Objectives/Hypothesis
Repair of large, recurrent, and complex tracheoesophageal fistulas (TEFs) is challenging and numerous different surgical approaches exist. These various techniques each carry a ...set of risks and possible complications such as fistula recurrence, tracheal stenosis or pouches, esophageal stenosis, and recurrent laryngeal nerve injury. Slide tracheoplasty is a reconstructive technique successfully used in many different airway pathologies, including TEF repair. This study examines the success, limits, and complications related to slide tracheoplasty for repair of complex TEFs.
Study Design
Retrospective chart review.
Methods
Patients undergoing TEF repair using a cervical or thoracic approach slide tracheoplasty, at a single institution, between July 2008 and December 2019 were retrospectively reviewed. Demographic data, comorbidities, TEF etiology and surgical history, slide tracheoplasty details and outcomes, and postoperative complication data were examined using descriptive statistics.
Results
Twenty‐six patients underwent 27 slide tracheoplasties for TEF (20 cervical approaches, 7 thoracic approaches) with a mean age of 5.2 years (IQR 0.7–7.6) at time of surgery. The most common TEF etiologies included congenital (n = 13), tracheostomy tube erosion (n = 5), and button battery ingestion (n = 4). Fistulas ranged in size from <0.5 mm to 4 cm and 59% had previous endoscopic or open repairs. There were two TEF recurrences (7.4%), one of which was successfully revised and the other which was treated with stent placement. Postoperative complications included dehiscence (3.7%), unilateral vocal fold paralysis (3.7%), and mild tracheal stenosis (18.5%).
Conclusions
Slide tracheoplasty is an effective surgical technique for treating complex congenital and acquired TEFs with lower rates of complications when compared to other techniques.
Level of Evidence
4 Laryngoscope, 132:1542–1547, 2022
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
There has been an increase in the use of imaging modalities to diagnose appendicitis despite evidence that can help identify children at especially high or low risk of appendicitis who may not ...benefit. We hypothesized that the passive diffusion of a standardized care pathway (including diagnostic imaging recommendations) would improve the diagnostic workup of appendicitis by safely decreasing the use of unnecessary imaging when compared with historical controls and that an electronic, real-time decision support tool would decrease unnecessary imaging.
We used an interrupted time series trial to compare proportions of patients who underwent diagnostic imaging (computed tomography CT and ultrasound) between 3 time periods: baseline historical controls, after passive diffusion of a diagnostic workup clinical pathway, and after introduction of an electronic medical record-embedded clinical decision support tool that provides point-of-care imaging recommendations (active intervention).
The moderate- and high-risk groups showed lower proportions of CT in the passive and active intervention time periods compared with the historical control group. Proportions of patients undergoing ultrasound in all 3 risk groups showed an increase from the historical baseline. Time series analysis confirmed that time trends within any individual time period were not significant; thus, incidental secular trends over time did not appear to explain the decreased use of CT.
Passive and active decision support tools minimized unnecessary CT imaging; long-term effects remain an important area of study.
Perianal fistulas and abscesses occur commonly as complications of pediatric Crohn's disease (CD). A validated imaging assessment tool for quantification of perianal disease severity and activity is ...needed to evaluate treatment response. We aimed to identify magnetic resonance imaging (MRI)-based measures of perianal fistulizing disease activity and study design features appropriate for pediatric patients.
Seventy-nine statements relevant to MRI-based assessment of pediatric perianal fistulizing CD activity and clinical trial design were generated from literature review and expert opinion. Statement appropriateness was rated by a panel (N = 15) of gastroenterologists, radiologists, and surgeons using modified RAND/University of California Los Angeles appropriateness methodology.
The modified Van Assche Index (mVAI) and the Magnetic Resonance Novel Index for Fistula Imaging in CD (MAGNIFI-CD) were considered appropriate instruments for use in pediatric perianal fistulizing disease clinical trials. Although there was concern regarding the use of intravascular contrast material in pediatric patients, its use in clinical trials was considered appropriate. A clinically evident fistula tract and radiologic disease defined as at least 1 fistula or abscess on pelvic MRI were considered appropriate trial inclusion criteria. A coprimary clinical and radiologic end point and inclusion of a patient-reported outcome were also considered appropriate.
Outcomes of treatment of perianal fistulizing disease in children must include MRI. Existing multi-item measures, specifically the mVAI and MAGNIFI-CD, can be adapted and used for children. Further research to assess the operating properties of the indices when used in a pediatric patient population is ongoing.
Objectives:
Aerodigestive disorders encompass various pathological conditions affecting the lungs, upper airway, and gastrointestinal tract in children. While advanced care has primarily occurred in ...specialty centers, many children first present to general pediatric gastroenterologists with aerodigestive symptoms necessitating awareness of these conditions. At the 2021 Annual North American Society for Pediatric Gastroenterology, Hepatology and Nutrition meeting, the aerodigestive Special Interest Group held a full‐day symposium entitled, Pediatric Aerodigestive Medicine: Advancing Collaborative Care of Children with Aerodigestive Disorders. The symposium aimed to underline the significance of a multidisciplinary approach to achieve better outcomes for these complex patients.
Methods:
The symposium brought together leading experts to highlight the growing aerodigestive field, promote new scientific and therapeutic strategies, share the structure and benefits of a multidisciplinary approach in diagnosing common and rare aerodigestive disorders, and foster multidisciplinary discussion of complex cases while highlighting the range of therapeutic and diagnostic options. In this article, we showcase the diagnostic and therapeutic approach to oropharyngeal dysphagia (OPD), one of the most common aerodigestive conditions, emphasizing the role of a collaborative model.
Conclusions:
The aerodigestive field has made significant progress and continues to grow due to a unique multidisciplinary, collaborative model of care for these conditions. Despite diagnostic and therapeutic challenges, the multidisciplinary approach has enabled and greatly improved efficient, high‐quality, and evidence‐based care for patients, including those with OPD.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Purpose
Neuroblastoma is the most common extracranial solid pediatric malignancy, with poor outcomes in high‐risk disease. Standard treatment approaches employ an increasing array of aggressive ...multimodal therapies, of which local control with surgery and radiotherapy remains a backbone; however, the benefit of broad regional nodal irradiation remains controversial. We analyzed centrally reviewed radiation therapy data from patients enrolled on COG A3973 to evaluate the impact of primary site irradiation and the extent of regional nodal coverage stratified by extent of surgical resection.
Methods
Three hundred thirty high‐risk neuroblastoma patients with centrally reviewed radiotherapy plans were analyzed. Outcome was evaluated by the extent of nodal irradiation. For the 171 patients who also underwent surgery (centrally reviewed), outcome was likewise analyzed according to the extent of resection. Overall survival (OS), event‐free survival (EFS), and cumulative incidence of local progression (CILP) were examined by Kaplan–Meier, log‐rank test (EFS, OS), and Grey test (CILP).
Results
The five‐year CILP, EFS, and OS for all 330 patients receiving radiotherapy on A3973 were 8.5% ± 1.5%, 47.2% ± 3.0%, and 59.7% ± 3.0%, respectively. There were no significant differences in outcomes based on the extent of lymph node irradiation regardless of the degree of surgical resection (< 90% or ≥90%).
Conclusion
Although local control remains a significant component of treatment of high‐risk neuroblastoma, our results suggest there is no benefit of extensive lymph node irradiation, irrespective of the extent of surgical resection preceding stem cell transplant.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Background
Changes in three‐dimensional (3D) measurements of neuroblastoma are used to assess response. Linear measurements may not accurately characterize tumor size due to the infiltrative ...character of these tumors. The purpose of this study was to assess the accuracy of one‐dimensional (1D), two‐dimensional (2D), and 3D measurements in characterizing neuroblastoma response compared to a reference standard of tumor volume.
Procedure
We retrospectively reviewed imaging for 34 patients with stage 3 or 4 neuroblastoma. Blinded readers contoured or made linear measurements of tumors. Correlation coefficients were used to compare linear measurements to volumetric and 3D measurements. Bland–Altman analyses were used to assess bias between measurements. Sensitivity and specificity for patient events and survival were calculated for each measurement technique.
Results
Mean patient age was 2.9 ± 3.0 years (range 0–15 years). There was strong correlation between volumetric and 1D (r = 0.78, P < 0.0001), 2D (r = 0.86, P < 0.0001), and 3D (r = 0.88, P < 0.0001) measurements. Mean bias between volumetric measurements and 1D, 2D, and 3D measurements was 37.1% (95% limits: 6.2–67.9%), 16.1% (95% limits: –11.7–43.8%), and 7.7% (95% limits: –19.7–35.1%), respectively. 1D and 2D measurements undercategorized response versus volumetric change in 88.2% (30/34) and 29.4% (10/34) of cases. 3D measurements incorrectly characterized response in 16.7% (4/24) of cases versus volumetric change. 3D measurements were highly sensitive for patient events and survival, but all measurement techniques had poor specificity.
Conclusions
3D measurements most accurately quantify neuroblastoma size response versus volumetric change in patients with stage 3 and 4 neuroblastoma. 1D and 2D measurements underrepresent tumor response.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
The evolution of the treatment of pediatric solid tumors has been one of progressive improvements in survival. With the advent of pediatric cooperative groups, a systematic approach has brought ...integrated multidisciplinary care to childhood cancer patients. Improved medical regimens and advances in the basic understanding and characterization of molecular biology of individual tumors continues to bring new treatment options. As long term survival has improved, a greater appreciation of the late effects of treatment has led to increase awareness and intervention for things like infertility. The surgeon remains a critical member of the treatment team. Surgical treatment techniques continue to evolve and the role of surgery in each tumor type is continually redefined. It is incumbent on the treating surgeon to know the treatment guidelines for each case in order to provide the patient with the best opportunity for a successful outcome.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Abstract Purpose We aim to investigate the post-operative outcomes, bowel habits and quality of life (QoL) of younger pediatric ulcerative colitis (UC) patients following surgical intervention ...compared to an older pediatric population. Methods Medical records of UC patients after colectomy with ileoanal reconstruction (2002-2013) at our institution were reviewed. Patients/parents completed a QoL, bowel habits and disease course questionnaire. Surgical outcomes, bowel habits and QoL were reported comparing the younger (≤ 11 years old, n = 26) to older (> 11 years old, n = 38) cohorts. Results The mean age at colectomy was 7.04 ± 0.63 years vs 14.71 ± 0.32 years in the two groups. Patients had a significant (P < 0.001) reduction in stooling frequency after surgery in both age groups and had favorable rates of fecal continence. The frequency of pouchitis and post-operative small bowel obstruction was similar in both cohorts. Dehydration was slightly increased in the younger population but not significant. Anastomotic leak and stricture rates were slightly reduced in younger patients. Post-operative QoL was favorable and similar regardless of age at surgery. Conclusions Colectomy with ileoanal anastomosis for young children (≤ 11 years old) with UC is without increased complications relative to older patients and maintains a post-operative QoL and stool patterns.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
One of the least appealing responsibilities of physician leadership is managing situations in which a physician partner is creating problems. Nevertheless, it is one of the most important aspects in ...maintaining a healthy team dynamic. When the behavior of problem partners goes unchecked these situations often grow to negatively impact others and detract from providing optimal patient care on multiple levels. Although little guidance has been given on how to handle these challenging situations, many of the principles of dealing with surgical complications are applicable and may be more familiar to surgeons. Similar to complications, preventing problems by carefully recruiting those who work well with the team is optimal. However, if and when disruptive behaviors occur, providing clear communication and setting well defined expectations is critical to the resolution.
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