutrition >90days) at a multidisciplinary intestinal failure program 2002-2015 were included. Data were expressed as median (Q1, Q3). RESULTS Thirty-six children aged 0.8 (0.4, 3.7) years were analyzed. Fifty-six percent had intestinal malrotation, and 58% had prior serial transverse enteroplasty. Studies were conducted within 10 (7, 20) days of surgery. Intraoperative bowel length was 90cm (45, 142), while UGI/SBFT measurement by radiologist was 45cm (28, 63), with a mean difference of 47cm (SD 58cm, p<0.001) and a mean percent error of 50%. Radiographic assessment underestimated intestinal length in 83% of patients. CONCLUSION Bowel length measured retrospectively from upper GI with small bowel follow-through studies usually underestimated intraoperative bowel length. The limits of agreement were too wide for this technique to be clinically useful. Operative measurement remains necessary to assess intestinal length and rehabilitation potential. TYPE OF STUDY Study of Diagnostic Test. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Joseph A Brazzo
- Department of Surgery Boston Children's Hospital, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, Boston, MA; Department of Surgery Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Carol E Barnewolt
- Department of Radiology, Boston Children's Hospital, Boston, MA; Harvard Medical School, Boston, MA.
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Fullerton BS, Hong CR, Velazco CS, Mercier CE, Morrow KA, Edwards EM, Ferrelli KR, Soll RF, Modi BP, Horbar JD, Jaksic T. Severe neurodevelopmental disability and healthcare needs among survivors of medical and surgical necrotizing enterocolitis: A prospective cohort study. J Pediatr Surg 2017; 53:S0022-3468(17)30651-6. [PMID: 29079317 DOI: 10.1016/j.jpedsurg.2017.10.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
PURPOSE This study characterizes neurodevelopmental outcomes and healthcare needs of extremely low birth weight (ELBW) survivors of necrotizing enterocolitis (NEC) compared to ELBW infants without NEC. METHODS Data were collected prospectively on neonates born 22-27weeks' gestation or 401-1000g at 47 Vermont Oxford Network member centers from 1999 to 2012. Detailed neurodevelopmental evaluations were conducted at 18-24months corrected age. Information regarding rehospitalizations, postdischarge surgeries, and feeding was also collected. "Severe neurodevelopmental disability" was defined as: bilateral blindness, hearing impairment requiring amplification, inability to walk 10 steps with support, cerebral palsy, and/or Bayley Mental or Psychomotor Developmental Index <70. Diagnosis of NEC required both clinical and radiographic findings. RESULTS There were 9063 children without NEC, 417 with medical NEC, and 449 with surgical NEC evaluated. Significantly higher rates of morbidity were observed among infants with a history of NEC. Those with surgical NEC were more frequently affected across all outcome measures at 18-24months corrected age: 38% demonstrated severe neurodevelopmental disability, nearly half underwent postdischarge operations, and a quarter required tube feeding at home. CONCLUSION At 18-24months, extremely low birth weight survivors of necrotizing enterocolitis were at markedly increased risk (p<0.001) for severe neurodevelopmental disability, postdischarge surgery, and tube feeding. LEVEL OF EVIDENCE II (prospective cohort study with <80% follow-up rate).
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Affiliation(s)
- Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | | | - Erika M Edwards
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | | | - Roger F Soll
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Horbar
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Velazco CS, Fullerton BS, Hong CR, Morrow KA, Edwards EM, Soll RF, Jaksic T, Horbar JD, Modi BP. Morbidity and mortality among "big" babies who develop necrotizing enterocolitis: A prospective multicenter cohort analysis. J Pediatr Surg 2017; 53:S0022-3468(17)30650-4. [PMID: 29111080 DOI: 10.1016/j.jpedsurg.2017.10.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 10/05/2017] [Indexed: 12/23/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is classically a disease of prematurity, with less reported regarding morbidity and mortality of this disease among other infants. METHODS Data were prospectively collected from 2009 to 2015 at 252 Vermont Oxford Network member centers on neonates with birth weight>2500g admitted to a participating NICU within 28days of birth. RESULTS Of 1629 neonates with NEC, gestational age was 37 (36, 39) weeks, and 45% had major congenital anomalies, most commonly gastrointestinal defects (20%), congenital heart defects (18%), and chromosomal anomalies (7%). For the 23% of infants who had surgery for NEC, mortality and length of stay were 23% and 63 (36, 94) days versus 8% and 34 (22, 61) days in medical NEC. Independent predictors of mortality were congenital heart defects (p<0.0001), chromosomal abnormalities (p<0.05), other congenital malformations (p<0.001), surgical NEC (p<0.0001), and sepsis (p<0.05). All of these in addition to gastrointestinal defects were independent predictors of increased length of stay. Nutritional morbidity at discharge included 6% receiving no enteral feeds and 27% who were <10th percentile weight-for-age. CONCLUSIONS Major congenital anomalies are present in nearly half of >2500g birth weight infants diagnosed with necrotizing enterocolitis. Morbidity and mortality increase with sepsis, surgical disease, and congenital anomalies. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Charles R Hong
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Erika M Edwards
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Roger F Soll
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Horbar
- University of Vermont, Burlington, VT; Vermont Oxford Network, Burlington, VT
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
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Velazco CS, Wasif N, Pockaj BA, Gray RJ. Discussion of: "Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve". Am J Surg 2017; 214:1094-1095. [PMID: 28985889 DOI: 10.1016/j.amjsurg.2017.09.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Cristine S Velazco
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Nabil Wasif
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Barbara A Pockaj
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Richard J Gray
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
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Velazco CS, Wasif N, Pockaj BA, Gray RJ. Radioactive seed localization for breast conservation surgery: Low positive margin rate with no learning curve. Am J Surg 2017; 214:1091-1093. [PMID: 28947271 DOI: 10.1016/j.amjsurg.2017.08.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 08/22/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Radioactive seed localization (RSL) is an alternative to wire localization. We compared the rate of positive margins for evidence of a learning curve in implementing RSL. METHODS A retrospective review of RSL by three surgeons at a single institution from 2002 to 2016. Positive margins were defined as ink on tumor. RESULTS Surgeon experience with RSL for ranged from 142 to >500 cases. The positive margin rate among the first 100 of each surgeons' experience (n = 300) was 2.3% and the rate during the most recent up to 100 cases after experience with at least 100 RSL procedures (n = 242) was 4.1% (p = 0.32). Individual surgeon's positive margin rates ranged from 2 to 5% in the early experience and 2-7% in the later experience (p = NS). CONCLUSIONS RSL for breast conservation surgery has a low rate of positive margins even early in a surgeon's experience. Implementation of RSL can be done with no evidence of a learning curve.
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Affiliation(s)
- Cristine S Velazco
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
| | - Nabil Wasif
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
| | - Barbara A Pockaj
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
| | - Richard J Gray
- Division of Surgical Oncology, Department of Surgery, Mayo Clinic, Phoenix, AZ, USA.
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Fullerton BS, Velazco CS, Sparks EA, Morrow KA, Edwards EM, Soll RF, Modi BP, Horbar JD, Jaksic T. Contemporary Outcomes of Infants with Gastroschisis in North America: A Multicenter Cohort Study. J Pediatr 2017; 188:192-197.e6. [PMID: 28712519 DOI: 10.1016/j.jpeds.2017.06.013] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Revised: 04/13/2017] [Accepted: 06/06/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To quantify outcomes and analyze factors predictive of morbidity and mortality in infants with gastroschisis. STUDY DESIGN Clinical data regarding neonates with gastroschisis born between 2009 and 2014 were prospectively collected at 175 North American centers. Multivariate regression was used to assess risk factors for mortality and length of stay (LOS). RESULTS Gastroschisis was diagnosed in 4420 neonates with median birth weight 2410 g (IQR 2105-2747). Survival (discharge home or alive in hospital at 1 year) was 97.8% with a 37 day median LOS (IQR 27-59). Sepsis, defined by positive blood or cerebrospinal fluid culture, was the only significant independent predictor of mortality (P = .04). Significant independent determinants of LOS and the percentage of neonates affected were as follows: bowel resection (9.8%, P < .0001), sepsis (8.6%, P < .0001), presence of other congenital anomalies (7.6%, including 5.8% with intestinal atresias, P < .0001), necrotizing enterocolitis (4.5%, P < .0001), and small for gestational age (37.3%, P = .0006). Abdominal surgery in addition to gastroschisis repair occurred in 22.3%, with 6.4% receiving gastrostomy or jejunostomy tubes and 6.3% requiring ostomy creation. At discharge, 57.0% were less than the 10th percentile weight for age. The mode of delivery (52.4% cesarean delivery) was not associated with any differences in outcome. CONCLUSIONS Although neonates with gastroschisis have excellent overall survival they remain at risk for death from sepsis, prolonged hospitalization, multiple abdominal operations, and malnutrition at discharge. Outcomes appear unaffected by the use of cesarean delivery. Further opportunities for quality improvement include sepsis prevention and enhanced nutritional support.
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Affiliation(s)
- Brenna S Fullerton
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Cristine S Velazco
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Eric A Sparks
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | | | - Erika M Edwards
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Roger F Soll
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Biren P Modi
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jeffrey D Horbar
- Vermont Oxford Network, Burlington, VT; University of Vermont, Burlington, VT
| | - Tom Jaksic
- Center for Advanced Intestinal Rehabilitation, Department of Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Fullerton BS, Sparks EA, Hall AM, Velazco CS, Modi BP, Lund DP, Jaksic T, Hendren WH. High prevalence of same-sex twins in patients with cloacal exstrophy: Support for embryological association with monozygotic twinning. J Pediatr Surg 2017; 52:807-809. [PMID: 28202184 DOI: 10.1016/j.jpedsurg.2017.01.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 01/23/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE Previous studies have hypothesized that cloacal exstrophy may be caused by errors early in embryological development related to monozygotic twinning. This study reports the prevalence of twins in a large cohort of patients with cloacal exstrophy. METHODS Patients with cloacal exstrophy treated 1974-2015 were reviewed for reports of multiple gestation or conjoined twinning. The genetic sex of the patient and their twin, and any mention of anomaly in the twin were recorded. Neither placental exam nor genetic testing results were available to definitively determine zygosity. RESULTS Of 71 patients, 10 had a live born twin (14%), all of whom were of the same genetic sex as the affected patient. One additional patient's twin suffered intrauterine fetal demise, and another patient had a conjoined heteropagus twin. None of the twins were affected by exstrophy-epispadias complex. The rate of twin birth in this cohort was 4.4-7.7 higher than that reported by the Centers for Disease Control in the general population time period (P<0.001), with a striking preponderance of same-sex pairs. CONCLUSIONS The highly significant prevalence of same-sex twin pairs within this cohort supports the hypothesis that the embryogenesis of cloacal exstrophy may be related to errors in monozygotic twinning. LEVEL OF EVIDENCE 2b.
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Affiliation(s)
- Brenna S Fullerton
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA.
| | - Eric A Sparks
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Amber M Hall
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Cristine S Velazco
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Biren P Modi
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - Dennis P Lund
- Stanford University Department of Surgery and Lucile Packard Children's Hospital, 725 Welch Road, Palo Alto, CA 94304, USA
| | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA; Center for Advanced Intestinal Rehabilitation, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
| | - W Hardy Hendren
- Department of Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, USA
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Davila VJ, Velazco CS, Stone WM, Fowl RJ, Abdul-Muhsin HM, Castle EP, Money SR. Robotic inferior vena cava surgery. J Vasc Surg Venous Lymphat Disord 2017; 5:194-199. [DOI: 10.1016/j.jvsv.2016.08.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/12/2016] [Indexed: 11/26/2022]
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Velazco CS, Zurakowski D, Fullerton BS, Bechard LJ, Jaksic T, Mehta NM. Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit. J Pediatr Surg 2017; 52:145-148. [PMID: 27856012 DOI: 10.1016/j.jpedsurg.2016.10.041] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2016] [Accepted: 10/20/2016] [Indexed: 01/28/2023]
Abstract
PURPOSE Inadequate nutrient intake is associated with poor outcomes in critically ill children. We examined macronutrient delivery in surgical patients in the pediatric intensive care unit (PICU). METHODS In a prospective international cohort study of mechanically ventilated children (1month to 18years), we recorded adequacy of cumulative nutrient delivery in the PICU. Surgical patients enrolled in this study were included in the current analysis. Protein intake <60% of the prescribed goal was deemed inadequate. RESULTS Five hundred nineteen surgical patients, 45% female, median age 2years (IQR 0.5, 8), BMI z score -0.26, with 9-day median PICU stay and 60-day mortality 5.8% were enrolled. Three hundred forty-one (66%) patients received enteral nutrition (EN), and median time of initiation was PICU day 2. EN delivery was interrupted in 68% of these patients for a median duration of 9hours. Median enteral protein delivery was <15% of the prescribed goal and was <60% in two-thirds of the cohort. Patients with inadequate enteral protein delivery had longer time to EN initiation (p<0.001) and longer duration of EN interruptions (p<0.001) compared to those with adequate delivery. CONCLUSION Enteral protein delivery in critically ill pediatric surgical patients is inadequate. Early EN initiation and minimizing interruptions may increase protein delivery and potentially improve outcomes in this population. LEVEL OF EVIDENCE I. TYPE OF STUDY Prospective study.
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Affiliation(s)
- Cristine S Velazco
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - David Zurakowski
- Department of Surgery, Boston Children's Hospital; Division of Critical Care Medicine; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Brenna S Fullerton
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Lori J Bechard
- Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital
| | - Tom Jaksic
- Department of Surgery, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115
| | - Nilesh M Mehta
- Division of Critical Care Medicine; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital; Center for Nutrition, Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital; Harvard Medical School, Boston, MA 02115.
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Kelley CA, Velazco CS, Delaney TV, Bensimhon A, Huang KN, Jarvis PR, Jolin JS, Schaberg KB, Burke M, Finley C, Carney JK. Factors contributing to suboptimal rates of childhood vaccinations in Vermont. J Child Health Care 2015; 19:558-68. [PMID: 24821076 DOI: 10.1177/1367493514530955] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Childhood immunizations are invaluable in preventing contagious diseases. Nonetheless, vaccines have become increasingly controversial with growing numbers of caregivers refusing to vaccinate their children. The percentage of fully vaccinated children in Vermont is one of the lowest nationally. This study set out to determine Vermont caregivers' attitudes toward immunizations to better explain why the percentage of fully vaccinated children has fallen in Vermont. A survey regarding caregivers' health care knowledge about children, their vaccination concerns, and their children's vaccination status was sent to participants in the Vermont Women, Infants and Children's Program from two districts. In total, 83% (n = 379) of respondents reported their children received all recommended vaccinations for their age. Respondents who considered themselves highly knowledgeable regarding their children's health care and confident about the safety of vaccinations were significantly associated with reporting their children as being current on vaccinations and with their intent to continue vaccinations. Respondents indicated highest concern regarding the safety and number of vaccinations administered during one visit. Primary care providers were indicated as important resources for addressing concerns about vaccinations and health care knowledge of children. The results help to understand low vaccination rates in Vermont and can be used for targeting health campaigns to improve vaccination rates.
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Affiliation(s)
- Catherine A Kelley
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Cristine S Velazco
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Thomas V Delaney
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Adam Bensimhon
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Kuang-Ning Huang
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Paul R Jarvis
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Jonathan S Jolin
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
| | - Kurt B Schaberg
- University of Vermont College of Medicine, USAVermont Department of Health, USAUniversity of Vermont College of Medicine, USA
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Shepherd MN, Pomicter AD, Velazco CS, Henderson SC, Dupree JL. Paranodal reorganization results in the depletion of transverse bands in the aged central nervous system. Neurobiol Aging 2012; 33:203.e13-24. [PMID: 20888080 PMCID: PMC3282488 DOI: 10.1016/j.neurobiolaging.2010.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2010] [Revised: 07/26/2010] [Accepted: 08/05/2010] [Indexed: 11/16/2022]
Abstract
Paranodal axo-glial junctional complexes anchor the myelin sheath to the axon and breakdown of these complexes presumably facilitates demyelination. Myelin deterioration is also prominent in the aging central nervous system (CNS); however, the stability of the paranodal complexes in the aged CNS has not been examined. Here, we show that transverse bands, prominent components of paranodal junctions, are significantly reduced in the aged CNS; however, the number of paired clusters of both myelin and axonal paranodal proteins is not altered. Ultrastructural analyses also reveal that thicker myelin sheaths display a "piling" of paranodal loops, the cytoplasm-containing sacs that demarcate the paranode. Loops involved in piling are observed throughout the paranode and are not limited to loops positioned in either the nodal- or juxtanodal-most regions. Here, we propose that as myelination continues, previously anchored loops lose their transverse bands and recede away from the axolemma. Newly juxtaposed loops then lose their transverse bands, move laterally to fill in the gap left by the receded loops and finally reform their transverse bands. This paranodal reorganization results in conservation of paranodal length, which may be important in maintaining ion channel spacing and axonal function. Furthermore, we propose that transverse band reformation is less efficient in the aged CNS, resulting in the significant reduction of these junctional components. Although demyelination was not observed, we propose that loss of transverse bands facilitates myelin degeneration and may predispose the aged CNS to a poorer prognosis following a secondary insult.
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Affiliation(s)
- Mark N. Shepherd
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, USA 23298
- MD Biosciences, 2575 University Avenue W. Suite 100 St Paul, MN, USA 55114 (present address)
| | - Anthony D. Pomicter
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, USA 23298
| | - Cristine S. Velazco
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, USA 23298
| | - Scott C. Henderson
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, USA 23298
| | - Jeffrey L. Dupree
- Department of Anatomy and Neurobiology, Virginia Commonwealth University, Richmond, VA, USA 23298
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