Browsing by Author "Kohler, Jonathan E."

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    Association of Nonoperative Management Using Antibiotic Therapy vs Laparoscopic Appendectomy With Treatment Success and Disability Days in Children With Uncomplicated Appendicitis
    (American Medical Association, 2020-08) Minneci, Peter C.; Hade, Erinn M.; Lawrence, Amy E.; Sebastião, Yuri V.; Saito, Jacqueline M.; Mak, Grace Z.; Fox, Christa; Hirschl, Ronald B.; Gadepalli, Samir; Helmrath, Michael A.; Kohler, Jonathan E.; Leys, Charles M.; Sato, Thomas T.; Lal, Dave R.; Landman, Matthew P.; Kabre, Rashmi; Fallat, Mary E.; Cooper, Jennifer N.; Deans, Katherine J.; Surgery, School of Medicine
    Importance: Nonoperative management with antibiotics alone has the potential to treat uncomplicated pediatric appendicitis with fewer disability days than surgery. Objective: To determine the success rate of nonoperative management and compare differences in treatment-related disability, satisfaction, health-related quality of life, and complications between nonoperative management and surgery in children with uncomplicated appendicitis. Design, setting, and participants: Multi-institutional nonrandomized controlled intervention study of 1068 children aged 7 through 17 years with uncomplicated appendicitis treated at 10 tertiary children's hospitals across 7 US states between May 2015 and October 2018 with 1-year follow-up through October 2019. Of the 1209 eligible patients approached, 1068 enrolled in the study. Interventions: Patient and family selection of nonoperative management with antibiotics alone (nonoperative group, n = 370) or urgent (≤12 hours of admission) laparoscopic appendectomy (surgery group, n = 698). Main outcomes and measures: The 2 primary outcomes assessed at 1 year were disability days, defined as the total number of days the child was not able to participate in all of his/her normal activities secondary to appendicitis-related care (expected difference, 5 days), and success rate of nonoperative management, defined as the proportion of patients initially managed nonoperatively who did not undergo appendectomy by 1 year (lowest acceptable success rate, ≥70%). Inverse probability of treatment weighting (IPTW) was used to adjust for differences between treatment groups for all outcome assessments. Results: Among 1068 patients who were enrolled (median age, 12.4 years; 38% girls), 370 (35%) chose nonoperative management and 698 (65%) chose surgery. A total of 806 (75%) had complete follow-up: 284 (77%) in the nonoperative group; 522 (75%) in the surgery group. Patients in the nonoperative group were more often younger (median age, 12.3 years vs 12.5 years), Black (9.6% vs 4.9%) or other race (14.6% vs 8.7%), had caregivers with a bachelor's degree (29.8% vs 23.5%), and underwent diagnostic ultrasound (79.7% vs 74.5%). After IPTW, the success rate of nonoperative management at 1 year was 67.1% (96% CI, 61.5%-72.31%; P = .86). Nonoperative management was associated with significantly fewer patient disability days at 1 year than did surgery (adjusted mean, 6.6 vs 10.9 days; mean difference, -4.3 days (99% CI, -6.17 to -2.43; P < .001). Of 16 other prespecified secondary end points, 10 showed no significant difference. Conclusion and relevance: Among children with uncomplicated appendicitis, an initial nonoperative management strategy with antibiotics alone had a success rate of 67.1% and, compared with urgent surgery, was associated with statistically significantly fewer disability days at 1 year. However, there was substantial loss to follow-up, the comparison with the prespecified threshold for an acceptable success rate of nonoperative management was not statistically significant, and the hypothesized difference in disability days was not met.
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    Can Fecal Continence be Predicted in Patients Born with Anorectal Malformations?
    (Elsevier, 2019) Minneci, Peter C.; Kabre, Rashmi S.; Mak, Grace Z.; Halleran, Devin R.; Cooper, Jennifer N.; Afrazi, Amin; Calkins, Casey M.; Corkum, Kristine; Downard, Cynthia D.; Ehrlich, Peter; Fraser, Jason D.; Gadepalli, Samir K.; Helmrath, Michael A.; Kohler, Jonathan E.; Landisch, Rachel; Landman, Matthew P.; Lee, Constance; Leys, Charles M.; Lodwick, Daniel L.; McLeod, Jennifer; Mon, Rodrigo; McClure, Beth; Rymeski, Beth; Saito, Jacqueline M.; Sato, Thomas T.; St. Peter, Shawn D.; Wood, Richard; Levitt, Marc A.; Deans, Katherine J.; Surgery, School of Medicine
    Purpose The purpose of this study was to identify factors associated with attaining fecal continence in children with anorectal malformations (ARM). Methods We performed a multi-institutional cohort study of children born with ARM in 2007–2011 who had spinal and sacral imaging. Questions from the Baylor Social Continence Scale were used to assess fecal continence at the age of ≥ 4 years. Factors present at birth that predicted continence were identified using multivariable logistic regression. Results Among 144 ARM patients with a median age of 7 years (IQR 6–8), 58 (40%) were continent. The rate of fecal continence varied by ARM subtype (p = 0.002) with the highest rate of continence in patients with perineal fistula (60%). Spinal anomalies and the lateral sacral ratio were not associated with continence. On multivariable analysis, patients with less severe ARM subtypes (perineal fistula, recto-bulbar fistula, recto-vestibular fistula, no fistula, rectal stenosis) were more likely to be continent (OR = 7.4, p = 0.001). Conclusion Type of ARM was the only factor that predicted fecal continence in children with ARM. The high degree of incontinence, even in the least severe subtypes, highlights that predicting fecal continence is difficult at birth and supports the need for long-term follow-up and bowel management programs for children with ARM.
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    Changing the Paradigm for Management of Pediatric Primary Spontaneous Pneumothorax: A Simple Aspiration Test Predicts Need for Operation
    (Elsevier, 2019) Leys, Charles M.; Hirschl, Ronald B.; Kohler, Jonathan E.; Cherney-Stafford, Linda; Marka, Nicholas; Fallat, Mary E.; Gadepalli, Samir K.; Fraser, Jason D.; Grabowski, Julia; Burns, R. Cartland; Downard, Cynthia D.; Foley, David S.; Halleran, Devin R.; Helmrath, Michael A.; Kabre, Rashmi; Knezevich, Michellle S.; Lal, Dave R.; Landman, Matthew P.; Lawrence, Amy E.; Mak, Grace Z.; Minneci, Peter C.; Musili, Ninette; Rymeski, Beth; Saito, Jacqueline M.; Sato, Thomas T.; St. Peter, Shawn D.; Warner, Brad W.; Ostlie, Daniel J.; Surgery, School of Medicine
    Purpose Chest tube (CT) management for pediatric primary spontaneous pneumothorax (PSP) is associated with long hospital stays and high recurrence rates. To streamline management, we explored simple aspiration as a test to predict need for surgery. Methods A multi-institution, prospective pilot study of patients with first presentation for PSP at 9 children’s hospitals was performed. Aspiration was performed through a pigtail catheter, followed by 6 h observation with CT clamped. If pneumothorax recurred during observation, the aspiration test failed and subsequent management was per surgeon discretion. Results Thirty-three patients were managed with simple aspiration. Aspiration was successful in 16 of 33 (48%), while 17 (52%) failed the aspiration test and required hospitalization. Twelve who failed aspiration underwent CT management, of which 10 (83%) failed CT management owing to either persistent air leak requiring VATS or subsequent PSP recurrence. Recurrence rate was significantly greater in the group that failed aspiration compared to the group that passed aspiration [10/12 (83%) vs 7/16 (44%), respectively, P = 0.028]. Conclusion Simple aspiration test upon presentation with PSP predicts chest tube failure with 83% positive predictive value. We recommend changing the PSP management algorithm to include an initial simple aspiration test, and if that fails, proceed directly to VATS.