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Reiter AJ, Huang L, Craig BT, Davidoff AM, Talbot LJ, Coggins J, Smith J, Aldrink JH, Bergus KC, MacArthur TA, Polites SF, Boehmer C, Brungardt J, Malek MM, Rinehardt HN, Kastenberg ZJ, Arkin CM, Gourmel A, Piche N, Wallace M, Liang J, Lovvorn HN, Petroze RT, Gillies G, Marquart JP, Becktell K, Le HD, Favela J, Rich BS, Glick RD, Seemann NM, Davidson J, Wilson CA, Roach J, Brown EG, Doyle KE, Coakley BA, Emengo P, Merola P, Grant CN, Tirumani A, Tracy ET, Moya-Mendez ME, Dasgupta R, Lautz TB. Survival outcomes in pediatric patients with metastatic Ewing sarcoma who achieve a rapid complete response of pulmonary metastases. Pediatr Blood Cancer 2024:e31026. [PMID: 38679864 DOI: 10.1002/pbc.31026] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 02/26/2024] [Accepted: 04/05/2024] [Indexed: 05/01/2024]
Abstract
PURPOSE Our objectives were to compare overall survival (OS) and pulmonary relapse between patients with metastatic Ewing sarcoma (EWS) at diagnosis who achieve rapid complete response (RCR) and those with residual pulmonary nodules after induction chemotherapy (non-RCR). PATIENTS AND METHODS This retrospective cohort study included children under 20 years with metastatic EWS treated from 2007 to 2020 at 19 institutions in the Pediatric Surgical Oncology Research Collaborative. Chi-square tests were conducted for differences among groups. Kaplan-Meier curves were generated for OS and pulmonary relapse. RESULTS Among 148 patients with metastatic EWS at diagnosis, 61 (41.2%) achieved RCR. Five-year OS was 71.2% for patients who achieved RCR, and 50.2% for those without RCR (p = .04), and in multivariable regression among patients with isolated pulmonary metastases, RCR (hazards ratio [HR] 0.42; 95% confidence interval [CI]: 0.17-0.99) and whole lung irradiation (WLI) (HR 0.35; 95% CI: 0.16-0.77) were associated with improved survival. Pulmonary relapse occurred in 57 (37%) patients, including 18 (29%) in the RCR and 36 (41%) in the non-RCR groups (p = .14). Five-year pulmonary relapse rates did not significantly differ based on RCR (33.0%) versus non-RCR (47.0%, p = .13), or WLI (38.8%) versus no WLI (46.0%, p = .32). DISCUSSION Patients with EWS who had isolated pulmonary metastases at diagnosis had improved OS if they achieved RCR and received WLI, despite having no significant differences in rates of pulmonary relapse.
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Affiliation(s)
- Audra J Reiter
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Lynn Huang
- Northwestern Quality Improvement, Research, and Education in Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Brian T Craig
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Lindsay J Talbot
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jordan Coggins
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jasmine Smith
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Katherine C Bergus
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | | | | | - Chloe Boehmer
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Joseph Brungardt
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hannah N Rinehardt
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zachary J Kastenberg
- Division of Pediatric Surgery, Department of Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Cameron M Arkin
- Division of Pediatric Surgery, Department of Surgery, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Antoine Gourmel
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Québec, Canada
| | - Nelson Piche
- Department of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, University of Montreal, Montreal, Québec, Canada
| | - Marshall Wallace
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Jiancong Liang
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Vanderbilt University, Nashville, Tennessee, USA
| | - Robin T Petroze
- Division of Pediatric Surgery, University of Florida, Gainesville, Florida, USA
| | - Gwendolyn Gillies
- Division of Pediatric Surgery, University of Florida, Gainesville, Florida, USA
| | - John P Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kerri Becktell
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Hau D Le
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Juan Favela
- Division of Pediatric Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York, USA
| | - Richard D Glick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Northwell/Hofstra, New Hyde Park, New York, USA
| | - Natashia M Seemann
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jacob Davidson
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Claire A Wilson
- Division of Paediatric Surgery, Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - Jonathan Roach
- Department of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Erin G Brown
- Division of Pediatric Surgery, University of California Davis, Sacramento, California, USA
| | - Kathleen E Doyle
- Division of Pediatric Surgery, University of California Davis, Sacramento, California, USA
| | - Brian A Coakley
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Emengo
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Pamela Merola
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christa N Grant
- Division of Pediatric Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Anuritha Tirumani
- Division of Pediatric Surgery, Westchester Medical Center, Valhalla, New York, USA
| | - Elisabeth T Tracy
- Division of Pediatric Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Mary E Moya-Mendez
- Division of Pediatric Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
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2
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French MP, Busing J, Acra S, Chen H, Stafman L, Zamora I, Holzman M, Lovvorn HN. Effects of Anterior Fundoplication on Postoperative Dysphagia and Reflux After Laparoscopic Esophagocardiomyotomy for Pediatric Achalasia. J Laparoendosc Adv Surg Tech A 2024. [PMID: 38597929 DOI: 10.1089/lap.2023.0415] [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: 04/11/2024] Open
Abstract
Introduction: Achalasia among children often fails endoscopic management (e.g., dilation, botulinum toxin). Laparoscopic esophagocardiomyotomy (L-ECM) is a standard intervention to relieve obstruction but can induce gastroesophageal reflux (GER). Concurrent anterior fundoplication (A-fundo) has been evaluated in randomized trials among adults, demonstrating mixed results on controlling postoperative GER without exacerbating dysphagia. Furthermore, evidence for the best approach among children remains sparse. We hypothesized that, among children undergoing L-ECM without mucosal violation, routine A-fundo would not improve postoperative GER control while exacerbating dysphagia. Materials and Methods: Observational data of 47 consecutive achalasia patients ≤18 years who received L-ECM (2002-2023) at a single academic institution were collected. Patient records were culled for demographics, achalasia characteristics, and outcomes. Two L-ECM groups were identified: with or without A-fundo. Patients were screened for postoperative dysphagia (additional procedures) and GER (new antireflux medications). Univariate independence testing was conducted to identify statistically significant variables. Results: Among 47 patients undergoing L-ECM, 28 (59.6%) received concurrent A-fundo. Compared with patients undergoing L-ECM alone, patients with L-ECM/A-fundo had significantly longer hospital stays (P < .01) without statistically different rates of postoperative dysphagia (P = .81) or GER (P = .51). Five children (10.6%) experienced mucosal injury with L-ECM: 4 recognized intraoperatively received A-Fundo without subsequent leak; 1 mucosal injury was missed and did not receive A-Fundo, which subsequently leaked. Conclusion: In this largest observation of pediatric achalasia patients, A-fundo appeared clinically insignificant when determining contributors to control GER or exacerbate postoperative dysphagia. A-fundo should not be routinely adopted in children having L-ECM for achalasia without further multicenter analysis but appears beneficial in cases having inadvertent mucosal violation.
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Affiliation(s)
| | - Jordan Busing
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Sari Acra
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Laura Stafman
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Irving Zamora
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Michael Holzman
- Department of Surgery, Vanderbilt University, Nashville, Tennessee, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, USA
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Lovvorn HN, Renfro LA, Benedetti DJ, Kotagal M, Phelps HM, Ehrlich PF, Lo AC, Sandberg JK, Treece AL, Gow KW, Glick RD, Davidoff AM, Cost NG, Dix DB, Fernandez CV, Dome JS, Geller JI, Mullen EA. Race and Ethnic Group Enrollment and Outcomes for Wilms Tumor: Analysis of the Current Era Children's Oncology Group Study, AREN03B2. J Am Coll Surg 2024; 238:733-749. [PMID: 38251681 DOI: 10.1097/xcs.0000000000000999] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
BACKGROUND To review race and ethnic group enrollment and outcomes for Wilms tumor (WT) across all 4 risk-assigned therapeutic trials from the current era Children's Oncology Group Renal Tumor Biology and Risk Stratification Protocol, AREN03B2. STUDY DESIGN For patients with WT enrolled in AREN03B2 (2006 to 2019), disease and biologic features, therapeutic study-specific enrollment, and event-free (EFS) and overall (OS) 4-year survival were compared between institutionally reported race and ethnic groups. RESULTS Among 5,146 patients with WT, no statistically significant differences were detected between race and ethnic groups regarding subsequent risk-assigned therapeutic study enrollment, disease stage, histology, biologic factors, or overall EFS or OS, except the following variables: Black children were older and had larger tumors at enrollment, whereas Hispanic children had lower rates of diffuse anaplasia WT and loss of heterozygosity at 1p. The only significant difference in EFS or OS between race and ethnic groups was observed among the few children treated for diffuse anaplasia WT with regimen UH-1 and -2 on high-risk protocol, AREN0321. On this therapeutic arm only, Black children showed worse EFS (hazard ratio = 3.18) and OS (hazard ratio = 3.42). However, this finding was not replicated for patients treated with regimen UH-1 and -2 under AREN03B2 but not on AREN0321. CONCLUSIONS Race and ethnic group enrollment appeared constant across AREN03B2 risk-assigned therapeutic trials. EFS and OS on these therapeutic trials when analyzed together were comparable regarding race and ethnicity. Black children may have experienced worse stage-specific survival when treated with regimen UH-1 and -2 on AREN0321, but this survival gap was not confirmed when analyzing additional high-risk AREN03B2 patients.
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Affiliation(s)
| | - Lindsay A Renfro
- Division of Biostatistics, University of Southern California, and Children's Oncology Group, Los Angeles, CA (Renfro)
| | - Daniel J Benedetti
- Division of Pediatric Hematology/Oncology, Department of Pediatrics (Benedetti), Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, TN
| | - Meera Kotagal
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH (Kotagal)
- Department of Surgery, University of Cincinnati College of Medicine, Cincinnati, OH (Kotagal)
| | - Hannah M Phelps
- Department of Surgery, Washington University in St Louis School of Medicine, St Louis, MO (Phelps)
| | - Peter F Ehrlich
- Section of Pediatric Surgery, C. S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI (Ehrlich)
| | - Andrea C Lo
- Department of Radiation on Oncology, BC Cancer, Vancouver, British Columbia, Canada (Lo)
| | - Jesse K Sandberg
- Division of Pediatric Radiology, Lucille Packard Children's Hospital, Stanford University, Palo Alto, CA (Sandberg)
| | - Amanda L Treece
- Department of Pathology and Laboratory Medicine, Children's Hospital of Alabama, Birmingham, AL (Treece)
| | - Kenneth W Gow
- Division of General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA (Gow)
| | - Richard D Glick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY (Glick)
| | - Andrew M Davidoff
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN (Davidoff)
| | - Nicholas G Cost
- Division of Urology, Department of Surgery, University of Colorado School of Medicine, Surgical Oncology Program, Children's Hospital Colorado, Aurora, CO (Cost)
| | - David B Dix
- Division of Hematology and Oncology, Department of Pediatrics, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada (Dix)
| | - Conrad V Fernandez
- Division of Paediatric Haematology Oncology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia (Fernandez)
| | - Jeffrey S Dome
- Center for Cancer and Blood Disorders, Children's National Hospital, Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC (Dome)
| | - James I Geller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH (Geller)
| | - Elizabeth A Mullen
- Division of Pediatric Hematology and Oncology, Dana-Farber Cancer Institute, Boston, MA (Mullen)
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4
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Kontchou NAT, Amankwah E, Seidu I, Stafman LL, Zhao S, Abrahams AOD, Appeadu-Mensah W, Lovvorn HN, Renner LA. Current Realities of Wilms Tumor Burden and Therapy in Ghana. J Pediatr Surg 2024:S0022-3468(24)00184-2. [PMID: 38589272 DOI: 10.1016/j.jpedsurg.2024.03.032] [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: 02/17/2024] [Accepted: 03/04/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Between 2005 and 2014, Ghana's Wilms tumor (WT) 2-year disease-free survival of 44% trailed behind that of high-income countries. This study aimed to uncover social determinants of health leading to preventable WT death in Ghana. METHODS WT patient records (2014-2022) at Korle-Bu Teaching Hospital (KBTH; Ghana) were reviewed retrospectively. Demographics, clinical course, tumor characteristics, and survival were evaluated using t-tests, Pearson Chi-square, and multivariate Cox logistic regression. RESULTS Of 127 patients identified, 65 were female. Median age was 44 months [IQR 25-66]. Forty-eight patients (38%) presented with distant metastasis (75% lung, 25% liver), which associated with hypoalbuminemia (p = 0.009), caregiver informal employment (p = 0.04), and larger tumors (p = 0.002). Despite neoadjuvant chemotherapy shrinking 84% of tumors, larger initial size associated with incomplete resection (p = 0.046). Of 110 nephrectomies, 31 patients had residual disease, negatively impacting survival (p = 2.7 × 10-5). Twenty-two patients (17%) abandoned treatment (45% before nephrectomy; 55% after nephrectomy), with seven patients ultimately lost to follow-up (LTFU). Decedents represented 43% of stage IV patients compared to 28% in other stages. Event-free survival (EFS) was 60% at 4 years with overall survival (OS) at 67%. CONCLUSIONS Although Ghana's WT survival has improved, informal employment and distance from KBTH predisposed patients to delayed referral, greater tumor burden, hypoalbuminemia, and lower survival. TYPE OF STUDY Prognosis Study. LEVEL OF EVIDENCE II.
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Affiliation(s)
| | | | - Issah Seidu
- University of Ghana Legon, Department of Statistics, Accra, Ghana
| | - Laura L Stafman
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shilin Zhao
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Lorna A Renner
- Department of Pediatric Oncology, Korle-Bu Teaching Hospital, Accra, Ghana
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Naik-Mathuria B, Utria AF, Ehrlich PF, Aldrink JH, Murphy AJ, Lautz T, Dasgupta R, Short SS, Lovvorn HN, Kim ES, Newman E, Lal DR, Rich BS, Piché N, Kastenberg ZJ, Malek MM, Glick RD, Petroze RT, Polites SF, Whitlock R, Alore E, Sutthatarn P, Chen SY, Wong-Michalak S, Romao RLP, Al-Hadidi A, Rubalcava NS, Marquart JP, Gainer H, Johnson M, Boehmer C, Rinehardt H, Seemann NM, Davidson J, Polcz V, Lund SB, McKay KG, Correa H, Rothstein DH. Management and Outcomes of Wilms Tumor With Suprarenal Intravascular Extension: A Pediatric Surgical Oncology Research Collaborative Study. Ann Surg 2024; 279:528-535. [PMID: 37264925 PMCID: PMC10829895 DOI: 10.1097/sla.0000000000005921] [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: 06/03/2023]
Abstract
OBJECTIVE The purpose of this study was to describe management and outcomes from a contemporary cohort of children with Wilms tumor complicated by inferior vena caval thrombus. BACKGROUND The largest series of these patients was published almost 2 decades ago. Since then, neoadjuvant chemotherapy has been commonly used to manage these patients, and outcomes have not been reported. METHODS Retrospective review of 19 North American centers between 2009 and 2019. Patient and disease characteristics, management, and outcomes were investigated and analyzed. RESULTS Of 124 patients, 81% had favorable histology (FH), and 52% were stage IV. IVC thrombus level was infrahepatic in 53 (43%), intrahepatic in 32 (26%), suprahepatic in 14 (11%), and cardiac in 24 (19%). Neoadjuvant chemotherapy using a 3-drug regimen was administered in 82% and postresection radiation in 90%. Thrombus level regression was 45% overall, with suprahepatic level showing the best response (62%). Cardiopulmonary bypass (CPB) was potentially avoided in 67%. The perioperative complication rate was significantly lower after neoadjuvant chemotherapy [(25%) vs upfront surgery (55%); P =0.005]. CPB was not associated with higher complications [CPB (50%) vs no CPB (27%); P =0.08]. Two-year event-free survival was 93% and overall survival was 96%, higher in FH cases (FH 98% vs unfavorable histology/anaplastic 82%; P =0.73). Neither incomplete resection nor viable thrombus cells affected event-free survival or overall survival. CONCLUSIONS Multimodal therapy resulted in excellent outcomes, even with advanced-stage disease and cardiac extension. Neoadjuvant chemotherapy decreased the need for CPB to facilitate resection. Complete thrombectomy may not always be necessary.
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Affiliation(s)
- Bindi Naik-Mathuria
- Department of Surgery, Division of Pediatric Surgery, University of Texas Medical Branch, Galveston, TX
| | - Alan F. Utria
- Department of Surgery, Division of General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Peter F. Ehrlich
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children’s Hospital, The University of Michigan, Ann Arbor, MI
| | - Jennifer H. Aldrink
- Department of Surgery, Division of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Andrew J. Murphy
- Department of Surgery, St. Jude Children’s Research Hospital, Memphis, TN
| | - Timothy Lautz
- Department of Surgery, Division of Pediatric Surgery, Lurie Children’s Hospital, Northwestern School of Medicine, Chicago, IL
| | - Roshni Dasgupta
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Scott S. Short
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Primary Children’s Hospital, Salt Lake City, UT
| | - Harold N. Lovvorn
- Department of Pediatric Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Eugene S. Kim
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Erica Newman
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children’s Hospital, The University of Michigan, Ann Arbor, MI
| | - Dave R. Lal
- Division of Pediatric Surgery, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI
| | - Barrie S. Rich
- Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/
| | - Nelson Piché
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Zachary J. Kastenberg
- Department of Surgery, Division of Pediatric Surgery, University of Utah, Primary Children’s Hospital, Salt Lake City, UT
| | - Marcus M. Malek
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Richard D. Glick
- Division of Pediatric Surgery, Zucker School of Medicine at Hofstra/
| | - Robin T. Petroze
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | | | - Richard Whitlock
- Department of Surgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Elizabeth Alore
- Department of Surgery, Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | | | - Stephanie Y. Chen
- Division of Pediatric Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Shannon Wong-Michalak
- Department of Surgery, Division of Pediatric Surgery, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Rodrigo LP Romao
- Division of Pediatric Surgery and Pediatric Urology, IWK Health, Dalhousie University, Halifax, NS, Canada
| | - Ameer Al-Hadidi
- Department of Surgery, Division of Pediatric Surgery, Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH
| | - Nathan S. Rubalcava
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children’s Hospital, The University of Michigan, Ann Arbor, MI
| | - John P. Marquart
- Division of Pediatric Surgery, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI
| | - Hailey Gainer
- Division of Pediatric Surgery, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI
| | - Mike Johnson
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Chloe Boehmer
- Department of Pediatric General and Thoracic Surgery, Cincinnati Children’s Medical Center, Cincinnati, OH
| | - Hannah Rinehardt
- Division of Pediatric General and Thoracic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Natashia M. Seemann
- Department of Surgery, Division of Pediatric Surgery, Western University, London, ON, Canada
| | - Jacob Davidson
- Department of Surgery, Division of Pediatric Surgery, Western University, London, ON, Canada
| | - Valerie Polcz
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | | | - Katlyn G. McKay
- Department of Pediatric Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Hernan Correa
- Department of Pediatric Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - David H. Rothstein
- Department of Surgery, Division of General and Thoracic Surgery, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
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6
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Scoville SD, Stanek JR, Rinehardt H, Sutthatarn P, Abdelhafeez AH, Talbot LJ, Malek M, Leraas HJ, Tracy ET, Chen SY, Kim ES, Lotakis DM, Ehrlich PF, Favela JG, Le HD, Davidson J, Wilson CA, Seemann NM, Osman Y, Piche N, Hoang V, Petroze RT, Polites SF, McKay KG, Correa H, Lovvorn HN, Lee YM, Balagani A, Dasgupta R, Aldrink JH. Comparison of Outcomes Between Surveillance Ultrasound and Completion Lymph Node Dissection in Children and Adolescents With Sentinel Lymph Node-Positive Cutaneous Melanoma. Ann Surg 2024; 279:536-541. [PMID: 37487006 DOI: 10.1097/sla.0000000000006022] [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] [Indexed: 07/26/2023]
Abstract
OBJECTIVE To determine the impact of nodal basin ultrasound (US) surveillance versus completion lymph node dissection (CLND) in children and adolescents with sentinel lymph node (SLN) positive melanoma. BACKGROUND Treatment for children and adolescents with melanoma are extrapolated from adult trials. However, there is increasing evidence that important clinical and biological differences exist between pediatric and adult melanoma. METHODS Patients ≤18 years diagnosed with cutaneous melanoma between 2010 and 2020 from 14 pediatric hospitals were included. Data extracted included demographics, histopathology, nodal basin strategies, surveillance intervals, and survival information. RESULTS Of 252 patients, 90.1% (n=227) underwent SLN biopsy (SLNB), 50.9% (n=115) had at least 1 positive node. A total of 67 patients underwent CLND with 97.0% (n=65/67) performed after a positive SLNB. In contrast, 46 total patients underwent US observation of nodal basins with 78.3% (n=36/46) of these occurring after positive SLNB. Younger patients were more likely to undergo US surveillance (median age 8.5 y) than CLND (median age 11.3 y; P =0.0103). Overall, 8.9% (n=21/235) experienced disease recurrence: 6 primary, 6 nodal, and 9 distant. There was no difference in recurrence (11.1% vs 18.8%; P =0.28) or death from disease (2.2% vs 9.7%; P =0.36) for those who underwent US versus CLND, respectively. CONCLUSIONS Children and adolescents with cutaneous melanoma frequently have nodal metastases identified by SLN. Recurrence was more common among patients with thicker primary lesions and positive SLN. No significant differences in oncologic outcomes were observed with US surveillance and CLND following the identification of a positive SLN.
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Affiliation(s)
- Steven D Scoville
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | | | - Hannah Rinehardt
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - Lindsay J Talbot
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Marcus Malek
- Department of Surgery, Division of Pediatric Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Harold J Leraas
- Department of Surgery, Duke University Medical Center, Durham, NC
- Duke Children's Hospital and Health Center, Division of Pediatric Surgery, Durham, NC
| | - Elisabeth T Tracy
- Department of Surgery, Duke University Medical Center, Durham, NC
- Duke Children's Hospital and Health Center, Division of Pediatric Surgery, Durham, NC
| | - Stephanie Y Chen
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | - Eugene S Kim
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA
| | | | - Peter F Ehrlich
- Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI
| | - Juan G Favela
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Hau D Le
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, American Family Children's Hospital, Madison, WI
| | - Jacob Davidson
- Children's Hospital at London Health Sciences Centre, Division of Pediatric Surgery, London Ontario, CA
| | - Claire A Wilson
- Children's Hospital at London Health Sciences Centre, Division of Pediatric Surgery, London Ontario, CA
| | - Natashia M Seemann
- Children's Hospital at London Health Sciences Centre, Division of Pediatric Surgery, London Ontario, CA
| | - Yasmin Osman
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Nelson Piche
- Division of Pediatric Surgery, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Cannada
| | - Victoria Hoang
- College of Medicine, University of Florida, Gainesville, FL
| | - Robin T Petroze
- Department of Surgery, Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | | | - Katlyn G McKay
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Hernan Correa
- Division of Pediatric Pathology, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N Lovvorn
- Division of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Yu M Lee
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Akshitha Balagani
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rohni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Department of Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
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Papastefan ST, Zeineddin S, Blakely ML, Lovvorn HN, Huang LW, Raval MV, Lautz TB. Association of Prophylactic Antibiotics With Early Infectious Complications in Children With Cancer Undergoing Central Venous Access Device Placement. Ann Surg 2023:00000658-990000000-00686. [PMID: 37870252 DOI: 10.1097/sla.0000000000006140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
OBJECTIVE To evaluate the impact of prophylactic antibiotics on early infectious complications after central venous access device (VAD) placement in children with cancer. SUMMARY OF BACKGROUND DATA Despite the frequency of VAD procedures in children, the effectiveness of prophylactic antibiotics for reducing infectious complications is unknown. METHODS This was a retrospective cohort study of children with cancer undergoing central VAD placement identified in the Pediatric Health Information System database between 2017-2021. The primary outcome was the rate of early infectious complications (composite surgical site infections, central line-associated bloodstream infections, and bacteremia). Multivariable logistic regression was used to evaluate factors associated with early infection, and heterogeneity of treatment effect of prophylactic antibiotics was compared across subgroups. RESULTS 9,216 patients were included (6,058 ports and 3,158 tunneled lines). Prophylactic antibiotics were associated with lower early infectious complications overall (1.3% vs. 2.4%; OR 0.55 [95% C.I. 0.39-0.79], P<0.001), an effect demonstrated for tunneled lines (OR 0.59, 95% C.I.: 0.41-0.84) but not ports (OR 3.01, 95% C.I.: 0.66-13.78). On multivariate analysis, prophylactic antibiotics (OR 0.67, 95% C.I.: 0.45-0.97) and solid tumors (OR 0.38, 95% C.I.: 0.22-0.64) were associated with reduced odds of early infections, while tunneled lines (OR 20.78, 95% C.I.: 9.83-43.93) and acute myelogenous leukemia (OR 2.37, 95% C.I.: 1.58-3.57) had increased odds. CONCLUSIONS Prophylactic antibiotics are associated with reduced early infectious complications after central VAD placement overall. Despite recommendations from multiple national organizations against prophylactic antibiotics, these findings suggest a benefit in children with malignancy undergoing tunneled line placement.
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Affiliation(s)
- Steven T Papastefan
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Suhail Zeineddin
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Martin L Blakely
- Department of Surgery, Center for Clinical Research and Evidence Based Medicine, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX
| | - Harold N Lovvorn
- Department of Surgery, Center for Clinical Research and Evidence Based Medicine, Institute for Implementation Science, University of Texas Health Science Center at Houston, Houston, TX
| | - Lynn Wei Huang
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Mehul V Raval
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- Northwestern Quality Improvement, Research, & Education in Surgery (NQUIRES), Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Timothy B Lautz
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Wallace MW, Niec JA, Mirza MB, Achey MA, Oros J, Danko ME, Hilmes MA, Hatch LD, Morris EA, Lovvorn HN. Enteric tube position on preoperative radiographs predicts clinical outcomes in neonatal congenital diaphragmatic hernia with and without prenatal diagnosis. J Perinatol 2023; 43:1131-1138. [PMID: 37391509 DOI: 10.1038/s41372-023-01712-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 07/02/2023]
Abstract
OBJECTIVE Congenital Diaphragmatic Hernia (CDH) is diagnosed prenatally in ~60% of cases. Prenatal measures typically guide management and prognostication. Simple postnatal prognosticators are needed when prenatal diagnosis is lacking. We hypothesized that preoperative orogastric tube (OGT) tip position relative to the contralateral diaphragm correlates with defect severity, resource utilization, and clinical outcomes regardless of diagnostic status. STUDY DESIGN 150 neonates with left-posterolateral CDH were analyzed. Impact of intrathoracic and intraabdominal preoperative tip position on clinical outcomes was compared. RESULTS Ninety-nine neonates were prenatally diagnosed. Overall, intrathoracic position significantly correlated with larger diaphragmatic defects, advanced postnatal pulmonary support requirements (HFOV, pulmonary vasodilators, and ECMO), operative complexity, longer hospitalization, and poorer survival to discharge. These observations persisted when analyzing only cases lacking prenatal diagnosis. CONCLUSIONS Preoperative OGT tip position predicts defect severity, resource utilization, and outcomes in CDH. This observation enhances postnatal prognostication and care planning for neonates without a prenatal diagnosis.
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Affiliation(s)
| | - Jan A Niec
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Muhammad B Mirza
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Meredith A Achey
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Joseph Oros
- Department of Radiology, Children's Hospital at Erlanger, Chattanooga, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa A Hilmes
- Division of Pediatric Radiology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - L Dupree Hatch
- Division of Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Morris
- Division of Neonatology, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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9
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Mina AS, Nashed GN, Hermina AM, Schauwecker SM, Phelps HM, Benedetti DJ, Correa H, Lovvorn HN. Outcomes and Histological Variations of Neuroblastoma and Ganglioneuroblastoma with Paraneoplastic Syndromes. Am Surg 2023; 89:3745-3750. [PMID: 37150742 DOI: 10.1177/00031348231175112] [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: 05/09/2023]
Abstract
BACKGROUND Neuroblastomas are the most common extracranial solid malignancy in children with variable manifestations and complications depending on the presence of paraneoplastic syndromes. MATERIALS AND METHODS We performed a single institution retrospective cohort study of all patients less than 18 years old diagnosed with neuroblastoma or ganglioneuroblastoma between January 2002 and July 2022. Patients were identified through the pathology and cancer registry and cross-referenced with pediatric records. Patient demographics, clinical presentation, treatment, and outcomes were collected. A univariate descriptive analysis of the collected data was conducted. RESULTS In our study period, 130 children were diagnosed with neuroblastoma, and 15 were diagnosed with ganglioneuroblastoma. There were 12 children with a paraneoplastic syndrome identified, 8 with NBL and 4 with ganglioneuroblastoma (GNBL). The average age at diagnosis was 22 months. All but 1 underwent resection prior to treatment of paraneoplastic syndrome, and 4 children required neoadjuvant therapy. Neurological complications were the most common with 10 children (83%). The average time from symptom onset to diagnosis was 0.7 months. Eight children had complete resolution of their symptoms after treatment and resection, 2 children recently started treatment within a year, 1 had partial resolution, and 1 died during treatment. The presence of tumor-infiltrating lymphocytes occurred in 4 children with neurologic paraneoplastic syndromes. Six children had neuropil rich tumors. CONCLUSION The histological profile of paraneoplastic syndromes of neuroblastoma and ganglioneuroblastoma and their treatment across a single institution can be highly variable. The presence of tumor-infiltrating lymphocytes and neuropil may have an impact on paraneoplastic pathology.
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Affiliation(s)
- Alexander S Mina
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gloria N Nashed
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Andrew M Hermina
- Department of Pathology, The University of Chicago, Chicago, IL, USA
| | | | - Hannah M Phelps
- Department of Surgery, Washington University School of Medicine, St Louis, MO, USA
| | - Daniel J Benedetti
- Department of Pediatrics, Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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10
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Wallace MW, Niec JA, Ghani MOA, McKay KG, Idrees K, Liang J, Borinstein SC, Lovvorn HN. Distribution and Surgical Management of Visceral Ewing Sarcoma Among Children and Adolescents. J Pediatr Surg 2023; 58:1727-1735. [PMID: 36774201 DOI: 10.1016/j.jpedsurg.2023.01.006] [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: 11/29/2022] [Revised: 12/21/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Ewing sarcoma (EWS) is a highly malignant tumor of bone and soft tissue that occasionally arises from viscera. Visceral EWS (V-EWS) is challenging to manage given its varied organ distribution and often late-stage presentation. We aimed to characterize our institutional experience with V-EWS, focusing on its surgical management, and to compare V-EWS outcomes against those with osseous (O-EWS) and soft tissue EWS (ST-EWS). METHODS Retrospective review of all EWS patients ≤21 years presenting to a single institution between 2000 and 2022. Patient- and disease-specific characteristics were compared. Overall and relapse-free survival were estimated using Kaplan Meier methods and log-rank test. RESULTS 156 EWS patients were identified: 117 O-EWS, 20 ST-EWS, and 19 V-EWS. V-EWS arose in the kidney (n = 5), lung (n = 5), intestine (n = 2), esophagus (n = 1), liver (n = 1), pancreas (n = 1), adrenal gland (n = 1), vagina (n = 1), brain (n = 1), and spinal cord (n = 1). No significant demographic differences were detected between EWS groups. V-EWS was more frequently metastatic at presentation (63.2%; p = 0.005), yet no significant overall or relapse-free survival differences emerged between EWS groups, with similar follow-up intervals. While V-EWS required multiple unique operative strategies to gain primary control, no significant difference in treatment strategies appeared between groups. Surgery-only primary control was associated with improved overall and relapse-free survival in all groups. CONCLUSIONS V-EWS presents unique management challenges in children and adolescents given its variable sites of origin. This large cohort is the first to describe the surgical management and outcomes of V-EWS, demonstrating more frequent metastatic presentation, while achieving similar survival across groups. LEVEL OF EVIDENCE Level 2 - Cohort Study.
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Affiliation(s)
| | - Jan A Niec
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Katlyn G McKay
- Department of General Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kamran Idrees
- Division of Surgical Oncology and Endocrine Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jiancong Liang
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C Borinstein
- Division of Pediatric Hematology-Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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McKay KG, Ghani MO, Henry C, Pruthi S, Benedetti D, Friedman D, Lovvorn HN, Zamora IJ. 3D printed model aiding in minimally invasive ganglioneuroblastoma resection: A case report. Journal of Pediatric Surgery Case Reports 2023. [DOI: 10.1016/j.epsc.2023.102630] [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: 04/04/2023] Open
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12
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Light-Olson H, Niec JA, Zwaschka TA, Wong G, Ragheb D, Oros J, Correa H, Lopez ME, Stafman LL, Lovvorn HN. Minimally invasive adnexa-sparing surgery for benign ovarian and paratubal masses in children. J Pediatr Surg 2023; 58:702-707. [PMID: 36670003 DOI: 10.1016/j.jpedsurg.2022.12.021] [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: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The precision of minimally invasive surgery (MIS) to resect benign ovarian and paratubal masses while preserving adnexa in children is unclear. This study evaluated the integrity of laparoscopy to spare adnexa while resecting benign pathologies in children. METHODS The institutional pathology database was queried to identify patients aged 18 years and younger having any ovarian or tubal lesion resected at a comprehensive children's hospital between 2006 and 2021. Adnexa-sparing surgery was defined as preserving both the ovary and tube from which the lesion was resected. Postoperative ultrasounds were reviewed to document ovarian follicles, blood flow, volumes, and lesion recurrence. RESULTS Adnexal preservation was implemented in 168 of 328 pathological resections. MIS approach was used in 149 cases. Median age was 13.4 [11.0-15.3]. Among sparing surgeries, MIS associated with benign pathology, shorter operative time (median minutes: 78 MIS [59-111.5]; 130 open [92.8-149.8]; 174 MIS-to-open [132.8-199.5]; p = 0.010), and reduced hospital stay (median days: 1 MIS (Lindfors, 1971; Lovvorn III et al., 1998) [1-2]; 2 open [2-2.9], 2 MIS-to-open [1-3.3]; p = 0.001). Postoperative ovarian volume ipsilateral to the MIS procedure (median, 7.6 ml [4.3-12.1]) was relatively smaller than the contralateral ovary (median, 9.1 ml [5.5-15.0]). Blood flow was documented to the ovary in 70/94 (74.4%) of patients after MIS adnexal-sparing surgery. Distinct follicles were detected in 48/74 (64.8%) of post-menarchal patients after MIS adnexal-sparing surgery. Five ovarian cysts recurred. CONCLUSIONS MIS preserves adnexa reliably, with postoperative ovarian follicles and blood flow detected in most patients, and maintains ∼80% of contralateral volume, while achieving definitive tumor resection. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Hannah Light-Olson
- Vanderbilt University School of Medicine, 1161 21st Ave S #D300, Nashville, TN, 37232, United States.
| | - Jan A Niec
- Vanderbilt University School of Medicine, 1161 21st Ave S #D300, Nashville, TN, 37232, United States
| | - Theresa A Zwaschka
- Vanderbilt University School of Medicine, 1161 21st Ave S #D300, Nashville, TN, 37232, United States
| | - Gunther Wong
- Vanderbilt University School of Medicine, 1161 21st Ave S #D300, Nashville, TN, 37232, United States
| | - Daniel Ragheb
- Vanderbilt University School of Medicine, 1161 21st Ave S #D300, Nashville, TN, 37232, United States
| | - Joseph Oros
- Division of Pediatric Radiology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, 1211 Medical Center Drive, Nashville, TN, 37232, United States
| | - Hernan Correa
- Division of Pediatric Pathology, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, 1211 Medical Center Drive, Nashville, TN, 37232, United States
| | - Monica E Lopez
- Department of Pediatric Surgery, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, 1211 Medical Center Drive, Nashville, TN, 37232, United States
| | - Laura L Stafman
- Department of Pediatric Surgery, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, 1211 Medical Center Drive, Nashville, TN, 37232, United States
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, 1211 Medical Center Drive, Nashville, TN, 37232, United States
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Wojcik HM, Lovvorn HN, Hollingshead M, Pierce J, Stotler H, Murphy AJ, Borgel S, Phelps HM, Correa H, Perantoni AO. Exploiting embryonic niche conditions to grow Wilms tumor blastema in culture. Front Oncol 2023; 13:1091274. [PMID: 37007076 PMCID: PMC10061139 DOI: 10.3389/fonc.2023.1091274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 02/27/2023] [Indexed: 03/18/2023] Open
Abstract
IntroductionWilms Tumor (WT), or nephroblastoma, is the most common pediatric kidney cancer. Most WTs display a “favorable” triphasic histology, in which the tumor is comprised of blastemal, stromal, and epithelial cell types. Blastemal predominance after neoadjuvant chemotherapy or diffuse anaplasia (“unfavorable” histology; 5-8%) portend a worse prognosis. Blastema likely provide the putative cancer stem cells (CSCs), which retain molecular and histologic features characteristic of nephron progenitor cells (NPCs), within WTs. NPCs arise in the metanephric mesenchyme (MM) and populate the cap mesenchyme (CM) in the developing kidney. WT blastemal cells, like NPCs, similarly express markers, SIX2 and CITED1. Tumor xenotransplantation is currently the only dependable method to propagate tumor tissue for research or therapeutic screening, since efforts to culture tumors in vitro as monolayers have invariably failed. Therefore, a critical need exists to propagate WT stem cells rapidly and efficiently for high-throughput, real-time drug screening.MethodsPreviously, our lab developed niche conditions that support the propagation of murine NPCs in culture. Applying similar conditions to WTs, we assessed our ability to maintain key NPC "stemness" markers, SIX2, NCAM, and YAP1, and CSC marker ALDHI in cells from five distinct untreated patient tumors.ResultsAccordingly, our culture conditions maintained the expression of these markers in cultured WT cells through multiple passages of rapidly dividing cells.DiscussionThese findings suggest that our culture conditions sustain the WT blastemal population, as previously shown for normal NPCs. As a result, we have developed new WT cell lines and a multi-passage in vitro model for studying the blastemal lineage/CSCs in WTs. Furthermore, this system supports growth of heterogeneous WT cells, upon which potential drug therapies could be tested for efficacy and resistance.
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Affiliation(s)
- Heather M. Wojcik
- Cancer and Developmental Biology Laboratory, National Cancer Institute, Frederick, MD, United States
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, TN, United States
| | - Melinda Hollingshead
- Biological Testing Branch/Developmental Therapeutics Program, National Cancer Institute, Frederick, MD, United States
| | - Janene Pierce
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, TN, United States
| | - Howard Stotler
- Leidos Biomedical Research, National Cancer Institute at Frederick, Frederick, MD, United States
| | - Andrew J. Murphy
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, TN, United States
| | - Suzanne Borgel
- Leidos Biomedical Research, National Cancer Institute at Frederick, Frederick, MD, United States
| | - Hannah M. Phelps
- Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, TN, United States
| | - Hernan Correa
- Division of Pediatric Pathology, Monroe Carell Jr. Children’s Hospital at Vanderbilt University, Nashville, TN, United States
| | - Alan O. Perantoni
- Cancer and Developmental Biology Laboratory, National Cancer Institute, Frederick, MD, United States
- *Correspondence: Alan O. Perantoni,
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Evans LL, Chen CS, Muensterer OJ, Sahlabadi M, Lovvorn HN, Novotny NM, Upperman JS, Martinez JA, Bruzoni M, Dunn JCY, Harrison MR, Fuchs JR, Zamora IJ. The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia. J Pediatr Surg 2022; 57:810-818. [PMID: 35760639 DOI: 10.1016/j.jpedsurg.2022.05.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 01/14/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions. OPERATIVE TECHNIQUE Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device. OUTCOMES Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy. CONCLUSION The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.
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Affiliation(s)
- Lauren L Evans
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Caressa S Chen
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Oliver J Muensterer
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, LMU Munich, Lindwurmstrasse 4, 80337 Munich, Germany
| | - Mohammad Sahlabadi
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA
| | - Nathan M Novotny
- Section of Pediatric Surgery, Beaumont Children's, 3535W. 13 Mile Road, Royal Oak, MI 48073 USA
| | - Jeffrey S Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA
| | - J Andres Martinez
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, 2200 Children's Way, Nashville TN 37232 USA
| | - Matias Bruzoni
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - James C Y Dunn
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Michael R Harrison
- Department of Pediatric Surgery, University of California San Francisco, 550 16th Street Box 0570, San Francisco, CA 94143 USA
| | - Julie R Fuchs
- Division of Pediatric Surgery, Stanford University School of Medicine, 453 Quarry Road, Palo Alto, CA 94304 USA
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way 7th Floor, Nashville TN 37212 USA.
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Hanna DN, Haddadin Z, Stafman L, Godfrey CM, Huang EY, Aiello B, Greeno AL, Unni P, Lovvorn HN. Sledding while towed behind motorized vehicles associates with more severe and lethal injuries ☆. J Pediatr Surg 2022; 57:644-648. [PMID: 35396085 DOI: 10.1016/j.jpedsurg.2022.03.011] [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: 12/08/2021] [Revised: 02/14/2022] [Accepted: 03/10/2022] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Our institution has recently experienced an increase in sledding-related injuries, particularly when towed behind motorized vehicles. The purpose of this study was to characterize injury severity and clinical outcomes between pediatric patients who sustain injuries owing to motorized sledding accidents to aid in injury prevention messaging. METHODS This retrospective study queried all patients who presented with a sledding-related injury to a single ACS-verified Level 1 Pediatric Trauma Center located in the Southeastern United States between 01/2015 and 01/2022. Demographics, injury details, and clinical outcomes were compared between two groups: patients towed behind a motorized vehicle (MOTOR) and those who were not (GRAVITY). RESULTS Of the 67 patients included in our analysis, 15 (22%) were in the MOTOR group. Patients in the MOTOR group presented with significantly higher injury severity (ISS) and lower Glasgow coma scale (GCS) scores. Additionally, patients in this MOTOR group more often received a blood transfusion and intubation, had longer intensive care and overall hospital lengths of stay, and incurred higher hospital costs. In a multivariate analysis, the use of a motorized vehicle to sled was independently associated with increased ISS (OR: 9.7, 95% CI 1.9-17.5; p = 0.02). Two deaths occurred after sledding while being towed behind a motorized vehicle. CONCLUSION Children experiencing sledding accidents while being towed by motorized vehicles sustain significantly more severe injuries and require more intensive treatments that together lead to increased hospital costs. These findings provide the framework for community educational initiatives and injury prevention measures to mitigate risk among children engaged in sledding. LEVEL OF EVIDENCE IV retrospective cohort study.
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Affiliation(s)
- David N Hanna
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States.
| | - Zaid Haddadin
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Laura Stafman
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Caroline M Godfrey
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Eunice Y Huang
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Brittney Aiello
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Amber L Greeno
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Purnima Unni
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
| | - Harold N Lovvorn
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Doctor's Office Tower, 2220 Children's Way, Nashville, TN 37232, United States
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16
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Baird R, Puligandla P, Lopushinsky S, Blackmore C, Krishnaswami S, Nwomeh B, Downard C, Ponsky T, Ghani MO, Lovvorn HN. Virtual curriculum delivery in the COVID-19 era: the pediatric surgery boot camp v2.0. Pediatr Surg Int 2022; 38:1385-1390. [PMID: 35809106 PMCID: PMC9455938 DOI: 10.1007/s00383-022-05156-5] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/12/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE We evaluated the impact of a virtual Pediatric Surgery Bootcamp curriculum on resource utilization, learner engagement, knowledge retention, and stakeholder satisfaction. METHODS A virtual curriculum was developed around Pediatric Surgery Milestones. GlobalCastMD delivered pre-recorded and live content over a single 10-h day with a concluding social hour. Metrics of learner engagement, faculty interaction, knowledge retention, and satisfaction were collected and analyzed during and after the course. RESULTS Of 56 PS residencies, 31 registered (55.4%; 8/8 Canadian and 23/48 US; p = 0.006), including 42 learners overall. The virtual BC budget was $15,500 (USD), 54% of the anticipated in-person course. Pre- and post-tests were administered, revealing significant knowledge improvement (48.6% [286/589] vs 66.9% [89/133] p < 0.0002). Learner surveys (n = 14) suggested the virtual BC facilitated fellowship transition (85%) and strengthened peer-group camaraderie (69%), but in-person events were still favored (77%). Program Directors (PD) were surveyed, and respondents (n = 22) also favored in-person events (61%). PDs not registering their learners (n = 7) perceived insufficient value-added and concern for excessive participants. CONCLUSIONS The virtual bootcamp format reduced overall expenses, interfered less with schedules, achieved more inclusive reach, and facilitated content archiving. Despite these advantages, learners and program directors still favored in-person education. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Robert Baird
- Department of Pediatric Surgery, BC Children’s Hospital University of British Colombia, Ambulatory Care Bldg, K0-134, 4480 Oak Street, Vancouver, BC V6H 3V4 Canada
| | - Pramod Puligandla
- Department of Pediatric Surgery, Montreal Children’s Hospital, McGill University, Montreal, CA Canada
| | - Steven Lopushinsky
- Section of Pediatric Surgery, Alberta Children’s Hospital, University of Calgary, Calgary, CA Canada
| | - Christopher Blackmore
- Division of Pediatric General and Thoracic Surgery, IWK Health Centre, Dalhousie University, Halifax, NS Canada
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Doernbecher Children’s Hospital, Oregon Health and Science University, Portland, OR USA
| | - Benedict Nwomeh
- Department of Pediatric Surgery, Nationwide Children’s Hospital, Ohio State University, Columbus, OH USA
| | - Cynthia Downard
- Division of Pediatric Surgery, Hiram C Polk, Jr, MD Department of Surgery, University of Louisville, Norton Children’s Hospital, Louisville, KY USA
| | - Todd Ponsky
- Division of Pediatric Surgery, Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, OH USA
| | - Muhammad O. Ghani
- Department of Pediatric Surgery, Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN USA
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Monroe Carell, Jr. Children’s Hospital at Vanderbilt, Nashville, TN USA
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17
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Allen JH, Yengo-Kahn AM, Cools MJ, Greeno A, Ghani MOA, Unni P, Martus JE, Lovvorn HN, Bonfield CM. Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019. J Neurosurg Pediatr 2022; 30:386-393. [PMID: 35962971 DOI: 10.3171/2022.7.peds22178] [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: 05/07/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.
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Affiliation(s)
| | | | | | - Amber Greeno
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | | | - Purnima Unni
- 3Pediatric Surgery, Vanderbilt University Medical Center; and
| | - Jeffrey E Martus
- 4Department of Orthopedic Surgery, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital, Nashville, Tennessee
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18
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Reynolds RA, Kelly KA, Ahluwalia R, Zhao S, Vance EH, Lovvorn HN, Hanson H, Shannon CN, Bonfield CM. Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center. J Neurosurg Pediatr 2022; 30:255-262. [PMID: 35901741 DOI: 10.3171/2022.6.peds227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 01/05/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. METHODS Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. RESULTS The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. CONCLUSIONS Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine A Kelly
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ranbir Ahluwalia
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Shilin Zhao
- 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville
| | - E Haley Vance
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- 5Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville; and
| | - Holly Hanson
- 6Department of Pediatrics, Division of Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Al-Hadidi A, Rinehardt HN, Sutthatarn P, Talbot LJ, Murphy AJ, Whitlock R, Condon S, Naik-Mathuria B, Utria AF, Rothstein DH, Chen SY, Wong-Michalak S, Kim ES, Short SS, Meyers RL, Kastenberg ZJ, Johnston ME, Zens T, Dasgupta R, Malek MM, Calabro K, Piché N, Callas H, Lautz TB, McKay K, Lovvorn HN, Commander SJ, Tracy ET, Lund SB, Polites SF, Davidson J, Dhooma J, Seemann NM, Marquart JP, Gainer H, Lal DR, Rich BS, Glick RD, Maloney L, Radu S, Fialkowski EA, Kwok PE, Romao RL, Rubalcava N, Ehrlich PF, Newman E, Diehl T, Le HD, Polcz V, Petroze RT, Stanek J, Aldrink JH. Incidence and Management of Pleural Effusions in Patients with Wilms Tumor: A Pediatric Surgical Oncology Research Collaborative Study. Int J Cancer 2022; 151:1696-1702. [PMID: 35748343 DOI: 10.1002/ijc.34188] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/28/2021] [Revised: 02/11/2022] [Accepted: 03/24/2022] [Indexed: 11/10/2022]
Abstract
Wilms tumor (WT) is the most common renal malignancy in children. Children with favorable histology WT achieve survival rates of over 90%. Twelve percent of patients present with metastatic disease, most commonly to the lungs. The presence of a pleural effusion at the time of diagnosis of WT may be noted on staging imaging; however, minimal data exist regarding the significance and prognostic importance of this finding. The objectives of this study are to identify the incidence of pleural effusions in patients with WT, and to determine the potential impact on oncologic outcomes. A multi-institutional retrospective review was performed from January 2009 to December 2019, including children with WT and a pleural effusion on diagnostic imaging treated at Pediatric Surgical Oncology Research Collaborative (PSORC) participating institutions. Of 1,259 children with a new WT diagnosis, 94 (7.5%) had a pleural effusion. Patients with a pleural effusion were older than those without (median 4.3 vs 3.5 years; p=0.004), and advanced stages were more common (local stage III 85.9% vs 51.9%; p<0.0001). Only 14 patients underwent a thoracentesis for fluid evaluation; 3 had cytopathologic evidence of malignant cells. Event-free and overall survival of all children with WT and pleural effusions was 86.2% and 91.5%, respectively. The rate and significance of malignant cells present in pleural fluid is unknown due to low incidence of cytopathologic analysis in our cohort; therefore, the presence of an effusion does not appear to necessitate a change in therapy. Excellent survival can be expected with current stage-specific treatment regimens.
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Affiliation(s)
- Ameer Al-Hadidi
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Hannah N Rinehardt
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Lindsay J Talbot
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Andrew J Murphy
- Department of Surgery, St. Jude Children's Research Hospital, Memphis, TN
| | - Richard Whitlock
- Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Sienna Condon
- Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Bindi Naik-Mathuria
- Division of Pediatric Surgery, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Alan F Utria
- Seattle Children's Hospital, University of Washington, Seattle, WA
| | | | - Stephanie Y Chen
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California
| | - Shannon Wong-Michalak
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California
| | - Eugene S Kim
- Division of Pediatric Surgery, Department of Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California
| | - Scott S Short
- Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | - Rebecka L Meyers
- Primary Children's Hospital, University of Utah, Salt Lake City, UT
| | | | - Michael E Johnston
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH
| | - Tiffany Zens
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH
| | - Marcus M Malek
- Division of Pediatric General and Thoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kristen Calabro
- Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Qc, Canada
| | - Nelson Piché
- Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Qc, Canada
| | - Hannah Callas
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - Timothy B Lautz
- Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
| | - Katlyn McKay
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sarah Jane Commander
- Department of Surgery, Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | - Elisabeth T Tracy
- Department of Surgery, Division of Pediatric Surgery, Duke University Medical Center, Durham, NC
| | - Sarah B Lund
- Department of Surgery, Mayo Clinic, Rochester, MN
| | | | - Jacob Davidson
- Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Janel Dhooma
- Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Natashia M Seemann
- Department of Surgery, Division of Paediatric Surgery, Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - John P Marquart
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Haley Gainer
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Barrie S Rich
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
| | - Richard D Glick
- Division of Pediatric Surgery, Cohen Children's Medical Center, Northwell Health, New Hyde Park, NY
| | - Lauren Maloney
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, OR
| | - Stephani Radu
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, OR
| | - Elizabeth A Fialkowski
- Department of Surgery, Division of Pediatric Surgery, Oregon Health and Science University, Portland, OR
| | - Pei En Kwok
- Departments of Surgery and Urology, IWK Health, Dalhousie University, Halifax, NS, Canada
| | - Rodrigo Lp Romao
- Departments of Surgery and Urology, IWK Health, Dalhousie University, Halifax, NS, Canada
| | - Nathan Rubalcava
- University of Michigan Section of Pediatric Surgery, Ann Arbor, MI
| | - Peter F Ehrlich
- University of Michigan Section of Pediatric Surgery, Ann Arbor, MI
| | - Erika Newman
- University of Michigan Section of Pediatric Surgery, Ann Arbor, MI
| | - Thomas Diehl
- American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Hau D Le
- American Family Children's Hospital, University of Wisconsin-Madison, Madison, WI
| | - Valerie Polcz
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Robin T Petroze
- Division of Pediatric Surgery, University of Florida, Gainesville, FL
| | - Joseph Stanek
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Jennifer H Aldrink
- Department of Surgery, Division of Pediatric Surgery, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
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von Beck K, Robinson T, Nguyen CN, Perez TH, Olson J, Lovvorn HN, Baron CM, Zamora IJ. Use of a self-expanding metal stent to treat acute esophageal perforation in a 4-year-old child. Journal of Pediatric Surgery Case Reports 2022. [DOI: 10.1016/j.epsc.2022.102295] [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: 11/29/2022] Open
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21
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Hanna DN, McKay KG, Ghani MO, Correa H, Zamora IJ, Lovvorn HN. Elective choledochal cyst excision is associated with improved postoperative outcomes in children. Pediatr Surg Int 2022; 38:817-824. [PMID: 35338382 DOI: 10.1007/s00383-022-05108-z] [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] [Accepted: 02/27/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The majority of pediatric patients with choledochal cysts (CDC) are symptomatic prior to undergoing CDC excision. This study investigated the impact of surgical timing of CDC excision on postoperative outcomes among children. METHODS We performed a retrospective review of 59 patients undergoing open CDC excision with Roux-Y hepaticojejunostomy between 2000 and 2020. Patients were grouped based on whether they underwent an electively scheduled or urgent CDC excision, as defined as CDC excision within the same admission due to CDC-related symptoms. Patient characteristics and perioperative data were compared between the two groups. RESULTS Patients who underwent an elective surgery were older, had more Todani-type 1 CDC, and had decreased postoperative hospital length of stay and opioid use compared to patients who underwent CDC excision within the same admission due to CDC-related symptoms. No significant differences emerged regarding postoperative complications. Multivariable analysis showed that elective cyst excision (HR = 0.55, p = 0.04; HR = 0.59, p = 0.008) and type 1 CDC (HR = 0.32, p = 0.03; HR = 0.12, p < 0.001) were independently associated with decreased opioid use and postoperative hospital length of stay. CONCLUSIONS Elective CDC excision is associated with shortened hospital stay and decreased opioid use among children compared to patients who undergo a CDC excision during the same admission for CDC-related symptoms.
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Affiliation(s)
- David N Hanna
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Katlyn G McKay
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Muhammad O Ghani
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irving J Zamora
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Section of Surgical Sciences, Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA. .,Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt Nashville, Doctor's Office Tower 2220 Children's Way, Nashville, TN, 37232, USA.
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22
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McKay KG, Hanna DN, Martin L, Datye KA, Crane GL, Correa H, Lovvorn HN, Solorzano CC, Zamora IJ. Intraoperative Ultrasound Guided Laparoscopic Spleen-Preserving Distal Pancreatectomy for Primitive Neuroendocrine Tumors in a Pediatric Patient with MEN-1. Am Surg 2022; 88:2241-2243. [PMID: 35471864 DOI: 10.1177/00031348221093802] [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: 11/17/2022]
Abstract
This case details the presentation and surgical management of a 15-year-old male patient with multiple endocrine neoplasia syndrome type 1 (MEN1) who required distal pancreatectomy for multiple nonfunctional pancreatic tumors. An intraoperative ultrasound was utilized to allow for proper location of the distal pancreatectomy, as well as visualization of the splenic vessel relationships and to ensure all lesions were contained within the specimen. Pathology demonstrated 5 well-differentiated neuroendocrine tumors with no evidence of malignancy. This case utilized innovative technology and a multidisciplinary approach in a challenging case to achieve a safe minimally invasive resection. The use of ultrasound intraoperatively provided confidence that all lesions had been identified, as well as demonstration of safe planes separate from the nearby vasculature.
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Affiliation(s)
- Katlyn G McKay
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - David N Hanna
- Section of Surgical Sciences, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura Martin
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Karishma A Datye
- Division of Pediatric Endocrinology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gabriella L Crane
- Division of Pediatric Radiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Division of Pediatric Pathology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carmen C Solorzano
- Division of Surgical Oncology and Endocrine Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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Patel AD, D'Cruz R, Olson J, Lucas M, Baron CM, Novotny NM, Zamora IJ, Lovvorn HN. Endoluminal Silicone-Covered Stenting in Children: Novel Applications and Lessons Learned. Am Surg 2022; 88:1557-1560. [PMID: 35442816 DOI: 10.1177/00031348221083950] [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: 11/15/2022]
Abstract
BACKGROUND Silicone-covered endoluminal stents have been applied to various hollow visceral disorders in adult patients with varying success. Efficacy of retrievable endoluminal stenting in children is less well-established. PURPOSE The purpose of this study was to evaluate our experience with evolving applications of endoluminal silicone-covered stenting in children. RESEARCH DESIGN Eight children 19 years and younger having silicone-covered stent placement for various indications at a single institution (2014-2021) were reviewed retrospectively. RESULTS Eight patients received a total of 26 silicone-covered stents. Four stent placements (15.4%) were associated with a direct adverse event. To resolve the endoluminal disorder, four patients received multiple stents or further intervention. When evaluating novel applications, clinical benefit was noted for one patient with vaginal atresia, and another after ileal pouch anal anastomosis disruption. CONCLUSION This experience highlights the broad and innovative applications for endoluminal silicone-covered natural orifice stenting in children. Acute processes respond well and rapidly to stenting, although chronic, established fistula may require additional manipulations or surgery.
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Affiliation(s)
- Anuradha D Patel
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Roshan D'Cruz
- Department of Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jacob Olson
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Matthew Lucas
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Chris M Baron
- Department of Interventional Radiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathan M Novotny
- Department of Pediatric Surgery, 7005Beaumont Hospital, Royal Oak, MI, USA
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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24
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Niec JA, Achey MA, Wallace MW, Patel A, Zhao S, Hatch LD, Morris EA, Danko ME, Pietsch JB, Lovvorn HN. Congenital Diaphragmatic Hernia Repair at the Bedside or Operating Theater. Am Surg 2022; 88:1814-1821. [PMID: 35337188 DOI: 10.1177/00031348221084941] [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: 11/17/2022]
Abstract
BACKGROUND For critically ill congenital diaphragmatic hernia (CDH) patients on high frequency oscillatory ventilation (HFOV), extracorporeal membrane oxygenation (ECMO), and/or inhaled nitric oxide (iNO), operative repair in the neonatal intensive care unit (NICU) has been proposed to avoid complications during transport to an operating room (OR). This study compared neonates with CDH who received herniorrhaphy in the NICU or OR, with a subgroup analysis considering only patients supported with ECMO. METHODS Patients admitted to the NICU in the first 2 weeks of life at a free-standing children's hospital between July 2004 and September 2021 were examined. Patients were categorized according to location of CDH repair, and impact on operative complications and survival was compared. RESULTS 185 patients were admitted to the NICU with posterolateral CDH and received operative repair. 48 cases were operated on at the bedside in the NICU and 137 in the OR. Patients repaired in the NICU had higher use of HFOV, pulmonary vasodilators, and ECMO (all P < .001). Children repaired in the NICU experienced significantly higher in-hospital death and overall mortality (P < .001). However, in multivariate analysis, repair location was not a significant predictor of survival to discharge in patients receiving ECMO. No significant difference in surgical site infection was detected for operative location (P = .773). DISCUSSION Congenital diaphragmatic hernia repair in the NICU occurred more frequently among higher risk patients who experienced worse survival. The rate of surgical site infection appeared similar overall and across subgroups suggesting adequate sterility and technique for bedside procedures, when necessary, despite restricted access to advanced operative equipment.
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Affiliation(s)
- Jan A Niec
- 12327Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Meredith A Achey
- Department of Surgery, 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Anuradha Patel
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Shilin Zhao
- Department of Biostatistics, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - L Dupree Hatch
- Division of Neonatology, Department of Pediatrics, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Emily A Morris
- Division of Neonatology, Department of Pediatrics, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa E Danko
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - John B Pietsch
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Haddadin Z, Halasa N, McHenry R, Varjabedian R, Lynch TL, Chen H, Abdul Ghani MO, Schmitz JE, Sucre J, Isenberg K, Zamora I, Danko M, Blakely M, Olson J, Jackson GP, Lovvorn HN. SARS-CoV-2 Testing of Aerosols Emitted During Pediatric Minimally Invasive Surgery: A Prospective, Case-Controlled Study. Am Surg 2022; 88:2710-2718. [PMID: 35148619 DOI: 10.1177/00031348211067707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The COVID-19 pandemic has presented significant safety concerns for healthcare providers, especially those performing aerosol-generating procedures. Several surgical societies issued early warnings that aerosols generated during minimally invasive surgery (MIS) could harbor infectious quantities of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). This study tested the hypothesis that MIS-aerosols contain SARS-CoV-2. METHODS To evaluate SARS-CoV-2 presence in aerosols emitted during intracavitary MIS, children <18 years who required emergent MIS and were discovered to be SARS-CoV-2-positive were enrolled. Swabs were obtained from the port in-line with a filtered smoke evacuation system, the tubing adjacent to this port, the fluid collection chamber and filter, and the distal endotracheal tube (ETT). All swabs were analyzed for SARS-CoV-2 using quantitative reverse-transcription polymerase chain reaction. To evaluate viral distribution in tissues, fluorescence in situ hybridization for SARS-CoV-2 was performed on resected specimens. Outcomes were recorded, and participating healthcare workers were tracked for SARS-CoV-2 conversion. RESULTS From July 1, 2020, to June 30, 2021, 11 children requiring emergent MIS were discovered preoperatively to be SARS-CoV-2 positive (median age: 14 years [5-17]). SARS-CoV-2 was detected only in ETT swabs and not in surgical aerosols or specimens. Median operative time was 56.5 minutes (IQR: 46-66), and postoperative stay was 21.2 hours (IQR: 1.97-57.57). No complications or viral eruption were recorded, and none of 63 healthcare workers tested positive for SARS-CoV-2 within 6 weeks. DISCUSSION SARS-CoV-2 was detected only in ETT secretions and not in surgical aerosols or specimens among a pediatric cohort of asymptomatic patients having emergent MIS.
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Affiliation(s)
- Zaid Haddadin
- Department of General Surgery, 6566Albert Einstein Medical Center, Philadelphia, PA, USA
| | - Natasha Halasa
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical CenterRINGGOLD, Nashville, TN, USA
| | - Rendie McHenry
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical CenterRINGGOLD, Nashville, TN, USA
| | - Rebekkah Varjabedian
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical CenterRINGGOLD, Nashville, TN, USA
| | - Tricia L Lynch
- Division of Pediatric Infectious Diseases, Vanderbilt University Medical CenterRINGGOLD, Nashville, TN, USA
| | - Heidi Chen
- Department of Biostatistics, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jonathan E Schmitz
- Department of Pathology, Microbiology and Immunology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jennifer Sucre
- Division of Neonatology, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kimberly Isenberg
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Irving Zamora
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa Danko
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin Blakely
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jacob Olson
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gretchen P Jackson
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, 12328Vanderbilt University Medical Center, Nashville, TN, USA
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McKay KG, Abdul Ghani MO, Crane GL, Evans PT, Zhao S, Martin LY, Thomas JC, Correa H, Benedetti DJ, Lovvorn HN. Oncologic Fidelity of Minimally Invasive Surgery to Resect Neoadjuvant-Treated Wilms Tumors. Am Surg 2022; 88:943-952. [DOI: 10.1177/00031348211070796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The Children's Oncology Group recommends upfront resection of Wilms tumor (WT), however, unique scenarios warrant neoadjuvant chemotherapy and delayed resection. We hypothesized that in the context of neoadjuvant chemotherapy, minimally invasive surgery (MIS) to resect WT achieves equivalent oncologic fidelity and better maintains therapy schedules. Methods A retrospective analysis of WT treated between 2010-2021 at a free-standing children's hospital was performed. Patient and disease specific characteristics were collected, and pre-resection tumor volumes (TV) were calculated. Impact of MIS or open resection on oncologic fidelity and time to resume chemotherapy was analyzed. Results For the study period, 62 patients were treated for 65 WT, and 14 patients (22.6%) received neoadjuvant chemotherapy to treat 17 WT (26.2%): 7 Stage I (all predisposition syndromes), 2 stage III, 7 stage IV, and 1 stage V (bilateral). MIS was utilized to resect 6 WT from 5 patients. For partial nephrectomy, pre-resection TV was 0.38 ml if MIS and 10.38 ml if open ( P = .025). For radical nephrectomy, pre-resection TV was 31.58 ml if MIS and 175.00 ml if open ( P = .101). No significant differences between surgical approach were detected regarding pathologic variables or survival. Epidural use was significantly greater with open procedures ( P = .001). Length of stay was 2.00 days after MIS compared to 6.00 for open resection ( P = .004). Time to resume chemotherapy was 7.00 days after MIS versus 27.00 for open ( P = .004). Conclusion After neoadjuvant chemotherapy for WT, MIS partial and radical nephrectomies achieved equivalent oncologic fidelity, reduced epidural use and post-operative stays, and better maintained adjuvant therapy timelines when compared to open resections.
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Affiliation(s)
- Katlyn G. McKay
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | | | - Gabriella L. Crane
- Division of Pediatric Radiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Parker T. Evans
- Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Shilin Zhao
- Vanderbilt Center for Quantitative Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Laura Y. Martin
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - John C. Thomas
- Division of Pediatric Urology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Division of Pediatric Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel J. Benedetti
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, USA
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27
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Allen JH, Yengo-Kahn AM, Vittetoe KL, Greeno A, Owais Abdul Ghani M, Unni P, Lovvorn HN, Bonfield CM. The impact of helmet use on neurosurgical care and outcomes after pediatric all-terrain vehicle and dirt bike crashes: a 10-year single-center experience. J Neurosurg Pediatr 2022; 29:106-114. [PMID: 34638104 DOI: 10.3171/2021.6.peds21225] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE All-terrain vehicle (ATV) and dirt bike crashes frequently result in traumatic brain injury. The authors performed a retrospective study to evaluate the role of helmets in the neurosurgical outcomes of pediatric patients involved in ATV and dirt bike crashes who were treated at their institution during the last decade. METHODS The authors analyzed data on all pediatric patients involved in ATV or dirt bike crashes who were evaluated at a single regional level I pediatric trauma center between 2010 and 2019. Patients were excluded if the crash occurred in a competition (n = 70) or if helmet status could not be determined (n = 18). Multivariable logistic regression was used to analyze the association of helmet status with the primary outcomes of 1) neurosurgical consultation, 2) intracranial injury (including skull fracture), and 3) moderate or severe traumatic brain injury (MSTBI) and to control for literature-based, potentially confounding variables. RESULTS In total, 680 patients were included (230 [34%] helmeted patients and 450 [66%] unhelmeted patients). Helmeted patients were more frequently male (81% vs 66%). Drivers were more frequently helmeted (44.3%) than passengers (10.5%, p < 0.001). Head imaging was performed to evaluate 70.9% of unhelmeted patients and 48.3% of helmeted patients (p < 0.001). MSTBI (8.0% vs 1.7%, p = 0.001) and neurosurgical consultation (26.2% vs 9.1%, p < 0.001) were more frequent among unhelmeted patients. Neurosurgical injuries, including intracranial hemorrhage (16% vs 4%, p < 0.001) and skull fracture (18% vs 4%, p < 0.001), were more common in unhelmeted patients. Neurosurgical procedures were required by 2.7% of unhelmeted patients. One helmeted patient (0.4%) required placement of an intracranial pressure monitor, and no other helmeted patients required neurosurgical procedures. After adjustment for age, sex, driver status, vehicle type, and injury mechanism, helmet use significantly reduced the odds of neurosurgical consultation (OR 0.250, 95% CI 0.140-0.447, p < 0.001), intracranial injury (OR 0.172, 95% CI 0.087-0.337, p < 0.001), and MSTBI (OR 0.244, 95% CI 0.079-0.758, p = 0.015). The unadjusted absolute risk reduction provided by helmet use equated to a number-needed-to-helmet of 6 riders to prevent 1 neurosurgical consultation, 4 riders to prevent 1 intracranial injury, and 16 riders to prevent 1 MSTBI. CONCLUSIONS Helmet use remains problematically low among young ATV and dirt bike riders, especially passengers. Expanding helmet use among these children could significantly reduce the rates of intracranial injury and MSTBI, as well as the subsequent need for neurosurgical procedures. Promoting helmet use among recreational ATV and dirt bike riders must remain a priority for neurosurgeons, public health officials, and injury prevention professionals.
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Affiliation(s)
| | | | | | - Amber Greeno
- 3Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Purnima Unni
- 3Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Harold N Lovvorn
- 3Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Niec JA, Ghani MOA, Hilmes MA, McKay KG, Correa H, Zamora IJ, Lovvorn HN. Laparoscopic Resection of Pediatric Solid Pseudopapillary Tumors of the Pancreas. Am Surg 2021:31348211060443. [PMID: 34855532 DOI: 10.1177/00031348211060443] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Solid pseudopapillary tumors (SPTs) of the pancreas arise rarely in children, are often large, and can associate intimately with splenic vessels. Splenic preservation is a fundamental consideration when resecting distal SPT. Occasionally, the main splenic vessels must be divided to resect the SPT with negative margins, but the spleen can be preserved if the short gastric vessels remain intact (ie, Warshaw procedure). The purpose of this study was to evaluate outcomes of distal pancreatectomy (DP) for SPT in children and to highlight 2 cases of splenic preservation using the Warshaw procedure. METHODS Patients 19 years and younger who were treated at a single children's hospital between July 2004 and January 2021 were examined. Patient characteristics were collected from the electronic medical record. A pediatric radiologist calculated SPT and pre- and post-operative (ie, non-infarcted) splenic volumes. RESULTS Eleven patients received DP for SPT. Six DPs were performed open and 5 laparoscopically. The spleen was preserved in 3 open and 4 laparoscopic DPs. A laparoscopic Warshaw procedure was performed in 2 patients. Laparoscopic resection associated with less frequent epidural use (P = .015), shorter time to full diet (P = .030), and post-operative length of stay (P = .009), compared to open resection. Average residual splenic volume after the laparoscopic Warshaw procedure was 70% of preoperative volume. DISCUSSION Laparoscopic DP for pediatric SPT achieved similar oncologic goals to open resection. Splenic preservation was feasible with laparoscopy in most cases and was successfully supplemented with the Warshaw procedure, which has not been previously reported for SPT resection in children.
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Affiliation(s)
- Jan A Niec
- 12328Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Muhammad O A Ghani
- Surgical Outcomes Center for Kids, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Melissa A Hilmes
- Division of Pediatric Radiology, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Katlyn G McKay
- 12328Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Hernan Correa
- Division of Pediatric Pathology, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Irving J Zamora
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, 12328Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN, USA
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Xu MC, Ghani MO, Apple A, Chen H, Whiteside M, Borinstein SC, Correa H, Lovvorn HN. Changes in FXR1 expression after Chemotherapy for Rhabdomyosarcoma. J Pediatr Surg 2021; 56:1148-1156. [PMID: 33736876 DOI: 10.1016/j.jpedsurg.2021.02.038] [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: 01/16/2021] [Accepted: 02/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Rhabdomyosarcoma (RMS) arises from abnormal muscle development. We reported previously that Fragile-X-Related 1 (FXR1), essential to normal myogenesis, was highly expressed in RMS relative to other embryonal tumors. This current study explored FXR1 expression across RMS disease characteristics and treatment response. METHODS RMS patients ≤18 years (1980-2019; n = 152) were categorized according to tumor histology, PAX/FOXO1 translocation, and vital status. FXR1 protein expression was compared before and after chemotherapy. Impact of FXR1 expression on relapse-free (RFS) and overall survival (OS) was analyzed. RESULTS FXR1 was most intensely expressed in the cytosol of undifferentiated rhabdomyoblasts. At diagnosis, FXR1 expression was ubiquitous and strong across all disease characteristics and foremost associated with worse RFS in translocation-positive patients (p = 0.0411). Among embryonal and translocation-negative RMS, survivors showed a significantly greater decrease in FXR1 expression after chemotherapy (p < 0.001) compared to decedents (p = 0.8). In contrast, alveolar and translocation-positive RMS specimens showed insignificant changes in FXR1 expression across therapy. As expected, alveolar histology, translocation presence, stage, and clinical group associated with worse survival. CONCLUSIONS FXR1 was expressed strongly across RMS specimens at diagnosis regardless of disease or patient characteristics, and particularly in undifferentiated cells. Reduction in FXR1 expression after chemotherapy associated with improved survival for embryonal and translocation-negative RMS patients.
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Affiliation(s)
- Mark C Xu
- Vanderbilt University School of Medicine, Nashville, TN, USA.
| | - M Owais Ghani
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Annie Apple
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Martin Whiteside
- Office of Cancer Surveillance, Tennessee Department of Health, Nashville, TN, USA
| | - Scott C Borinstein
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Haddadin Z, Blozinski A, Fernandez K, Vittetoe K, Greeno AL, Halasa NB, Lovvorn HN. Changes in Pediatric Emergency Department Visits During the COVID-19 Pandemic. Hosp Pediatr 2021; 11:e57-e60. [PMID: 33436415 DOI: 10.1542/hpeds.2020-005074] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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: 06/12/2023]
Abstract
OBJECTIVES Community mitigation measures were implemented to decrease the spread of severe acute respiratory syndrome coronavirus 2. In this study, we aimed to evaluate changes in pediatric emergency department (ED) visits, secondary to acute respiratory illnesses (ARIs) and trauma, before and during the pandemic. We hypothesized that the numbers of ED visits and ARIs would decrease, whereas the proportion of trauma visits would increase. METHODS A retrospective study from 2018 to 2020 was performed on children 18 years and younger presenting to the ED either for ARI or trauma at a high-volume comprehensive pediatric hospital between March and May each year. International Classification of Diseases, 10th Revision, Clinical Modification admission diagnosis codes were used to identify ARI, trauma, and injury mechanisms. Pearson's χ2 test was used to compare proportions between categorical variables. RESULTS Overall, 6393 total ED visits occurred in 2020, compared with 11 758 and 12 138 in 2018 and 2019, respectively. In 2020, the total ARI number declined by 58%, and ARI frequency decreased significantly, whereas the total trauma number declined by 34%, and the proportion of trauma visits significantly increased. In addition, the number and proportion of recreational vehicle crashes increased, whereas the number and proportion decreased for all intentional and animal-related traumas. CONCLUSIONS The total number of pediatric ED visits dropped precipitously in 2020, but the proportion of trauma visits increased significantly in 2020, accounting for greater than one-quarter of all ED visits. Injury mechanism varied significantly compared to previous years. Future studies are needed to confirm these findings and evaluate the benefits of community mitigation to decrease ARIs and strategies directed to reduce mechanism-specific trauma.
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Affiliation(s)
| | | | | | - Kelly Vittetoe
- School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Amber L Greeno
- Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | | | - Harold N Lovvorn
- Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
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Apple A, Lovvorn HN. Wilms Tumor in Sub-Saharan Africa: Molecular and Social Determinants of a Global Pediatric Health Disparity. Front Oncol 2020; 10:606380. [PMID: 33344257 PMCID: PMC7746839 DOI: 10.3389/fonc.2020.606380] [Citation(s) in RCA: 7] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 11/06/2020] [Indexed: 12/26/2022] Open
Abstract
Wilms tumor (WT) is the most common renal malignancy of childhood. Global disparities in WT have been reported with the highest incidence and lowest overall survival occurring in sub-Saharan African nations. After a detailed search of PubMed, we reviewed available literature on WT in sub-Saharan Africa and summarized findings that explore biologic and social factors contributing to this alarming cancer health disparity. Access to care and treatment abandonment are the most frequently reported factors associated with decreased outcomes. Implementation of multidisciplinary teams, collaborative networks, and financial support has improved overall survival in some nations. However, treatment abandonment remains a challenge. In high-income countries globally, WT therapy now is risk-stratified according to biology and histology. To a significantly lesser extent, biologic features have been studied only recently in sub-Saharan African WT, yet unique molecular and genetic signatures, including congenital anomaly-associated syndromes and biomarkers associated with treatment-resistance and poor prognosis have been identified. Together, challenges with access to and delivery of health care in addition to adverse biologic features likely contribute to increased burden of disease in sub-Saharan African children having WT. Publications on biologic features of WT that inform treatment stratification and personalized therapy in resource-limited regions of sub-Saharan Africa have lagged in comparison to publications that discuss social determinants of health. Further efforts to understand both WT biology and social factors relevant to appropriate treatment delivery should be prioritized in order to reduce health disparities for children residing in resource-limited areas of sub-Saharan Africa battling this lethal childhood cancer.
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Affiliation(s)
- Annie Apple
- Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carrell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, TN, United States
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Stuckey ME, Abdul Ghani MO, Greeno A, Lovvorn HN, Danko ME. Non-accidental trauma causing inferior vena cava and liver injuries. Journal of Pediatric Surgery Case Reports 2020. [DOI: 10.1016/j.epsc.2020.101649] [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: 10/23/2022] Open
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Evans PT, Pennings JS, Samade R, Lovvorn HN, Martus JE. The financial burden of musculoskeletal firearm injuries in children with and without concomitant intra-cavitary injuries. J Pediatr Surg 2020; 55:1754-1760. [PMID: 31704045 DOI: 10.1016/j.jpedsurg.2019.09.030] [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: 06/18/2019] [Revised: 09/15/2019] [Accepted: 09/18/2019] [Indexed: 01/12/2023]
Abstract
BACKGROUND Musculoskeletal pediatric firearm injuries are a clinically significant and expensive public health problem in the United States. In this retrospective cohort analysis, we sought to characterize musculoskeletal firearm injuries in children and to describe the financial burden associated with these injuries. METHODS This study is a single center, retrospective review. Patients were identified from January 2002 - December 2015 from an institutional database using ICD-9 codes pertaining to firearm injury. Inclusion criteria were: 1) age < 18 years at injury; 2) firearm injury to an extremity, spine, or pelvis; and 3) patient received orthopedic evaluation and/or treatment. 140 patients with 142 distinct orthopedic injuries meeting inclusion criteria were analyzed (N = 142). Primary measures were demographic and situational data including intent, length of stay, follow-up, and complications; and financial outcomes including charges, costs, and net revenues. RESULTS Median age was 15.3 years [IQR: 13.3, 16.4], 84% were male, and 52% were African American. 59% of the firearm injuries were of violent intent. 32% of patients were privately insured, 61% were publicly insured, and 6% were uninsured. Median length of stay was 2 days [0, 4], with 73% of patients being admitted. 43% of patients required additional hospitalizations, emergency room visits, and/or outpatient surgeries, and 93% of patients had outpatient follow-up. 42% of patients experience an injury-related or long-term orthopedic complication. Total charges for the cohort were $11.4 million, with $3.7 million in costs and $45,042 in net revenues. In the multivariable analysis, more surgeries predicted higher charges, and more secondary encounters predicted higher costs and net revenues. Only privately-insured patients had a positive median net revenue. CONCLUSIONS Children who sustain musculoskeletal injuries from firearms experience high rates of orthopedic complications. Institutional costs to manage these preventable injuries are excessive. Policy makers should continue to pursue measures to reduce gun violence and improve gun safety in the pediatric population. LEVEL OF EVIDENCE Level III, economic/decision.
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Affiliation(s)
- Parker T Evans
- Vanderbilt University Medical Center, Department of Surgery, Nashville, TN.
| | - Jacquelyn S Pennings
- Vanderbilt University Medical Center, Department of Orthopedic Surgery, Nashville, TN
| | - Richard Samade
- The Ohio State University, Department of Orthopedic Surgery, Columbus, OH
| | - Harold N Lovvorn
- Vanderbilt University Medical Center, Department of Pediatric Surgery, Nashville, TN
| | - Jeffrey E Martus
- Monroe Carell Jr. Children's Hospital at Vanderbilt, Division of Pediatric Orthopedics, Nashville, TN
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Evans PT, Phelps HM, Zhao S, Van Arendonk KJ, Greeno AL, Collins KF, Lovvorn HN. Therapeutic laparoscopy for pediatric abdominal trauma. J Pediatr Surg 2020; 55:1211-1218. [PMID: 31350042 PMCID: PMC6960361 DOI: 10.1016/j.jpedsurg.2019.07.001] [Citation(s) in RCA: 7] [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: 03/14/2019] [Revised: 05/29/2019] [Accepted: 07/07/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND For the surgical treatment of traumatic hollow viscus injuries, laparoscopy offers a potentially less morbid approach to open exploration among appropriately selected patients. This study aimed to evaluate utilization trends and efficacy of laparoscopy in the management of pediatric abdominal trauma. STUDY DESIGN To gain both study granularity and power, our institutional trauma registry (2005-2017) and the National Trauma Data Bank (NTDB; 2010-2015) identified patients ≤18 years who required celiotomy for abdominal trauma. Injury mechanisms, patient characteristics, and hospital courses were compared between open and laparoscopic approaches. Unadjusted and adjusted statistical analyses were performed. RESULTS Overall, data were similar among 393 institutional and 11,399 NTDB patients undergoing laparoscopic (n = 88, 22%; n = 1663, 16%) or open (n = 305, 78%; n = 9736, 85%) surgery for abdominal trauma. In both registries, laparoscopy was more commonly employed in younger (institutional p = 0.026; NTDB p < 0.001) female (p = 0.019; p < 0.001) patients having lower injury severity (p < 0.001) and blunt injuries (p = 0.031; p < 0.001). Laparoscopy was associated with fewer complications overall when adjusting for demographics and injury severity [institutional OR 0.25 (0.08-0.75), p = 0.013; NTDB OR 0.69 (0.55-0.88), p = 0.002]. An increase in utilization of MIS for pediatric abdominal trauma was detected over time (NTDB: r = 0.88, p = 0.02). CONCLUSION For the management of pediatric abdominal trauma, laparoscopy was employed typically in younger, more stable, and female patients sustaining blunt injuries. Appropriately selected patients have similar or better outcomes to patients treated with laparotomy, with no increase in adverse events or missed injuries. Increased utilization of laparoscopy to manage abdominal trauma in children suggests greater acceptance of this approach. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
| | - Hannah M. Phelps
- Vanderbilt University School of Medicine, Nashville, TN,Surgical Outcomes Center for Kids, Vanderbilt University, Nashville, TN
| | - Shilin Zhao
- Surgical Outcomes Center for Kids, Vanderbilt University, Nashville, TN,Center for Quantitative Sciences, Vanderbilt University, Nashville, TN
| | - Kyle J. Van Arendonk
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Amber L. Greeno
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly F. Collins
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N. Lovvorn
- Surgical Outcomes Center for Kids, Vanderbilt University, Nashville, TN,Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
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Ziogas IA, Ye F, Zhao Z, Matsuoka LK, Montenovo MI, Izzy M, Benedetti DJ, Lovvorn HN, Gillis LA, Alexopoulos SP. Population-Based Analysis of Hepatocellular Carcinoma in Children: Identifying Optimal Surgical Treatment. J Am Coll Surg 2020; 230:1035-1044.e3. [PMID: 32272204 DOI: 10.1016/j.jamcollsurg.2020.03.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) constitutes 0.5% of childhood malignancies and exhibits poor prognosis. Complete tumor extirpation either by partial liver resection (LR) or liver transplantation (LT) is the only curative treatment. Due to the poor initial outcomes of LT, LR has remained the mainstay of treatment for all but select children fulfilling the Milan criteria (originally designed for adults). METHODS We conducted a retrospective cohort study of pediatric HCC patients (younger than 18 years of age) registered in the Surveillance, Epidemiology, and End Results database between 2004 and 2015. Survival analysis was performed by means of Kaplan-Meier methods, 2-sided stratified log-rank tests, and Cox regression models. RESULTS Of 127 children with HCC, 46 did not undergo operation (36.2%), 32 underwent LT (25.2%), and 49 underwent LR (38.6%). Using the Kaplan-Meier method, the 5-year cancer-specific survival (CSS) rates for LT and LR were 87% and 63%, respectively. LT exhibited superior CSS vs LR (log-rank, p = 0.007). For T1 stage, LT showed equivalent CSS compared with LR (log-rank, p = 0.23), and for T2 and T3 stage, LT exhibited superior CSS (log-rank, p = 0.047 and p = 0.01, respectively). On multivariable Cox regression analysis, T3/T4 stage (adjusted hazard ratio 13.63; 95% CI, 2.9 to 64.07; p = 0.001), and LR (adjusted hazard ratio 7.51; 95% CI, 2.07 to 27.29; p = 0.002) were found to be independently associated with cancer-specific mortality. Fibrolamellar histology and lymph node status were not found to be associated with mortality. CONCLUSIONS Our findings suggest that children diagnosed with nonmetastatic advanced-stage HCC have a favorable prognosis after LT compared with LR. Early inclusion of an LT consultation after the initial diagnosis is warranted, especially in children with unresectable HCC or when complete tumor extirpation with LR is not feasible.
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Affiliation(s)
- Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Fei Ye
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Zhiguo Zhao
- Center for Quantitative Sciences and Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Martin I Montenovo
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Manhal Izzy
- Department of Medicine, Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Daniel J Benedetti
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N Lovvorn
- Department of Pediatrics, D. Brent Polk Division of Gastroenterology, Hepatology, and Nutrition, Vanderbilt University Medical Center, Nashville, TN
| | - Lynette A Gillis
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN.
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Abstract
Minimally invasive surgery (MIS) to resect primary and metastatic pediatric embryonal tumors offers the potential for reduced postoperative morbidity with smaller wounds, less pain, fewer surgical site infections, decreased blood loss, shorter hospital stays, and less disruption to treatment regimens. However, significant controversy surrounds the question of whether a high-fidelity oncologic resection of childhood embryonal tumors with gross total resection, negative margins, and appropriate lymph node sampling can be achieved through MIS. This review outlines the diverse applications of MIS to treat definitively pediatric embryonal malignancies, including this approach to metastatic deposits. It outlines specific patient populations and presentations that may be particularly amenable to the minimally invasive approach. This work further summarizes the current evidence supporting the efficacy of MIS to accomplish a definitive, oncologic resection without compromising relapse-free or overall survival. Finally, the review offers technical considerations to consider in order to achieve a safe and complete resection.
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Affiliation(s)
- Hannah M Phelps
- Department of Surgery, Washington University School of Medicine, 9901 Wohl Hospital, Campus Box 8109, St. Louis, MO, 63110, USA.
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children's Way Doctor's Office Tower Suite 7102, Nashville, TN, 37232, USA
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Slater BJ, Borobia P, Lovvorn HN, Raees MA, Bass KD, Almond S, Hoover JD, Kumar T, Zaritzky M. Use of Magnets as a Minimally Invasive Approach for Anastomosis in Esophageal Atresia: Long-Term Outcomes. J Laparoendosc Adv Surg Tech A 2019; 29:1202-1206. [PMID: 31524560 DOI: 10.1089/lap.2019.0199] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [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: 12/21/2022] Open
Abstract
Introduction: The majority of esophageal atresia (EA) patients undergo surgical repair soon after birth. However, factors due to patient characteristics, esophageal length, or surgical complications can limit the ability to obtain esophageal continuity. A number of techniques have been described to treat these patients with "long-gap" EA. Magnets are a nonsurgical alternative for esophageal anastomosis. The purpose of this study was to report long-term outcomes for the use of magnets in EA. Materials and Methods: Between July 2001 and December 2017, 13 patients underwent placement of a magnetic catheter-based system under fluoroscopic guidance at six institutions. Daily chest radiographs were obtained until there was union of the magnets. Magnets were then removed and replaced with an oro- or nasogastric tube. Complications and outcomes were recorded. The average length of follow-up was 9.3 years (range 1.42-17.75). Results: A total of 85% of the patients had type A, pure EA, and 15% had type C with previous fistula ligation. The average length of time to achieve anastomosis was 6.3 days (range 3-13). No anastomotic leaks occurred, and all of the patients had an expected esophageal stenosis that required dilation given the 10F coupling surface of the magnets (average 9.8, range 3-22). Six patients (46%) had retrievable esophageal stents, and two underwent surgery; yet all maintained their native esophagus without interposition. A total of 92% were on full oral feeds at the time of follow-up. Conclusion: The use of magnets for treatment of long-gap EA is safe and feasible and accomplished good long-term outcomes. The main complication was esophageal stricture, although all patients maintained their native esophagus. A prospective observational study is currently enrolling patients to evaluate the safety and benefit of a catheter-based magnetic device for EA.
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Affiliation(s)
- Bethany J Slater
- Department of Pediatric Surgery, University of Chicago, Chicago, Illinois
| | - Paula Borobia
- Department of Pediatric of Gastroenterology, Hospital de Niños, de La Plata, Argentina
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Muhammad A Raees
- Department of Pediatric Surgery, Monroe Carell, Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Kathryn D Bass
- Department of Pediatric Surgery, Oishei Children's Hospital, Buffalo, New York
| | - Stephen Almond
- Department of Pediatric Surgery, Driscoll Children's Hospital, Corpus Christi, Texas
| | | | | | - Mario Zaritzky
- Department of Radiology, University of Chicago, Chicago, Illinois
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Phelps HM, Robinson JR, Chen H, Luckett TR, Conroy PC, Gillis LA, Hays SR, Lovvorn HN. Enhancing Recovery After Kasai Portoenterostomy With Epidural Analgesia. J Surg Res 2019; 243:354-362. [PMID: 31277012 DOI: 10.1016/j.jss.2019.05.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/07/2019] [Revised: 04/24/2019] [Accepted: 05/30/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Biliary atresia (BA) is a rare obstructive cholangiopathy that presents in early infancy. The Kasai portoenterostomy (PE) improves survival with the native liver. Epidural analgesia is an appealing option to control pain in this fragile patient population, yet its safety, efficacy, and potential benefits remain unproven. METHODS Patients undergoing PE for BA between 2001 and 2016 at a single institution were identified by ICD codes. Preoperative laboratories, procedure details, and recovery outcomes were reviewed retrospectively. Outcomes of interest were need for postoperative mechanical ventilation, pain scores, normalized opioid administration, return of bowel function, and length of hospital stay after PE. RESULTS Of 47 infants undergoing PE for BA, 25 received epidural analgesia, and 22 did not. Infants with epidurals received less systemic opioids over the first 96 h postoperatively than those without (P < 0.001). Epidurals were associated with lower pain scores between 6 and 30 h postoperatively (P = 0.01 to 0.04), during which the highest median 6-h interval pain score was 0.2 (IQR 0-1.3) for patients with epidurals yet 2.1 (IQR 1.2-3.3) for patients without. Patients with epidurals (88%, n = 22) were more commonly extubated before leaving the operating room than those without (59%, n = 13; P = 0.02). No significant difference was observed in time to first bowel movement (P = 0.48) or first oral feed (P = 0.81). However, infants with epidurals had shorter hospital stays after PE than those without (6 d [IQR 5-7] versus 8 d [IQR 6.3-11], P = 0.01). No major complications were associated with epidural catheters. CONCLUSIONS Epidural analgesia in patients undergoing PE for BA appears safe and effectively controls pain while minimizing the need for systemic opioids. Reduced need for mechanical ventilation postoperatively and shortened hospital stays serve as further evidence for using epidurals to enhance recovery after PE.
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Affiliation(s)
- Hannah M Phelps
- Vanderbilt University School of Medicine, Nashville, TN; Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN.
| | - Jamie R Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University, Nashville, TN
| | - Heidi Chen
- Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Twila R Luckett
- Pediatric Pain Service, Monroe Carell, Jr. Children's Hospital, Nashville, TN
| | | | - Lynette A Gillis
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Stephen R Hays
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN; Department of Anesthesia, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N Lovvorn
- Surgical Outcomes Center for Kids, Monroe Carell, Jr. Children's Hospital, Nashville, TN; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
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Abstract
BACKGROUND/PURPOSE Wilms tumor (WT) is the most common childhood kidney cancer globally. Our prior unbiased proteomic screen of WT disparities revealed increased expression of Fragile X-Related 1 (FXR1) in Kenyan specimens where survival is dismal. FXR1 is an RNA-binding protein that associates with poor outcomes in multiple adult cancers. The aim of this study therefore was to validate and characterize the FXR1 expression domain in WT. METHODS Quantitative FXR1 gene expression was compared between WT, adjacent, adult, and fetal kidney specimens. The cellular and subcellular expression domain of FXR1 was characterized across these tissues using immunoperoxidase staining. RNA-sequencing of FXR1 was performed from WT and other pediatric malignancies to examine its broader target potential. RESULTS FXR1 was detected in all clinical WT specimens evaluated (n = 82), and as a result appeared independent of demographic, histology, or adverse event. Specific cytosolic staining was strongest in blastema, intermediate and variable in epithelia, and weakest in stroma. When present, areas of skeletal muscle differentiation stained strongly for FXR1. qPCR revealed increased FXR1 expression in WT compared to adult and adjacent kidney (p < 0.0002) but was similar to fetal kidney (p = 0.648). RNA-sequencing revealed expression of FXR1 in multiple pediatric tumors, greatest in rhabdomyosarcoma and WT. CONCLUSIONS FXR1 was expressed consistently across this broad sampling of WT and most robustly in the primitive blastema. Notably, FXR1 labeled a specific self-renewing progenitor population of the fetal kidney.
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Affiliation(s)
| | - Janene M. Pierce
- Vanderbilt University Medical Center, Department of Pediatric Surgery, Nashville, TN
| | - Andrew J. Murphy
- St. Jude Children’s Research Hospital, Department of Surgery, Memphis, TN
| | - Hernan Correa
- Vanderbilt University Medical Center, Department of Pathology, Microbiology, and Immunology, Nashville, TN
| | - Jun Qian
- Vanderbilt University Medical Center, Department of Medicine and Vanderbilt Ingram Cancer Center, Nashville, TN
| | - Pierre P. Massion
- Vanderbilt University Medical Center, Department of Medicine and Vanderbilt Ingram Cancer Center, Nashville, TN
| | - Harold N. Lovvorn
- Vanderbilt University Medical Center, Department of Pediatric Surgery, Nashville, TN
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Phelps HM, Ndolo JM, Van Arendonk KJ, Chen H, Dietrich HL, Watson KD, Hilmes MA, Chung DH, Lovvorn HN. Association between image-defined risk factors and neuroblastoma outcomes. J Pediatr Surg 2019; 54:1184-1191. [PMID: 30885556 PMCID: PMC6628713 DOI: 10.1016/j.jpedsurg.2019.02.040] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [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: 02/12/2019] [Accepted: 02/21/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND The current neuroblastoma (NBL) staging system employs image-defined risk factors (IDRFs) to assess numerous anatomic features, but the impact of IDRFs on surgical and oncologic outcomes is unclear. METHODS The Vanderbilt Cancer Registry identified children treated for NBL from 2002 to 2017. Tumor volume (TV) and IDRFs were measured radiographically at diagnosis and before resection. Perioperative and oncologic outcomes were evaluated. RESULTS At diagnosis of 106 NBL, 61% were IDRF positive. MYCN-amplified and undifferentiated NBL had more IDRFs than nonamplified and more differentiated tumors (p = 0.001 and p = 0.01). Of 86 NBLs resected, 43% were IDRF positive, which associated with higher stage, risk, and TV (each p < 0.001). The presence of IDRF at resection was also associated with increased blood loss (p < 0.001), longer operating times (p < 0.001), greater incidence of intraoperative complications (p = 0.03), more frequent ICU admissions postoperatively (p < 0.001), and longer hospital stays (p < 0.001). IDRF negative and positive tumors did not have significantly different rates of gross total resection (p = 0.2). Five-year relapse-free and overall survival was similar for IDRF negative and positive NBL (p = 0.9 and p = 0.8). CONCLUSIONS IDRFs at diagnosis were associated with larger, less differentiated, advanced stage, and higher risk NBL and at resection with increased operative difficulty and perioperative morbidity. However, the frequency of gross total resection and patient survival after resection were not associated with the presence of IDRFs. TYPE OF STUDY Retrospective cohort study. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hannah M. Phelps
- School of Medicine, Vanderbilt University Medical Center, Nashville, TN,Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, TN,Corresponding author at: Vanderbilt University School of Medicine, 2209 Garland Avenue, Nashville, TN 37232-9780. (H.M. Phelps)
| | - Josephine M. Ndolo
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Kyle J. Van Arendonk
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Heidi Chen
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, TN,Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Katherine D. Watson
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa A. Hilmes
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN
| | - Dai H. Chung
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Harold N. Lovvorn
- Surgical Outcomes Center for Kids, Vanderbilt University Medical Center, Nashville, TN,Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
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Phelps HM, Lovvorn HN. Minimally Invasive Surgery in Pediatric Surgical Oncology. Children (Basel) 2018; 5:children5120158. [PMID: 30486309 PMCID: PMC6306705 DOI: 10.3390/children5120158] [Citation(s) in RCA: 11] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Revised: 11/13/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023]
Abstract
The application of minimally invasive surgery (MIS) to resect pediatric solid tumors offers the potential for reduced postoperative morbidity with smaller wounds, less pain, fewer surgical site infections, decreased blood loss, shorter hospital stays, and less disruption to treatment regimens. However, significant controversy surrounds the question of whether a high-fidelity oncologic resection of childhood cancers can be achieved through MIS. This review outlines the diverse applications of MIS to treat pediatric malignancies, up to and including definitive resection. This work further summarizes the current evidence supporting the efficacy of MIS to accomplish a definitive, oncologic resection as well as appropriate patient selection criteria for the minimally invasive approach.
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Affiliation(s)
- Hannah M Phelps
- School of Medicine, Vanderbilt University, Nashville, TN 37232, USA.
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
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Romano-Keeler J, Shilts MH, Tovchigrechko A, Wang C, Brucker RM, Moore DJ, Fonnesbeck C, Meng S, Correa H, Lovvorn HN, Tang YW, Hooper L, Bordenstein SR, Das SR, Weitkamp JH. Distinct mucosal microbial communities in infants with surgical necrotizing enterocolitis correlate with age and antibiotic exposure. PLoS One 2018; 13:e0206366. [PMID: 30365522 PMCID: PMC6203398 DOI: 10.1371/journal.pone.0206366] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/11/2018] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE Necrotizing enterocolitis (NEC) is the most common surgical emergency in preterm infants, and pathogenesis associates with changes in the fecal microbiome. As fecal samples incompletely represent microbial communities in intestinal mucosa, we sought to determine the NEC tissue-specific microbiome and assess its contribution to pathogenesis. DESIGN We amplified and sequenced the V1-V3 hypervariable region of the bacterial 16S rRNA gene extracted from intestinal tissue and corresponding fecal samples from 12 surgical patients with NEC and 14 surgical patients without NEC. Low quality and non-bacterial sequences were removed, and taxonomic assignment was made with the Ribosomal Database Project. Operational taxonomic units were clustered at 97%. We tested for differences between NEC and non-NEC samples in microbiome alpha- and beta-diversity and differential abundance of specific taxa between NEC and non-NEC samples. Additional analyses were performed to assess the contribution of other demographic and environmental confounding factors on the infant tissue and fecal microbiome. RESULTS The fecal and tissue microbial communities were different. NEC was associated with a distinct microbiome, which was characterized by low diversity, higher abundances of Staphylococcus and Clostridium_sensu_stricto, and lower abundances of Actinomyces and Corynebacterium. Infant age and vancomycin exposure correlated with shifts in the tissue microbiome. CONCLUSION The observed low diversity in NEC tissues suggests that NEC is associated with a bacterial bloom and a distinct mucosal bacterial community. The exact bacterial species that constitute the bloom varied by infant and were strongly influenced by age and exposure to vancomycin.
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Affiliation(s)
- Joann Romano-Keeler
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Meghan H. Shilts
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Andrey Tovchigrechko
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Research Bioinformatics, Medimmune, Gaithersburg, Maryland, Tennessee, United States of America
| | - Chunlin Wang
- Genome Technology Center, Stanford University, Palo Alto, California, United States of America
| | - Robert M. Brucker
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Daniel J. Moore
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
- Department of Pathology, Microbiology & Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical University, Nashville, Tennessee, United States of America
| | - Christopher Fonnesbeck
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Shufang Meng
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Hernan Correa
- Department of Pathology, Microbiology & Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical University, Nashville, Tennessee, United States of America
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Yi-Wei Tang
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, New York, United States of America
| | - Lora Hooper
- Department of Immunology, The University of Texas Southwestern Medical Center, Dallas, Texas, United States of America
| | - Seth R. Bordenstein
- Department of Pathology, Microbiology & Immunology, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical University, Nashville, Tennessee, United States of America
- Department of Biological Sciences, Vanderbilt University, Nashville, Tennessee, United States of America
| | - Suman R. Das
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical University, Nashville, Tennessee, United States of America
| | - Jörn-Hendrik Weitkamp
- Department of Pediatrics, Vanderbilt University, Nashville, Tennessee, United States of America
- Vanderbilt Institute for Infection, Immunology and Inflammation, Vanderbilt University Medical University, Nashville, Tennessee, United States of America
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Phelps HM, Ndolo JM, Van Arendonk KJ, Dietrich HL, Watson KD, Hilmes MA, Chung DH, Lovvorn HN. Association Between Image-Defined Risk Factors and Neuroblastoma Outcomes. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.424] [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: 10/28/2022]
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Evans PT, Phelps HM, Van Arendonk KJ, Greeno AL, Collins K, Lovvorn HN. Laparoscopy for Pediatric Abdominal Trauma. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.549] [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: 11/12/2022]
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Robinson JR, Conroy PC, Hardison D, Hamid R, Grubb PH, Pietsch JB, Lovvorn HN. Rapid resolution of hyperammonemia in neonates using extracorporeal membrane oxygenation as a platform to drive hemodialysis. J Perinatol 2018; 38:665-671. [PMID: 29467521 PMCID: PMC6030490 DOI: 10.1038/s41372-018-0084-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 01/30/2018] [Accepted: 02/01/2018] [Indexed: 12/31/2022]
Abstract
OBJECTIVE We aimed to clarify the impact of extracorporeal membrane oxygenation (ECMO) as a platform to drive hemodialysis (HD) for ammonia clearance on outcomes of neonates with severe hyperammonemia. STUDY DESIGN All neonates treated for hyperammonemia at a single children's hospital between 1992 and 2016 were identified. Patient characteristics and outcomes were compared between those receiving medical management or ECMO/HD. RESULT Twenty-five neonates were treated for hyperammonemia, of which 13 (52%) received ECMO/HD. Peak ammonia levels among neonates treated with ECMO/HD were significantly higher than those medically managed (1041 [IQR 902-1581] μmol/L versus 212 [IQR 110-410] μmol/L; p = 0.009). Serum ammonia levels in the ECMO/HD cohort declined to the median of medically managed within 4.5 (IQR 2.9-7.0) hours and normalized within 7.3 (IQR 3.6-13.5) hours. All neonates survived ECMO/HD, and nine (69.2%) survived to discharge. CONCLUSION ECMO/HD is an effective adjunct to rapidly clear severe hyperammonemia in newborns, reducing potential neurodevelopmental morbidity.
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Affiliation(s)
- Jamie R. Robinson
- Department of Biomedical Informatics, Vanderbilt University,Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Patricia C. Conroy
- School of Medicine, Vanderbilt University,Department of Surgery, University of California, San Francisco
| | - Daphne Hardison
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Rizwan Hamid
- Department of Pediatric Genetics, Vanderbilt University Medical Center
| | - Peter H. Grubb
- Department of Pediatrics, Neonatology, Vanderbilt University Medical Center,Department of Pediatrics, Neonatology, University of Utah,Primary Children’s Hospital, Intermountain Healthcare Corporation
| | - John B. Pietsch
- Department of Pediatric Surgery, Vanderbilt University Medical Center
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center
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Phelps HM, Ayers GD, Ndolo JM, Dietrich HL, Watson KD, Hilmes MA, Lovvorn HN. Maintaining oncologic integrity with minimally invasive resection of pediatric embryonal tumors. Surgery 2018; 164:333-343. [PMID: 29751968 DOI: 10.1016/j.surg.2018.03.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 03/05/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Embryonal tumors arise typically in infants and young children and are often massive at presentation. Operative resection is a cornerstone in the multimodal treatment of embryonal tumors but potentially disrupts therapeutic timelines. When used appropriately, minimally invasive surgery can minimize treatment delays. The oncologic integrity and safety attainable with minimally invasive resection of embryonal tumors, however, remains controversial. METHODS Query of the Vanderbilt Cancer Registry identified all children treated for intracavitary, embryonal tumors during a 15-year period. Tumors were assessed radiographically to measure volume (mL) and image-defined risk factors (neuroblastic tumors only) at time of diagnosis, and at preresection and postresection. Patient and tumor characteristics, perioperative details, and oncologic outcomes were compared between minimally invasive surgery and open resection of tumors of comparable size. RESULTS A total of 202 patients were treated for 206 intracavitary embryonal tumors, of which 178 were resected either open (n = 152, 85%) or with minimally invasive surgery (n = 26, 15%). The 5-year, relapse-free, and overall survival were not significantly different after minimally invasive surgery or open resection of tumors having a volume less than 100 mL, corresponding to the largest resected with minimally invasive surgery (P = .249 and P = .124, respectively). No difference in margin status or lymph node sampling between the 2 operative approaches was detected (p = .333 and p = .070, respectively). Advantages associated with minimally invasive surgery were decreased blood loss (P < .001), decreased operating time (P = .002), and shorter hospital stay (P < .001). Characteristically, minimally invasive surgery was used for smaller volume and earlier stage neuroblastic tumors without image-defined risk factors. CONCLUSION When selected appropriately, minimally invasive resection of pediatric embryonal tumors, particularly neuroblastic tumors, provides acceptable oncologic integrity. Large tumor volume, small patient size, and image-defined risk factors may limit the broader applicability of minimally invasive surgery.
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Affiliation(s)
- Hannah M Phelps
- Vanderbilt University School of Medicine, Nashville, TN, USA; Surgical Outcomes Center for Kids, Vanderbilt University, Nashville, TN, USA.
| | - Gregory D Ayers
- Division of Cancer Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Josephine M Ndolo
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Katherine D Watson
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Melissa A Hilmes
- Department of Radiology and Radiological Sciences, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Surgical Outcomes Center for Kids, Vanderbilt University, Nashville, TN, USA; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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47
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Rehman S, Lovvorn HN, Rickman OB, Wootten CT, Chinnadurai S. Unique application of awake tracheoscopy and endobronchial ultrasound in the management of tracheal mucoepidermoid carcinoma. Head Neck 2018; 40:E58-E61. [PMID: 29575399 DOI: 10.1002/hed.25147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 11/23/2017] [Accepted: 02/01/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Mucoepidermoid carcinoma of the trachea is a rare pediatric malignancy that presents unique challenges in diagnosis, operative management, and surveillance. METHODS AND RESULTS We present a 17-year-old girl with primary tracheal mucoepidermoid carcinoma presenting in acute respiratory distress due to near-total occlusion of the tracheal airway. An algorithmic approach to preoperative planning was developed to evaluate and remove the tumor endoscopically without compromising oxygenation. After initial palliative resection, endobronchial ultrasound was uniquely applied to evaluate depth of tumor invasion, and subsequent tracheal resection with primary anastomosis was performed as curative treatment. CONCLUSION Removal of distal tracheal masses can be performed safely with the implementation of an algorithmic approach to tumor visualization and resection. Endobronchial ultrasound can be used to evaluate the extent of tumor invasion and plan for definitive resection.
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Affiliation(s)
- Saad Rehman
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Harold N Lovvorn
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Otis B Rickman
- Department of Otolaryngology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher T Wootten
- Children's Ear, Nose, and Throat, and Facial Plastic Surgery, Minneapolis, Minnesota
| | - Sivakumar Chinnadurai
- Children's Ear, Nose, and Throat, and Facial Plastic Surgery, Minneapolis, Minnesota
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48
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Schlegel C, Greeno A, Chen H, Raees MA, Collins KF, Chung DH, Lovvorn HN. Evolution of a level I pediatric trauma center: Changes in injury mechanisms and improved outcomes. Surgery 2018; 163:1173-1177. [PMID: 29373171 DOI: 10.1016/j.surg.2017.10.070] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 09/12/2017] [Accepted: 10/31/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Trauma is the leading cause of mortality among children, underscoring the need for specialized child-centered care. The impact on presenting mechanisms of injury and outcomes during the evolution of independent pediatric trauma centers is unknown. The aim of this study was to evaluate the impact of our single center transition from an adult to American College of Surgeons-verified pediatric trauma center. METHODS A retrospective analysis was performed of 1,190 children who presented as level I trauma activations between 2005 and 2016. Patients were divided into 3 chronological treatment eras: adult trauma center, early pediatric trauma center, and late pediatric trauma center after American College of Surgeons verification review. Comparisons were made using Pearson χ2, Wilcoxon rank sum, and Kruskal-Wallis tests. RESULTS The predominant mechanism of injury was motor vehicle crash, with increases noted in assault/abuse (2% adult trauma center, 11% late pediatric trauma center). A decrease in intensive care admissions was identified during late pediatric trauma center compared with early pediatric trauma center and adult trauma center (51% vs 62.4% vs 67%, P < .001), with concomitant increases in admissions to the floor and immediate operative interventions, but overall mortality was unchanged. CONCLUSION Transition to a verified pediatric trauma center maintains the safety expected of the American College of Surgeons certification, but with notable changes identified in mechanism of injury and improvements in resource utilization.
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Affiliation(s)
- Cameron Schlegel
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Amber Greeno
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Muhammad Aanish Raees
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelly F Collins
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dai H Chung
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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49
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Robinson JR, Correa H, Brinkman AS, Lovvorn HN. Optimizing surgical resection of the bleeding Meckel diverticulum in children. J Pediatr Surg 2017; 52:1610-1615. [PMID: 28359587 PMCID: PMC5610599 DOI: 10.1016/j.jpedsurg.2017.03.047] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 12/22/2016] [Revised: 02/22/2017] [Accepted: 03/20/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Meckel diverticula containing gastric heterotopia predispose to local hyperacidity, mucosal ulceration, and gastrointestinal bleeding in children. Eradication of acid-producing oxyntic cells is performed by either of two surgical methods: segmental enterectomy including the diverticulum or diverticulectomy only. METHODS Retrospective review of all children having surgical resection of a Meckel diverticulum at a tertiary-referral children's hospital from 2002 to 2016 was performed. Demographic data, surgical method, pathological specimens, and outcomes were evaluated. RESULTS 102 children underwent surgical resection of a Meckel diverticulum during the study period. 27 (26.5%) children presented with bleeding, of which 16 (59%) had diverticulectomy only, and 11 (41%) had segmental ileal resection. All Meckel diverticula in children presenting with bleeding contained gastric heterotopia, and resection margins were free of gastric mucosa. Histologically, 19 specimens showed microscopic features of ulceration, on average 2.95mm (SD 4.49) from the nearest gastric mucosa (range: 0-16mm). Mean length of hospitalization after ileal resection was 4.0days (SD 1.2) compared to 1.6days (SD 0.9) for diverticulectomy only (p<0.001), with no re-bleeding occurrences. CONCLUSION In the operative management of children having a bleeding Meckel diverticulum, diverticulectomy-only completely eradicates gastric heterotopia without increased risk of continued bleeding or complications and significantly shortens hospitalization. LEVEL OF EVIDENCE Treatment Study: Level III.
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Affiliation(s)
- Jamie R. Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hernan Correa
- Department of Pathology, Microbiology, and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Adam S. Brinkman
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Harold N. Lovvorn
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
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Lovvorn HN, Hardison DC, Chen H, Westrick AC, Danko ME, Bridges BC, Walsh WF, Pietsch JB. Review of 1,000 consecutive extracorporeal membrane oxygenation runs as a quality initiative. Surgery 2017; 162:385-396. [PMID: 28551379 DOI: 10.1016/j.surg.2017.03.020] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Revised: 03/10/2017] [Accepted: 03/17/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation is a resource-intensive mode of life-support potentially applicable when conventional therapies fail. Given the initial success of extracorporeal membrane oxygenation to support neonates and infants in the 1980s, indications have expanded to include adolescents, adults, and selected moribund patients during cardiopulmonary resuscitation. This single-institution analysis was conducted to evaluate programmatic growth, outcomes, and risk for death despite extracorporeal membrane oxygenation across all ages and diseases. METHODS Beginning in 1989, we registered prospectively all extracorporeal membrane oxygenation patient data with the Extracorporeal Life Support Organization. We queried this registry for our institution-specific data to compare the parameter of "discharge alive" between age groups (neonatal, pediatric, adult), disease groups (respiratory, cardiac, cardiopulmonary resuscitation), and modes of extracorporeal membrane oxygenation (veno-venous; veno-arterial). Extracorporeal membrane oxygenation-specific complications (mechanical, hemorrhagic, neurologic, renal, cardiovascular, pulmonary, infectious, metabolic) were analyzed similarly. Descriptive statistics, Kaplan-Meier, and linear regression analyses were conducted. RESULTS After 1,052 extracorporeal membrane oxygenation runs, indications have expanded to include adults, to supplement cardiopulmonary resuscitation, to support hemodialysis in neonates and plasmapheresis in children, and to bridge all age patients to heart and lung transplant. Overall survival to discharge was 52% and was better for respiratory diseases (P < .001). Probability of individual survival decreased to <50% if pre-extracorporeal membrane oxygenation mechanical ventilation exceeded respectively 123 hours for cardiac, 166 hours for cardiopulmonary resuscitation, and 183 hours for respiratory diseases (P = .013). Complications occurred most commonly among cardiac and cardiopulmonary resuscitation runs (P < .001), the veno-arterial mode (P < .001), and in adults (P = .044). CONCLUSION Our extracorporeal membrane oxygenation program, an Extracorporeal Life Support Organization-designated Center of Excellence, has experienced substantial growth in volume and indications, including increasing age and disease severity. Considering the entire cohort, pre-extracorporeal membrane oxygenation ventilation exceeding 7 days was associated with an increased probability of death.
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Affiliation(s)
- Harold N Lovvorn
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN.
| | - Daphne C Hardison
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Heidi Chen
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
| | - Ashly C Westrick
- Department of Neurological Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Melissa E Danko
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Brian C Bridges
- Division of Pediatric Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - William F Walsh
- Division of Neonatology, Vanderbilt University School of Medicine, Nashville, TN
| | - John B Pietsch
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
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