Timothy B. Lautz

Successful nontransplant resection of POST-TEXT III and IV hepatoblastoma.

Liver transplantation is increasingly advocated as primary surgical therapy for children with hepatoblastoma involving 3 or 4 sectors of the liver after neoadjuvant chemotherapy. This study evaluated the results of nontransplant hepatectomy in children who might otherwise have been considered for liver transplantation.

Acute pancreatitis in children: spectrum of disease and predictors of severity

BACKGROUND The aim of this study was to describe the spectrum of disease in children with acute pancreatitis and assess predictors of severity. METHODS Children (≤ 18 years) admitted to a single institution with acute pancreatitis from 2000 to 2009 were included. The accuracy of the Ranson, modified Glasgow, and pediatric acute pancreatitis severity (PAPS) scoring systems for predicting major complications was assessed. RESULTS The etiology of pancreatitis in these 211 children was idiopathic (31.3%), medication-induced (19.9%), gallstones (11.8%), trauma (7.6%), transplantation (7.6%), structural (5.2%), and hemolytic-uremic syndrome (3.3%). Fifty-six patients (26.5%) developed severe complications. Using the cutoff thresholds in the PAPS scoring system, only admission white blood cell count more than 18,500/μL (odds ratio [OR], 3.1; P = .010), trough calcium less than 8.3 mg/dL (OR, 3.0; P = .019), and blood urea nitrogen rise greater than 5 mg/dL (OR, 4.1; P = .004) were independent predictors of severe outcome in a logistic regression model. The sensitivity (51.8%, 51.8%, 48.2%) and negative predictive value (83.2%, 83.5%, 80.5%) of the Ranson, modified Glasgow, and PAPS scores were, respectively, insufficient to guide clinical decision making. CONCLUSION Commonly used scoring systems have limited ability to predict disease severity in children and adolescents with acute pancreatitis. Careful and repeated evaluations are essential in managing these patients who may develop major complications without early signs.

Isolated gastrocnemius and soleal vein thrombosis: should these patients receive therapeutic anticoagulation?

Objective:To determine the incidence of isolated gastrocnemius and soleal vein thrombosis (IGSVT) and the effect of anticoagulation on venous thromboembolism (VTE) events in patients with IGSVT. Summary Background Data:Although IGSVT is diagnosed with increasing frequency, the clinical significance and optimal management remains unknown. Methods:Vascular laboratory studies from April 2002 to April 2007 were retrospectively reviewed to identify patients with IGSVT. Medical records were reviewed for demographic data, risk factors, treatment modalities, and VTE events. Univariate and multivariate analysis were performed. Results:Of 38,426 lower extremity venous duplex studies, 406 patients with IGSVT were included in this study. Mean follow-up was 7.5 ± 11 months. The overall incidence of VTE among the entire cohort was 18.7%, which included 3.9% pulmonary embolism and 16.3% deep venous thrombosis, with 1.5% of patients having both pulmonary embolism and deep venous thrombosis. However, the incidence of VTE was 30% (36/119) and 27% (13/48) in patients who received no or prophylactic anticoagulation, respectively, but only 12% in patients treated with therapeutic anticoagulation (23/188; P = 0.0003). Multivariate analysis identified lack of therapeutic anticoagulation (P = 0.017) and history of VTE (P = 0.011) as independent predictors of subsequent VTE development. The rate of IGSVT resolution during follow up was 61.2% with therapeutic anticoagulation, but only 40.0% and 41.0% with prophylactic or no anticoagulation, respectively (P = 0.003). Conclusions:IGSVT is associated with a clinically significant rate of VTE which is dramatically reduced with therapeutic anticoagulation. These data warrant further investigation, taking into account the risks and benefits of anticoagulation.

Management and classification of type II congenital portosystemic shunts.

BACKGROUND Congenital portosystemic shunts (PSS) with preserved intrahepatic portal flow (type II) present with a range of clinical signs. The indications for and benefits of repair of PSS remain incompletely understood. A more comprehensive classification may also benefit comparative analyses from different institutions. METHODS All children treated at our institution for type II congenital PSS from 1999 through 2009 were reviewed for presentation, treatment, and outcome. RESULTS Ten children (7 boys) with type II PSS were identified at a median age of 5.5 years. Hyperammonemia with varying degrees of neurocognitive dysfunction occurred in 80%. The shunt arose from a branch of the portal vein (type IIa; n = 2), from the main portal vein (type IIb; n = 7), or from a splenic or mesenteric vein (type IIc; n = 1). Management included operative ligation (n = 6), endovascular occlusion (n = 3), or a combined approach (n = 1). Shunt occlusion was successful in all cases. Serum ammonia decreased from 130 ± 115 μmol/L preoperatively to 31 ± 15 μmol/L postoperatively (P = .03). Additional benefits included resolution of neurocognitive dysfunction (n = 3), liver nodules (n = 1), and vaginal bleeding (n = 1). CONCLUSION Correction of type II PSS relieves a wide array of symptoms. Surgery is indicated for patients with clinically significant shunting. A refined classification system will permit future comparison of patients with similar physiology.

Postoperative complications in children undergoing gastrostomy tube placement.

BACKGROUND Gastrostomy tube placement is associated with frequent postoperative complications. The aims of this study were to 1) determine the incidence of postoperative gastrostomy complications and 2) determine if patient demographics, comorbidities, or operative technique could predict these complications. METHODS A retrospective review was conducted on children who underwent gastrostomy tube placement from June 2006 through August 2009. Patient demographics, comorbidities, operative technique, health care visits, and complications were collected. Data were analyzed by chi-squared analysis (P < 0.05 significant). RESULTS One hundred and fifty-nine patients were evaluated, with the majority of patients <5 years of age (129/159). Ninety-four patients underwent open gastrostomy, 31 laparoscopic gastrostomy, and 34 laparoscopic-assisted gastrostomy. Granulation tissue was the most common postoperative complication, occurring in 58% of patients (93/159). The majority of patients with granulation tissue had full resolution by the fourth postoperative month. Tube dislodgement was the second most common complication, occurring 69 times in 44 of the patients (28%) and resulting in 59 emergency department (ED) visits. Overall, gastrostomy complications resulted in 100 ED and 462 clinic visits. Ninety-three percent (93/100) of ED visits resulted in discharge home from the ED. Gender, age, insurance status, and operative technique were not predictive of complications. CONCLUSIONS Granulation tissue and tube dislodgement are the most common complications after gastrostomy placement in children. Gender, age, insurance status, and operative technique were not predictive of complications. Emergency department utilization is high in children with gastrostomy tubes.

Growth impairment in children with extrahepatic portal vein obstruction is improved by mesenterico-left portal vein bypass

BACKGROUND Extrahepatic portal vein obstruction (EHPVO) has been associated with growth impairment in children. We hypothesized that growth parameters improve after reversal of portal hypertension and restoration of mesenteric venous blood flow to the liver by the mesenterico-left portal vein bypass (MLPVB). METHODS A retrospective review of 45 children with idiopathic EHPVO who underwent MLPVB between 1997 and 2007 and had follow-up data for analysis was carried out. Growth was assessed using SD scores (z scores) for height, weight, and body mass index (BMI) at the time of operation and at early (5-12 months) and late (13-24 months) follow-up. RESULTS The mean height and weight of children with EHPVO was significantly lower than the general population before surgery. Mean BMI was also lower, although statistically insignificant. All parameters increased significantly after MLPVB as follows: height from -0.42 before surgery to -0.12 (P = .027) at 5 to 12 months and -0.14 (P = .026) at 13 to 24 months; weight from -0.49 before surgery to 0.03 (P < .001) at 5 to 12 months and 0.35 (P < .001) at 13 to 24 months; and BMI from -0.22 before surgery to 0.17 (P = .001) at 5 to 12 months and 0.48 (P < .001) at 13 to 24 months. CONCLUSION Restoration of portal blood flow to the liver by MLPVB improves growth in children with EHPVO.

Focal nodular hyperplasia in children: clinical features and current management practice

BACKGROUND Although nonoperative management is an accepted practice for most adults with focal nodular hyperplasia (FNH), questions remain about the safety and feasibility of this strategy in children. Our aim was to review the clinical features of children with FNH and determine current management patterns. METHODS We reviewed records of all children and adolescents with FNH managed at our institution from 1999 to 2009 and performed a MEDLINE search to identify all published cases of FNH in the pediatric population. RESULTS A total of 172 patients with FNH were identified, including 11 at our institution. The median age at diagnosis was 8.7 years and 66% were female. Median tumor size was 6 cm, and 25% had multiple lesions. Thirty-six percent were symptomatic at presentation. Twenty-four percent had a history of malignancy. Management included resection (61%), biopsy followed by observation (21%), and observation alone (18%). Indications for resection included symptoms (48%), inability to rule out malignancy (24%), tumor growth (15%), and biopsy-proven concurrent malignancy (9%). CONCLUSIONS Although FNH is a benign lesion that is typically managed nonoperatively in adults, most children with FNH currently undergo resection because of symptoms, increasing size, or inability to confidently rule out malignancy.

Utility of the computed tomography severity index (Balthazar score) in children with acute pancreatitis

BACKGROUND Previous studies in children with acute pancreatitis have demonstrated that clinical scoring systems such as the Ranson, modified Glasgow, and pediatric acute pancreatitis scores are of value in predicting severity of the disease. The aim of this study was to determine the predictive value of the computed tomography severity index (CTSI or Balthazar score) in pediatric patients. METHODS All children (≤ 18 years) admitted to our institution with acute pancreatitis from 2000 through 2009 were reviewed. Contrast-enhanced computed tomographic (CT) images at presentation were retrospectively reviewed by 2 pediatric radiologists. Peripancreatic fluid and the extent of necrosis were assessed to determine the CTSI. The predictive value of the CTSI was calculated and compared with clinical scoring systems. RESULTS Of 211 children with acute pancreatitis, 64 underwent contrast-enhanced CT at presentation. The median age was 12.3 years. Etiology of pancreatitis was idiopathic (35.9%), gallstone (17.2%), medication-induced (20.3%), posttransplant (9.4%), traumatic (6.3%), structural (1.6%), and other (9.4%). The sensitivity, specificity, positive predictive value, and negative predictive value of the CTSI (using a cutoff score of 4+) were 81%, 76%, 62%, and 90%, respectively, which compared favorably to the results of the pediatric acute pancreatitis (53%, 72%, 41%, 80%), Ranson (71%, 87%, 67%, 89%), and modified Glasgow (71%, 87%, 67%, 89%) scores. CONCLUSION The CTSI is superior to clinical scoring systems for identifying children with acute pancreatitis at heightened risk for developing serious complications.

Effect of resident postgraduate year on outcomes after laparoscopic appendectomy for appendicitis in children.

PURPOSE The purpose of this study was to determine if the postgraduate level of resident in the operating room correlates with outcomes for pediatric patients undergoing laparoscopic appendectomy. SUBJECTS AND METHODS The charts of all children who underwent laparoscopic appendectomy for appendicitis from 2007 to 2011 at a free-standing childrens hospital were reviewed. Outcomes of interest were compared between patient groups based on postgraduate level of the junior-most surgeon in the operating room: (1) junior resident (postgraduate year [PGY]-1, -2, and -3); (2) senior resident (PGY-4 or -5); (3) fellow (PGY-6 or -7); or (4) attending surgeon only. RESULTS Junior resident (n=327), senior resident (n=129), fellow (n=246), and attending (n=73) groups were similar in terms of age (P=.69), gender distribution (P=.51), race (P=.08), and perforation status (P=.30). Operative time was shorter for senior residents (P=.002), fellows (P<.001), and attending surgeons operating without a resident (P<.001) compared with cases with junior residents. The rate of conversion to an open operation was similar among groups (P=.46). Resident level was not predictive of complications, which occurred in 26 junior resident cases (8.0%; referent), 17 senior resident cases (13.2%; odds ratio [OR] 1.73; P=.11), 33 fellow cases (13.4%; OR 1.71; P=.06), and 8 attending cases (11.0%; OR 1.62; P=.27). Fellow involvement was associated with an increased rate of postoperative percutaneous abscess drainage or re-operation for abscess or bowel obstruction (9.8%; OR 2.31; P=.020). CONCLUSIONS Involvement of junior residents in pediatric laparoscopic appendectomy is associated with increased operative time but no higher rate of complications.

Context and significance of emergency department visits and readmissions after pediatric appendectomy

BACKGROUND The readmission rate after pediatric appendectomy is frequently reported in clinical outcomes studies and quality improvement initiatives without proper description. Our aim was to delineate the context and significance of these encounters. METHODS Patients (<18 years old) who underwent appendectomy for acute appendicitis at a tertiary childrens hospital from January 2007 through June 2010 were reviewed. Emergency department (ED) visits and inpatient readmissions within 90 days were identified and classified as unrelated, related surgical complications, or potentially avoidable visits for minor related concerns. RESULTS Of 629 patients, 119 (18.9%) had 141 ED visits or readmissions within 90 days after discharge. Eighty-three (58.9%) encounters were limited to the ED, and 58 (41.1%) required inpatient hospitalization. Eighty-seven percent of encounters within the first 30 days after discharge, but only 26% of those occurring beyond 30 days, were related to the operation (P < .001). Overall, 45 (31.9%) ED visits or readmissions were totally unrelated to the appendectomy, 36 (25.5%) represented true surgical complications requiring inpatient hospitalization, and 60 (42.6%) were minor, potentially avoidable visits related to the appendectomy. Potentially avoidable encounters were more common in Spanish-speaking patients (P < .01). CONCLUSIONS Emergency department visits and inpatient readmissions after pediatric appendectomy are frequent but not uniformly indicative of surgical complications or suboptimal care. Opportunities exist to reduce avoidable ED visits related to minor postoperative concerns.