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Reduced Hospital Mortality With Surgical Ligation of Patent Ductus Arteriosus in Premature, Extremely Low Birth Weight Infants: A Propensity Score-matched Outcome Study
Tashiro, Jun; Perez, Eduardo A; Sola, Juan E
OBJECTIVES/OBJECTIVE:To evaluate outcomes after surgical ligation (SL) of patent ductus arteriosus (PDA) in premature, extremely low birth weight (ELBW) infants. BACKGROUND:Optimal management of PDA in this specialized population remains undefined. Currently, surgical therapy is largely reserved for infants failing medical management. To date, a large-scale, risk-matched population-based study has not been performed to evaluate differences in mortality and resource utilization. METHODS:Data on identified premature (<37 weeks) and ELBW (<1000  g) infants with PDA (International Classification of Diseases, 9th revision, Clinical Modification, 747.0) and respiratory distress (769) were obtained from Kids' Inpatient Database (2003-2009). RESULTS:Overall, 12,470 cases were identified, with 3008 undergoing SL. Propensity score-matched analysis of 1620 SL versus 1584 non-SL found reduced mortality (15% vs 26%) and more routine disposition (48% vs 41%) for SL (P < 0.001). SL had longer length of stay and higher total cost (P < 0.001). On multivariate analysis, SL mortality predictors were necrotizing enterocolitis (NEC; surgical odds ratio, 5.95; medical odds ratio, 4.42) and sepsis (3.43) (P < 0.006). Length of stay increased with bronchopulmonary dysplasia (BPD; 1.77), whereas total cost increased with surgical NEC (1.82) and sepsis (1.26) (P < 0.04). Non-SL mortality predictors were NEC (surgical, 76.3; medical, 6.17), sepsis (2.66), and intraventricular hemorrhage (1.97) (P < 0.005). Length of stay increased with BPD (2.92) and NEC (surgical, 2.04; medical, 1.28) (P < 0.03). Total cost increased with surgical NEC (2.06), medical NEC (1.57), sepsis (1.43), and BPD (1.30) (P < 0.001). CONCLUSIONS:Propensity score-matched analysis demonstrates reduced mortality in premature/ELBW infants with SL for PDA. NEC and sepsis are predictors of mortality and resource utilization.
PMID: 25822689
ISSN: 1528-1140
CID: 4603882
Pattern of Biliary Disease Following Laparoscopic Sleeve Gastrectomy in Adolescents
Tashiro, Jun; Thenappan, Arunachalam A; Nadler, Evan P
OBJECTIVE:The use of laparoscopic sleeve gastrectomy (LSG) has risen steadily as a treatment for adolescents with obesity. This study determined whether obstructive biliary complications after rapid, LSG-related weight loss occur similarly in adolescents compared with adults. METHODS:Between 2010 and 2019, 309 patients underwent LSG. Demographics and clinical factors, including pre- and perioperative BMI and weight changes, were included. RESULTS:. Preoperative excess BMI loss was 7.1% (SD 11.3%). An ultrasound revealed gallstones (71%) and sludge or crystals (12%). Eighteen patients underwent cholecystectomy between 4 weeks and 29 months after LSG. CONCLUSIONS:Pediatric patients present with BD at a similar rate after LSG compared with adults. The majority of adolescents, however, manifest with AP. Thus, pancreatitis should be high on the differential diagnosis list when evaluating post-LSG abdominal symptoms. Additional studies are warranted to elucidate the pathophysiology of post-LSG AP for prevention in the future because its etiology may or may not be solely related to BD.
PMID: 31689004
ISSN: 1930-739x
CID: 4604272
Peritoneal drainage is associated with higher survival rates for necrotizing enterocolitis in premature, extremely low birth weight infants
Tashiro, Jun; Wagenaar, Amy E; Perez, Eduardo A; Sola, Juan E
BACKGROUND:To evaluate peritoneal drainage (PD) and laparotomy ± resection/ostomy (LAP) as initial approaches to the surgical management of necrotizing enterocolitis (NEC) in premature, extremely low birth weight (ELBW) infants. METHODS:Kids' Inpatient Database (2003-2012) was searched for cases of NEC (International Classification of Diseases, ninth revision, Clinical Modification [ICD-9-CM] 777.5x) in premature (<37 weeks), extremely low birth weight (<1000 g) infants. Infants were admitted at <28 days of life. Propensity score (PS)-matched analyses were performed, using end points of hospital mortality, length of stay (LOS), and cost of hospitalization. Cases were matched 1:1 on 48 confounding variables (demographic, clinical, and hospital characteristics and 39 comorbidities). RESULTS:On PS-matched comparison, PD had higher survival versus LAP, P = 0.0009. LOS and cost were higher for PD versus LAP, P < 0.003. Survival rates did not differ between PD + LAP and PD-only treatments. LOS and cost were higher for PD + LAP versus PD-only, P < 0.02. PD + LAP infants had higher survival versus LAP, P = 0.0193. LOS and cost were higher for PD + LAP, P < 0.005. CONCLUSIONS:A risk-adjusted PS-matched analysis of operative management in premature, ELBW infants with NEC found higher survival rates associated with PD placement versus LAP, whether PD was used as definitive treatment or with subsequent LAP even after controlling for potential contributors to selection bias (i.e., stability influencing management preference).
PMID: 28985839
ISSN: 1095-8673
CID: 4604212
Classification and Surgical Management of Anorectal Malformations: A Systematic Review and Evidence-based Guideline From the APSA Outcomes and Evidence-based Practice Committee
Smith, Caitlin A; Rialon, Kristy L; Kawaguchi, Akemi; Dellinger, Matthew B; Goldin, Adam B; Acker, Shannon; Kulaylat, Afif N; Chang, Henry; Russell, Katie; Wakeman, Derek; Derderian, S Christopher; Englum, Brian R; Polites, Stephanie F; Lucas, Donald J; Ricca, Robert; Levene, Tamar L; Sulkowski, Jason P; Kelley-Quon, Lorraine I; Tashiro, Jun; Christison-Lagay, Emily R; Mansfield, Sara A; Beres, Alana L; Huerta, Carlos T; Ben Ham, P; Yousef, Yasmine; Rentea, Rebecca M; ,
OBJECTIVE:Treatment of neonates with anorectal malformations (ARMs) can be challenging due to variability in anatomic definitions, multiple approaches to surgical management, and heterogeneity of reported outcomes. The purpose of this systematic review is to summarize existing evidence, identify treatment controversies, and provide guidelines for perioperative care. METHODS:The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee (OEBP) drafted five consensus-based questions regarding management of children with ARMs. These questions were related to categorization of ARMs and optimal methods and timing of surgical management. A comprehensive search strategy was performed, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform the systematic review to attempt to answer five questions related to surgical care of ARM. RESULTS:A total of 10,843 publications were reviewed, of which 90 were included in final recommendations, and some publications addressed more than one question (question: 1 n = 6, 2 n = 63, n = 15, 4 n = 44). Studies contained largely heterogenous groups of ARMs, making direct comparison for each subtype challenging and therefore, no specific recommendation for optimal surgical approach based on outcomes can be made. Both loop and divided colostomy may be acceptable methods of fecal diversion for patients with a diagnosis of anorectal malformation, however, loop colostomies have higher rates of prolapse in the literature reviewed. In terms of timing of repair, there did not appear to be significant differences in outcomes between early and late repair groups. Clear and uniform definitions are needed in order to ensure similar populations of patients are compared moving forward. Recommendations are provided based primarily on A-D levels of evidence. CONCLUSIONS:Evidence-based best practices for ARMs are lacking for many aspects of care. Multi-institutional registries have made progress to address some of these gaps. Further prospective and comparative studies are needed to improve care and provide consensus guidelines for this complex patient population.
PMID: 38997855
ISSN: 1531-5037
CID: 5689682
Management and Outcomes of Pediatric Lymphatic Malformations: A Systematic Review From the APSA Outcomes and Evidence-Based Practice Committee
Huerta, Carlos Theodore; Beres, Alana L; Englum, Brian R; Gonzalez, Katherine; Levene, Tamar; Wakeman, Derek; Yousef, Yasmine; Gulack, Brian C; Chang, Henry L; Christison-Lagay, Emily R; Ham, Phillip Benson; Mansfield, Sara A; Kulaylat, Afif N; Lucas, Donald J; Rentea, Rebecca M; Pennell, Christopher P; Sulkowski, Jason P; Russell, Katie W; Ricca, Robert L; Kelley-Quon, Lorraine I; Tashiro, Jun; Rialon, Kristy L; ,
BACKGROUND:Significant variation in management strategies for lymphatic malformations (LMs) in children persists. The goal of this systematic review is to summarize outcomes for medical therapy, sclerotherapy, and surgery, and to provide evidence-based recommendations regarding the treatment. METHODS:Three questions regarding LM management were generated according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Publicly available databases were queried to identify articles published from January 1, 1990, to December 31, 2021. A consensus statement of recommendations was generated in response to each question. RESULTS:The initial search identified 9326 abstracts, each reviewed by two authors. A total of 600 abstracts met selection criteria for full manuscript review with 202 subsequently utilized for extraction of data. Medical therapy, such as sirolimus, can be used as an adjunct with percutaneous treatments or surgery, or for extensive LM. Sclerotherapy can achieve partial or complete response in over 90% of patients and is most effective for macrocystic lesions. Depending on the size, extent, and location of the malformation, surgery can be considered. CONCLUSION/CONCLUSIONS:Evidence supporting best practices for the safety and effectiveness of management for LMs is currently of moderate quality. Many patients benefit from multi-modal treatment determined by the extent and type of LM. A multidisciplinary approach is recommended to determine the optimal individualized treatment for each patient.
PMID: 38914511
ISSN: 1531-5037
CID: 5689642
Evaluation and Management of Biliary Dyskinesia in Children and Adolescents: A Systematic Review From the APSA Outcomes and Evidence-Based Committee
Kulaylat, Afif N; Lucas, Donald J; Chang, Henry L; Derderian, S Christopher; Beres, Alana L; Ham, P Benson; Huerta, Carlos T; Sulkowski, Jason P; Wakeman, Derek; Englum, Brian R; Gulack, Brian C; Acker, Shannon N; Gonzalez, Katherine W; Levene, Tamar L; Christison-Lagay, Emily; Mansfield, Sara A; Yousef, Yasmine; Pennell, Christopher P; Russell, Katie W; Rentea, Rebecca M; Tashiro, Jun; Diesen, Diana L; Alemayehu, Hanna; Ricca, Robert; Kelley-Quon, Lorraine; Rialon, Kristy L
INTRODUCTION/BACKGROUND:The diagnosis and management of biliary dyskinesia in children and adolescents remains variable and controversial. The American Pediatric Surgical Association Outcomes and Evidence-Based Practice Committee (APSA OEBP) performed a systematic review of the literature to develop evidence-based recommendations. METHODS:Through an iterative process, the membership of the APSA OEBP developed five a priori questions focused on diagnostic criteria, indications for cholecystectomy, short and long-term outcomes, predictors of success/benefit, and outcomes of medical management. A systematic review was conducted, and articles were selected for review following Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) guidelines. Risk of bias was assessed using Methodologic Index for Non-Randomized Studies (MINORS) criteria. The Oxford Levels of Evidence and Grades of Recommendation were utilized. RESULTS:The diagnostic criteria for biliary dyskinesia in children and adolescents are not clearly defined. Cholecystectomy may provide long-term partial or complete relief in some patients; however, there are no reliable predictors of symptom relief. Some patients may experience resolution of symptoms with non-operative management. CONCLUSIONS:Pediatric biliary dyskinesia remains an ill-defined clinical entity. Pediatric-specific guidelines are necessary to better characterize the condition, guide work-up, and provide management recommendations. Prospective studies are necessary to more reliably identify patients who may benefit from cholecystectomy. LEVEL OF EVIDENCE/METHODS:Level 3-4. TYPE OF STUDY/METHODS:Systematic Review of Level 3-4 Studies.
PMID: 39227244
ISSN: 1531-5037
CID: 5687842
The impact of parental bariatric surgery and patient age on laparoscopic sleeve gastrectomy outcomes in adolescents
Tashiro, Jun; McKenna, Elise; Alberto, Emily C; Mackey, Eleanor R; Nadler, Evan P
BACKGROUND:Adolescent obesity is multifactorial, but parental history is the most significant risk factor. Laparoscopic sleeve gastrectomy (LSG) is part of the multidisciplinary approach to adolescent weight loss. OBJECTIVE:We aimed to evaluate the effects of parental history of bariatric surgery, as well as age at time of operation, on adolescents who underwent LSG at our institution. METHODS:We performed a retrospective review of patients, aged 10 to 19 years, who underwent LSG from January 2010 to December 2019. The adolescent bariatric surgical dataset maintained by our group was used to obtain patient demographics, weight, body mass index (BMI), and parental history of bariatric surgery. RESULTS:Among 328 patients, 76 (23.2%) had parents who had previously undergone bariatric surgery. These patients were significantly heavier by weight (p = 0.012) at the time of operation but had no difference in postoperative weight loss. When all patients were compared by age at operation (< 16 years, n = 102, ≥ 16 years, n = 226), there were few differences in outcomes. CONCLUSIONS:LSG is an effective approach to surgical weight loss in adolescents. Patient age should not be a barrier to weight loss surgery, especially among patients with a parental history of obesity. By intervening at a younger age, the metabolic sequelae of obesity may be reduced.
PMID: 35403902
ISSN: 1432-2218
CID: 5201792
It's time to deconstruct treatment-failure: A randomized controlled trial of nonoperative management of uncomplicated pediatric appendicitis with antibiotics alone [Meeting Abstract]
Otero, Sofia Perez; Metzger, Julia W.; Choi, Beatrix H.; Ramaraj, Akila; Tashiro, Jun; Kuenzler, Keith A.; Ginsburg, Howard B.; Tomita, Sandra S.; Fisher, Jason C.
ISI:000748293000011
ISSN: 0022-3468
CID: 5242732
Metrics of shock in pediatric trauma patients: A systematic search and review
Alberto, Emily C; McKenna, Elise; Amberson, Michael J; Tashiro, Jun; Donnelly, Katie; Thenappan, Arunachalam A; Tempel, Peyton E; Ranganna, Adesh S; Keller, Susan; Marsic, Ivan; Sarcevic, Aleksandra; O'Connell, Karen J; Burd, Randall S
INTRODUCTION/BACKGROUND:. Shock-index (SI) and systolic blood pressure (SBP) are metrics for identifying children and adults with hemodynamic instability following injury. The purpose of this systematic review was to assess the quality of these metrics as predictors of outcomes following pediatric injury. MATERIALS AND METHODS/METHODS:We conducted a literature search in Pubmed, SCOPUS, and CINAHL to identify studies describing the association between shock metrics on the morbidity and mortality of injured children and adolescents. We used the data presented in the studies to calculate the sensitivity and specificity for each metric. This study was registered with Prospero, protocol CRD42020162971. RESULTS:Fifteen articles met the inclusion criteria. seven studies evaluated SI or SIPA score, an age-corrected version of SI, as predictors of outcomes following pediatric trauma, with one study comparing SIPA score and SBP and one study comparing SI and SBP. The remaining eight studies evaluated SBP as the primary indicator of shock. The median sensitivity for predicting mortality and need for blood transfusion was highest for SI, followed by SIPA, and then SBP. The median specificity for predicting these outcomes was highest for SBP, followed by SIPA, and then SI. CONCLUSIONS:Common conclusions were that high SIPA scores were more specific than SI and more sensitive than SBP. SIPA score had better discrimination for severely injured children compared to SI and SBP. An elevated SIPA was associated with a greater need for blood transfusion and higher in-hospital mortality. SIPA is specific enough to exclude most patients who do not require a blood transfusion.
PMID: 34238538
ISSN: 1879-0267
CID: 4996482
Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway
Alberto, Emily C; Tashiro, Jun; Zheng, Yinan; Sandler, Anthony; Kane, Timothy; Gomez-Lobo, Veronica; Petrosyan, Mikael
PURPOSE/OBJECTIVE:Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays. METHODS:A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed. RESULTS:Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001). CONCLUSIONS:Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.
PMID: 33242170
ISSN: 1437-9813
CID: 4996452