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Biomedical subjects

J Duncan Phillips

Publications and source records attributed to J Duncan Phillips.

11 recordsLinked to original sources
PubMed2007

Patent ductus arteriosus ligation in premature infants: who really benefits, and at what cost?

PURPOSE: Patent ductus arteriosus (PDA) ligation in premature infants has been shown to have low surgical morbidity and mortality. Ligation goals include prompt improvement in cardiorespiratory failure, with rapid wean from mechanical ventilation; less risk of prolonged mechanical ventilation and subsequent chronic lung disease (CLD); and survival to discharge. This study was designed to examine true morbidity after ligation and elucidate which preoperative factors might predict favorable outcomes. METHODS: Institutional review board-approved retrospective review of 197 infants less than 38 weeks of gestational age (GA), undergoing PDA ligation via thoracotomy between January 1, 1992, and January 1, 2004. Chronic lung disease defined as need for supplemental oxygen at 36 weeks corrected GA. Student t and chi2 tests were used. RESULTS: Mean GA was 27 weeks (range, 23-35 weeks), birth weight was 957 g (range, 440-3170 g); infants underwent ligation at 16 days of life (range, 1-132 days). Duration of surgery was 50.5 minutes (range, 13-150 minutes). Mean postoperative times were 27 days to extubation, 60 days to wean from supplemental oxygen, and 84 days to discharge. Early extubation (within 10 days of ligation) occurred in only 54 patients (30%). Only 44 (22%) survived to discharge without CLD. Forty patients (20%) died, with respiratory failure the most common cause (70%). In general, early extubation, survival without CLD and survival to discharge were associated with greater GA and birth weight, higher Apgar scores, greater age and weight at surgery, no preoperative intraventricular hemorrhage, lack of ventilator dependence, and lower ventilator settings (P < .05). Preoperative amount and duration of indomethacin use, chest x-ray findings, and echocardiographic assessment of ductus size did not predict favorable outcomes (all P > .05). CONCLUSIONS: Most premature infants currently undergoing PDA ligation at our institution do not experience the anticipated rapid improvements in cardiorespiratory status and go on to develop CLD. Few preoperative variables (including radiographic and echocardiographic assessments) definitively predict outcomes.

Ductus Arteriosus, Patent↗
PubMed2006

Multifocal gastrointestinal stromal tumor (GIST) of the stomach in an 11-year-old girl.

A previously healthy 11-year-old girl presented with an 8-month history of anemia and left upper quadrant abdominal pain. US examination demonstrated a 9-cm cystic mass with a fluid-fluid level in the left upper quadrant with unclear organ of origin. Abdominal MR imaging demonstrated a complex cystic mass, likely arising from the stomach. Additional T2 hyperintense submucosal lesions were identified in the gastric wall. Surgical excision confirmed the diagnosis of multifocal gastric gastrointestinal stromal tumor (GIST). MR imaging was helpful in suggesting a gastric origin of the primary mass and in demonstrating multifocal disease within the stomach.

Child↗
PubMed2006

Optimal enteral feeding in children with gastric dysfunction: surgical jejunostomy vs image-guided gastrojejunal tube placement.

PURPOSE: Long-term feeding access in children who fail initial gastrostomy is a management quandary. Although image-guided gastrojejunal feeding tube placement (IGJ) is becoming the access of choice in many centers, few studies have compared long-term results with surgical jejunostomy (SJ). The authors compare outcomes with these 2 techniques. METHOD: A retrospective review of 20 children requiring jejunal feeding access after failing initial gastrostomy was done. Procedures were performed at a tertiary referral center by interventional radiologists (IGJ) or board-certified pediatric surgeons (SJ). RESULTS: Initially, patients underwent IGJ (n = 14) or SJ (n = 6). Image-guided gastrojejunal feeding tube placement patients required gastrostomy at an average age of 23.8 months, with conversion to IGJ an average of 17.2 months later. SJ patients required gastrostomy at average age of 16.2 months, with conversion to SJ 30.7 months later. Of 14 patients undergoing IGJ, 7 (50%) eventually required SJ because of recurring tube management issues. Thus, 13 patients ultimately had SJ, with 11 (85%) Roux-en-Y jejunostomies. Mean operating time for SJ was 158 minutes, with an average of 5.1 days to initiation of feeds, 11 days to full feeds, and 19.9 days to discharge (range, 3-66 days). Image-guided gastrojejunal feeding tube placement patients averaged 4.6 tube adjustments per year requiring fluoroscopic guidance. Surgical jejunostomy averaged 1.5 tube adjustments per year requiring outpatient hospital visits. Image-guided gastrojejunal feeding tube placement patients averaged 3.9 hospital d/y secondary to feeding tube management issues, whereas SJ patients averaged 1.4 hospital days per year. CONCLUSION: In this group of children with long-term jejunal feeding access, half of those with IGJ eventually required SJ. Surgical jejunostomy required fewer adjustments and hospitalizations per year. Although initially more invasive than IGJ, SJ may provide more stable feeding access with fewer complications. This represents the first published report comparing long-term outcomes between IGJ and SJ.

Adolescent↗
PubMed2005

The influence of advanced radiographic imaging on the treatment of pediatric appendicitis.

PURPOSE: Since 1998, the use of advanced radiographic imaging with computed tomography (CT) and/or diagnostic ultrasound (US) has increased dramatically for the diagnosis of acute appendicitis in children. This study investigates the impact of this imaging on the evaluation, management, and outcome of pediatric patients who underwent appendectomy for suspected appendicitis. METHODS: Retrospective review of 197 consecutive children with a preoperative diagnosis of acute appendicitis, from January 2002 through May 2004, undergoing appendectomy at a university-affiliated community hospital by pediatric and general surgeons. RESULTS: Patients were divided into two groups: imaged (n = 106; 54%) and nonimaged (n = 91; 46%). Groups were similar with respect to age, sex, temperature, white blood count, and insurance status. Ninety-seven imaged patients had CT, 6 had US, and 3 had both CT and US. Seventy-one percent of imaging studies were ordered by emergency department physicians and 24% by treating surgeons. Average wait from emergency department triage to operative incision for the imaged and nonimaged groups was 12.1 and 5.4 hours, respectively (P < .0001). Both groups had similar perforation rates (imaged: 15.1%, nonimaged: 14.6%). Negative appendectomy rates were 10.4% (imaged) and 4.4% (nonimaged). Average hospital charges were 11,791 dollars (imaged) and 9360 dollars (nonimaged) (P = .001). Time on antibiotics, complication rates, and length of stay were similar for both groups. CONCLUSIONS: More than half of pediatric patients with suspected appendicitis now undergo advanced imaging and experience a significant delay in surgical treatment with a 26% increase in hospital charges and no clear-cut improvement in diagnostic accuracy nor outcome, when compared with evaluation by the treating surgeons.

Adolescent↗
PubMed2005

Laparoscopic evaluation of the contralateral groin in pediatric inguinal hernia patients: a comparison of 70- and 120-degree endoscopes.

BACKGROUND: Transinguinal laparoscopic groin evaluation using a 70-degree endoscope can obviate the need for a second incision when attempting to identify a contralateral patent processus vaginalis (PPV) during open repair of a symptomatic pediatric inguinal hernia. This technique can be technically unsatisfactory when a medial veil of peritoneum obscures adequate visualization of the internal inguinal ring. This study compared 70- degree and 120-degree endoscopes in identification of a contralateral PPV in the same patients. MATERIALS AND METHODS: From September 2000 to October 2003, 81 patients with known inguinal hernias underwent open hernia repair and transinguinal laparoscopic evaluation of the contralateral side. The patients were 62 male, 19 female; mean age 26 months (range, 1 month-10 years); mean weight 11.7 kg (range, 2-33 kg). There were 53 right side hernias and 28 left side. Mean operative time was 43 minutes. Fifty seven patients (70%) had one or more risk factors for developing a contralateral inguinal hernia (49 were younger than 1 year old and 19 were ex-premature). Nineteen patients underwent concurrent procedures (7 circumcisions, 10 hydrocelectomies, 1 orchidopexy, 1 appendectomy). RESULTS: Using the 70-degree endoscope, a medial veil of peritoneum made visualization of the internal inguinal ring impossible in 14 patients (17%) and difficult in an additional 5 patients (6%). Visualization with the 120-degree endoscope was deemed to be superior in 46 (57%), equal in 35 patients (43%), and inferior in none. Overall, contralateral PPVs were detected in 31 patients (38%) with the 120-degree endoscope and in only 23 patients (28%) with the 70-degree endoscope. Had we used only the 70-degree endoscope, 8 PPVs (10%) would have been missed. None of the negative 120-degree endoscope evaluations have developed symptomatic contralateral inguinal hernias. CONCLUSION: In this trial, transinguinal laparoscopic evaluation using the 120-degree endoscope provided superior visualization and identification of contralateral PPVs. This new technique obviates the need for a separate abdominal wall puncture, reduces missed contralateral PPVs, and should be considered for use during pediatric inguinal hernia repair.

Child↗
PubMed2005

Laparoscopic Roux-en-Y feeding jejunostomy: a new minimally invasive surgical procedure for permanent feeding access in children with gastric dysfunction.

Long-term feeding access in children with foregut dysfunction has traditionally been achieved by gastrostomy tube placement with or without fundoplication. Alternatives after failed procedures have included re-do fundoplication, transpyloric gastrojejunal tube placement, loop jejunostomy (open or laparoscopic), and open Roux-en-Y jejunostomy. We describe a new technique, laparoscopic Roux-en-Y feeding jejunostomy (LRFJ), which offers a minimally invasive option in providing long-term enteral access to these children. Five children, ages 10 months to 9 years (mean age, 3.4 years), weighing 8.8 to 15.2 kilograms (mean weight, 12.3 kg), underwent LRFJ. Four children had mental retardation/cerebral palsy. In 3 children, LRFJ was the only intra-abdominal procedure performed. No technical complications related to the procedure were observed. Mean operative time was 98 minutes in the children in which LRFJ was the only procedure performed. Enteral feeds were typically begun by postoperative day (POD) 5. Follow-up has ranged from 12 to 30 months (mean follow-up, 23 months). All 4 survivors remain on full jejunal feedings and are doing well. One child developed stomal stenosis requiring dilatation. In summary, LRFJ can be performed safely in children with gastric dysfunction, may be performed in conjunction with a variety of other laparoscopic procedures, and offers a new option for nutritional access in this challenging pediatric population.

Anastomosis, Roux-en-Y↗
PubMed2004

From gunstore to smoking gun: tracking guns that kill children in North Carolina.

PURPOSE: This study reviews the epidemiology of pediatric firearm deaths in North Carolina and estimates the time from the retail sale of guns to their involvement in pediatric firearm deaths. METHODS: The authors reviewed autopsy reports for all children 0 to 14 years of age that died of firearm-related injuries in North Carolina from January 1999 through December 2002. Data obtained included demographic information, firearm type, and manner of death. Data from the Bureau of Alcohol, Tobacco and Firearms, which traced guns involved in crimes and determined the time elapsed from purchase to their involvement in a crime (ie, time-to-crime were also reviewed). RESULTS: During the study period, 40 children died of firearm injuries. Mean age was 7.6 years. Handguns were responsible for the majority of deaths (59%) followed by shotguns (27%), rifles (10%), and undetermined cause (10%). Most deaths were homicides (67%) followed by unintentional death (18%), suicide (13%), and undetermined cause (2%). Most crime guns (76%) were purchased legally, and many (40%) had a time-to-crime of less than 3 years. CONCLUSIONS: Legally purchased firearms pose a significant threat to children in North Carolina. A more restrictive approach to the sale of handguns is a logical approach to reducing pediatric firearm-related deaths in the United States.

Adolescent↗
PubMed2004

Case of the missing penny: thoracoscopic removal of a mediastinal coin.

Complications of coin ingestion in children, although rare, include esophageal perforation, tracheoesophageal fistula, esophago-aortic fistula, and death. The authors describe thoracoscopic removal of a mediastinal coin that migrated extraluminally from the esophagus in a 23-month-old girl. Right-sided thoracoscopic exploration using a 3-trocar technique in a modified prone position was used. Coin location was assisted by manipulation of a transorally placed Foley catheter and intraoperative fluoroscopy. The coin was retrieved successfully with no intraoperative or postoperative complications and minimal postoperative pain. This is the first report of successful thoracoscopic removal of a mediastinal coin. Thoracoscopy may be a valuable approach for mediastinal foreign body removal in children.

Female↗
PubMedDate not supplied

Successful multimodality therapy of recurrent multifocal juvenile granulosa cell tumor of the ovary.

Juvenile granulosa cell tumor (JGCT) of the ovary, a rare pediatric cancer, carries a very poor prognosis in advanced and recurrent cases. A 10-year-old girl with stage IA JGCT, initially treated with resection only, presented with extensive unresectable multifocal pelvic recurrence. She underwent surgery, chemotherapy (cisplatin/paclitaxel alternating with cisplatin/cyclophosphamide/etoposide/bleomycin), myeloablative chemotherapy (carboplatin/etoposide/melphalan) with autologous bone marrow transplant, and pelvic radiation. She tolerated therapy well and is in complete remission 69 months after her recurrence.

Antineoplastic Combined Chemotherapy Protocols↗
PubMedDate not supplied

Interval laparoscopic appendectomy for appendicitis complicated by pylephlebitis.

BACKGROUND: Although rare, portal mesenteric venous thrombosis and pylephlebitis remain potential life-threatening sequelae of ruptured appendicitis in children. Treatment recommendations from recent reports have included urgent exploratory laparotomy with appendectomy, prolonged intravenous antibiotic therapy, and anticoagulation for up to a year. METHODS: This report describes successful management of pylephlebitis and mesenteric venous thrombosis complicating ruptured appendicitis with intravenous antibiotics and anticoagulation followed by interval laparoscopic appendectomy. RESULTS: A previously healthy 5-year-old girl was diagnosed with ruptured appendicitis complicated by pylephlebitis and mesenteric venous thrombosis at the time of presentation. She was treated with intravenous antibiotics and anticoagulated for 3 months. She subsequently underwent interval laparoscopic appendectomy. At 3-year follow-up, she is healthy without evidence of adverse sequelae. DISCUSSION: This is the first reported case of successful, minimally invasive management of ruptured appendicitis complicated by mesenteric venous thrombosis and pylephlebitis. CONCLUSION: Similar treatment of other children with this rare presentation seems reasonable.

Anti-Bacterial Agents↗