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Luckhurst CM, Wiberg HM, Brown RL, Bruch SW, Chandler NM, Danielson PD, Draus JM, Fallat ME, Gaines BA, Haynes JH, Inaba K, Islam S, Kaminski SS, Kang HS, Madabhushi VV, Murray J, Nance ML, Qureshi FG, Rubsam J, Stylianos S, Bertsimas DJ, Masiakos PT. Pediatric Cervical Spine Injury Following Blunt Trauma in Children Younger Than 3 Years: The PEDSPINE II Study. JAMA Surg 2023; 158:1126-1132. [PMID: 37703025 PMCID: PMC10500431 DOI: 10.1001/jamasurg.2023.4213] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Received: 04/11/2023] [Accepted: 06/16/2023] [Indexed: 09/14/2023]
Abstract
Importance There is variability in practice and imaging usage to diagnose cervical spine injury (CSI) following blunt trauma in pediatric patients. Objective To develop a prediction model to guide imaging usage and to identify trends in imaging and to evaluate the PEDSPINE model. Design, Setting, and Participants This cohort study included pediatric patients (<3 years years) following blunt trauma between January 2007 and July 2017. Of 22 centers in PEDSPINE, 15 centers, comprising level 1 and 2 stand-alone pediatric hospitals, level 1 and 2 pediatric hospitals within an adult hospital, and level 1 adult hospitals, were included. Patients who died prior to obtaining cervical spine imaging were excluded. Descriptive analysis was performed to describe the population, use of imaging, and injury patterns. PEDSPINE model validation was performed. A new algorithm was derived using clinical criteria and formulation of a multiclass classification problem. Analysis took place from January to October 2022. Exposure Blunt trauma. Main Outcomes and Measures Primary outcome was CSI. The primary and secondary objectives were predetermined. Results The current study, PEDSPINE II, included 9389 patients, of which 128 (1.36%) had CSI, twice the rate in PEDSPINE (0.66%). The mean (SD) age was 1.3 (0.9) years; and 70 patients (54.7%) were male. Overall, 7113 children (80%) underwent cervical spine imaging, compared with 7882 (63%) in PEDSPINE. Several candidate models were fitted for the multiclass classification problem. After comparative analysis, the multinomial regression model was chosen with one-vs-rest area under the curve (AUC) of 0.903 (95% CI, 0.836-0.943) and was able to discriminate between bony and ligamentous injury. PEDSPINE and PEDSPINE II models' ability to identify CSI were compared. In predicting the presence of any injury, PEDSPINE II obtained a one-vs-rest AUC of 0.885 (95% CI, 0.804-0.934), outperforming the PEDSPINE score (AUC, 0.845; 95% CI, 0.769-0.915). Conclusion and Relevance This study found wide clinical variability in the evaluation of pediatric trauma patients with increased use of cervical spine imaging. This has implications of increased cost, increased radiation exposure, and a potential for overdiagnosis. This prediction tool could help to decrease the use of imaging, aid in clinical decision-making, and decrease hospital resource use and cost.
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Affiliation(s)
- Casey M. Luckhurst
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Boston
| | | | - Rebeccah L. Brown
- Division of Pediatric Surgery at Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Steven W. Bruch
- Division of Pediatric Surgery at University of Michigan Medical Center, Ann Arbor
| | - Nicole M. Chandler
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Paul D. Danielson
- Division of Pediatric Surgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - John M. Draus
- Division of Pediatric Surgery at Kentucky Children’s Hospital, Lexington
| | - Mary E. Fallat
- Division of Pediatric Surgery at Norton Children’s Hospital, Louisville, Kentucky
| | - Barbara A. Gaines
- Division of Pediatric Surgery at University of Pittsburgh Medical Center Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jeffrey H. Haynes
- Department of Pediatric Surgery, Children’s Hospital of Richmond at Virginia Commonwealth University Health, Richmond
| | - Kenji Inaba
- Division of Trauma, Emergency Surgery, and Surgical Critical Care at University of Southern California Medical Center, Los Angeles
| | - Saleem Islam
- Division of Pediatric Surgery at University of Florida Health, Gainesville
| | - Stephen S. Kaminski
- Department of Surgery at Santa Barbara Cottage Hospital, Santa Barbara, California
| | - Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond
| | | | - Jason Murray
- Department of Surgery, University of Texas Health Tyler, Tyler
| | - Michael L. Nance
- Division of Pediatric Surgery at Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Faisal G. Qureshi
- Division of Pediatric Surgery at Children’s Medical Center Dallas, Dallas, Texas
| | - Jeanne Rubsam
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | - Steven Stylianos
- Division of Pediatric Surgery at Morgan Stanley Children’s Hospital of New York-Presbyterian, New York
| | | | - Peter T. Masiakos
- Division of Pediatric Surgery, Massachusetts General Hospital, Boston
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Bruch SW. Surgery for Thyroid Disease in Children. Adv Pediatr 2023; 70:123-130. [PMID: 37422290 DOI: 10.1016/j.yapd.2023.04.005] [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] [Indexed: 07/10/2023]
Abstract
Thyroid surgery in children results from three main etiologies: Medullary thyroid cancer in MEN syndromes, benign disease most often Graves' disease, and thyroid nodules which may harbor differentiated thyroid cancers. I will discuss the evaluation of these etiologies, pre-operative preparation, and operative strategies for each of these pediatric thyroid problems.
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Affiliation(s)
- Steven W Bruch
- University of Michigan, C.S. Mott Children's Hospital, 1540 East Hospital Drive, Ann Arbor, MI 48109, USA.
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Rubalcava NS, Overman RE, Kartal TT, Bruch SW, Else T, Newman EA. Laparoscopic adrenal-sparing approach for children with bilateral pheochromocytoma in Von Hippel-Lindau disease. J Pediatr Surg 2022; 57:414-417. [PMID: 34016427 DOI: 10.1016/j.jpedsurg.2021.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 01/20/2021] [Revised: 04/03/2021] [Accepted: 04/10/2021] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Von Hippel-Lindau disease (VHL) is a rare cause of hereditary bilateral Pheochromocytomas (PHEO). Traditionally, treatment has been total adrenalectomy due to a lifetime risk of developing new tumors. Limited data exists on the surgical management of bilateral PHEO in children with VHL. We reviewed our experience with laparoscopic partial adrenalectomy for bilateral PHEO. METHODS A retrospective review was performed of patients undergoing adrenalectomy for PHEO in children with VHL from 2004 to 2019. RESULTS Eight children with VHL diagnosed with bilateral PHEO underwent 16 adrenalectomies (10 synchronous, 5 metachronous, 1 for recurrence). Median age at diagnosis was 13 [range 8-17] years with a median tumor size of 2.3 [range 0.5-7.7] cm. Of 16 adrenalectomies, all were performed laparoscopically, 14 were partial adrenalectomies; 2 patients required a contralateral total adrenalectomy due to size and diffuse multinodularity. There were no postoperative complications. No patients required corticosteroid replacement at the end of the study period. Two patients had new ipsilateral tumors identified after a median follow up of 5 [range 4-6] years with one undergoing repeat partial adrenalectomy. There were no mortalities in the study period. CONCLUSION Partial adrenalectomy for bilateral PHEO in patients with VHL is safe and does not compromise outcomes. When technically feasible, laparoscopic partial adrenalectomy should be considered as a primary surgical approach for children with VHL. LEVEL OF EVIDENCE Level IV - Case series with no comparison group.
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Affiliation(s)
- Nathan S Rubalcava
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor 48109 MI, USA
| | - R Elliott Overman
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor 48109 MI, USA
| | - Tanvi T Kartal
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor 48109 MI, USA
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor 48109 MI, USA
| | - Tobias Else
- Division of Metabolism, Endocrinology, & Diabetes, Department of Internal Medicine Michigan Medicine, Ann Arbor 48109, MI, USA
| | - Erika A Newman
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, Ann Arbor 48109 MI, USA.
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Overman RE, Hsieh LB, Menon R, Thomas IH, Bruch SW. 4-Hour postoperative PTH level predicts hypocalcemia after thyroidectomy in children. J Pediatr Surg 2020; 55:1265-1269. [PMID: 31892477 DOI: 10.1016/j.jpedsurg.2019.11.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 03/04/2019] [Revised: 10/31/2019] [Accepted: 11/30/2019] [Indexed: 01/26/2023]
Abstract
BACKGROUND Hypocalcemia occurs frequently after a total thyroidectomy in pediatric patients. Four hour postoperative PTH monitoring predicts the need for calcium supplementation in the adult thyroidectomy population. We evaluated the role of the 4 h postoperative PTH level in determining the need for calcium supplementation after thyroidectomy in the pediatric population. METHODS This is a retrospective review of children undergoing total thyroidectomy by a single pediatric surgeon from July 2011 through July 2018. Intact PTH obtained four hours postoperatively determined the need for calcium supplementation for patients beginning in November 2014 onward. Serum total calcium levels were monitored concurrently with serum intact PTH levels. Serum calcium levels were followed in our Multispecialty Pediatric Endocrine Surgery clinic within the month following thyroidectomy. RESULTS From July 2011 through July 2018, there were a total of 56 total thyroidectomies at our institution. Prior to November 2014, all pediatric total thyroidectomies received calcium supplementation per our institutional protocol. Based on ionized calcium levels, 26.3% (5/19) of children developed hypocalcemia. From November 2014 to July 2018, 37 pediatric patients required total thyroidectomies. 29.7% (11/37) had low 4-h postoperative PTH levels. 72.7% (8/11) patients with low 4-h postoperative PTH levels had corresponding postoperative day 1 total calcium levels less than 8.5 or ionized calcium levels less than 1.12, and five children (45.5%) developed symptomatic hypocalcemia. 70% (26/37) of children had normal 4-h postop PTH levels, with only 5 (19%) ever developing hypocalcemia. No patients with a normal postop PTH level developed symptomatic hypocalcemia or required IV calcium repletion. A single 4-h postoperative PTH <10 pg/dl for identifying hypocalcemia has a sensitivity of 81% and specificity of 91%, with AUC 0.81. CONCLUSION The 4-h postoperative serum PTH level can help determine the need for calcium supplementation in pediatric patients undergoing total thyroidectomy, thereby reducing unnecessary calcium supplementation and serial lab draws to monitor for postoperative hypocalcemia. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- R Elliott Overman
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
| | - Lily B Hsieh
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
| | - Ram Menon
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, D1205 MPB, Ann Arbor, MI 48109.
| | - Inas H Thomas
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Department of Pediatrics, University of Michigan, 1500 E Medical Center Dr, D1205 MPB, Ann Arbor, MI 48109.
| | - Steven W Bruch
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, 1540 E Hospital Dr. Rm 4972, Ann Arbor, MI 48109.
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Raymond SL, Downard CD, St Peter SD, Baerg J, Qureshi FG, Bruch SW, Danielson PD, Renaud E, Islam S. Outcomes in omphalocele correlate with size of defect. J Pediatr Surg 2019; 54:1546-1550. [PMID: 30414688 DOI: 10.1016/j.jpedsurg.2018.10.047] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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: 05/10/2018] [Revised: 07/29/2018] [Accepted: 10/04/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Omphaloceles can be some of the more challenging cases managed by pediatric surgeons. Single center studies have not been meaningful in delineating outcomes due to the length of time required to accumulate a large enough series with historical changes in management negating the results. The purpose of this study was to evaluate factors impacting the morbidity and mortality of neonates with omphaloceles. METHODS A multicenter, retrospective observational study was performed for live born neonates with omphalocele between 2005 and 2013 at nine centers in the United States. Maternal and neonatal data were collected for each case. In-hospital management and outcomes were also reported and compared between neonates with small and large omphaloceles. RESULTS Two hundred seventy-four neonates with omphalocele were identified. The majority were delivered by cesarean section with a median gestational age of 37 weeks. Overall survival to hospital discharge was 81%. The presence of an associated anomaly was common, with cardiac abnormalities being the most frequent. Large omphaloceles had a significantly longer hospital and ICU length of stay, time on ventilator, number of tracheostomies, time on total parenteral nutrition, and time to full feeds, compared to small omphaloceles. Birth weight and defect size were independent predictors of survival. CONCLUSION This is the largest contemporary study of neonates with omphalocele. Increased defect size is an independent predictor of neonatal morbidity and mortality. LEVEL OF EVIDENCE Level II.
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MESH Headings
- Birth Weight
- Hernia, Umbilical/epidemiology
- Hernia, Umbilical/mortality
- Hernia, Umbilical/pathology
- Humans
- Infant, Newborn
- Infant, Newborn, Diseases/epidemiology
- Infant, Newborn, Diseases/mortality
- Infant, Newborn, Diseases/pathology
- Retrospective Studies
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Affiliation(s)
- Steven L Raymond
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Cynthia D Downard
- Division of Pediatric Surgery, Department of Surgery, University of Louisville, Louisville, KY, USA
| | | | - Joanne Baerg
- Loma Linda University Children's Hospital, Loma Linda, CA, USA
| | - Faisal G Qureshi
- Division of Pediatric Surgery, Department of Surgery, University of Texas Southwestern, Dallas, TX, USA
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Elizabeth Renaud
- Division of Pediatric Surgery, Department of Surgery, Albany Medical College, Albany, NY, USA
| | - Saleem Islam
- Division of Pediatric Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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Church JT, Klein EJ, Carr BD, Bruch SW. Early appendectomy reduces costs in children with perforated appendicitis. J Surg Res 2017; 220:119-124. [PMID: 29180172 DOI: 10.1016/j.jss.2017.07.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 01/30/2017] [Revised: 06/14/2017] [Accepted: 07/03/2017] [Indexed: 12/29/2022]
Abstract
BACKGROUND Perforated appendicitis can be managed with early appendectomy, or nonoperative management followed by interval appendectomy. We aimed to identify the strategy with the lowest health care utilization and cost. METHODS We retrospectively reviewed the medical records of all children ≤18 years old with perforated appendicitis admitted to a single institution between January 2009 and March 2016. After excluding immunosuppressed patients and transfers from outside hospitals, we grouped the remaining patients by early or interval appendectomy. Cost accounting data were obtained from our institutional database. The primary outcome was total hospital cost over 2 y from initial admission for appendicitis. Other outcomes analyzed included initial admission costs, number of admissions, emergency room and clinic visits, percutaneous procedures, cross-sectional and overall imaging studies, and length of stay. RESULTS A total of 203 children with perforated appendicitis were identified. After exclusion of immunosuppressed patients and outside hospital transfers, 94 patients were included in the study. Thirty-nine underwent early appendectomy and 55 initial nonoperative management; of these, 54 underwent elective interval appendectomy. Five of 55 patients (9%) failed initial nonoperative management and required earlier-than-planned appendectomy. Total cost over 2 y was significantly lower with early appendectomy than initial nonoperative management ($19,300 ± 14,300 versus $26,000 ± 17,500; P = 0.05). Early appendectomy resulted in fewer hospital admissions, clinic visits, invasive procedures, and imaging studies. CONCLUSIONS Early appendectomy results in lower hospital costs and less health care utilization compared with initial nonoperative management with elective interval appendectomy. A prospective study will shed more light on this question and can assess the role of nonoperative management without interval appendectomy in children with perforated appendicitis.
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Affiliation(s)
- Joseph T Church
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan.
| | - Edwin J Klein
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Benjamin D Carr
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Steven W Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan
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Church J, Coughlin MA, Antunez AG, Smith E, Bruch SW. Creating a Diagnostic Algorithm for Complicated Appendicitis. J Am Coll Surg 2016. [DOI: 10.1016/j.jamcollsurg.2016.08.394] [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: 11/30/2022]
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Moudgil P, Vellody R, Heider A, Smith EA, Grove JJ, Jarboe MD, Bruch SW, Dillman JR. Ultrasound-guided fine-needle aspiration biopsy of pediatric thyroid nodules. Pediatr Radiol 2016; 46:365-71. [PMID: 26554855 DOI: 10.1007/s00247-015-3478-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [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: 05/18/2015] [Revised: 08/24/2015] [Accepted: 10/13/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND The role of US-guided fine-needle aspiration biopsy (US-FNAB) of thyroid nodules is not well-established in children. OBJECTIVE To retrospectively assess the utility of US-FNAB of pediatric thyroid nodules. MATERIALS AND METHODS We reviewed Department of Radiology records to identify children who underwent US-FNAB of the thyroid between 2005 and 2013. Two board-certified pediatric radiologists reviewed pre-procedural thyroid US exams and documented findings by consensus. We recorded cytopathology findings and compared them to surgical pathology diagnoses if the nodule was resected. We also recorded demographic information, use of sedation or general anesthesia, and presence of on-site cytopathological feedback. The Student's t-test was used to compare continuous data; the Fisher exact test was used to compare proportions. RESULTS US-FNAB was conducted on a total of 86 thyroid nodules in 70 children; 56 were girls (80%). Seventy-eight of the 86 (90.7%) US-FNAB procedures were diagnostic; 69/78 (88.5%) diagnostic specimens were benign (including six indeterminate follicular lesions that were proved at surgery to be benign) and 9/78 (11.5%) were malignant/suspicious for malignancy (all proved to be papillary carcinomas). There was no difference in size of benign vs. malignant lesions (P = 0.82) or diagnostic vs. non-diagnostic lesions (P = 0.87). Gender (P = 0.19), use of sedation/general anesthesia (P = 0.99), and presence of onsite cytopathological feedback (P = 0.99) did not affect diagnostic adequacy. Microcalcifications (P < 0.0001; odds ratio [OR] = 113.7) and coarse calcifications (P = 0.03; OR = 19.4) were associated with malignancy. Diagnoses at cytopathology and surgical pathology were concordant in 27/29 (93.1%) nodules; no US-FNAB procedure yielded false-positive or false-negative results for malignancy. CONCLUSION US-FNAB of pediatric thyroid nodules is feasible, allows diagnostic cytopathological evaluation, and correlates with surgical pathology results in resected nodules.
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Affiliation(s)
- Pranav Moudgil
- Wayne State University School of Medicine, Detroit, MI, USA
| | - Ranjith Vellody
- Department of Radiology, Division of Interventional Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Amer Heider
- Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ethan A Smith
- Department of Radiology, University of Michigan Health System, Section of Pediatric Radiology, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jason J Grove
- Department of Radiology, Division of Interventional Radiology, University of Michigan Health System, Ann Arbor, MI, USA
| | - Marcus D Jarboe
- Department of Radiology, Division of Interventional Radiology, University of Michigan Health System, Ann Arbor, MI, USA.,Department of Surgery, University of Michigan Health System, Section of Pediatric Surgery, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Steven W Bruch
- Department of Surgery, University of Michigan Health System, Section of Pediatric Surgery, C. S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jonathan R Dillman
- Department of Radiology, University of Michigan Health System, Section of Pediatric Radiology, C. S. Mott Children's Hospital, Ann Arbor, MI, USA. .,Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA.
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Kunisaki SM, Bruch SW, Hirschl RB, Mychaliska GB, Treadwell MC, Coran AG. The diagnosis of fetal esophageal atresia and its implications on perinatal outcome. Pediatr Surg Int 2014; 30:971-7. [PMID: 25056797 DOI: 10.1007/s00383-014-3562-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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] [Accepted: 07/16/2014] [Indexed: 11/24/2022]
Abstract
The current diagnostic accuracy and perinatal outcome of fetuses with esophageal atresia (EA) continues to be debated. In this review, we report on our experience at a tertiary care fetal center with the prenatal ultrasound diagnosis of EA. Enrollment criteria included a small/absent stomach bubble with a normal or elevated amniotic fluid index between 2005 and 2013. Perinatal outcomes were analyzed and compared to postnatally diagnosed EA cases. Of the 22 fetuses evaluated, polyhydramnios occurred in 73%. Three (14%) died in utero or shortly after birth, but none had EA. In the presence of an absent/small stomach and polyhydramnios, the positive predictive value for EA was 67%. In fetal EA cases confirmed postnatally (group 1, n = 11), there were no differences in gestational age, birthweight, or mortality when compared to postnatally diagnosed infants (group 2, n = 59). Group 1 was associated with long-gap EA, need for esophageal replacement, and increased hospital length of stay. When taken in context with the current literature, we conclude that ultrasound findings suggestive of EA continue to be associated with a relatively high rate of false positives. However, among postnatally confirmed cases, there is an increased risk for long-gap EA and prolonged hospitalization.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Drive, SPC 4211, Ann Arbor, MI, 48109, USA,
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Kunisaki SM, Powelson IA, Bruch SW, Jarboe MD, Geiger JD, Mychaliska GB. Thoracoscopic Repair of Recurrent Bochdalek Diaphragmatic Hernias in Children. J Laparoendosc Adv Surg Tech A 2012; 22:1004-9. [DOI: 10.1089/lap.2012.0048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Shaun M. Kunisaki
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Ian A. Powelson
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Steven W. Bruch
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - Marcus D. Jarboe
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - James D. Geiger
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
| | - George B. Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, C.S. Mott Children's Hospital, Ann Arbor, Michigan
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Hashish MS, Dawoud HH, Hirschl RB, Bruch SW, El Batarny AM, Mychaliska GB, Drongowski RA, Ehrlich PF, Hassaballa SZ, El-Dosuky NI, Teitelbaum DH. Long-term functional outcome and quality of life in patients with high imperforate anus. J Pediatr Surg 2010; 45:224-30. [PMID: 20105608 DOI: 10.1016/j.jpedsurg.2009.10.041] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [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] [Received: 10/05/2009] [Accepted: 10/06/2009] [Indexed: 11/29/2022]
Abstract
PURPOSE Anorectal malformations (ARMs) are associated with a large number of functional sequale that may affect a child's long-term quality of life (QOL). The purposes of this study were to better quantify patient functional stooling outcome and to identify how these outcomes related to the QOL in patients with high imperforate anus. METHODS Forty-eight patients from 2 children's hospitals underwent scoring of stooling after 4 years of life. Scoring consisted of a 13-item questionnaire to assess long-term stooling habits (score range: 0-30, worst to best). These results were then correlated with a QOL survey as judged by a parent or guardian. RESULT Mean (SD) age at survey was 6.5 (1.6) years. Comparison of QOL and clinical scoring showed no signficant difference between the 2 institutions (P > .05). There was a direct correlation between the QOL and stooling score (Pearson r(2) = 0.827; beta coefficient = 24.7, P < .001). Interestingly, functional stooling scores worsened with increasing age (Pearson r(2) = 0.318, P = .02). Patients with associated congenital anomalies had a high rate of poor QOL (44% in poor range; P = .001). Stooling scores decreased significantly with increasing severity/complexity of the ARM (P = .001). CONCLUSION A large number of children experience functional stooling problems, and these were directly associated with poor QOL. In contrast to previous perceptions, our study showed that stooling patterns are perceived to worsen with age. This suggests that children with ARMs need long-term follow-up and counseling.
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Affiliation(s)
- Mohamed S Hashish
- Section of Pediatric Surgery, Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Hasan RA, Inoue S, Bruch SW, Onwuzurike N, Golladay ES. Variceal hemorrhage 13 years after nephrectomy for Wilms tumor. J Pediatr Gastroenterol Nutr 2005; 40:600-2. [PMID: 15861023 DOI: 10.1097/01.mpg.0000155564.87150.c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Rashed A Hasan
- Michigan State University College of Human Medicine, Hurley Medical Center, Flint, Michigan, USA
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Abstract
BACKGROUND/PURPOSE An increasing number of children are diagnosed with gallstones today. The best management of nonpigmented gallstones in children without hematologic disorders is not known. METHODS The authors prospectively studied 74 children with cholelithiasis diagnosed with ultrasonography. Clinical presentation, natural history, complications, and indications for cholecystectomy were examined. The follow-up (mean, 21 months) consisted of routine clinic visits, chart reviews, and telephone questionnaires with the children or their parents. RESULTS Of the 74 children, 33 required cholecystectomies, and 41 were followed. The average age was similar in the 2 groups (11.7 v 11.0 years). Children with risk factors for cholelithiasis required earlier surgical treatment (P < .001). In the operative group, 8 presented acutely and 25 electively. There were 2 complications, a wound infection and a retained common duct stone. In the group that underwent follow-up, 34 of 41 children remained asymptomatic or had symptoms improve with dietary manipulation. No complications developed during the follow-up period. CONCLUSIONS Children with gallstones and typical symptoms of right upper quadrant or epigastric pain with food intolerance should undergo cholecystectomy. Eighty-two percent of children with cholelithiasis and atypical symptoms had improvement with dietary manipulation. Pediatric patients with gallstones that are asymptomatic or associated with atypical symptoms can be safely followed without complications.
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Affiliation(s)
- S W Bruch
- University of Toronto, The Hospital for Sick Children, Ontario, Canada
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14
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Abstract
Although the majority of reported pericardial teratomas have been excised successfully in the postnatal period, the outcome of prenatally diagnosed pericardial teratomas remains less favorable. Two recent cases of prenatally diagnosed pericardial teratomas and a review of previously reported cases suggest a new management algorithm for those pericardial teratomas discovered in utero. Fetuses in whom hydrops does not develop may be safely followed up and treated postnatally. However, if hydrops develops, the fetus requires treatment with either aspiration of the pericardial effusion, or fetal surgery and resection.
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Affiliation(s)
- S W Bruch
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco, 94143-0570, USA
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15
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Abstract
In gastroschisis, the eviscerated fetal bowel frequently is damaged and this results in hypoperistalsis and malabsorption. The mechanistic link that ties gastroschisis-induced intestinal damage to dysfunction may be nitric oxide (NO) and the enzyme responsible for producing it, NO synthase. Using a fetal rabbit model, the authors investigated the hypothesis that the hypoperistalsis and malabsorption associated with gastroschisis may be attributable to abnormal small bowel NO synthase activity. Using the 3H-arginine-to-3H-citrulline conversion assay, they measured NO synthase activity in the small bowel of full-term fetal rabbits with and without gastroschisis. The mean total small bowel NO synthase activity of fetal rabbits with gastroschisis was 2.5 times greater than that of control littermates without gastroschisis (n = 6; 5,726 +/- 834 v 2,208 +/- 537 mean pmol/mg protein/min; P = .004). This increased NO synthase activity also was studied by measuring the individual isoforms of NO synthase, and the site of increased NO synthase activity was localized to the small bowel epithelium and neurons. After detecting and localizing the gastroschisis-induced increase in NO synthase activity, the authors explored the mechanism of this increase using NADPH-diaphorase staining. With this histological staining technique, no quantitative increase was found in the small bowel NO synthase of the rabbits with gastroschisis. This suggests that the increased NO synthase activity found in these rabbits is the result of accelerated enzyme kinetics. These findings suggest that the increased NO synthase activity caused by gastroschisis may contribute to the common clinical sequelae of malabsorption and intestinal dysmotility.
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Affiliation(s)
- J F Bealer
- Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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16
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Kohl T, Stelnicki EJ, VanderWall KJ, Szabo Z, Ko E, Bruch SW, Harrison MR, Silverman NH, Hanley FL, Chou TM. Transesophageal echocardiography in fetal sheep. A monitoring tool for open and fetoscopic cardiac procedures. Surg Endosc 1996; 10:820-4. [PMID: 8694946 DOI: 10.1007/s004649900169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cardiac procedures in exteriorized fetuses or assisted by fetoscopy require monitoring capabilities not attended by conventional maternal transabdominal echocardiography. METHODS We, therefore, assessed the potential of fetal transesophageal echocardiography (TEE) utilizing an intravascular ultrasound catheter (IVUC) for fetal cardiac monitoring. We inserted a 10-F-10-MHz IVUC into the esophagus in 12 exteriorized fetal sheep and by a fetoscopic approach in 4 fetal sheep. Cardiac events were observed. Heart rate, cardiac rhythm, patency of the foramen ovale and ductus arteriosus, and the width of the branch pulmonary arteries could be assessed in all fetuses. Ventricular contractility could be assessed only in fetuses weighing less than 2.5 kg. Larger fetuses did not allow adequate imaging of the apical portion of the ventricles because of limited tissue penetration of the IVUC. Fetal TEE permitted placing small guide wires in the cardiac atria and left ventricle. Short-lived premature beats following intracardiac manipulations of these wires could be observed by fetal TEE in all cases. RESULTS At autopsy, no complications from IVUC insertion were observed in the exteriorized fetuses. Fetoscopic placement of the IVUC resulted in minor perioral skin erosion in two nonexteriorized fetuses. CONCLUSIONS In conclusion, fetal TEE can be achieved with minor fetal injury and may provide useful information during open and fetoscopic cardiac procedures. Further improvements in IVUC design will permit the application of this technique to monitor human fetal cardiac procedures.
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Affiliation(s)
- T Kohl
- Division of Pediatric Cardiothoracic Surgery, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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17
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Abstract
Fetal surgery can correct several life-threatening malformations before birth. Despite recent advances in fetal surgery, preterm labor remains a major problem directly related to the large uterine incision required for fetal exposure. Fetal endoscopic surgery ("Fetendo") obviates the need for a large uterine incision and may reduce the overall risks of fetal surgery by causing less uterine trauma and ultimately less preterm labor. Temporary tracheal occlusion is a promising strategy to enlarge the lungs in fetuses with congenital diaphragmatic hernia. Using the technology developed for laparoscopic surgery and for temporary tracheal occlusion, we have developed an endoscopic technique for tracheal occlusion with an endoscopic clip in a fetal sheep model. The evolution of this technique may allow temporary tracheal occlusion without incisional hysterotomy or maternal laparotomy.
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Affiliation(s)
- K J VanderWall
- Fetal Treatment Center, University of California, San Francisco, 94143-0570, USA
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18
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Abstract
The goal of treatment for penile agenesis is early female gender assignment and feminizing reconstruction of the perineum. Historically, this required multiple operations including both vesicostomy and colostomy. The present case demonstrates the feasibility of early total reconstruction through a posterior sagittal approach that avoids diversion of stool and urine.
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Affiliation(s)
- S W Bruch
- Department of Surgery, University of California, San Francisco 94143-0570, USA
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19
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Abstract
As presently understood, cloacal exstrophy results from a migration failure of the lateral mesodermal folds of the infraumbilical anterior abdominal wall, and rupture of the resulting enlarged, persistent cloacal membrane before the eighth week of gestation. The authors present ultrasonographic evidence that disputes this embryological theory. Routine ultrasonography of a twin gestation at 18 weeks showed that one twin had a dilated cloacal abnormality, bilateral hydronephrosis, and oligohydramnios. Repeat ultrasonography at 24 weeks demonstrated rupture of the cloacal anomaly, with resolution of both the hydronephrosis and oligohydramnios. This twin was born with classic cloacal exstrophy. This striking ultrasound evidence of an intact cloacal membrane at 18 weeks, which ruptured before 24 weeks, relieving the urinary tract outlet obstruction, forces us to rethink how this surgically correctable anomaly develops.
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Affiliation(s)
- S W Bruch
- Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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20
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VanderWall KJ, Meuli M, Szabo Z, Bruch SW, Kohl T, Hoffman WY, Adzick NS, Harrison MR. Percutaneous access to the uterus for fetal surgery. J Laparoendosc Surg 1996; 6 Suppl 1:S65-7. [PMID: 8832931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In utero repair of selected life-threatening malformations in the human fetus is now a clinical reality, yet fetal surgery continues to pose significant risks to both the mother and the unborn child. Preterm labor is a major problem directly related to the large uterine incision required for fetal exposure. Using technology developed for laparoscopic surgery, we have devised instruments and techniques to perform fetal endoscopic surgery. We now report a percutaneous technique for direct endoscopic access to the uterus. Minimally invasive fetoscopic surgery may expand the indications for fetal surgery by decreasing fetal risks, facilitating intervention earlier in gestation, and reducing preterm labor. This technique was developed in 4 fetal lambs who underwent endoscopic intervention at 105-110 days gestation (term = 145 days). Under ultrasound guidance, a 20-gauge spinal needle was advanced through the maternal abdomen, uterus, and directly into the amniotic cavity. Warmed saline was infused through the needle to expand the amniotic cavity. Next, a 5-mm balloon-tipped trocar was placed percutaneously with ultrasound guidance into the amniotic cavity. A 5-mm laparoscope was introduced and under endoamniotic vision two more 5-mm trocars were percutaneously placed. In all four sheep a 5-mm trocar was placed percutaneously into the gravid uterus. The most difficult step was puncturing through the amniotic membranes, but the sharp tip of the trocar facilitated getting into the amniotic cavity. Excellent visualization of the fetus was obtained with minimal uterine trauma. We have developed a fetoscopic technique in sheep for percutaneous placement of trocars into the uterus using ultrasound guidance. This approach allowed excellent visualization of the fetus with significantly less uterine trauma than open fetal surgery and is an essential prerequisite for future fetal endoscopic interventions.
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Affiliation(s)
- K J VanderWall
- Fetal Treatment Center, Department of Surgery, University of California, San Francisco, USA
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