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Outcomes of Bariatric Surgery in Older Versus Younger Adolescents. Pediatrics Ogle, S. B., Dewberry, L. C., Jenkins, T. M., Inge, T. H., Kelsey, M., Bruzoni, M., Pratt, J. S. 2021
Abstract

OBJECTIVES: In this report, we compare weight loss, comorbidity resolution, nutritional abnormalities, and quality of life between younger and older adolescents after metabolic and bariatric surgery.METHODS: From March 2007 to December 2011, 242 adolescents (?19 years of age) who underwent bariatric surgery at 5 clinical centers in the United States were enrolled in the prospective, multicenter, long-term outcome study Teen-Longitudinal Assessment of Bariatric Surgery. Outcome data from younger (13-15 years; n = 66) and older (16-19 years; n = 162) study participants were compared. Outcomes included percent BMI change, comorbidity outcomes (hypertension, dyslipidemia, and type 2 diabetes mellitus), nutritional abnormalities, and quality of life over 5 years post surgery.RESULTS: Baseline characteristics, except for age, between the 2 cohorts were similar. No significant differences in frequency of remission of hypertension (P = .84) or dyslipidemia (P = .74) were observed between age groups. Remission of type 2 diabetes mellitus was high in both groups, although statistically higher in older adolescents (relative risk 0.86; P = .046). Weight loss and quality of life were similar in the 2 age groups. Younger adolescents were less likely to develop elevated transferrin (prevalence ratio 0.52; P = .048) and low vitamin D levels (prevalence ratio 0.8; P = .034).CONCLUSIONS: The differences in outcome of metabolic and bariatric surgery between younger and older adolescents were few. These data suggest that younger adolescents with severe obesity should not be denied consideration for surgical therapy on the basis of age alone and that providers should consider adolescents of all ages for surgical therapy for obesity when clinically indicated.

View details for DOI 10.1542/peds.2020-024182

View details for PubMedID 33526606
EPIGENETIC TARGETING OF TERT-ASSOCIATED GENE EXPRESSION SIGNATURE IN HUMAN NEUROBLASTOMA WITH TERT OVEREXPRESSION. Cancer research Huang, M., Zeki, J., Sumarsono, N., Coles, G. L., Taylor, J. S., Danzer, E., Bruzoni, M., Hazard, F. K., Lacayo, N. J., Sakamoto, K. M., Dunn, J. C., Spunt, S. L., Chiu, B. 2020
Abstract

Neuroblastoma is a deadly pediatric solid tumor with infrequent recurrent somatic mutations. Particularly, the pathophysiology of tumors without MYCN amplification remains poorly defined. Utilizing an unbiased approach, we performed gene set enrichment analysis of RNA-seq data from 498 neuroblastoma patients and revealed a differentially overexpressed gene signature in MYCN non-amplified neuroblastomas with telomerase reverse transcriptase (TERT) gene overexpression and coordinated activation of oncogenic signaling pathways, including E2Fs, Wnt, Myc, and the DNA repair pathway. Promoter rearrangement of the TERT gene juxtaposes the coding sequence to strong enhancer elements, leading to TERT overexpression and poor prognosis in neuroblastoma, but TERT-associated oncogenic signaling remains unclear. ChIP-seq analysis of the human CLB-GA neuroblastoma cells harboring TERT rearrangement uncovered genome-wide chromatin co-occupancy of Brd4 and H3K27Ac and robust enrichment of H3K36me3 in TERT and multiple TERT-associated genes. Brd4 and cyclin-dependent kinases (CDKs) had critical regulatory roles in the expression and chromatin activation of TERT and multiple TERT-associated genes. Epigenetically targeting Brd4 or CDKs with their respective inhibitors suppressed the expression of TERT and multiple TERT-associated genes in neuroblastoma with TERT overexpression or MYCN amplification. ChIP-seq and ChIP-qPCR provided evidence that the CDK inhibitor directly inhibited Brd4 recruitment to activate chromatin globally. Therefore, inhibiting Brd4 and CDK concurrently with AZD5153 and dinaciclib would be most effective in tumor growth suppression, which we demonstrated in neuroblastoma cell lines, primary human cells, and xenografts. In summary, we describe a unique mechanism in neuroblastoma with TERT overexpression and an epigenetically targeted novel therapeutic strategy.

View details for DOI 10.1158/0008-5472.CAN-19-2560

View details for PubMedID 31900258
Seven-Year Experience with Laparoscopic Pedicled Omental Flap for Cerebral Revascularization in Patients with Moyamoya Disease Wood, L. Y., Jones, R. E., Chandler, J. M., Taylor, J., Dutta, S., Steinberg, G., Bruzoni, M. ELSEVIER SCIENCE INC. 2019: E126?E127
View details for Web of Science ID 000492749600297
10-Year Experience of Kasai Hepatoportoenterostomy in Biliary Atresia: High-Dose Adjuvant Steroids Improve Outcomes Taylor, J., Abadilla, N., Narayan, R., Pickering, J. M., Bruzoni, M. ELSEVIER SCIENCE INC. 2019: E164
View details for Web of Science ID 000492749600386
Intraoperative Liver Biopsy During Adolescent Bariatric Surgery: Is It Really Necessary? Obesity surgery Jones, R. E., Yeh, A. M., Kambham, N., El Haija, M. A., Pratt, J., Bruzoni, M. 2019
Abstract

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is prevalent in children with obesity and is definitively diagnosed with liver biopsy. However, the utility of routine biopsy during adolescent bariatric surgery remains unknown. We describe the usefulness of routine versus selective intraoperative liver biopsy in adolescents undergoing bariatric surgery.METHODS: A retrospective review of adolescents who received bariatric surgery at our institution between 2007 and 2018 was performed. Prior to 2014, all patients routinely received intraoperative liver biopsy. After 2014, biopsy was performed selectively on an individual basis for transaminitis or clinical concern. Demographic, biochemical, and histopathologic data were compared between patients who underwent routine, selective, or no biopsy.RESULTS: There were 77 patients who received bariatric surgery during the study period: 32 underwent routine biopsy, 13 selective biopsy, and 32 no biopsy. Selective liver biopsy was more likely to show pathologic evidence of fibrosis (84.6% versus 31.2%, p=0.000) and steatosis (100.0% versus 59.4%, p=0.003), and higher mean NAFLD activity score compared with routine biopsies (4.4 versus 2.1, p=0.001). Patients with steatosis had significantly higher preoperative fasting insulin (41.4 versus 21.1mIU/L, p=0.000), and patients with fibrosis had significantly higher glycated hemoglobin (6.1% versus 5.5%, p=0.033) and alanine aminotransferase (81.5 versus 52.7mg/dL, p=0.043). There were no biopsy complications or changes in management due to biopsy results.CONCLUSIONS: Routine intraoperative liver biopsy during adolescent bariatric surgery possesses questionable benefit, as it does not appear to impact short-term postoperative management. Prospective, longitudinal studies are needed to better understand the meaningfulness of liver histopathology in this population.

View details for DOI 10.1007/s11695-019-04136-4

View details for PubMedID 31446562
Obstetric and neonatal outcomes in pregnancies complicated by fetal lung masses: does final histology matter? Anderson, J. N., Girsen, A. I., Hintz, S. R., El-Sayed, Y. Y., Davis, A. S., Barth, R. A., Halabi, S., Sylvester, K. G., Bruzoni, M., Blumenfeld, Y. J. MOSBY-ELSEVIER. 2019: S151
View details for DOI 10.1016/j.ajog.2018.11.230

View details for Web of Science ID 000454249400210
Obstetric and neonatal outcomes in pregnancies complicated by fetal lung masses: does final histology matter? The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians Anderson, J. N., Girsen, A. I., Hintz, S. R., El-Sayed, Y. Y., Davis, A. S., Barth, R. A., Halabi, S., Hazard, F. K., Sylvester, K. G., Bruzoni, M., Blumenfeld, Y. J. 2019: 1?7
Abstract

Purpose: Fetal lung masses complicate approximately 1 in 2000 live births. Our aim was to determine whether obstetric and neonatal outcomes differ by final fetal lung mass histology.Materials and methods: A review of all pregnancies complicated by a prenatally diagnosed fetal lung mass between 2009 and 2017 at a single academic center was conducted. All cases included in the final analysis underwent surgical resection and histology diagnosis was determined by a trained pathologist. Clinical data were obtained from review of stored electronic medical records which contained linked maternal and neonatal records. Imaging records included both prenatal ultrasound and magnetic resonance imaging. Fisher's exact test was used for categorical variables and the Kruskal-Wallis test was used for continuous variables. The level of significance was p<.05.Results: Of 61 pregnancies complicated by fetal lung mass during the study period, 45 cases underwent both prenatal care and postnatal resection. Final histology revealed 10 cases of congenital pulmonary airway malformation (CPAM) type 1, nine cases of CPAM type 2, and 16 cases of bronchopulmonary sequestration. There was no difference in initial, maximal, or final CPAM volume ratio between groups, with median final CPAM volume ratio of 0.6 for CPAM type 1, 0.7 for CPAM type 2, and 0.3 for bronchopulmonary sequestration (p?=?.12). There were no differences in any of the maternal or obstetric outcomes including gestational age at delivery and mode of delivery between the groups. The primary outcome of neonatal respiratory distress was not statistically different between groups (p?=?.66). Median neonatal length of stay following delivery ranged from 3 to 4?days, and time to postnatal resection was similar as well, with a median of 126?days for CPAM type 1, 122?days for CPAM type 2, and 132?days for bronchopulmonary sequestration (p?=?.76).Conclusions: In our cohort, there was no significant association between histologic lung mass subtypes and any obstetric or neonatal morbidity including respiratory distress.

View details for DOI 10.1080/14767058.2019.1689559

View details for PubMedID 31722592
Predicting Pathology From Imaging in Children Undergoing Resection of Congenital Lung Lesions. The Journal of surgical research Narayan, R. R., Abadilla, N., Greenberg, D. R., Sylvester, K. G., Hintz, S. R., Barth, R. A., Bruzoni, M. 2018; 236: 68?73
Abstract

BACKGROUND: Prenatal magnetic resonance imaging (MRI) is increasingly obtained to define congenital lung lesions (CLL) for surgical management. Postnatal, preoperative computed tomography (CT) provides further clarity at the cost of radiation. Depending on the lesion identified, the indication for resection remains controversial. We investigated the differences in detail found on prenatal MRI and postnatal CT compared with final pathology to determine their utility in preoperative decision-making.MATERIALS AND METHODS: All children undergoing resection of CLLs at a single institution between July 2009 and February 2018 were retrospectively identified. Their imaging, operative, and pathology reports were compared. All imaging studies were examined by pediatric radiologists with experience in prenatal CLL diagnosis.RESULTS: Fifty-five patients underwent CLL resection during the study period with 31 undergoing prenatal MRI, 45 postnatal CT, and 22 both. Resection was performed before 6 mo of age in 62% of patients. In the cohort undergoing both imaging studies, pathologic CLL diagnosis correlated with prenatal MRI and CT in 82% and 100% of patients, respectively (P=0.13). Eight patients had systemic feeding vessels, of which 38% were identified on MRI, and 88% on CT (P=0.13). Both studies had a specificity of 100% for detecting systemic feeding vessels.CONCLUSIONS: For children where prenatal MRI detected a systemic feeding vessel, CT was redundant for preoperative planning but had greater sensitivity. Ultimately, the CLL type predicted from postnatal CT was not significantly different from that predicted by prenatal MRI; however, both imaging modalities had some level of discrepancy with pathology.

View details for PubMedID 30694781
ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery Pratt, J. S., Browne, A., Browne, N. T., Bruzoni, M., Cohen, M., Desai, A., Inge, T., Linden, B. C., Mattar, S. G., Michalsky, M., Podkameni, D., Reichard, K. W., Stanford, F. C., Zeller, M. H., Zitsman, J. 2018; 14 (7): 882?901
Abstract

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

View details for PubMedID 30077361
The challenges of closing an ileostomy in patients with total intestinal aganglionosis after small bowel transplant PEDIATRIC SURGERY INTERNATIONAL Jazi, F., Sinclair, T. J., Thorson, C. M., Castillo, R., Bonham, A. C., Esquivel, C. O., Bruzoni, M. 2018; 34 (1): 113?16
Abstract

We present the case of a 14-year-old male with a history of small bowel transplantation for long segment Hirschsprung's disease who underwent Duhamel ileorectal pull-through procedure. In post-transplant, the patient had no restrictions and was not TPN-dependent. To improve his quality of life, he and his family were interested in closing the ileostomy and undergoing pull-through surgery. The complexity of the case includes the presence of an aganglionic rectal segment-a short root of the mesentery due to the small bowel transplant-and significant immunosuppression. At the moment, he is continent, doing well, and has not had any remarkable complications.

View details for PubMedID 29170900
Serial Reduction of an Extremely Large Gastroschisis using Vacuum-Assisted Closure. European journal of pediatric surgery reports Butler, M. W., Fuchs, J., Bruzoni, M. 2018; 6 (1): e97?e99
Abstract

We herein describe a case of serial reduction of an extremely large and complex gastroschisis using vacuum-assisted closure (VAC) therapy in a boy born at 35 5/7 weeks' gestation. A spring-loaded silicone silo was placed at birth. By day of life (DOL) 22, minimal visceral contents had been reduced, and the silo was difficult to maintain due to the size of the fascial defect and loss of abdominal domain. A bespoke VAC dressing was constructed, and biweekly dressing changes allowed gradual reduction of the gastroschisis until the viscera were consolidated. By DOL 50, the viscera were completely reduced, and VAC therapy was discontinued. Feeds were commenced on DOL 57 and increased to goal by DOL 86. The baby was discharged home on DOL 115. We conclude that VAC dressings can be used to aid gradual reduction of an extremely large gastroschisis, particularly in medical fragile infants.

View details for PubMedID 30591853
Endoscopic Excision of Benign Facial Masses in Children: A Review of Outcomes. Journal of laparoendoscopic & advanced surgical techniques. Part A Foster, D., Sinclair, T. J., Taylor, J. S., Dutta, S., Lorenz, H. P., Bruzoni, M. 2018
Abstract

Benign masses of the eyebrow and forehead are common in pediatric patients and can result in facial asymmetry, discomfort, or super-infection. Excision is classically conducted via an incision directly over the mass, which can produce sub-optimal cosmesis. Recently, an endoscopic approach using pediatric brow-lift equipment has been adopted. We reviewed our center's experience with endoscopic removal of benign facial lesions and compared these cases with an equivalent series of open cases.A retrospective chart review was conducted to identify pediatric cases of endoscopic and open removal of benign eyebrow or forehead lesions at our institution from 2009 to 2016. Clinical and cosmetic outcomes were reviewed.A total of 40 endoscopic and 25 open cases of excision of benign facial lesions in children were identified. For the patients who underwent endoscopic excision, the majority (85%) presented with a cyst located at the eyebrow. Histologic examination revealed 36 dermoid cysts (90%), 2 epidermal cysts, and 2 pilomatrixomas. Of the 36 cases with post-operative follow-up, 32 patients (89%) had an uncomplicated recovery with good cosmesis. Two patients had an eyebrow droop that resolved without intervention. One patient had localized numbness overlying the site, but no motor deficits. One patient presented with a recurrent dermoid cyst that required open resection. For the patients who underwent open excision, the majority (52%) had dermoid cysts located at the eyebrow. Of the 22 cases with follow-up, 20 of the patients had an uncomplicated recovery (90%). Comparing the rate of complications, there was no statistically significant difference between the two groups (P?=?1.0).Endoscopic excision of benign forehead and eyebrow lesions in pediatric patients is feasible and yields excellent cosmetic results. When compared with open excision, complication rates are similar between both approaches and a facial scar can be avoided with an endoscopic approach.

View details for PubMedID 29446701
Sutureless vs Sutured Gastroschisis Closure: A Prospective Randomized Controlled Trial. Journal of the American College of Surgeons Bruzoni, M., Jaramillo, J. D., Dunlap, J. L., Abrajano, C., Stack, S. W., Hintz, S. R., Hernandez-Boussard, T., Dutta, S. 2017; 224 (6): 1091-1096 e1
Abstract

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 Wall, J. K., Sinclair, T. J., Kethman, W., Williams, C., Albanese, C., Sylvester, K. G., Bruzoni, M. 2017
Abstract

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
Advanced minimal access surgery in infants weighing less than 3kg: A single center experience. Journal of pediatric surgery Wall, J. K., Sinclair, T. J., Kethman, W., Williams, C., Albanese, C., Sylvester, K. G., Bruzoni, M. 2017
Abstract

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 Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2017; 52 (3): 318-323
Abstract

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 Web of Science ID 000397089400023
MRI vs. Ultrasound as the initial imaging modality for pediatric and young adult patients with suspected appendicitis. Academic emergency medicine Imler, D., Keller, C., Sivasankar, S., Wang, N. E., Vasanawala, S., Bruzoni, M., Quinn, J. 2017
Abstract

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 Jaramillo, J. D., Snyder, E., Farrales, S., Stevens, M., Wall, J. K., Chao, S., Morton, J., Pratt, J. S., Hammer, L., Shepard, W. E., Bruzoni, M. 2017
Abstract

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 PubMedID 28697852
Predictors of Nondiagnostic Ultrasound for Appendicitis. journal of emergency medicine Keller, C., Wang, N. E., Imler, D. L., Vasanawala, S. S., Bruzoni, M., Quinn, J. V. 2016
Abstract

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
Laparoscopic harvesting of omental pedicle flap for cerebral revascularization in children with moyamoya disease JOURNAL OF PEDIATRIC SURGERY Bruzoni, M., Steinberg, G. K., Dutta, S. 2016; 51 (4): 592-597
Abstract

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
The Hispanic Clinic for Pediatric Surgery: A model to improve parent-provider communication for Hispanic pediatric surgery patients JOURNAL OF PEDIATRIC SURGERY Jaramillo, J., Snyder, E., Dunlap, J. L., Wright, R., Mendoza, F., Bruzoni, M. 2016; 51 (4): 670-674
Abstract

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 PubMedID 26474548
Endoscopic Submucosal Dissection of a Large Hamartoma in a Young Child. Journal of pediatric gastroenterology and nutrition Wall, J., Esquivel, M., Bruzoni, M., Wright, R., Berquist, W., Albanese, C. 2016; 62 (1): e5-7
View details for DOI 10.1097/MPG.0000000000000376

View details for PubMedID 26709909
Infant, maternal, and geographic factors influencing gastroschisis related mortality in Zimbabwe SURGERY Apfeld, J. C., Wren, S. M., Macheka, N., Mbuwayesango, B. A., Bruzoni, M., Sylvester, K. G., Kastenberg, Z. J. 2015; 158 (6): 1476-1481
Abstract

Survival for infants with gastroschisis in developed countries has improved dramatically in recent decades with reported mortality rates of 4-7%. Conversely, mortality rates for gastroschisis in sub-Saharan Africa remain as great as 60% in contemporary series. This study describes the burden of gastroschisis at the major pediatric hospital in Zimbabwe with the goal of identifying modifiable factors influencing gastroschisis-related infant mortality.We performed a retrospective cohort study of all cases of gastroschisis admitted to Harare Children's Hospital in 2013. Univariate and multivariate analyses were performed to describe infant, maternal, and geographic factors influencing survival.A total of 5,585 neonatal unit admissions were identified including 95 (1.7%) infants born with gastroschisis. Gastroschisis-related mortality was 84% (n = 80). Of infants with gastroschisis, 96% (n = 91) were born outside Harare Hospital, 82% (n = 78) were born outside Harare Province, and 23% (n = 25) were home births. The unadjusted odds of survival for these neonates with gastroschisis were decreased for low birth weight infants (<2,500 grams; odds ratio [OR], 0.15; 95% CI, 0.05-0.51), preterm births (<37 weeks gestational age; OR, 0.06; 95% CI, 0.01-0.50), and for those born to teenage mothers (<20 years of age; OR, 0.05; 95% CI, 0.01-0.46). There was also a trend toward decreased odds of survival for home births (OR, 0.16; 95% CI, 0.02-1.34) and for those born outside Harare Province (OR, 0.35; 95% CI, 0.10-1.22).Gastroschisis-related infant mortality in Zimbabwe is associated with well-known risk factors, including low birth weight, prematurity, and teenage mothers. However, modifiable factors identified in this study signify potential opportunities for developing innovative approaches to perinatal care in such a resource-constrained environment.

View details for DOI 10.1016/j.surg.2015.04.037

View details for Web of Science ID 000364612200004
Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac. Journal of pediatric surgery Bruzoni, M., Jaramillo, J. D., Kastenberg, Z. J., Wall, J. K., Wright, R., Dutta, S. 2015; 50 (10): 1767-1771
Abstract

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 Snyder, E., Amado, V., Jacobe, M., Sacks, G. D., Bruzoni, M., Mapasse, D., DeUgarte, D. A. 2015; 198 (2): 340-345
Abstract

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 Dunlap, J. L., Jaramillo, J. D., Koppolu, R., Wright, R., Mendoza, F., Bruzoni, M. 2015; 50 (9): 1586-1589
Abstract

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 Wright, R., Abrajano, C., Koppolu, R., Stevens, M., Nyznyk, S., Chao, S., Bruzoni, M., Wall, J. 2015; 25 (1): 69-72
Abstract

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
Long-term follow-up of laparoscopic transcutaneous inguinal herniorraphy with high transfixation suture ligature of the hernia sac Journal Pediatric Surgery Bruzoni, M., Jaramillo, J. D., Kastenberg, Z. J., Wall, J., Wright, R. K., Dutta, S. 2015
Abstract

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
Less invasive pedicled omental-cranial transposition in pediatric patients with moyamoya disease and failed prior revascularization. Neurosurgery Navarro, R., Chao, K., Gooderham, P. A., Bruzoni, M., Dutta, S., Steinberg, G. K. 2014; 10: 1-14
Abstract

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 Bruzoni, M., Slater, B. J., Wall, J., St Peter, S. D., Dutta, S. 2013; 216 (5): 939-943
Abstract

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 Salles, A., Kastenberg, Z. J., Wall, J. K., Visser, B. C., Bruzoni, M. 2013; 48 (3): 652-654
Abstract

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 Lin, S. R., Kastenberg, Z. J., Bruzoni, M., Albanese, C. T., Dutta, S. 2012; 47 (7): 1472-1475
Abstract

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 Bruzoni, M., Dutta, S. 2011; 20 (4): 212-218
Abstract

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 Kastenberg, Z., Bruzoni, M., Dutta, S. 2011; 46 (8): 1658-1664
Abstract

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 Bruzoni, M., Parikh, P., Celis, R., Are, C., Ly, Q. P., Meza, J. L., Sasson, A. R. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2009: 376?80
Abstract

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 Bruzoni, M., Sudan, D. L., Cusick, R. A., Thompson, J. S. LIPPINCOTT WILLIAMS & WILKINS. 2008: 63?66
Abstract

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 Bruzoni, M., Sasson, A. R. SPRINGER. 2008: 1202?6
Abstract

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 Bruzoni, M., Johnston, E., Sasson, A. R. EXCERPTA MEDICA INC-ELSEVIER SCIENCE INC. 2008: 329?32
Abstract

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 Plotkin, H., Coughlin, S., Kreikemeier, R., Heldt, K., Bruzoni, M., Lerner, G. 2006; 48 (9): 709-712
Abstract

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 VASCULAR Pipinos, I. I., Bruzoni, M., Johanning, J. M., Longo, G. M., Lynch, T. G. 2006; 14 (5): 245-255
Abstract

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 Amarillo, H. A., Bruzoni, M., Loto, M., Castagneto, G. H., Mihura, M. E. 2004; 18 (10)
Abstract

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

Matias Bruzoni, MD FACS

Associate Professor of Surgery (Pediatric Surgery) at the Stanford University Medical Center

Surgery - Pediatric Surgery

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