[Show abstract][Hide abstract] ABSTRACT: The outcomes of children with congenital hemolytic anemia (CHA) undergoing total splenectomy (TS) or partial splenectomy (PS) remain unclear. In this study, we collected data from 100 children with CHA who underwent TS or PS from 2005-2013 at 16 sites in the Splenectomy in Congenital Hemolytic Anemia (SICHA) consortium using a patient registry. We analyzed demographics and baseline clinical status, operative details, and outcomes at 4, 24, and 52 weeks after surgery. Results were summarized as hematologic outcomes, short-term adverse events (AEs) (≤ 30 days after surgery), and long-term AEs (31-365 days after surgery). For children with hereditary spherocytosis, after surgery there was an increase in hemoglobin (baseline 10.1 ± 1.8 gm/dl, 52 week 12.8 ± 1.6 gm/dl; mean ± SD), decrease in reticulocyte and bilirubin as well as control of symptoms. Children with sickle cell disease had control of clinical symptoms after surgery, but had no change in hematologic parameters. There was an 11% rate of short-term AEs and 11% rate of long-term AEs. As we accumulate more subjects and longer follow-up, use of a patient registry should enhance our capacity for clinical trials and engage all stakeholders in the decision-making process.
[Show abstract][Hide abstract] ABSTRACT: Children with perianal Crohn’s disease (PCD) are a unique and diverse patient population. The purpose of this study was to describe the spectrum of disease and role of surgery.
[Show abstract][Hide abstract] ABSTRACT: Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP).
Journal of pediatric surgery. 07/2014; 49(7):1083-6.
[Show abstract][Hide abstract] ABSTRACT: In 2000, we described the variability of pediatric surgical information on the Internet. Since then, online videos have become an increasingly popular medium for education and personal expression. The purpose of this study was to examine the content and quality of videos related to pediatric surgical diagnoses on the Internet.
YouTube™ was searched for videos on gastroschisis, congenital diaphragmatic hernia, pediatric inguinal hernia, and pectus excavatum. The first 40 English language videos for each diagnosis were reviewed for owner and audience characteristics, content and quality.
A small majority of videos were made by medical professionals (50.63%, vs. 41.25% by lay persons and 8.13% by fundraising organizations). Eighty percent of videos were intended for a lay audience. Videos by medical professionals were more accurate and complete than those posted by lay persons.
The YouTube™ videos varied significantly in content and quality. Videos by lay persons often focused on the emotional aspect of the diagnosis and clinical course. Videos by members of the medical profession tended to be more complete and accurate. These findings underscore the continued need for high quality pediatric surgical information on the Internet for patients and their families.
Journal of Pediatric Surgery 04/2014; 49(4):586-9. · 1.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Canada faces a similar epidemic of obesity in their adolescent population as other Western countries. However, the development of programs to treat obesity and manage its sequelae has evolved in a unique way. This is in part due to differences in health care funding, population distribution, public demand, and availability of expertise and resources. In this article, we will describe the evolution of adolescent bariatric care in Canada and describe the current programs and future directions. The focus will be on the province of Ontario, the site of the first adolescent bariatric program in the country.
Seminars in Pediatric Surgery 02/2014; 23(1):31-6. · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Large solid sacrococcygeal teratomas (SCT) can cause high output cardiac failure and fetal or neonatal death. We describe the outcomes of minimally invasive antenatal procedures for the treatment of fetal SCT. Material and methodsCase review of 5 fetuses with large SCT's treated antenatally using minimally invasive techniques and systematic literature review on fetal therapy for solid SCT's.
Five women were referred between 17.7-26.6 weeks gestation for large fetal SCT's with evidence of fetal cardiac failure. Vascular flow to the tumors was interrupted by fetoscopic laser ablation (n = 1), radiofrequency ablation (RFA, n = 2) and interstitial laser ablation +/- vascular coiling(n = 2). There were 2 intra-uterine fetal deaths. The other 3 cases resulted in preterm labor within 10 days of surgery. One neonate died. Two survived without procedure related complications but had long-term morbidity related to prematurity. Systematic literature review revealed 15 SCT's treated minimally invasively for (early) hydrops. Including ours, 6 of 20 hydropic fetuses survived after minimally invasive therapy (30%). Survival after RFA or interstitial laser was 45% (n = 5/11). Of 12 fetuses treated for SCT without obvious hydrops, 67% (n = 8/12) survived. Mean gestational age at delivery after minimally invasive therapy was 29.7 ± 4.0 weeks. Survival after open fetal surgery in hydropic fetuses was 55% (n = 6/11) with a mean gestational age at delivery of 29.8 ± 2.9 weeks.
Fetal therapy can potentially improve perinatal outcomes for hydropic fetuses with solid SCT's but is often complicated by intrauterine death and preterm birth.
Ultrasound in Obstetrics and Gynecology 01/2014; · 3.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background
Longer wait time for infant inguinal hernia (IH) repair is associated with higher complication rates. We wished to determine if socioeconomic and demographic factors influence wait times for IH repair.
Children < 2 yo with IH at a Canadian children’s hospital were retrospectively reviewed. Days from diagnosis to surgical consultation (W1) and from consultation to repair (W2) were collected along with demographic, medical ,and socioeconomic data. Linear regression analysis was performed.
131 patients were appropriate for analysis (82.4% male). Median distance to hospital was 27.5 km (IQR = 10.5-50.4) and median income was $34,477 (IQR = 30,127-41,986). Median W1, W2. and Wtotal (W1 + W2) were 24 (IQR = 8-48), 43 (IQR = 21-69) and 79 (IQR = 38-112) days, respectively. Wait times were shorter in infants who were male (p = 0.044), symptomatic (p < 0.001), diagnosed in the ED (p < 0.001), or had an incarcerated hernia (p = 0.006). They were longer for premature infants (p = 0.009) and those with significant comorbidities (p = 0.018). Neither income (p = 0.328) nor distance from hospital (p = 0.292) was associated with longer wait times.
Wait times for IH repair were appropriately influenced by medical risk factors. Income and distance to hospital did not appear to influence wait times. A population-based study is needed to determine if these findings reflect a general trend within the Canadian health care system.
[Show abstract][Hide abstract] ABSTRACT: Background
Both the Swenson and the Soave procedures have been adapted to a transanal approach. The purpose of this study was to compare outcomes following the transanal Swenson and Soave procedures using a matched case control analysis.
A retrospective chart review was performed to identify all transanal Soave and Swenson pullthroughs done at 2 tertiary care children’s hospitals between 2000 and 2010. Patients were matched for gestational age, mean weight at time of the operation, level of aganglionosis, and presence of co-morbidities. Student’s t-test and chi-squared analysis were performed.
Fifty-four patients (Soave 27, Swenson 27) had adequate data for matching and analysis. Mean follow-up was 4 ± 1.6 years and 3.2 ± 2.7 years for the Soave and Swenson groups, respectively. No significant differences in mean operating time (Soave:191 ± 55, Swenson:167 ± 61 mins, p = 0.6), overall hospital stay (6 ± 4vs7.8 ± 5 days, p = 0.7) , and number with intra-operative complications (3vs4, p = 1.0), post-operative obstructive symptoms (6vs9, p = 0.5), enterocolitis episodes (4vs4, p = 1.0),or fecal incontinence (0vs2, p = 0.4) were noted.
After controlling for potential confounders, there were no significant differences in the short and intermediate term outcome between transanal Soave and transanal Swenson pullthrough procedures.
[Show abstract][Hide abstract] ABSTRACT: Background
There is significant lack of information regarding the Canadian pediatric surgery workforce.
An IRB-approved survey aimed at assessing workforce issues was administered to pediatric surgeons and pediatric surgery chiefs in Canada in 2012.
The survey was completed by 98% of practising surgeons and 13 of the 18 division chiefs. Only 6% of surgeons are older than 60 years, and only a fifth anticipate retirement over the next decade. The workforce is stable, with 82% of surgeons unlikely to change current positions. Surgical volume showed essentially no growth during the 5-year period 2006–2010. The majority of surgeons felt they were performing the right number or too few cases and anticipated minimal or no future growth in their individual practices or that of their group. Based on anticipated vacancies, the best estimate is a need for 20 new pediatric surgeons over the next decade. This need is significantly surpassed by the current output from the Canadian training programs.
The Canadian pediatric surgery workforce is currently saturated. The mismatch between the number of graduating trainees and the available positions over the next decade has significant repercussions for current surgery and pediatric surgery residents wishing to practice in Canada.
[Show abstract][Hide abstract] ABSTRACT: In hemodynamically normal children with blunt splenic injury (BSI), the standard of care is non-operative management. Several studies have reported that non-paediatric and non-trauma centres have higher operative rates in children with BSI compared to paediatric hospitals and trauma centres. We investigate the feasibility of using operative rate for BSI as a quality of care indicator.
We performed a population-based retrospective cohort study of children (≤18 years) with BSI admitted to all acute-care hospitals in Canada from 2001 to 2010. The main outcome was rate of operative management for BSI. Hierarchical multivariable logistic regression models were constructed to evaluate the relationship between operative rate and different hospital types (paediatric or non-paediatric, trauma or non-trauma). These models also allowed for generation of hospital-level observed to expected (O/E) ratios for rate of operative management.
We identified 3122 children with BSI. The majority (74%) were isolated splenic injuries and the grade of splenic injury was specified in 45% of cases (n=1391, 38% grade I or II; 62% grade III, IV, or V). The overall operative rate was 11% (n=315), of which 9% were total splenectomy and 2% were spleen-preserving operations. After adjusting for age, gender, mechanism of injury, splenic injury grade, ISS, and centre volume, admission to non-paediatric hospitals was associated with a higher probability of operative management (OR 7.6, 95% CI 2.4-24.4), whereas there was no significant difference in operative management between trauma and non-trauma centres (OR 1.6, 95% CI 0.8-3.2). Outlier status based on O/E ratio was determined to identify centres with higher or lower than expected operative rates.
The operative rates for children with BSI are significantly higher in non-paediatric hospitals. In these hospitals that do not routinely care for children and have higher than expected operative rates, we have used operative rate for BSI as a quality of care indicator and identified opportunities for quality improvement initiatives. Level of evidence: III, Retrospective comparative study.
[Show abstract][Hide abstract] ABSTRACT: There is considerable controversy regarding optimal mode and timing of delivery for fetuses with gastroschisis. Our objectives were to describe the variation in institutional approach regarding these factors, and to evaluate the effect of timing of delivery on outcomes in fetuses with gastroschesis.
Members of the maternal-fetal medicine community across Canada were surveyed regarding their personal and institutional approach of delivery. Data from the Canadian Pediatric Surgery Network (CAPSnet) were analyzed.
The survey showed significant variability in delivery approach between institutions, although no center routinely performs cesarean section. Infants delivered vaginally (VD) were categorized into three groups: Group 1, VD <36weeks (n=114); Group 2, VD 36-37weeks (n=218); and Group 3, VD ≥38weeks (n=75). Score of Neonatal Acute Physiology, complication rates, length of time on total parenteral nutrition (TPN), and length of hospital stay (LOS) were higher in Group 1; bowel matting was greater in Group 3. There were no differences between the groups regarding other complications.
Our data suggest that preterm delivery was associated with more complications, longer time on TPN, and longer LOS; delivery ≥38weeks was associated with increased bowel matting. These outcomes should be considered when determining institutional protocol.
Journal of Pediatric Surgery 11/2013; 48(11):2251-5. · 1.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The differential diagnosis of an axillary mass during childhood is extensive and malignant processes such as lymphoma or metastatic disease must be excluded. We describe an unusual case of a fibroadenoma growing within ectopic breast tissue located in the axilla in a 10 year old girl. The mass grew rapidly and was removed during an excisional biopsy. Histological evaluation revealed a diagnosis of fibroadenoma. Fibroadenoma of ectopic breast tissue has not previously been reported in the pediatric age group, and must be considered as part of the differential diagnosis for pediatric axillary masses.
Journal of Pediatric Surgery Case Reports. 10/2013; 1(10):359–361.
[Show abstract][Hide abstract] ABSTRACT: Background Long-gap esophageal atresia (EA) represents a challenging problem for pediatric surgeons, and a large number of techniques and approaches have been proposed. One of the more recent, initially published by Foker, is the use of mechanical traction to accelerate the growth of the esophageal ends and permit earlier primary anastomosis. The purpose of this study is to critically evaluate the existing literature on this topic and to compare the Foker technique to the more conventional delayed primary anastomosis.Methods A systematic review and cumulative meta-analysis was performed, including all articles describing the Foker technique or delayed primary anastomosis. Primary outcome was complications, and secondary outcome was time to final anastomosis.Results Six articles on the Foker procedure met the criteria for inclusion. None were prospective or randomized. These articles represented 71 infants undergoing the Foker procedure, which were compared with 451 children from 44 studies utilizing delayed primary anastomosis. The Foker procedure was associated with a significantly lower risk of complications (leak, stricture, and gastroesophageal reflux), and with a significantly shorter time to definitive anastomosis.Conclusions The use of mechanical traction appears to be at least as effective as delayed primary anastomosis for the management of long-gap EA. Future prospective studies and the establishment of a prospective registry are required to further elucidate this issue.
European Journal of Pediatric Surgery 05/2013; · 0.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: To report 3 different antenatal therapeutic approaches for fetal lung masses associated with hydrops. METHODS: Three prospectively followed cases are described and all 17 previously published minimally invasive cases of fetal therapy for hydropic lung masses are reviewed. RESULTS: Three hydropic fetuses with large intra-thoracic lung masses presented at 17, 21 and 24 weeks gestation, respectively. An aortic feeding vessel was identified in each case and thus a broncho-pulmonary sequestration (BPS) was suspected. Under ultrasound guidance, the feeding vessel was successfully occluded with: (1) interstitial laser; (2) thrombogenic coil embolisation and (3) radio-frequency ablation (RFA). Complete (1&3) or partial (2) resolution of the lung mass and hydrops was observed in all cases. An healthy infant was born at term after laser therapy (1), and the involved lung lobe was resected at day on day 2 of life. Despite technical success in complete vascular occlusion with coils, a stillbirth ensued 2 days after embolisation. In case 3, hydrops resolved completely following RFA, but an iatrogenic congenital diaphragmatic hernia and abdominal wall defect became apparent 4 weeks later. The neonate died from sepsis following spontaneous preterm labour at 33 weeks. CONCLUSIONS: The natural history of large microcystic or echogenic fetal chest masses associated with hydrops is dismal. This has prompted attempts at treatment by open fetal surgery, with mixed results, high risk of premature labor and consequences for future pregnancies. We have demonstrated the possibility of improved outcome following ultrasound-guided laser ablation of the systemic arterial supply. Despite technical success, RFA and coil embolisation led to procedure related complications and need further evaluation.
Ultrasound in Obstetrics and Gynecology 05/2013; · 3.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: : To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis.
: The management of 296 pregnancies involving fetal gastroschisis (1980-2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation.
: Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced.
: In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation.
Obstetrics and Gynecology 05/2013; 121(5):990-8. · 4.80 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: PURPOSE OF REVIEW: Hirschsprung disease is relatively common in children. Surgical techniques are available to remove the aganglionic bowel and reconstruct the intestinal tract. Despite many advances, these children may still be difficult to diagnose, and may have ongoing functional problems after surgical correction. RECENT FINDINGS: The genetic basis and cause of Hirschsprung disease are becoming increasingly clearer. Definitive diagnosis is based on rectal biopsy, but more sophisticated techniques are permitting earlier and more accurate diagnosis. Surgical correction has evolved from routine use of a colostomy and open laparotomy to one-stage transanal and laparoscopic approaches. The range of postoperative problems is reviewed so that the practicing pediatrician and primary care physician can effectively care for these children. Future advances may include better genotype-phenotype correlation and development of neuronal stem cell techniques. SUMMARY: Pediatricians and primary care physicians have an important role to play in diagnosing and managing children with Hirschsprung disease.
Current opinion in pediatrics 04/2013; · 2.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Higher recurrence rates have been reported for thoracoscopic repair (TR) of neonatal congenital diaphragmatic hernia (CDH) compared to open repair. Our centre initiated changes in surgical management following a quality review in order to improve outcome.
A retrospective review of TR patients from 2000 to 2011 at a single institution was performed. A review was done in 2007, and changes were implemented to decrease recurrence rates. These included use of pledgets, an extracorporeal corner stitch, liberal prosthetic patch use, lower insufflation pressures, and TR was limited to two experienced surgeons. Outcome data before and after this quality improvement process were compared. Non-TR patients from the same time period served as controls. Data are quoted as median (range) and non-parametric tests used to compare. P<0.05 was regarded as significant.
There were 23 neonatal TR patients with median follow-up of 3.6 (range 0.4-7) years. Median age at repair was 2 (range 0-21) days. There were 5 patch repairs (22%), all after 2008. There were 9 recurrences (39%) at a median time of 162 days after TR, compared to 13 (10%) recurrences in the control cohort. For primary TR, there was a trend towards a decreased recurrence rate from 50% prior to 2008 to 25% after 2008 (P=0.26).
Systematic quality review was modestly effective in decreasing the recurrence rate for neonatal TR, but further outcome data are required.
Journal of Pediatric Surgery 02/2013; 48(2):321-5. · 1.38 Impact Factor