Faculty Bibliography
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Journal of laparoendoscopic & advanced surgical techniques. Pt. A. 2020:30(1):87-91.DOI: 10.1089/lap.2019.0248
Laparoscopic Technique in the Management of High Anorectal Malformations: A Propensity Score-Matched Outcome Study Using a Large Inpatient Database
PMID: 31770066
ISSN: 1557-9034
CID: 4603642
Lymph Node Sampling and Survival in Child and Adolescent Extremity Soft-Tissue Sarcoma
BACKGROUND:The significance of lymph node sampling (LNS) on disease-specific survival (DSS) of extremity soft tissue sarcomas (STS) is unknown. We investigated the effect of LNS on DSS in child and adolescent extremity STS. MATERIALS AND METHODS:The Surveillance, Epidemiology, and End Results registry was queried for patients aged <20Â y with extremity STS who underwent surgery. Patient demographics were collected and analyzed. RESULTS:A total of 1550 patients were included, with findings of 10-y DSS of 74% for all extremity STS and 49% for rhabdoymyosarcoma (RMS) (PÂ <Â 0.005). LNS was associated with worse DSS in patients with extremity nonrhabdomyosacrcoma soft tissue sarcomas (79% versus 84%, PÂ =Â 0.036). Conversely, LNS was associated with an improved DSS in patients with extremity RMS (64% versus 49%, PÂ =Â 0.005). CONCLUSIONS:LNS is positively associated with an improved DSS in child and adolescent extremity RMS. Multivariate analysis found no correlation between DSS and LNS in child and adolescent extremity nonrhabdomyosarcoma soft tissue sarcomas.
PMID: 31028942
ISSN: 1095-8673
CID: 4604262
Swimming Pool Electrical Injuries: Steps Toward Prevention
OBJECTIVE:Electrical injuries in swimming pools are an important pediatric public health concern. We sought to (1) improve our understanding of the clinical presentation and outcomes following and (2) describe the epidemiology of swimming pool electrical injuries in the United States. METHODS:We reviewed 4 cases of pediatric (<18 y old) electrical injury from a single, urban level 1 pediatric trauma center. We also queried the National Electronic Injury Surveillance System (NEISS) for emergency department visits due to electrical injury associated with swimming pools, occurring between 1991 and 2013. RESULTS:Overall, 566 cases were reported, with a mean (SD) age of 9.2 (4.1) years. Patients were mostly treated and released from the emergency department (91.8%), whereas 8.2% were hospitalized. When stated, injuries occurred most frequently at home (57.0%), followed by public (23.9%) and sports facilities (19.1%). Electrical outlets or receptacles (39.8%) were most commonly implicated, followed by electrical system doors (18.2%), electric wiring systems (17.0%), thermostats (16.3%), hair dryers (4.6%), and radios (4.1%). Pediatric cases represented 48.4% of swimming pool-related electrical injuries reported to NEISS. CONCLUSIONS:Electrical injuries occurring in and around swimming pools remain an important source of morbidity and mortality. Although NEISS monitors sentinel events, current efforts at preventing such cases are less than adequate. All electrical outlets near swimming pools should be properly wired with ground fault circuit interrupter devices. Possible approaches to increasing safe electrical device installation are through strengthening public awareness and education of the potential for injury, as well as changes to current inspection regulations.
PMID: 28072669
ISSN: 1535-1815
CID: 4604152
Teenage Trauma Patients Are at Increased Risk for Readmission for Mental Diseases and Disorders
BACKGROUND:Most studies of readmission after trauma are limited to single institutions or single states. The purpose of this study was to determine the risk factors for readmission after trauma for mental illness including readmissions to different hospitals across the United States. MATERIALS AND METHODS:The Nationwide Readmission Database for 2013 and 2014 was queried for all patients aged 13 to 64Â y with a nonelective admission for trauma and a nonelective readmission within 30 d. Multivariable logistic regression was performed for readmission for mental diseases and disorders. RESULTS:During the study period, 53,402 patients were readmitted within 30 d after trauma. The most common major diagnostic category on readmission was mental diseases and disorders (12.1%). The age group with the highest percentage of readmissions for mental diseases and disorders was 13 to 17Â y (38%). On multivariable regression, the teenage group was also the most likely to be readmitted for mental diseases and disorders compared to 18-44Â y (odds ratio [OR] 0.45, PÂ <Â 0.01) and 45-64Â y (OR 0.24, PÂ <Â 0.01). Other high-risk comorbidities included HIV infection (OR 2.4, PÂ <Â 0.01), psychosis (OR 2.2, PÂ <Â 0.01), drug (OR 2.0, PÂ <Â 0.01), and alcohol (OR 1.4, PÂ <Â 0.01) abuse. CONCLUSIONS:Teenage trauma patients are at increased risk for hospital readmission for mental illness. Efforts to reduce these admissions should be targeted toward individuals with high-risk comorbidities such as HIV infection, psychosis, and substance abuse.
PMID: 30463750
ISSN: 1095-8673
CID: 4604252
Incidence and outcomes of pediatric extremity melanoma: A propensity score matched SEER study
BACKGROUND:There is a paucity of literature on treatment of melanoma in children with surgical management extrapolated from adult experience. The incidence and clinical outcomes of pediatric extremity melanoma were studied. METHODS:SEER registry was analyzed between 1973 and 2010 for patients <20years old with extremity melanoma. Multivariate and propensity-score matched analyses were performed to identify independent predictors of survival. RESULTS:Overall, 917 patients were identified with an age-adjusted incidence of 0.2/100,000 persons, annual percent change 0.96. Most had localized disease (77%), histology revealing melanoma-not otherwise specified (52%). Surgical procedures performed included wide local excision (50%), excisional biopsy (32%), lymphadenectomy (LA) (28%), and sentinel lymph node biopsy (SLNB) (15%). Overall, 30-year disease specific mortality was 7% with lower survival for extremity melanoma (90%), males (89%), nodular histology (69%), and distant disease (36%) (all P<0.05). Post-treatment multivariate analysis revealed localized disease (HR 9.76; P=0.006) as an independent prognosticator of survival; earlier diagnostic years 1988-1999 (HR 2.606; P=0.017) were a negative prognosticator of survival. Propensity-score matched analysis found no difference in survival between SLNB/LA vs no sampling for regional/distant disease. CONCLUSIONS:Pediatric extremity melanoma in SEER demonstrate no survival advantage between children undergoing sampling procedures vs no sampling for regional/distant disease. TYPE OF STUDY/METHODS:Retrospective, prognostic study. LEVEL OF EVIDENCE/METHODS:III.
PMID: 29602554
ISSN: 1531-5037
CID: 4604232
Weekend vs. weekday appendectomy for complicated appendicitis, effects on outcomes and operative approach
PURPOSE/OBJECTIVE:We hypothesized that laparoscopic (LA) or open appendectomy (OA) outcomes in complicated appendicitis are associated with weekend vs. weekday procedure date. METHODS:We queried the Kids' Inpatient Database (1997-2012) for complicated (540.0, 540.1) appendicitis treated with LA or OA. Propensity score (PS)-matched analysis compared outcomes associated with weekend vs. weekday LA and OA. RESULTS:Overall, 103,501 cases of complicated appendicitis were identified. On 1:1 PS-matched analyses of complicated appendicitis, weekday OA had increased wound infection rates (odds ratio: 1.3) vs. weekend OA, p < 0.001. Weekend OA had higher pneumonia rates (1.4) and longer length of stay, but lower home healthcare requirement following discharge vs. weekday OA, p < 0.05. Weekend and weekday LA had no significant outcome differences. CONCLUSION/CONCLUSIONS:On a PS-matched comparison of appendectomies performed for complicated appendicitis on weekends and weekdays, procedure day is associated with different complication rates and resource utilization for OA. For LA, no weekend effect was noted for complicated appendicitis. To ensure the optimal patient care, prospective studies should be sought to identify causes of complications dependent on the day of procedure.
PMID: 29626244
ISSN: 1437-9813
CID: 4604242
Looped suture versus stapler device in pediatric laparoscopic appendectomy: a comparative outcomes and intraoperative cost analysis
BACKGROUND:Appendiceal ligation during pediatric laparoscopic appendectomy (LA) may be performed using looped suture versus stapler. Controversy regarding the utility of either method exists. Clinical outcomes and cost analysis of LA with both methods were compared. METHODS:All pediatric LA were performed from fiscal years 2013 and 2014 by two pediatric surgeons. While one surgeon used looped suture, the other used stapler exclusively. chi-Square tests were performed to analyze associations. RESULTS:Two hundred thirty-eight cases were analyzed where looped suture versus stapler LA was performed in 46% and 54% of patients, respectively. Operating room costs were $317.10 and $707.12/person for looped suture and stapler LA, respectively (P<0.0001). Difference in cost of $390.02/person was attributed solely to ligation type. On bivariate analysis, rate of in-hospital complications, length of stay, return-to-ER and readmission within 30 days did not significantly differ between groups. CONCLUSION/CONCLUSIONS:A comparative analysis of looped suture versus stapler device during LA for pediatric appendicitis revealed that postoperative complications, length of stay, ER visits and readmissions were not significantly different. Looped suture LA was significantly more cost efficient than stapler LA. In pediatric appendicitis, appendiceal ligation during LA may be performed safely and cost effectively with looped suture versus stapler. TYPE OF STUDY/METHODS:Cost effectiveness LEVEL OF EVIDENCE: III.
PMID: 28550935
ISSN: 1531-5037
CID: 4604172
Total retroperitoneal approach to aortic reconstruction: A novel technique for aorto-enteric fistulae and graft infections [Case Report]
Aorto-enteric fistulae pose a challenging negative outcome of aortic intervention. Treatment involves graft excision, and recently, more enthusiasm has met in situ revascularization over extra-anatomic bypass. This has been traditionally performed through the transperitoneal approach via a midline abdominal incision. We propose an exclusively total retroperitoneal technique in managing this complication with regard to both the vascular and alimentary tract technical aspects of the procedure. This involves exclusion and bypass of the affected segment followed by en-mass resection of the affected segment with the duodenum, and finally, bowel anastomosis. We present a case of an aorto-enteric fistulae illustrating classical radiological findings treated via a flank incision and retroperitoneal technique after a temporizing endovascular stent placement at an outside institution. Peri-operative course was uneventful. The retroperitoneal approach has been shown to be equivalent to its transperitoneal counterpart in many aspects of treating aortic disease. It has also been shown to be superior in others, including but not limited to, faster return of bowel function, decreased respiratory complications, less blood loss and shorter length of stay in the intensive care unit (ICU) and hospital. We recommend adding this approach to every vascular surgeons operative armamentarium when it comes to managing aorto-enteric fistulae. This might be especially helpful in avoiding re-operative planes, thus minimizing blood loss and iatrogenic bowel injury, better aortic exposure, and adequate access to the duodenum.
PMCID:5833235
PMID: 29511543
ISSN: 2050-313x
CID: 4604222
Open Versus Closed Reduction of Maxillary Fractures: Complications and Resource Utilization
INTRODUCTION/BACKGROUND:Maxillary fractures are frequently managed depending on the surgeon's preferences, nature of the injury, presence of associated injuries, and comorbidities. Current literature advocates open reduction with plating versus closed techniques. However, data defining associated costs and complications comparing the 2 approaches remains lacking. METHODS:National Inpatient Sample (2006-2011) was examined for patients undergoing closed or open (76.73-76.74) reduction of maxillary fractures. Treatment-related complications were regarded as re-exploration of surgical site, hemorrhage, hematoma, seroma, wound infection, and dehiscence. RESULTS:Overall, 22,157 patients were identified. There were 18,874 closed and 3283 open procedures. Median age was 35 (interquartile range 27). Median length of stay (LOS) was 4 days. Median total charges were reported as 51486.80 USD. Males comprised 77% of the cohort. 68% of patients were Caucasian. Private payer/HMO accounted for the largest source of health care coverage (43.5%). On risk-adjusted multivariate analysis, there was no difference in surgical approach regarding incidence of postoperative complications. Males (2.73), nonprivate insurer payer (P = 0.002), South region (2.49), and transferred patients (2.55) had higher incidence of complications. Presence of chronic pulmonary disease (2.87) and coagulopathy (6.62) also increased risk of complications. Length of stay was shorter for open reduction (0.68) versus closed. Total charges were also less for open approach (0.37). CONCLUSION/CONCLUSIONS:While surgical approach did not affect complications, open approach favorably affected LOS and total charges. Future studies should focus on comorbidities, demographics, and associated injuries in relation to resource utilization for maxillary fractures. In current economic environment, such information might further dictate management options.
PMID: 28834837
ISSN: 1536-3732
CID: 4604202
Success and safety of endoscopic retrograde cholangiopancreatography in children
PURPOSE/OBJECTIVE:Despite its diagnostic and therapeutic utility, endoscopic retrograde cholangiopancreatography (ERCP) is underutilized in children. METHODS:Patients younger than 18years undergoing ERCP from 2000 to 2014 at a children's hospital were identified. Patient characteristics and outcomes were evaluated. RESULTS:Overall, 215 ERCPs (78% therapeutic) were performed in 184 patients. Our cohort was 67% female, with a median age (IQR) of 14 (8) years. Common indications were choledocholithiasis, pancreatitis, sclerosing cholangitis, and postoperative complication. ERCP was performed with an adult duodenoscope in 96% of cases and with a pediatric duodenoscope in the remainder. Patients requiring a pediatric scope ranged in weight from 4.3 to 22.8kg, with ages from 2months to 6years. Cannulation was successful in 97% of cases. Findings included bile duct (BD) stones, BD dilatation, sclerosing cholangitis, BD stricture, pancreatic duct (PD) disruption, choledochal cyst, pancreas divisum, and BD leak. The most common therapeutic techniques were sphincterotomy, stone extraction, and stent. Complication rate was overall 10% with no deaths. On multivariate analysis, PD cannulation was associated with pancreatitis (OR 3.48), while age<4years (10.7), male gender (12.8), and precut sphincterotomy (31.3) were associated with hemorrhage (all p<0.05). CONCLUSION/CONCLUSIONS:ERCP can be performed successfully and safely in children with complication rates comparable to those in adults. The type of cannulation and patient age are independent risk factors for complications. LEVEL OF EVIDENCE/METHODS:Treatment study-IV.
PMID: 28188033
ISSN: 1531-5037
CID: 4604162
