- Pediatric Surgery
- Minimal access neonatal surgery
- Surgical Oncology
- Adolescent Bariatric Surgery
- Chest Wall Deformities
- Congenital Diaphragmatic Hernia
- Omental Transposition in Moya Moya Disease
Assistant Professor - Med Center Line, Surgery - Pediatric Surgery
Program Director Pediatric Surgery Fellowship, Lucile Packard Children's Hospital (2015 - Present)
Director Bariatric Surgery Program, Lucile Packard Childrens Stanford (2014 - Present)
Director Outpatient Pediatric Surgery Clinics, Lucile Packard Children's Hospital (2011 - Present)
Associate Program Director Pediatric Surgery Fellowship, Lucile Packard Children's Hospital-Stanford University (2013 - 2015)
Site Director Pediatric Surgery Rotation-General Sugery Residents, Lucile Packard Children's Hospital-Stanford University (2011 - Present)
Director Hispanic Center for Pediatric Surgery, Lucile Packard Children's Hospital (2011 - Present)
Medical Director Vascular Access program, Lucile Packard Children's Hospital-Stanford University (2011 - 2016)
Honors & Awards
Fellow of the American College of Surgeons, American College of Surgeons (2013)
Outstanding Faculty Teaching Award, Pediatric Surgery Fellowship, Stanford University (2013)
Hispanic Center of Excellence Fellow, Hispanic Center of Excellence-Stanford University (2011-2012)
Ramsay Family endowed Fellow in Pediatric Surgery, Lucile Packard Children's Hospital-Stanford University (2009-2011)
House Officer of the Year, College of Medicine, University of Nebraska Medical Center (2008)
Alpha Omega Alpha, AOA (2007)
Outstanding House Staff Teaching Award, University of Nebraska Medical Center (2007)
Outstanding Laparoendoscopic House Staff Award, Society of Laparoendoscopic Surgeons (2006)
Board Certification: Pediatric Surgery, American Board of Surgery (2012)
Board Certification: General Surgery, American Board of Surgery (2009)
Fellowship:Stanford Hospital and Clinics - Pediatric Surgery (2011) CA
General Surgery Residency, University of Nebraska Medical Center, General Surgery (2009)
Internship:University of Nebraska Medical Center (2009) NE
Residency:British Hospital of Buenos Aires (2005)
Medical Education:University of Buenos Aires (2001)
Community and International Work
Hispanic Center for Pediatric Surgery, Stanford University
Clinical Outcomes-Quality Improvement
Opportunities for Student Involvement
Current Research and Scholarly Interests
Minimal Access Surgery
Sutured vs Sutureless Gastroschisis Closure
Ultrasound vs anatomic landmark central line placement
Hispanic Center for Pediatric Surgery
A Prospective Trial of Ultrasound Versus Landmark Guided Central Venous Access in the Pediatric Population
The investigators hypothesized that, in children undergoing venous cannulation for central line placement by pediatric surgeons, ultrasound-guided cannulation leads to an increase in successful venous cannulation at first attempt compared to landmark guided cannulation.
Stanford is currently not accepting patients for this trial.
Sutureless vs Sutured Gastroschisis Closure
This study aims to prospectively assess outcomes of sutureless versus sutured gastroschisis closure with a randomized control trial. The parameters of this trial were determined using our retrospective study as pilot data. Primary outcome measures will be time on ventilator and time to initiating enteral feeds. Other outcome measures will include cosmetic outcome, length of hospital stay and the associated rate of complications, including bowel resection, sepsis, and death.
Stanford is currently not accepting patients for this trial. For more information, please contact Sanjeev Dutta, MD, 650-723-6439.
Advanced Laparoscopic Cases in Infants Less than 3 kg
The Hispanic Clinic for Pediatric Surgery at Stanford: Investigating the Effects of Language Concordance on Patient Satisfaction and Quality of Care.
Laparoscopic Sleeve Gastrectomy in Adolescents
Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial.
Journal of the American College of Surgeons
2017; 224 (6): 1091-1096 e1
Sutureless gastroschisis repair involves covering the abdominal wall defect with the umbilical cord or a synthetic dressing to allow closure by secondary intention. No randomized studies have described the outcomes of this technique. Our objective was to prospectively compare short-term outcomes of sutureless vs sutured closure in a randomized fashion.We recruited patients who presented with gastroschisis between 2009 and 2014 and were randomized into either sutureless or sutured treatment groups. Patients with complicated gastroschisis (stricture, perforation, and ischemia) were excluded. Predefined ventilation, feeding, and dressing change protocols were instituted. Primary outcomes were time to extubation and time to full feeds. Secondary outcomes included time to discharge and rate of complications. Data were analyzed using Fisher's exact or t-tests using a p value ≤ 0.05. Factors associated with increased time to discharge were estimated using multivariate analyses.Thirty-nine patients were enrolled, 19 to sutureless and 20 to sutured repair. There was no statistical difference in time to extubation (sutureless 1.89 vs sutured 3.15 days; p = 0.061). The sutureless group had a significant increase in mean time to full feeds (45.1 vs 27.8 days; p = 0.031) and mean time to discharge (49.3 vs 31.4 days; p = 0.016). Complication rates were similar in both groups. Multivariate regression modeling showed that an increase in time to discharge was independently associated with sutureless repair, feeding complications, and sepsis.Sutureless repair of uncomplicated gastroschisis can be performed safely, however, it is associated with a significant increase in time to full feeds and time to discharge.
View details for DOI 10.1016/j.jamcollsurg.2017.02.014
View details for PubMedID 28279777
Advanced minimal access surgery in infants weighing less than 3kg: A single center experience.
Journal of pediatric surgery
Minimal access surgery (MAS) has gained popularity in infants less than 5kg, however, significant challenges still arise in very low weight infants.A retrospective chart review was performed to identify all infants weighing less than 3kg who underwent an advanced MAS or equivalent open procedure from 2009 to 2016. Advanced case types included Nissen fundoplication, duodenal atresia repair, Ladd procedure, congenital diaphragmatic hernia repair, esophageal atresia/tracheoesophageal fistula repair, diaphragmatic plication, and pyloric atresia repair. A comparative analysis was performed between the MAS and open cohorts.A total of 45 advanced MAS cases and 17 open cases met the inclusion criteria. Gestational age and age at operation were similar between the cohorts, while infants who underwent open procedures had significantly lower weight at operation (p=0.003). There were no deaths within 30days related to surgery in either group. Only 3 MAS cases required unintended conversion to open. There were 2 (4.4%) postoperative complications related to surgery in the MAS cohort and 2 (11.8%) in the open cohort.Advanced MAS may be performed in infants weighing less than 3kg with low mortality, acceptable rates of conversion, and similar rates of complications as open procedures.Prognosis study.Level III.
View details for DOI 10.1016/j.jpedsurg.2017.05.006
View details for PubMedID 28549685
- PREDICTORS OF NONDIAGNOSTIC ULTRASOUND FOR APPENDICITIS JOURNAL OF EMERGENCY MEDICINE 2017; 52 (3): 318-323
MRI vs. Ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis.
Academic emergency medicine
While ultrasound (US), given its lack of ionizing radiation is currently the recommended initial imaging study of choice for the diagnosis of appendicitis in pediatric and young adult patients, it does have significant shortcomings. US is time intensive, operator dependent, and results in frequent inconclusive studies, thus necessitating further imaging, and admission for observation or repeat clinical visits. A rapid focused Magnetic Resonance Imaging (MRI) for appendicitis has been shown to have definitive sensitivity and specificity, similar to Computed tomography (CT) but without radiation and offers a potential alternative to US.In this single-center prospective cohort study, we sought to determine the difference in total length of stay and charges between rapid MRI and US as the initial imaging modality in pediatric and young adult patients presenting to the Emergency Department (ED) with suspected appendicitis. We hypothesized that rapid MRI would be more efficient and cost effective than US as the initial imaging modality in the ED diagnosis of appendicitis.A prospective randomized cohort study of consecutive patients was conducted in patients 2-30 years of age in an academic ED with access to both rapid MRI and US imaging modalities 24/7. Prior to the start of the study, the days of the week were randomized to either rapid MRI or US as the initial imaging modality. Physicians evaluated patients with suspected appendicitis per their usual manner. If the physician decided to obtain radiologic imaging, the pre-determined imaging modality for the day of the week was used. All decisions regarding other diagnostic testing and/or further imaging were left to the physician's discretion. Time intervals (min) between triage, order placement, start of imaging, end of imaging, image result and disposition (discharge vs. admission), as well as total charges (diagnostic testing, imaging and repeat ED visits) were recorded.Over a 100-day period, 82 patients were imaged to evaluate for appendicitis; 45/82 (55%) of patients were in the US first group; and 37/82 (45%) patients were in the rapid MRI first group. There were no differences in patient demographics or clinical characteristics between the groups and no cases of missed appendicitis in either group. 11/45 (24%) of US first patients had inconclusive studies, resulting in follow-up rapid MRI and 5 return ED visits contrasted with no inconclusive studies or return visits (p< 0.05) in the rapid MRI group. The rapid MRI compared to US group was associated with longer ED length of stay (mean difference 100 min; 95% CI 35-169) and increased ED charges (mean difference $4,887; 95% CI $1,821 - $8,513).In the diagnosis of appendicitis, US first imaging is more time efficient and less costly than rapid MRI despite inconclusive studies after US imaging. Unless the process of obtaining a rapid MRI becomes more efficient and less expensive, US should be the first line imaging modality for appendicitis in patients 2-30 years of age. This article is protected by copyright. All rights reserved.
View details for DOI 10.1111/acem.13180
View details for PubMedID 28207968
A multidisciplinary approach to laparoscopic sleeve gastrectomy among multiethnic adolescents in the United States.
Journal of pediatric surgery
Childhood obesity has become a serious public health problem in our country with a prevalence that is disproportionately higher among minority groups. Laparoscopic sleeve gastrectomy (LSG) is gaining attention as a safe bariatric alternative for severely obese adolescents.A retrospective study on morbidly obese adolescents that underwent LSG at our institution from 2009 to 2017. Primary outcomes were weight loss as measured by change in BMI and percent excess weight loss (%EWL) at 1 year after surgery, resolution of comorbidities and occurrence of complications.Thirty-eight patients, of whom 71% were female and 74% were ethnic minorities, underwent LSG between 2009 and 2016. Mean age was 16.8years, mean weight was 132.0kg and mean BMI was 46.7. There were no surgical complications. Mean %EWL was 19.4%, 27.9%, 37.4%, 44.9%, and 47.7% at 1.5, 3, 6, 9, and 12month follow up visits, respectively. Comorbidity resolution rates were 100% for hypertension and nonalcoholic fatty liver disease, 91% for diabetes, 44% for prediabetes, 82% for dyslipidemia and 89% for OSA.LSG is an effective and safe method of treatment of morbid obesity in adolescents as it can significantly decrease excess body weight and resolve comorbid conditions. Further studies are needed to investigate the long-term effects of LSG in adolescents.Descriptive case series with prospective database.IV.
View details for DOI 10.1016/j.jpedsurg.2017.06.021
View details for PubMedID 28697852
Predictors of Nondiagnostic Ultrasound for Appendicitis.
journal of emergency medicine
Ionizing radiation and cost make ultrasound (US), when available, the first imaging study for the diagnosis of suspected pediatric appendicitis. US is less sensitive and specific than computed tomography (CT) or magnetic resonance imaging (MRI) scans, which are often performed after nondiagnostic US.We sought to determine predictors of nondiagnostic US in order to guide efficient ordering of imaging studies.A prospective cohort study of consecutive patients 4 to 30 years of age with suspected appendicitis took place at an emergency department with access to 24/7 US, MRI, and CT capabilities. Patients with US as their initial study were identified. Clinical (i.e., duration of illness, highest fever, and right lower quadrant pain) and demographic (i.e., age and sex) variables were collected. Body mass index (BMI) was calculated based on Centers for Disease Control and Prevention criteria; BMI >85th percentile was categorized as overweight. Patients were followed until day 7. Univariate and stepwise multivariate logistic regression analysis was performed.Over 3 months, 106 patients had US first for suspected appendicitis; 52 (49%) had nondiagnostic US results. Eighteen patients had appendicitis, and there were no missed cases after discharge. On univariate analysis, male sex, a yearly increase in age, and overweight BMI were associated with nondiagnostic US (p < 0.05). In the multivariate model, only BMI (odds ratio 4.9 [95% CI 2.0-12.2]) and age (odds ratio 1.1 [95% CI 1.02-1.20]) were predictors. Sixty-eight percent of nondiagnostic US results occurred in overweight patients.Overweight and older patients are more likely to have a nondiagnostic US or appendicitis, and it may be more efficient to consider alternatives to US first for these patients. Also, this information about the accuracy of US to diagnose suspected appendicitis may be useful to clinicians who wish to engage in shared decision-making with the parents or guardians of children regarding imaging options for children with acute abdominal pain.
View details for DOI 10.1016/j.jemermed.2016.07.101
View details for PubMedID 27692650
The Hispanic Clinic for Pediatric Surgery: A model to improve parent-provider communication for Hispanic pediatric surgery patients
JOURNAL OF PEDIATRIC SURGERY
2016; 51 (4): 670-674
26 million Americans have limited English proficiency (LEP). It is well established that language barriers adversely affect health and health care. Despite growing awareness of language barriers, there is essentially a void in the medical literature regarding the influence of language disparity on pediatric surgery patients. This study was designed to assess the impact of patient-provider language concordance on question-asking behavior and patient satisfaction for pediatric surgery patients.Participants included families of patients in a General Pediatric Surgery Clinic categorized into 3 groups by patient-provider language concordance: concordant English-speaking, LEP concordant Spanish-speaking, and LEP discordant Spanish-speaking using an interpreter. Clinical visits were audio recorded and the number of patient-initiated questions and the length of clinical encounter were measured. Families were administered a surgery-specific, 5-point Likert scale questionnaire modeled after validated surveys concerning communication, trust, perceived discrimination and patient-provider language concordance. Regression models were performed to analyze associations between language concordance and patient's question-asking behavior and between language concordance and survey results.A total of 156 participants were enrolled including 57 concordant-English, 52 LEP concordant-Spanish and 47 LEP-discordant-Spanish. There was significant variation in the mean number of patient-initiated questions among the groups (p=0.002). Both the English and Spanish concordant groups asked a similar number of questions (p=0.9), and they both asked more questions compared to the Spanish-discordant participants (p=0.002 and p=0.001). Language discordance was associated with fewer questions asked after adjustment for socioeconomic status. Language concordant participants rated higher scores of communication. Both Spanish-concordant and Spanish-discordant patients reported significantly increased preference for, and value of language concordant care. Language discordant participants reported that they desired to ask more questions but were limited by a language barrier (p=0.001).In a pediatric surgery clinic, language concordant care increases the number of patient-asked questions during a clinical visit and improves communication suggesting that discordant care is a potential source of disparities in access to information. Future efforts should focus on expanding access to language concordant providers in other surgery subspecialties as a step towards limiting disparities in surgical care for all patients.
View details for DOI 10.1016/j.jpedsurg.2015.08.065
View details for Web of Science ID 000374482200031
View details for PubMedID 26474548
Laparoscopic harvesting of omental pedicle flap for cerebral revascularization in children with moyamoya disease
JOURNAL OF PEDIATRIC SURGERY
2016; 51 (4): 592-597
An abundance of angiogenic and immunologic factors makes the omentum an ideal tissue for reconstruction and revascularization of a variety of extraperitoneal wounds and defects. Omental harvesting was historically performed through a large laparotomy and subcutaneous tunneling to the site of disease. Several complications of the open procedure including abdominal wound infection, fascial dehiscence, ventral hernia, and postoperative ileus have been described. The use of laparoscopy to harvest the omentum has the potential to reduce such complications. We describe the surgical technique and outcomes of a series of patients undergoing laparoscopic pedicled omental flap mobilization for cerebral revascularization in moyamoya disease.A retrospective chart review of all patients undergoing laparoscopic omental cerebral transposition for moyamoya disease between 2011 and 2014 was performed. Clinical indication, surgical technique, operative times, complications, and outcomes at follow-up were reviewed.A total of 7 children underwent the procedure. The general surgery team performed laparoscopic omental mobilization, extraperitonealization, and subcutaneous tunneling, while the neurosurgical team performed craniotomy and cerebral application of the graft. The patients were followed postoperatively with clinic visits and angiography. There was one intraoperative complication (colon injury) and one postoperative complication (intermittent omental hernia at fascial defect for pedicle). All patients had partial to complete symptomatic resolution and demonstrated adequate intracranial revascularization on angiography.Laparoscopic omental pedicle flap mobilization and subcutaneous transposition is feasible in children who require salvage cerebral revascularization for moyamoya disease. The procedure should be considered for other conditions requiring extraperitoneal revascularization.
View details for DOI 10.1016/j.jpedsurg.2015.10.048
View details for Web of Science ID 000374482200016
View details for PubMedID 26611331
- Endoscopic Submucosal Dissection of a Large Hamartoma in a Young Child. Journal of pediatric gastroenterology and nutrition 2016; 62 (1): e5-7
- Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe SURGERY 2015; 158 (6): 1476-1481
Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac.
Journal of pediatric surgery
2015; 50 (10): 1767-1771
Laparoscopic transcutaneous inguinal hernia repair in children may reduce postoperative pain, improve cosmesis, allow for less manipulation of the cord structures, and offer easy access to the contralateral groin. However, there is concern for unacceptably high recurrence rates when the procedure is generalized. To address this increase in recurrence, in 2011 we described in this journal a modification of the laparoscopic transcutaneous technique that replicates high transfixation ligature of the hernia sac with the aim of inducing more secure healing, preventing suture slippage, and distributing tension across two suture passes. We now describe our long-term follow-up of this novel repair.After obtaining IRB approval, a retrospective chart review and phone follow-up were performed on all patients who underwent laparoscopic transfixation ligature hernia repair between October 2009 and August 2014 (including further follow-up of the 21 patients reviewed in the 2011 report of this technique). Data collection included demographics, laterality of hernia, evidence of recurrence, complications, and time to follow-up.Median follow-up was 24months (range 2-52months). Three pediatric surgeons performed 216 laparoscopic transfixation ligature repairs on 166 patients. Demographics: mean age 29.5months (range 1-192months); male 67.2% and female 32.8%; 4.2% of patients were premature at operation. Repairs were bilateral in 42% of patients, right sided in 34%, and left sided in 24%. Three patients together experienced 4 recurrences, for an overall recurrence rate of 1.8%. Two of the recurrences occurred in a 2-month old syndromic patient with severe congenital heart disease who recurred twice after laparoscopic transfixation ligature repair then subsequently failed an attempt at open repair. Excluding this one outlier patient, the recurrence rate was 0.9%. The complication rate was 1.7% (3 hydroceles and 1 inguinal hematoma; all resolved spontaneously).Laparoscopic high transfixation ligature hernia repair can be adopted by surgeons with basic laparoscopic skills, and result in excellent outcomes with acceptable recurrence rates.
View details for DOI 10.1016/j.jpedsurg.2015.06.006
View details for PubMedID 26201542
General surgical services at an urban teaching hospital in Mozambique.
journal of surgical research
2015; 198 (2): 340-345
As surgery becomes incorporated into global health programs, it will be critical for clinicians to take into account already existing surgical care systems within low-income countries. To inform future efforts to expand the local system and systems in comparable regions of the developing world, we aimed to describe current patterns of surgical care at a major urban teaching hospital in Mozambique.We performed a retrospective review of all general surgery patients treated between August 2012 and August 2013 at the Hospital Central Maputo in Maputo, Mozambique. We reviewed emergency and elective surgical logbooks, inpatient discharge records, and death records to report case volume, disease etiology, and mortality.There were 1598 operations (910 emergency and 688 elective) and 2606 patient discharges during our study period. The most common emergent surgeries were for nontrauma laparotomy (22%) followed by all trauma procedures (18%), whereas the most common elective surgery was hernia repair (31%). The majority of lower extremity amputations were above knee (69%). The most common diagnostic categories for inpatients were infectious (31%), trauma (18%), hernia (12%), neoplasm (10%), and appendicitis (5%). The mortality rate was 5.6% (146 deaths), approximately half of which were related to sepsis.Our data demonstrate the general surgery caseload of a large, academic, urban training and referral center in Mozambique. We describe resource limitations that impact operative capacity, trauma care, and management of amputations and cancer. These findings highlight challenges that are applicable to a broad range of global surgery efforts.
View details for DOI 10.1016/j.jss.2015.04.010
View details for PubMedID 25940163
View details for PubMedCentralID PMC4560971
The effects of language concordant care on patient satisfaction and clinical understanding for Hispanic pediatric surgery patients.
Journal of pediatric surgery
2015; 50 (9): 1586-1589
Hispanics account for over 60% of the U.S. population growth and 25% speak little-to-no English. This language barrier adversely affects both access to and quality of care. Surgical specialties trail other medical fields in assessing the effects of language barriers to surgical clinical care and patient satisfaction. This study was designed to assess the effects of patient-provider language concordance on a pediatric surgery practice.A surgery-specific, 7-point Likert scale questionnaire was designed with 14 questions modeled after validated patient satisfaction surveys from the literature. Questions concerning provider-patient language concordance, quality of understanding, and general satisfaction were included. Surveys were administered to families of patients in the General Pediatric Surgery Clinic at our institution. Families were categorized into three groups: English-speaking, regardless of race/ethnicity; Spanish-speaking using interpreter services with an English-speaking medical team; and Spanish-speaking communicating directly with a Spanish-speaking medical team (Hispanic Center for Pediatric Surgery, HCPS). One-way analysis of variance was used to test for group differences.We administered 226 surveys; 49 were removed due to lack literacy proficiency. Families in the HCPS group reported a higher level of satisfaction than the interpreter and English groups (p<0.01). The HCPS group also indicated improved understanding of the information from the visit (p<0.001). Spanish-speaking only families felt that communicating directly with their health care team in their primary language was more important than their English-speaking counterparts (p<0.001).In a pediatric surgery clinic, language concordant care improves patient satisfaction and understanding for Hispanic families in comparison to language discordant care. Other clinics in other surgery sub-specialties may consider using this model to eliminate language barriers and improve patient satisfaction and understanding of surgical care.
View details for DOI 10.1016/j.jpedsurg.2014.12.020
View details for PubMedID 25783324
Initial Results of Endoscopic Gastrocutaneous Fistula Closure in Children Using an Over-the-Scope Clip.
Journal of laparoendoscopic & advanced surgical techniques. Part A
2015; 25 (1): 69-72
Gastrocutaneous fistula (GCF) occurs commonly in pediatric patients after removal of long-term gastrostomy tubes. Although open repair is generally successful, endoscopic approaches may offer benefits in terms of incisional complications, postoperative pain, and procedure time. In addition, endoscopic approaches may offer particular benefit in patients with varied degrees of skin irritation or erosion surrounding a GCF, making surgical repair difficult, or patients with significant comorbidities, making minimal intervention and anesthesia time preferable. Over-the-scope (OSC) clips are a new technology that enables endoscopic closure of intestinal fistulas up to 2 cm in diameter. Six pediatric patients underwent endoscopic GCF closure using OSC clips under Institutional Review Board approval. The procedure was technically successful in 5 of 6 cases with an average operating time of 29 minutes. The technical failure required an open revision, whereas all other patients reported full healing of the GCF site at 1 month. All successful cases were performed as outpatients without postoperative narcotics. In addition, all patients reported high satisfaction with the procedure and cosmetic results. Endoscopic GCF closure using an OSC clip is technically feasible in the pediatric population. Based on limited cases with a 1-month follow-up, the functional and cosmetic results of technically successful cases are excellent. Endoscopic GCF closure is a potential alternative to standard surgical closure in patients with skin irritation or erosion and/or significant comorbidities.
View details for DOI 10.1089/lap.2014.0379
View details for PubMedID 25531644
Less invasive pedicled omental-cranial transposition in pediatric patients with moyamoya disease and failed prior revascularization.
2014; 10: 1-14
Patients with moyamoya disease and progressive neurologic deterioration despite previous revascularization pose a major treatment challenge. Many have exhausted typical sources for bypass or have ischemia in areas that are difficult to reach with an indirect pedicled flap. Omental-cranial transposition has been an effective, but sparingly used technique because of its associated morbidity.We have refined a laparoscopic method of harvesting an omental flap that preserves its gastroepiploic arterial supply.The pedicled omentum can be lengthened as needed by dividing it between the vascular arcades. It is transposed to the brain via skip incisions. The flap can be trimmed or stretched to cover ischemic areas of the brain. The cranial exposure is performed in parallel with pediatric surgeons. We performed this technique in 3 pediatric moyamoya patients (aged 5 to 12 years) with prior STA-MCA bypasses and progressive ischemic symptoms. In 1 patient, we transposed omentum to both hemispheres.Blood loss ranged from 75 to 250 ml. After surgery, patients immediately tolerated a diet and were discharged in 3 to 5 days. All 3 children's ischemic symptoms resolved within 3 months postoperatively. MRI at 1 year showed improved perfusion and no new infarcts. Angiography showed excellent revascularization of targeted areas and patency of the donor gastroepiploic artery.Laparoscopic omental harvest for cranial-omental transposition can be performed efficiently and safely. Moyamoya patients appear to tolerate this technique much better than laparotomy. With this method we can achieve excellent angiographic revascularization and resolution of ischemic symptoms.
View details for DOI 10.1227/NEU.0000000000000119
View details for PubMedID 23921707
A Prospective Randomized Trial of Ultrasound- vs Landmark-Guided Central Venous Access in the Pediatric Population.
Journal of the American College of Surgeons
2013; 216 (5): 939-943
The purpose of this prospective randomized study was to compare landmark- to ultrasound-guided central venous access when performed by pediatric surgeons. The American College of Surgeons advocates for use of ultrasound in central venous catheter placement; however, this is not universally embraced by pediatric surgeons. Complication risk correlates positively with number of venous cannulation attempts.With IRB approval, a randomized prospective study of children under 18 years of age undergoing tunneled central venous catheter placement was performed. Patient accrual was based on power analysis. Exclusion criteria included known nonpatency of a central vein or coagulopathy. After randomization, the patients were assigned to either ultrasound-guided internal jugular vein access or landmark-guided subclavian/internal jugular vein access. The primary outcomes measure was number of attempts at venous cannulation. Secondary outcomes measures included: access times, number of arterial punctures, and other complications. Continuous variables were compared using 2-tailed Student's t-test. Discrete variables were analyzed with chi-square. Significance was defined as p < 0.05.There were 150 patients enrolled between April 2008 and September 2011. There was no difference when comparing demographic data. Success at first attempt was achieved in 65% of patients in the ultrasound group vs 45% in the landmark group (p = 0.021). Success within 3 attempts was achieved in 95% of ultrasound group vs 74% of landmark group (p = 0.0001).Ultrasound reduced the number of cannulation attempts necessary for venous access. This indicates a potential to reduce complications when ultrasound is used by pediatric surgeons.
View details for DOI 10.1016/j.jamcollsurg.2013.01.054
View details for PubMedID 23478546
Complete resection of a rare intrahepatic variant of a choledochal cyst
JOURNAL OF PEDIATRIC SURGERY
2013; 48 (3): 652-654
The vast majority of choledochal cysts occur as either saccular or diffuse fusiform dilatation of the extrahepatic bile duct. We describe the complete resection of a rare single intrahepatic choledochal cyst communicating with the extrahepatic biliary tree. While previous reports describe partial resection with enteral drainage, we performed a complete resection of this rare choledochal cyst.
View details for DOI 10.1016/j.jpedsurg.2012.12.016
View details for Web of Science ID 000316470100037
View details for PubMedID 23480926
Chest wall reconstruction using implantable cross-linked porcine dermal collagen matrix (Permacol)
JOURNAL OF PEDIATRIC SURGERY
2012; 47 (7): 1472-1475
Chest wall reconstruction in children is typically accomplished with either primary tissue repair or synthetic mesh prostheses. Primary tissue repair has been associated with high rates of scoliosis, whereas synthetic prostheses necessitate the placement of a permanent foreign body in growing children. This report describes the use of biologic mesh (Permacol; Covidien, Mansfield, MA) as an alternative to both tissue repair and synthetic prostheses in pediatric chest wall reconstruction.A retrospective chart review was performed identifying patients undergoing chest wall reconstruction with biologic mesh at our tertiary referral children's hospital between 2007 and 2011. Data collection included patient demographics, indication for chest wall resection, number of ribs resected, the administration of postoperative radiation, length of follow-up, postoperative complications, and the degree of spinal angulation (preoperatively and at most recent follow-up).Five patients (age, 9.0-21.7 years; mean, 15.4 years) underwent resection for primary chest wall malignancy followed by reconstruction with biologic mesh (Permacol) during the study period. There were no postoperative mesh-related complications, and none of the patients developed clinically significant scoliosis (follow-up, 1.1-2.6 years; mean 1.9 years).Biologic mesh offers a safe and dependable alternative to both primary tissue repair and synthetic mesh in pediatric patients undergoing chest wall reconstruction.
View details for DOI 10.1016/j.jpedsurg.2012.05.002
View details for Web of Science ID 000306523300039
View details for PubMedID 22813819
Single-site umbilical laparoscopic splenectomy
SEMINARS IN PEDIATRIC SURGERY
2011; 20 (4): 212-218
Laparoscopic splenectomy was first described in children in 1993. Since then, it has become a commonly performed procedure in children because of reduced discomfort and hospitalization and significantly improved cosmesis compared with the open approach. With the advent of single-site laparoscopic surgery, it is only natural that this approach be used for splenectomy. This article will describe the reasons that the single-site approach might be useful for splenectomy and also the technique used at the author's institution. Moreover, a brief review of the current literature in children will be presented.
View details for DOI 10.1053/j.sempedsurg.2011.05.005
View details for Web of Science ID 000296043500006
View details for PubMedID 21968157
A modification of the laparoscopic transcutaneous inguinal hernia repair to achieve transfixation ligature of the hernia sac
JOURNAL OF PEDIATRIC SURGERY
2011; 46 (8): 1658-1664
The proposed benefits of laparoscopic inguinal hernia repair in the pediatric population include less postoperative pain, smaller scars, and easier access to the contralateral groin. This is countered by slightly higher recurrence rates reported in some series. These differences are attributable to variation in the laparoscopic technique, surgeon experience, and certain anatomic features. We describe a modification of the laparoscopic-assisted transcutaneous hernia repair that achieves transfixation ligature of the hernia sac and that may further reduce recurrence.Institutional review board approval was obtained, and a retrospective chart review of all patients undergoing repair of symptomatic hernias using this new technique was carried out. Data collection included demographics, laterality of hernia, operative time, recurrence rate, and complications.Twenty-one patients (age 1-144 months) underwent hernia repair between October 2009 and October 2010 using a novel technique of transcutaneous transfixation ligature of the neck of the hernia sac. The mean operative time was 18 minutes (8-35 minutes). Follow-up was from 1 to 12 months. There was no intraoperative or postoperative complication and no recurrences to date.The technique described is a modification of the existing laparoscopic-assisted transcutaneous inguinal hernia repair that more closely approximates the criterion standard open repair. The technique addresses some prevailing concerns with the initially described method of transcutaneous repair, and short-term outcomes are positive. Long-term outcomes remain to be defined.
View details for DOI 10.1016/j.jpedsurg.2011.03.022
View details for Web of Science ID 000293950100040
View details for PubMedID 21843740
Management of the primary tumor in patients with metastatic pancreatic neuroendocrine tumor: a contemporary single-institution review
50th Annual Meeting of the Midwest-Surgical-Association
EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2009: 376–80
Pancreatic nonfunctioning neuroendocrine tumors (PNFNETs) are an uncommon malignancy and often present with metastatic disease. There is a lack of information on the management of the primary tumor in patients who present with unresectable synchronous hepatic metastases.A retrospective review (2001-2008) of PNFNETs was conducted. Patients were divided into 3 groups: PNFNET without evidence of hepatic metastasis (group A), PNFNET with metastatic disease involving less than 50% of the liver (group B), and PNFNET with metastatic disease involving more than 50% of the liver (group C). Clinical data and outcomes were analyzed.Thirty-five patients with PNFNET were identified (group A = 15, group B = 11, group C = 9). Resection of the pancreatic tumor was performed in 26 patients. With a mean follow-up period of 30 months, death from disease progression occurred in 1 patient in group A, none in group B, and in 7 in group C.In selected patients, resection of the primary pancreatic tumor even in the setting of unresectable but limited hepatic metastases may be indicated.
View details for DOI 10.1016/j.amjsurg.2008.11.005
View details for Web of Science ID 000264277400037
View details for PubMedID 19245918
Comparison of short bowel syndrome acquired early in life and during adolescence
10th International Symposium on Small Bowel Transplantation
LIPPINCOTT WILLIAMS & WILKINS. 2008: 63–66
Prolonged survival in pediatric patients with short bowel syndrome (SBS) is now possible because of parenteral nutrition and small bowel transplantation. We hypothesized that there may be important differences between adult patients who developed SBS during early childhood and those who develop this as adolescents.Sixty-seven patients between the ages of 16 and 40 years were studied. Thirty patients developing SBS younger than 12 years comprised the pediatric group (PG), 37 developing SBS at age 13 to 25 constituted the adolescent group (AG).Midgut volvulus (n=11) was the most common cause in the PG followed by gastroschisis (n=5), intestinal atresia (n=5), and necrotizing enterocolitis (n=4). The most common cause of SBS in the AG was trauma (n=13), followed by tumors (n=7) and postoperative complications (n=5). A similar portion in each group had intestinal remnants less than 60 cm (69% vs. 58%), however, the PG was more likely to have a colon remnant (97% vs. 71%, P<0.05), and less likely to have an ostomy (7% vs. 47%, P<0.05). Patients in PG were followed significantly longer than AG (246+/-67 vs. 90+/-58 months, P<0.05). A similar portion of the patients require long-term parenteral nutrition (86% vs. 84%) or have undergone intestinal transplant (28% vs. 23%). Significantly more pediatric patients had negative height z scores when compared with the adolescents.Acknowledging the inherent biases created in defining the two groups, pediatric patients developing SBS early in life seem to be similar to those who develop SBS as adolescents with regards to long-term outcome, despite differences in origin and intestinal anatomy.
View details for DOI 10.1097/TP.0b013e3181734995
View details for Web of Science ID 000257790400012
View details for PubMedID 18622279
Open and laparoscopic spleen-preserving, splenic vessel-preserving distal pancreatectomy: Indications and outcomes
Annual Meeting of the American-Hepato-Pancreato-Biliary-Association
SPRINGER. 2008: 1202–6
Spleen-preserving distal pancreatectomy has been described lately in order to reduce the risks associated with splenectomy. The aim of this study is to report a series of open and laparoscopic distal pancreatectomies with splenic vessel preservation.From June 2001 to April 2007, 11 spleen-preserving distal pancreatectomies were performed, utilizing open and laparoscopic techniques. The main variables recorded were demographics, intra- and postoperative complications, and final pathology results.All 11 spleen-preserving distal pancreatectomies were performed successfully. Laparoscopic resection was possible in seven patients. Postoperative morbidity consisted of one pancreatic fluid collection. The overall incidence of pancreatic leak was 18%. The final pathology revealed serous cystadenoma in 36% of the cases, neuroendocrine tumor in two cases, three mucinous cystadenomas, one carcinoid tumor, and one intrapancreatic spleen. With a median follow-up of 26 months, no splenic vein thrombosis was detected.Open or laparoscopic spleen-preserving distal pancreatectomy with splenic vessel preservation is a feasible and safe procedure. In selected cases of cystic lesions and low grade neoplasms, distal pancreatectomy with splenic preservation is possible.
View details for DOI 10.1007/s11605-008-0512-0
View details for Web of Science ID 000257206100011
View details for PubMedID 18437500
Pancreatic incidentalomas: clinical and pathologic spectrum
50th Annual Meeting of the Midwest-Surgical-Association
EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2008: 329–32
Incidental abnormalities are increasingly being detected. The pathology and clinical outcome of patients with pancreatic incidentalomas have not been well characterized.We reviewed the records of 356 patients with pancreatic abnormalities from August 2001 to June 2007. Clinical and pathologic data were collected for a cohort of patients who had incidental pancreatic lesions detected by imaging modalities.Fifty-seven pancreatic incidentalomas were identified. Ninety percent of them were detected by computed axial tomography (CT). The most frequent indications for imaging were genitourinary symptoms and cancer surveillance. Sixty percent of the lesions were solid, and 40% were cystic. Surgical resection was performed in 33 patients. Locally advanced disease was found in six patients, and metastatic disease was found in 9 patients. The most frequent diagnoses were ductal adenocarcinoma, neuroendocrine tumors, and serous cystadenoma.Patients with pancreatic incidentalomas account for a significant patient subgroup. Incidental pancreatic lesions occur frequently and require prompt surgical evaluation.
View details for DOI 10.1016/j.amjsurg.2007.12.027
View details for Web of Science ID 000253847600017
View details for PubMedID 18308040
Low doses of pamidronate to treat osteopenia in children with severe cerebral palsy: a pilot study
DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY
2006; 48 (9): 709-712
The aim of this study was to test the efficacy of low doses of pamidronate in increasing bone mineral density (BMD) in non-ambulatory children and adolescents with cerebral palsy (CP). Twenty-three non-ambulatory children and adolescents (12 females, 11 males; mean age 10y [SD 5y], range 4y 1 mo-17 y 11 mo) with severe spastic quadriplegic CP and low BMD were recruited from a multidisciplinary clinic. Severity of CP was graded at Level IV (n=10) and Level V (n=13) using the Gross Motor Function Classification System. Patients received intravenous pamidronate (4.12 mg/kg/y, maximum 45 mg/d) every 4 months. Lumbar spine and femoral neck BMD were measured at baseline and after 4 and 12 months. Twelve months after the first dose of pamidronate there was a significant increase in lumbar spine and femoral neck BMD (p<0.01 for both sites) and z scores compared with baseline values (p<0.01 for both sites). Mean BMD z scores increased 1.6 points for femoral neck and 1.9 points for lumbar spine after 12 months of pamidronate treatment. Serum intact parathyroid hormone increased significantly and cross-linked N-teleopeptide of type I collagen decreased significantly at 12 months. No significant side effect was noted. Low doses of pamidronate are well tolerated and significantly increase BMD in non-ambulatory children and adolescents with CP.
View details for DOI 10.1017/S0012162206001526
View details for Web of Science ID 000240173500003
View details for PubMedID 16904014
Transcervical carotid stenting with flow reversal for neuroprotection: Technique, results, advantages, and limitations
2006; 14 (5): 245-255
Carotid angioplasty and stenting are progressively earning a role as a less invasive alternative in the treatment of carotid occlusive disease. The most common approach for carotid artery stenting involves transfemoral access and use of a filter or balloon device for neuroprotection. This approach has limitations related to both the site of access and the method of neuroprotection. Specifically, an aortoiliac segment with advanced occlusive or aneurysmal disease or an anatomically unfavorable or atheromatous arch and arch branches can significantly limit the safety of the retrograde transfemoral pathway to the carotid bifurcation. Additionally, data provided by the use of transcranial Doppler monitoring and diffusion-weighted magnetic resonance imaging in patients undergoing filter- or balloon-protected carotid artery stenting demonstrate that currently available devices are associated with a considerable incidence of cerebral embolization. To address these limitations, we, along with others, have employed a direct transcervical approach for carotid artery stenting that incorporates the principle of flow reversal for neuroprotection. The technique bypasses all of the anatomic limitations of transfemoral access and simplifies the application of flow reversal, which is one of the safest neuroprotection techniques. The purpose of this review is to describe our method of transcervical carotid artery stenting, review the accumulating outcomes data, and discuss the clinical advantages of and indications for this increasingly popular technique.
View details for DOI 10.2310/6670.2006.00050
View details for Web of Science ID 000202989800002
View details for PubMedID 17038294
Hemorrhagic adrenal pseudocyst: laparoscopic treatment
SURGICAL ENDOSCOPY AND OTHER INTERVENTIONAL TECHNIQUES
2004; 18 (10)
The incidence of adrenal hemorrhagic pseudocyst is very low. A total of 613 adrenal cysts and 85 hemorrhagic pseudocysts have been reported. A laparoscopically diagnosed and resolved case is presented here, together with the current diagnostic and therapeutic procedures.A 40-year-old woman was admitted because of an asymptomatic nonfunctional right adrenal tumor. Right laparoscopic adrenalectomy was performed, 8-cm cyst which found an with thick walls and organized hematic content. The postoperative course was uneventful. Follow-up was 14 months. The pathology was an adrenal hemorrhagic pseudocyst.A total of 56% of adrenal cysts are pseudocysts. One third of them have hematic content. They may present as an asymptomatic finding with nonspecific symptoms or as a hormone secreting or complicated tumor. Their vascular etiology is not yet totally accepted. There is a tendency for intracystic bleeding. it is advisable to evaluate the hormonal profile and morphologic characteristics in all cases. Treatment options include needle aspiration, percutaneous drainage, and cyst or gland resection. Laparoscopic excision should be evaluated.
View details for DOI 10.1007/s00464-003-4547-8
View details for Web of Science ID 000224475100029
View details for PubMedID 15791385