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1.  Laparoscopic Transperitoneal Repair of Pediatric Diaphragm Eventration Using an Endostapler Device 
Abstract
Background
Minimally invasive repairs of pediatric diaphragm eventration have been well described via a thoracoscopic approach, oftentimes requiring single-lung ventilation and tube thoracostomy, with the disadvantage of not being able to clearly visualize what lies beneath the diaphragm. We describe a novel pediatric diaphragm eventration repair using a laparoscopic transperitoneal approach and an endostapler device. We also describe our initial experience with this technique.
Patients and Methods
Four pediatric diaphragmatic eventration patients underwent laparoscopic transperitoneal repair using an endostapler device. Repairs were performed in both male and female patients with right-sided eventrations. We approach the repair in a transperitoneal fashion using inverting sutures at the apex of the diaphragm to create tension toward the pelvis. Subsequently, an endostapler is used to remove the redundant portion of diaphragm, leaving a repaired, taut diaphragm.
Results
The median age at operation was 10.5 months. The median operative time was 70 minutes. There was no mortality, surgical complications, or recurrence at a median follow-up of 17 months.
Conclusions
This laparoscopic approach allows for clear visualization of the intraabdominal organs and, at least in our early experience, a very simple, straightforward operation. Additionally, with the use of the endostapler, the redundant, often weakened diaphragm is removed, leaving the native, healthy diaphragm behind, resulting in a reliable and reproducible repair. This repair should be considered as a feasible alternative approach to the more traditional open and thoracoscopic repairs.
doi:10.1089/lap.2013.0113
PMCID: PMC3806401  PMID: 23937143
2.  Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Infancy 
Abstract
Background
Minimally invasive surgical techniques, specifically the thoracoscopic approach, have been applied to congenital diaphragmatic hernia (CDH) with varying outcomes from selected centers. The aim of our study was to examine the rate of successful completion and compare outcomes between open and thoracoscopic approaches in CDH repair.
Methods
We performed a retrospective analysis of infants with CDH repair (From February 2004 to January 2008). Patients were divided into thoracoscopic and open groups, based on operative approach. We analyzed demographic, clinical, and hospitalization characteristics to compare the completion rate and outcomes in these two groups.
Results
Analysis of 31 infants with CDH (14 thorascocopic and 17 open) demonstrated no differences in sex (P = 0.132), age (P = 0.807), birthweight (P = 0.256), weight at operation (P = 0.647), pulmonary hypertension (P = 0.067), preoperative intensive care unit (ICU) days (P = 0.673), ventilator days (P = 0.944), or use of a patch (P = 0.999) between the groups. Seventy-nine percent of thoracoscopic operative approaches were completed successfully. There was a significant difference between the open and thoracoscopic groups with respect to estimated gestational age (39 versus 36.5 weeks; P = 0.006) and operating room time (70 versus 145 minutes; P = 0.004). The total (P = 0.662), ICU (P = 0.889), and postoperative (P = 0.619) length of stay and days on ventilator (P = 0.705), as well as days until initial enteral feeds (P = 0.092), were not significantly different between groups. There were no deaths and no evidence of recurrence, with a mean follow-up of 346 days.
Conclusions
In our early experience, the thoracoscopic approach for congenital diaphragmatic hernia repair was completed in 80% of our patient population with minimal exclusion criteria. Further study, with larger sample sizes, is needed to ascertain differences in outcomes, such as length of stay and initiation of enteral feeding.
doi:10.1089/lap.2009.0150
PMCID: PMC2854018  PMID: 20059390
3.  OUTCOMES IN CHILDREN WITH INTESTINAL FAILURE FOLLOWING LISTING FOR INTESTINAL TRANSPLANT 
Purpose
The purpose of this study was to describe the population of pediatric patients waiting for intestinal transplant and to evaluate the risk of death or transplant by specific disease states.
Methods
We studied the United Network for Organ Sharing (UNOS) database (1/1/1991–5/16/08) for patients ≤21years-old at first listing for intestinal transplant and examined their age, sex, weight, and diagnoses. Time to list removal was summarized with cumulative incidence curves. Multinomial logistic regression was used to compare relative risk ratios for removal from the list for transplant, death or other reasons.
Results
We identified 1,712 children listed for intestinal transplant (57% male, 51% < 1 yr, weight 8.1kg (IQR 6.1–14.1) at listing). Median age and weight at transplant (N=852) were 1yr (IQR 1–5) and 10kg (IQR 6.5–16.3). Regression analysis demonstrated significant differences in outcomes among disease conditions (p <0.001). Compared to the gastroschisis group, the relative risk ratio for death versus transplant was higher in the NEC group (p=0.015), lower in the SGS group (p=0.001) and not different in the volvulus group (p=0.94) after adjustment for weight and sex.
Conclusions
We conclude that the relative risk of transplant versus death varies significantly by the disease condition of the patient.
doi:10.1016/j.jpedsurg.2009.10.019
PMCID: PMC2813842  PMID: 20105588
Intestinal Failure; Intestinal Transplant; Outcomes; Gastroschisis; Necrotizing Enterocolitis; Volvulus; Short Gut Syndrome
4.  Outcomes in Children After Intestinal Transplant 
Pediatrics  2010;125(3):e550-e558.
OBJECTIVE
The survival rates after pediatric intestinal transplant according to underlying disease are unknown. The objective of our study was to describe the population of pediatric patients receiving an intestinal transplant and to evaluate survival according to specific disease condition.
PATIENTS
Pediatric patients (≤21 years of age) with intestinal failure meeting criteria for intestinal transplant were included in the study.
METHODS
A retrospective review of the United Network for Organ Sharing intestinal transplant database (January 1, 1991, to May 16, 2008), including all pediatric transplant centers participating in the United Network for Organ Sharing, was conducted. The main outcome measures were survival and mortality.
RESULTS
Eight hundred fifty-two children received an intestinal transplant (54% male). Median age and weight at the time of transplant were 1 year (interquartile rage: 1–5) and 10.7 kg (interquartile rage: 7.8–21.7). Sixty-nine percent of patients also received a simultaneous liver transplant. The most common diagnoses among patients who received a transplant were gastroschisis (24%), necrotizing enterocolitis (15%), volvulus (14%), other causes of short-gut syndrome (19%), functional bowel syndrome (16%), and Hirschsprung disease (7%). The Kaplan-Meier curves demonstrated variation in patient survival according to diagnosis. Cox regression analysis confirmed a survival difference according to diagnosis (P < .001) and demonstrated a survival advantage for those patients listed with a diagnosis of volvulus (P < .01) compared with the reference gastroschisis. After adjusting for gender, recipient weight, and concomitant liver transplant, children with volvulus had a lower hazard ratio for survival and a lower risk of mortality.
CONCLUSIONS
Survival after intestinal transplant was associated with the underlying disease state. The explanation for these findings requiresadditionalinvestigationintothedifferencesincharacteristics of the population of children with intestinal failure.
doi:10.1542/peds.2009-1713
PMCID: PMC2854035  PMID: 20142294
intestinal failure; intestinal transplant; outcomes; survival; mortality; pediatrics; children
5.  Outcomes in Neonates with Gastroschisis in U.S. Children’s Hospitals 
American journal of perinatology  2009;27(1):97-101.
Our objectives are to report patient characteristics, comorbidities, and outcomes for gastroschisis patients and analyze factors associated with mortality and sepsis. Using Pediatric Health Information System data, we examined neonates with both an International Classification of Diseases, 9th Revision diagnosis (756.79) and procedure (54.71) code for gastroschisis (2003 to 2008). We examined descriptive characteristics and conducted multivariate regression models examining risk factors for mortality, during the birth hospitalization, and sepsis. Analysis of 2490 neonates with gastroschisis found 90 deaths (3.6%) and sepsis in 766 (31%). Critical comorbidities and procedures are cardiovascular defects (15%), pulmonary conditions (5%), intestinal atresia (11%), intestinal resection (12.5%), and ostomy formation (8.3%). Factors associated with mortality were large bowel resection (odds ratio [OR] 8.26, 95% confidence interval [CI] 1.17 to 58.17), congenital circulatory (OR 5.62, 95% CI 2.11 to 14.91), and pulmonary (OR 8.22, 95% CI 2.75 to 24.58) disease, and sepsis (OR 3.87, 95% CI 1.51 to 9.91). Factors associated with sepsis include intestinal ostomy (OR 2.94, 95% CI 1.71 to 5.05), respiratory failure (OR 2.48, 95% CI 1.85 to 3.34), congenital circulatory anomalies (OR 1.58, 95% CI 1.10 to 2.28), and necrotizing enterocolitis (OR 4.38, 95% CI 2.51 to 7.67). Further investigation into modifiable factors such as small bowel ostomy and prevention of sepsis and necrotizing enterocolitis is warranted to guide surgical decision making and postoperative management.
doi:10.1055/s-0029-1241729
PMCID: PMC2854024  PMID: 19866404
Gastroschisis; outcomes; mortality; sepsis; comorbidities
6.  Thoracoscopic Repair of Congenital Diaphragmatic Hernia in Infancy 
Background
Minimally invasive surgical techniques, specifically the thoracoscopic approach, have been applied to congenital diaphragmatic hernia (CDH) with varying outcomes from selected centers. The aim of our study was to examine the rate of successful completion and compare outcomes between open and thoracoscopic approaches in CDH repair.
Methods
We performed a retrospective analysis of infants with CDH repair (From February 2004 to January 2008). Patients were divided into thoracoscopic and open groups, based on operative approach. We analyzed demographic, clinical, and hospitalization characteristics to compare the completion rate and outcomes in these two groups.
Results
Analysis of 31 infants with CDH (14 thorascocopic and 17 open) demonstrated no differences in sex (P = 0.132), age (P = 0.807), birthweight (P = 0.256), weight at operation (P = 0.647), pulmonary hypertension (P = 0.067), preoperative intensive care unit (ICU) days (P = 0.673), ventilator days (P = 0.944), or use of a patch (P = 0.999) between the groups. Seventy-nine percent of thoracoscopic operative approaches were completed successfully. There was a significant difference between the open and thoracoscopic groups with respect to estimated gestational age (39 versus 36.5 weeks; P = 0.006) and operating room time (70 versus 145 minutes; P = 0.004). The total (P = 0.662), ICU (P = 0.889), and postoperative (P = 0.619) length of stay and days on ventilator (P = 0.705), as well as days until initial enteral feeds (P = 0.092), were not significantly different between groups. There were no deaths and no evidence of recurrence, with a mean follow-up of 346 days.
Conclusions
In our early experience, the thoracoscopic approach for congenital diaphragmatic hernia repair was completed in 80% of our patient population with minimal exclusion criteria. Further study, with larger sample sizes, is needed to ascertain differences in outcomes, such as length of stay and initiation of enteral feeding.
doi:10.1089/lap.2009.0150
PMCID: PMC2854018  PMID: 20059390
7.  Postoperative Bowel Perforation due to Heterotopic Ossification (Myositis Ossificans Traumatica): A Case Report and Review of the Literature 
Heterotopic ossification (HO) is the ectopic development of normal bone within soft tissue that can occur after traumatic injury. It is uncommon and may be missed or misdiagnosed, which can lead to complications. We report the case of an 84-year-old male with a previous history of a laparotomy who underwent resection of an intra-abdominal tumor through a midline incision. On postoperative day six, the patient was taken to the operating room, as succus was draining from the incision. Upon re-exploration, sharp bone-like material was found in the wound directly adjacent to an enterotomy. Pathology confirmed mature lamellar bone and the diagnosis of HO. This is the first report of postoperative intestinal perforation secondary to HO in a midline wound. We report this case to encourage accurate reporting of HO and its morbidity and complications for the benefit of appropriate surgical planning and epidemiologic tracking of outcomes.
doi:10.1155/2011/908514
PMCID: PMC3350174  PMID: 22606429
8.  STEROID USE AFTER THE KASAI PROCEDURE FOR BILIARY ATRESIA 
American journal of surgery  2010;199(5):680-684.
Purpose
To describe patients undergoing the Kasai procedure at childrens hospitals, evaluate outcomes, and analyze the association of these outcomes with systemic steroid use.
Methods
We identified biliary atresia patients (ICD-9 751.61) that underwent a Kasai procedure at free-standing children's hospitals in the Pediatric Health Information System database (2003-2008). We examined descriptive characteristics and used regression analyses to determine whether post-operative steroid usage was associated with length of stay, mortality, or cholangitis.
Results
Of the 516 children identified (40% male, 50% <2 months-old), 239 (46%) received peri-operative steroids. The mean total and post-operative length of stay was 14.5±19.7 days and 11.3±16.3 days, respectively. In our analysis, post-operative steroid use was significantly associated with a 3.5 day decrease in post-operative length of stay (95%CI 0.03-6.97).
Conclusions
Peri-operative steroids after the Kasai procedure are associated with shorter post-operative length of stay. Work is needed to ascertain whether this relationship is causal.
doi:10.1016/j.amjsurg.2010.01.014
PMCID: PMC2871160  PMID: 20466116
biliary atresia; Kasai procedure; steroids; outcomes; length of stay

Results 1-8 (8)