Katherine J. Baxter

The General Surgeon's Quandary: Atypical Lipomatous Tumor vs Lipoma, Who Needs a Surgical Oncologist?

BACKGROUND Differentiating large lipomas from atypical lipomatous tumors (ALT) is challenging, and preoperative management guidelines are not well defined. The diagnostic ambiguity leads many surgeons to refer all patients with large lipomatous masses to an oncologic specialist, perhaps unnecessarily. STUDY DESIGN In this retrospective cohort study of patients with nonretroperitoneal lipomatous tumors, preoperative characteristics discernible without invasive diagnostic procedures were evaluated for diagnostic predictive value. RESULTS We identified 319 patients (256 with lipomas, 63 with ALTs) treated between 1994 and 2012. Patients with ALTs were older (60.5 vs 53.5 years, p < 0.0001), had larger tumors (16.0 vs 8.3 cm, p < 0.0001), had tumors more often located on an extremity (88.9% vs 60.5% torso, p < 0.0001), and more frequently had a history of previous operations at the same site, exclusive of excision leading to diagnosis and referral (20.6% vs 5.9%, p = 0.001). Local recurrence was observed in 2 patients with lipomas (0.8%) vs 14 with ALTs (22.6%, p < 0.0001). No patients with ALTs developed distant metastases or disease-specific mortality, with a median follow-up of 27.4 months (range 0 to 164.6 months). On multivariate analysis, age ≥ 55 years, tumor size ≥ 10 cm, extremity location, and history of previous resections were predictors for diagnosis of ALT (p < 0.05). CONCLUSIONS Characteristics of lipomatous masses associated with a diagnosis of ALT include patient age ≥ 55 years, tumor size ≥ 10 cm, previous resection, and extremity location (vs torso). These easily identifiable traits may guide surgical management or referral to a specialist.

Is multimodality therapy necessary for the management of pure myxoid liposarcomas? A multi-institutional series of pure myxoid liposarcomas of the extremities and torso.

The treatment of patients with pure (<5% round cell component) myxoid liposarcomas (pMLS) has not been well characterized. We hypothesized that multimodality therapy (oncological resection with radiation therapy) may not be necessary for pMLS.

Association of Health Care Utilization With Rates of Perforated Appendicitis in Children 18 Years or Younger

Importance The pediatric perforated appendix rate is a quality metric measured by the Agency for Healthcare Research and Quality (AHRQ) that reflects access to care. The association of health care utilization prior to presentation with appendicitis is unknown. Objective To determine whether increased health care utilization prior to presentation with appendicitis is associated with lower perforated appendicitis rates in children. Design, Setting, and Participants Retrospective cohort study of privately insured children drawn from large employer and insurance company administrative data found in the Truven MarketScan national insurance claims database. Cases of appendicitis were identified among 38 348 children 18 years or younger from January 1, 2010, through December 31, 2013, with corresponding primary health care encounters from January 1, 2009, through December 31, 2012. In all, 19 109 eligible children were identified using International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes for appendicitis after excluding those patients who did not have continuous insurance coverage during the study period. Statistical analysis was performed from September 1, 2016, to October 15, 2017. Exposures Health care utilization was determined by the number of outpatient clinic encounters for each patient in the 1 to 12 months before presentation with appendicitis. Main Outcomes and Measures Perforated appendicitis was defined according to the AHRQ by using ICD-9 codes for perforation and hospital length of stay of 3 or more days. Logistic regression models were used for perforated appendicitis after adjustment for age, sex, income, gastrointestinal comorbidities, geographic region, and insurance type. Results We identified 38 348 children 18 years or younger with ICD-9 diagnosis codes for appendicitis, and 19 109 children remained for analysis after applying exclusion criteria. Of these, 11 422 were boys (59.8%); the mean (SD) age was 12.4 (3.9) years. Of the 19 109 children identified who underwent appendectomy, 5509 (28.8%) presented with perforated appendicitis. Children with perforation had lower outpatient health care utilization in the year before presentation compared with those diagnosed with acute appendicitis (4554 of 5509 children [82.7%] vs 11 937 of 13 600 [87.8%]; P < .001). In the adjusted model, outpatient health care utilization before presentation was associated with lower odds of perforated appendicitis (odds ratio [OR], 0.63; 95% CI, 0.58-0.69; P < .001). This association increased with visit frequency in the year before presentation (OR, 0.86; 95% CI, 0.77-0.95 for 1-2 visits, P = .003; OR, 0.61; 95% CI, 0.55-0.67 for 3-6 visits, P < .001; and OR, 0.43; 95% CI, 0.38-0.48 for ≥7 visits [5-18 years], P < .001). Covariates associated with perforation included younger age, geographic region, family income, and higher out-of-pocket insurance plans. Conclusions and Relevance Among insured children 18 years or younger, increased health care utilization was associated with lower rates of perforated appendicitis. Primary health care relationships may facilitate timely presentation or serve as a marker for health-related self-efficacy, thereby contributing to outcomes for acute surgical conditions.

Parent reported long-term quality of life outcomes in children after congenital diaphragmatic hernia repair

PURPOSE The aim of this study was to determine long-term outcomes for congenital diaphragmatic hernia (CDH) patients including quality of life (QoL), symptom burden, reoperation rates, and health status. METHODS A chart review and phone QoL survey were performed for patients who underwent CDH repair between 2007 and 2014 at a tertiary free-standing childrens hospital. Comprehensive outcomes were collected including subsequent operations and health status. Associations with QoL were tested using Wilcoxon Rank-Sum tests and Pearson correlation coefficients. RESULTS Of 102 CDH patients identified, 46 (45.1%) patient guardians agreed to participate with mean patient age of 5.8 (SD, 2.2) years at time of follow-up. Median PedsQLTM and PedsQLTM Gastrointestinal scores were 91.8 (IQR, 84.8-95.8) and 95.8 (IQR, 93.0-98.2), out of 100. Thoracoscopic repair was associated with higher PedsQLTM scores while defects with an intrathoracic stomach were associated with increased gas and bloating. No difference in QoL was found when comparing defect side, patch vs primary repair, prenatal diagnosis, extracorporeal membrane oxygenation, or recurrence. Older age weakly correlated with worse school functioning and heartburn. CONCLUSION Children with CDH have reassuring QoL scores. Given the correlation between older age and poor school function, longer follow-up of patients with CDH may be warranted. LEVEL OF EVIDENCE III (Retrospective comparative study).

Primary versus secondary anastomosis in intestinal atresia

PURPOSE Neonates with intestinal atresia (IA) undergo either primary anastomosis (PA) or ostomy creation with secondary anastomosis (SA). Our purpose was to compare outcomes for PA and SA and to assess factors influencing procedure selection. METHODS We conducted a retrospective cohort study of neonates with IA between 2009 and 2015. Patient characteristics, operative details, and outcomes were collected. Surgeon-level preferences (defined as performing >50% PA or SA) were assessed using logistic regression. RESULTS Of 92 IA patients, 70 (76.1%) underwent PA and 22 (23.9%) underwent SA. Neonates with PA had shorter hospitalizations (27 days vs. 95 days, p < 0.001), shorter total parenteral nutrition duration (19 days vs. 74.5 days, p < 0.001), and fewer readmissions (33.3% vs. 63.2%, p = 0.024). On multivariable regression analysis, higher Apgar scores (Odds Ratio (OR) 4.16, 95% Confidence Interval (CI) 1.20-14.29) and uncomplicated atresia (OR 3.97, 95% CI 1.37-11.48) were associated with PA. At the surgeon-level, utilization of PA varied from 43.5% to 100%. Surgeon preference is not influenced by the demographic, presentation, or surgical findings of this patient population. CONCLUSIONS PA has better outcomes than SA. Though procedural selection is influenced by the clinical status of the neonate, however surgeon preference plays a significant role in this clinical decision. LEVEL OF EVIDENCE Level III Treatment Study.

Structural airway abnormalities contribute to dysphagia in children with esophageal atresia and tracheoesophageal fistula

BACKGROUND Long-term dysphagia occurs in up to 50% of repaired esophageal atresia and tracheoesophageal fistula (EA/TEF) patients. The underlying factors are unclear and may include stricture, esophageal dysmotility, or associated anomalies. Our purpose was to determine whether structural airway abnormalities (SAA) are associated with dysphagia in EA/TEF. METHODS We conducted a retrospective chart review of children who underwent EA/TEF repair in our hospital system from 2007 to 2016. Children with identified SAA (oropharyngeal abnormalities, laryngeal clefts, laryngomalacia, vocal cord paralysis, and tracheomalacia) were compared to those without airway abnormalities. Dysphagia outcomes were determined by the need for tube feeding and the modified pediatric Functional Oral Intake Scale (FOIS) at 1 year. RESULTS SAA was diagnosed in 55/145 (37.9%) patients with EA/TEF. Oropharyngeal aspiration was more common in children with SAA (58.3% vs. 36.4%, p=0.028). Children with SAA were more likely to require tube feeding both at discharge (79.6% vs. 48.3%, p<0.001) and at 1 year (52.7% vs. 13.6%, p<0.001) and had lower mean FOIS (4.18 vs. 6.21, p<0.001). In the logistic regression model adjusting for gestational age, long gap EA, and esophageal stricture, the presence of SAA remained a significant risk factor for dysphagia (OR 4.17 (95% CI 1.58-11.03)). CONCLUSION SAA are common in children with EA/TEF and are associated with dysphagia, even after accounting for gestational age, esophageal gap and stricture. This study highlights the need for a multidisciplinary approach, including early laryngoscopy and bronchoscopy, in the evaluation of the EA/TEF child with dysphagia. LEVEL OF EVIDENCE Level II retrospective prognostic study.

Pediatric short bowel syndrome and subsequent development of inflammatory bowel disease: an illustrative case and literature review.

Short bowel syndrome (SBS) in neonates is an uncommon but highly morbid condition. As SBS survival increases, physiologic complications become more apparent. Few reports in the literature elucidate outcomes for adults with a pediatric history of SBS. We present a case report of a patient, born with complicated gastroschisis resulting in SBS at birth, who subsequently developed symptoms and pathologic changes of inflammatory bowel disease (IBD) as an adult. The patient lived from age 7, after a Bianchi intestinal lengthening procedure, to age 34 independent of parenteral nutrition (PN), but requiring hydration fluid via G-tube. He was then diagnosed with IBD, after presenting with weight loss, diarrhea, and malabsorption, which required resumption of PN and infliximab treatment. This report adds to a small body of the literature which points to a connection between SBS in neonates and subsequent diagnosis of IBD. Recent evidence suggests that SBS and IBD have shared features of mucosal immune dysfunction and altered intestinal microbiota. We review current treatment options for pediatric SBS as well as multidisciplinary and coordinated transition strategies. We conclude that there may be an etiologic connection between SBS and IBD and that this knowledge may impact outcomes and approaches to care.

Ramifications of the Children's Surgery Verification Program for Patients and Hospitals

BACKGROUND The American College of Surgeons in 2015 instituted the Childrens Surgery Verification program delineating requirements for hospitals providing pediatric surgical care. Our purpose was to examine possible effects of the Childrens Surgery Verification program by evaluating neonates undergoing high-risk operations. STUDY DESIGN Using the Kids Inpatient Database 2009, we identified infants undergoing operations for 5 high-risk neonatal conditions. We considered all childrens hospitals and childrens units Level I centers and considered all others Level II/III. We estimated the number of neonates requiring relocation and the additional distance traveled. We used propensity score adjusted logistic regression to model mortality at Level I vs Level II/III hospitals. RESULTS Overall, 7,938 neonates were identified across 21 states at 91 Level I and 459 Level II/III hospitals. Based on our classifications, 2,744 (34.6%) patients would need to relocate to Level I centers. The median additional distance traveled was 6.6 miles. The maximum distance traveled varied by state, from <55 miles (New Jersey and Rhode Island) to >200 miles (Montana, Oregon, Colorado, and California). The adjusted odds of mortality at Level II/III vs Level I centers was 1.67 (95% CI 1.44 to 1.93). We estimate 1 life would be saved for every 32 neonates moved. CONCLUSIONS Although this conservative estimate demonstrates that more than one-third of complex surgical neonates in 2009 would have needed to relocate under the Childrens Surgery Verification program, the additional distance traveled is relatively short for most but not all, and this program might improve mortality. Local level ramifications of this novel national program require additional investigation.

Cost comparison of initial lobectomy versus fine-needle aspiration for diagnostic workup of thyroid nodules in children

BACKGROUND Though uncommon in children, pediatric thyroid nodules carry a higher risk of malignancy than adult nodules. While fine-needle aspiration (FNA) has been well established as the initial diagnostic test in adults, it has been more slowly adopted in children. The purpose of this study was to examine the comparative cost of FNA versus initial diagnostic lobectomy (DL) in the pediatric patient with an ultrasound-confirmed thyroid nodule. METHODS A decision tree model was created using an adolescent with an asymptomatic thyroid nodule as the reference case. Probabilities were defined based on review of the pediatric and adult literature. Costs were determined from previous literature and the publicly available Medicare physician fee schedule. Tornado plot and sensitivity analyses were performed to assess sources of cost variation. RESULTS Using decision analysis, FNA was less costly than DL with an estimated cost of

A survey of pediatric surgeons' practices with enhanced recovery after children's surgery

2529 vs.