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Department of Surgery Annual Report - Texas Childrens Hospital

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D E PA R T M E N T O F S U R G E RY
D E PA R T M E N T O F S U R G E RY
D E PA RT M E N T
O F
S U R G E R Y A N N UA L
Welcome .
R E P O RT
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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Texas Children’s Hospital and
Baylor College of Medicine. . . . . . . . . . . . . . . . . . . . 3
Department of Surgery. . . . . . . . . . . . . . . . . . . . . . 5
Texas Children’s Hospital West Campus .
. . . . . . . . .
7
Texas Children’s Pavilion for Women . . . . . . . . . . . . . 8
Department of Surgery Research Seed Grants .
Department of Anesthesiology .
. . . .
. . . . . . . . . . . .
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Surgical Divisions
Congenital Heart Surgery. . . . . . . . . . . . . . . . . . . . . . 17
Dental. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
Neurosurgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Ophthalmology .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
Orthopaedics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Otolaryngology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Pediatric and Adolescent Gynecology . . . . . . . . . . . . 52
Pediatric General Surgery. . . . . . . . . . . . . . . . . . . . . . 59
Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Transplant Services . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Urology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Department of Surgery Services
Inpatient Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Operating Room and Perioperative Services.
. . . . .
86
Trauma Services and
the Center for Childhood Injury Prevention. . . . . 88
Medical Staff Directory. . . . . . . . . . . . . . . . . . . . . . . . 95
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D E PA R T M E N T O F S U R G E RY
Dear colleagues, parents and friends,
I am pleased to share with you the 2012 Department of Surgery Annual Report from Texas
Children’s Hospital. The Department of Surgery had a busy and productive year, completing more
than 24,000 operating room cases and over 98,000 clinic visits.
In 2012 the Department of Surgery received two sponsored fellowships from the Texas Children’s
Auxiliary. Oluyinka O. Olutoye, M.D., Ph.D., co-director of Texas Children’s Fetal Center, received
the Denton A. Cooley Fellowship for Surgical Innovation for his research in fetal and neonatal
surgery. Laura Monson, M.D., pediatric plastic surgeon, was granted the Surgical Outcomes
Research Fellowship for her clinical research in cleft lip and palate repair.
Additionally, we held the inaugural Denton A. Cooley Lecture Series in 2012. Designed to feature
leaders in health care and surgical innovation, we welcomed Delos Cosgrove, M.D., president and
chief executive officer at Cleveland Clinic as this year’s keynote speaker.
Over the last year, we also welcomed new leadership in two of our surgical divisions.
Larry Hollier, M.D., was appointed chief of the Plastic Surgery Division. A leader in the field
of pediatric plastic surgery, Dr. Hollier has authored 200 articles in scholarly and professional
publications.
David Roth, M.D., was named chief of the Urology Division. Dr. Roth is an accomplished clinical
surgeon as well as an academic surgeon and educator.
Of the many outstanding accomplishments this year, we are particularly proud of our Transplant
team. One of the largest and most comprehensive transplantation programs in the nation, the
Texas Children’s Hospital Transplant Services Division earned accreditation from the Centers
for Medicare & Medicaid Services (CMS) and the United Network for Organ Sharing (UNOS)
for our heart, liver and lung transplantation programs and reaccreditation for kidney transplant.
In our belief that we must provide the highest quality pediatric surgical care, the Texas Children’s
Hospital Outcomes and Impact Service tracks, analyzes and reports the outcomes of procedures
within Texas Children’s Hospital. Over the past year, we have initiated over 30 outcomes projects
incorporating each of our surgical divisions.
I hope you enjoy reading about our outstanding surgical team here at Texas Children’s Hospital.
I am privileged to work with these dedicated surgeons. With deepest respect, I remain,
Sincerely yours,
Charles D. Fraser, Jr., M.D.
Surgeon-in-Chief, Texas Children’s Hospital
Donovan Chair and Chief of Congenital Heart Surgery, Texas Children’s Hospital
Susan V. Clayton Chair in Surgery, Baylor College of Medicine
Professor of Surgery and Pediatrics, Baylor College of Medicine
D E PA R T M E N T O F S U R G E RY
Texas Children’s Hospital and Baylor College of Medicine
Texas Children’s Hospital, located in the Texas Medical Center in Houston, is committed to
a community of healthy children by providing the finest pediatric patient care, education and
research. Renowned worldwide for its expertise and breakthrough developments in clinical
care and research, Texas Children’s Hospital was recently ranked #4 among top children’s
hospitals in the nation and was also ranked in all ten subspecialties
in U.S.News & World Report’s list of America’s Best Children’s Hospitals.
Texas Children’s also operates Texas Children’s Pediatrics, the nation’s
largest primary pediatric care network, with 48 offices throughout
the greater Houston community and Texas Children’s Health Plan,
the nation’s first health maintenance organization (HMO) created
just for children.
Texas Children’s Hospital is affiliated with Baylor College of Medicine
(BCM), ranked by U.S.News & World Report as one of the nation’s
top 25 medical schools for research. Texas Children’s Hospital
serves as BCM’s primary pediatric training site, and BCM faculty are the division chiefs and staff
physicians of Texas Children’s patient care centers. The collaboration between Texas Children’s
Hospital and BCM is one of the top 10 such partnerships for pediatric research funding from the
National Institutes of Health. The hospital’s medical staff includes more than 1,500 board-certified,
primary-care physicians, pediatric subspecialists, pediatric surgical subspecialists and dentists,
offering the highest level of pediatric care in more than 40 subspecialties, programs and services
and a support staff in excess of 8,500.В 3
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D E PA R T M E N T O F S U R G E RY
Mission
D E PA R T M E N T O F S U R G E R Y M I S S I O N S TAT E M E N T
The Department of Surgery at Texas Children’s Hospital
strives to provide the highest quality surgical care in a
collaborative and family-centered environment while being
the national leader in surgical education and research.
Vision
D E PA R T M E N T O F S U R G E R Y V I S I O N S TAT E M E N T
The surgeons of Texas Children’s Hospital are committed
to setting the standard for quality surgical care, to inspiring
and educating the next generation of surgeons, and to being
leaders in research that changes lives.
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D E PA R T M E N T O F S U R G E RY
Department of Surgery
The Department of Surgery at Texas Children’s Hospital
represents a dedicated team of pediatric-focused surgeons
from nine surgical divisions – Congenital Heart, Dental, Neurosurgery,
Ophthalmology, Orthopaedics, Otolaryngology, Pediatric General Surgery, Plastic Surgery
and Urology. In conjunction with our partners in Pediatric and Adolescent Gynecology and
Transplant Services, we have over 65 full time surgeons and more than 500 Texas Children’s
Hospital and Baylor College of Medicine employees focused on ensuring children get the care
they need.
With an annual operating margin of $55 million, our team’s tireless efforts are evident in our
more than 24,000 operating room cases and over 98,000 outpatient visits completed in 2012,
millions of dollars in external research funding, and countless articles and presentations given
nationally and internationally each year.
Our team is dedicated to caring for children in and around the greater Houston area through
our four community health centers and two Texas Children’s Hospital locations. Additionally,
we take great pride in caring for children at other hospitals in the Houston area and from all 50
states and over 70 countries around the globe. When parents want the very best for their child,
we are humbled that they make Texas Children’s Hospital their choice. It is an honor to care for
these children and a responsibility we do not take lightly.
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D E PA R T M E N T O F S U R G E RY
2012
DEPARTMENT OF SURGERY OVERVIEW
S U RG IC AL DIVI S ION
CLINIC VISITS
O P E R AT I N G R O O M
CASES
1,457
767
2,245
785
5,689
962
Ophthalmology
16,195
1,317
Orthopaedics
23,035
2,222
Otolaryngology
18,659
9,403
5,544
226
11,292
5,564
3,583
1,058
Urology
11,098
2,049
TOTAL
98,797
24,353
Congenital Heart Surgery
Dental
Neurosurgery
Pediatric and Adolescent Gynecology
Pediatric General Surgery
Plastic Surgery
OPERATING ROOM CASES AND CLINIC VISITS
24, 353
86,686
22 ,641
83,432
2010
98,797
by year
22 ,472
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2011
O P E R AT I N G RO O M C A S E S
2012
CLINIC VISITS
Operating room cases are defined as cases when operating room staff and supplies are used.
Cases with multiple procedures count as one case and are attributed to the service line of
the primary surgeon. Operating room case volumes include procedures performed by Texas
Children’s Hospital, Baylor College of Medicine and private practice physicians at Texas Children’s
Hospital locations. Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor
College of Medicine faculty only.
D E PA R T M E N T O F S U R G E RY
Texas Children’s Hospital West Campus
Texas Children’s Hospital West Campus is Houston’s first community hospital designed,
built and staffed exclusively to care for children. This state-of-the-art 514,000 square-foot
facility incorporates best practices in pediatric treatment and serves the community as the
premier resource center for child wellness and healing. For more information, please visit
westcampus.texaschildrens.org.
2012
OPERATING ROOM CASES AND CLINIC VISITS COMPLETED
at the West Campus
Ophthalmology
73
2 ,748
382
Orthopaedics
7,160
1,743
4,185
Otolaryngology
799
General Pediatric Surgery
1, 567
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Plastic Surgery
44
Urology
O P E R AT I N G RO O M C A S E S
358
2 ,256
CLINIC VISITS
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital West Campus.
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
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D E PA R T M E N T O F S U R G E RY
Texas Children’s Pavilion for Women
Fully opened in March 2012, Texas Children’s Pavilion for Women enhances the Department
of Surgery’s capabilities to care for women, mothers and babies. As leaders in the fields of
obstetrics, gynecology, fetal and pediatric medicine, the Pavilion for Women offers some of the
most advanced technologies and treatments available from before conception to after delivery.
The Fetal Surgery Program benefits from the new operating rooms accommodating in utero
surgical procedures including spina bifida repair, twin-twin transfusion syndrome laser therapy,
interventional cardiology and balloon tracheal occlusion for severe congenital diaphragmatic
hernia. For more information, please visit women.texaschildrens.org.
OPERATING ROOM CASES COMPLETED
at the Pavilion for Women
771
Fetal
14
Pediatric General Surgery
Urology
110
3
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Pavilion for Women.
D E PA R T M E N T O F S U R G E RY
Department of Surgery Research Seed Grants
For the second year in a row, Texas Children’s Hospital gave surgical seed grant awards to
physicians in the Department of Surgery in order to advance the critical research being done
within the department. Two hundred fifty thousand dollars in funding was issued to the following
research projects:
CONGENITAL HEART SURGERY: IKI ADACHI, M.D.
Ex Vivo Perfusion for Pediatric Lung Transplantation: Pre-Clinical Trial
To address the overwhelming shortage of lungs available to children for transplantation, Iki Adachi,
M.D., and his team are adapting and testing an ex vivo lung perfusion system for pediatric use. Ex
vivo lung perfusion is used to perfuse harvested lungs that do not meet standard donor criteria
with lung-protective solution. Serial assessment of lung function allows clinicians to see if there
is any improvement in lung function and to determine if the lungs are potentially implantable.
With the support of the Department of Surgery Seed Grant, the team developed a pediatric ex
vivo perfusion system, tested its feasibility with animal lungs, and will determine the system’s
feasibility on human lungs and then move to clinical trials. The development of a pediatric ex vivo
lung perfusion system could save the lives of children who otherwise could not survive without
transplant. Since Texas Children’s Hospital has one of the largest pediatric lung transplant
programs in the world, the deployment of this system would have a major clinical impact.
PEDIATRIC GENERAL SURGERY: EUGENE KIM, M.D.
Targeting Stem Cells in Neuroblastoma
This research project focuses on the identification and characterization of a novel cancer stem cell
population of neuroblastoma. The leading cause of death in children with high-risk neuroblastoma
is tumor recurrence and relapse, despite chemotherapy, surgery and radiation. Cancer stem cells
are highly tumorigenic cells, which are resistant to chemotherapy and radiation, and just one cancer
stem cell can lead to regrowth of an entire tumor. While stem cells have been elusive in the past,
Eugene Kim, M.D., and his team have identified a novel cancer stem cell population based on the
expression of the receptor for G-CSF, CD114 and have shown1 that CD114+ cells are distinct
from CD114- cells in their ability to form tumors and the genes that they express. Future efforts
are now focused on targeting this population of cells to prevent tumor recurrence.
su DM, Agarwal S, BenhamA, Coarfa C, Trahan D, Chen Z, Stowers PN, Courtney AN, Lakoma A, Barbieri E,
H
Metelitsa LS, Gunaratne P, Kim ES, Shohet JM. G-CSF receptor positive neuroblastoma subpopulations are enriched
in chemotherapy-resistant or relapsed tumors and are highly tumorigenic. Cancer Research. May 16, 2013. [Epub ahead
of print].
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D E PA R T M E N T O F S U R G E RY
PEDIATRIC GENERAL SURGERY: MONICA LOPEZ, M.D.
Primary Versus Delayed Surgical Treatment for Pediatric Spontaneous Pneumothorax: A Pilot Randomized
Control Study
In the era of video-assisted thoracoscopic surgery (VATS) for the treatment of primary spontaneous
pneumothorax in children, the appropriate timing of surgery is unclear and controversial. Some
surgeons advocate for early VATS, aiming for definitive disease resolution based on high recurrence
rates associated with initial nonoperative management (> 50%). Others recommend reserving
surgery for those who fail nonoperative management in order to avoid unnecessary surgery in a
proportion of patients. Retrospective data from our institution demonstrate that more than 60%
of patients ultimately require surgery for recurrent disease or persistent air leak. Additionally, those
treated nonoperatively have a much greater rate of health care utilization and longer cumulative
hospital length of stay than those who had primary surgery. This will be the first randomized
prospective study to evaluate the comparative effectiveness of two management strategies for
primary spontaneous pneumothorax (PSP) in pediatric patients.
PEDIATRIC GENERAL SURGERY: OLUYINKA OLUTOYE, M.D., PH.D.
Near Infra-Red Spectroscopy (NIRS) in Necrotizing Entercolitis (NEC)
The first phase of this project yielded results showing both that low abdominal tissue oxygen
saturation values obtained by the use of NIRS are predictive of NEC and serum intestinal fatty
acid-binding protein correlates with severity and progression of NEC in premature piglets. This
data was accepted under the title “Low abdominal NIRS values and elevated serum intestinal
fatty acid-binding protein predict necrotizing enterocolitis in a premature piglet model” for oral
presentation at the annual American College of Surgeons Surgical Forum in October 2012 and will
follow with manuscript publication. Oluyinka Olutoye, M.D., Ph.D., will be commencing the second
phase of the study this fall to evaluate for the possible rescue effect of administering supplemental
oxygen to hypoxic piglets. To build further on the ability to predict the onset of NEC, he will
determine critical time points for changes in abdominal tissue oxygen saturation values using NIRS
and increases in serum fatty acid-binding protein with more frequent blood draws.
PEDIATRIC GENERAL SURGERY: SANJEEV VASUDEVAN, M.D.
Developing the Tools to Explore New Molecular Targets and Therapeutics for Hepatoblastoma
The goal of this research project was to characterize the relationship of DUSP26 to the MYCN
oncogene and to study how inhibiting DUSP26 function affects neuroblastoma tumor growth.
The team tested two constructs created from the promoter and Intron 1 of DUSP26 with both
p53 and MYCN binding sites. The results suggest that DUSP26 is a MYCN mediated gene. The
team plans to perform mutations of the Intron 1 binding site to inhibit this binding and perform
chromatin immunoprecipitation to establish DUSP26 as a MUYCN inducible gene. Testing on
the effects of DUSP26 knockdown with sh-RNA and inhibition with a small molecule inhibitor,
NSC-87877 was also completed on neuroblastoma cell lines. The team found that sh-RNA
knockdown of DUSP26 reduced proliferation of the cell lines and that this was caused by an
arrest in the G1-phase of the cell cycle mediated by p53 activation. In addition, they concluded
that NSC-87877 was able to cause a proliferation defect in most neuroblastoma cell lines.
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D E PA R T M E N T O F A N E S T H E S I O L O G Y
Department of Anesthesiology
The Department of Pediatric Anesthesiology has 50 fellowshiptrained pediatric anesthesiologists, making it one of the largest
and most well-trained specialized departments in the United
States. Our pediatric anesthesiology team also includes 15 certified registered nurse
anesthetists and 13 pediatric nurse practitioners. Last year, our team of highly skilled and
experienced pediatric anesthesiologists completed more than 37,000 cases, from simple
outpatient procedures to complicated, 12-hour-plus surgeries.
Anesthesia for children and babies requires specifically designed and sized equipment, and we
utilize the very latest in technology, including advanced monitors and near-infrared spectroscopy
to measure brain oxygen levels during complex cases.
Our goal is to ensure each child has a safe, pain-free and stress-free experience, whether it is
surgery in an operating room or a procedure or test completed elsewhere in the hospital
such as bedside sedation in or near patients’ rooms, which can help reduce anxiety and stress
during minor surgical procedures. Additionally, three anesthesiologists work as part of the
Cardiovascular Intensive Care Unit (CVICU) to provide specialized anesthesia services for
patients with complex conditions.
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D E PA R T M E N T O F A N E S T H E S I O L O G Y
The Department of Anesthesiology is committed to patient care, education and research. We
operate one of the leading fellowship programs in the United States, providing training in general
pediatric anesthesia and advanced second year fellowship training in pediatric cardiovascular
anesthesia, pediatric anesthesia education and research, and pediatric anesthesia quality and
outcomes. Our active clinical and basic research programs are involved in more than 20 projects.
We are also dedicated to optimizing safety and anesthetic outcomes. On a national level, the
Department of Anesthesiology participates in the Society for Pediatric Anesthesia Wake Up Safe
Project, the Congenital Cardiac Anesthesia Society Database, the Pediatric Regional Anesthesia
Network, and the Pediatric Sedation Research Consortium to gather and evaluate outcomes data
from across the nation in order to help identify evidence-based protocols and best practices.
This year we implemented new emergency checklist protocols for 24 types
of intraoperative emergencies. These checklists, developed in conjunction
with the Society for Pediatric Anesthesia, ensure that for these very rare
events, all proper procedures are followed to achieve the best possible
patient outcomes.
PEDIATRIC ANESTHESIA SCREENING SERVICE (PASS)
The PASS clinic is a comprehensive pre-anesthesia evaluation service for patients with
complicated underlying medical disease, patients undergoing complex surgeries, or both.
The team of pediatric anesthesia nurse practitioners and pediatric anesthesiologists performs
a comprehensive review of the patient’s past medical, surgical and anesthetic history, plans for
any additional testing or consultation required before surgery, and devises a comprehensive
plan for intraoperative anesthetic management and postoperative pain management, and makes
additional recommendations for postoperative intensive care if required. This detailed plan has led
to increased patient satisfaction and dramatically reduced delays on the day of surgery because all
required testing is complete.
ANESTHESIA SAFETY IN INFANTS AND CHILDREN
In recent years, laboratory research has raised the question of anesthesia drugs’ effects on
the developing brain in neonatal animal models. There has been conflicting data in several
retrospective studies in children, and the research has many limitations.
Dean Andropoulos, M.D., chief of Anesthesiology at Texas Children’s Hospital, is a member of the
SmartTots Scientific Advisory Board. SmartTots’ mission is to fund research into the question of
anesthetic neurotoxicity and to communicate to medical professionals and the public the latest
state-of-the-art information and recommendations. In September 2012, Dr. Andropoulos was a
member of a task force that released a major public statement on anesthesia safety in children.
The main conclusions were that currently used anesthesia drugs and techniques are safe and
necessary, parents should ask questions of their anesthesiologist, surgeon, and pediatrician about
any proposed procedures, and that all necessary surgical procedures should proceed as scheduled
in order to optimize the child’s health. The public statement can be found at smarttots.org.
D E PA R T M E N T O F A N E S T H E S I O L O G Y
NEURODEVELOPMENTAL OUTCOMES
Neonates undergoing complex congenital heart surgery have a significant incidence of neurologic
problems. Erythropoietin has antiapoptotic, antiexcitatory, and anti-inflammatory properties to
prevent neuronal cell death in animal models, and it improves neurodevelopmental outcomes in
full-term neonates with hypoxic ischemic encephalopathy. A multidisciplinary team from Texas
Children’s Hospital designed a prospective phase I/II trial2 of erythropoietin neuroprotection in
neonatal cardiac surgery to assess safety and indicate efficacy.
Total patients
59
• Neonates undergoing surgery for d-transposition
of the great vessels, hypoplastic left heart syndrome,
or aortic arch reconstruction were randomized to
3 perioperative doses of erythropoietin or placebo.
• Safety profile, including magnetic resonance imaging
brain injury, clinical events, and death, was not
different between groups.
Mortality
3 patients in each group
Received 12 month follow-up
42 patients, 79% of survivors
• 22 erythropoietin group
• 20 placebo group
Neurodevelopmental testing
Performed at age 12 months using the Bayley
Scales of Infant and Toddler Development III
Mean cognitive scores
Erythropoietin group – 101.1 ± 13.6
Placebo group – 106.3 ± 10.8 (P = .19)
Language scale scores
Erythropoietin group – 88.5 ± 12.8
Placebo group – 92.4 ± 12.4 (P = .33)
Motor scale scores
Erythropoietin group – 89.9 ± 12.3
Placebo group – 92.6 ± 14.1 (P = .51)
CONCLUSIONS
Safety profile for erythropoietin administration was not different than placebo.
Neurodevelopmental outcomes were not different between groups; however, this pilot
study was not powered to definitively address this outcome. Lessons learned suggest
optimized study design features for a larger prospective trial to definitively address the
utility of erythropoietin for neuroprotection in this population.
Andropoulos DB, Brady K, Easley RB, Dickerson HA, Voigt RG, Shekerdemian LS, Meador MR, Eisenman CA, Hunter
JV, Turcich M, Rivera C, McKenzie ED, Heinle JS, Fraser CD Jr. Erythropoietin neuroprotection in neonatal cardiac
surgery: A phase I/II safety and efficacy trial. J Thorac Cardiovasc Surg. 2013;146:124-31.
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D E PA R T M E N T O F A N E S T H E S I O L O G Y
CEREBRAL AUTOREGULATION MONITORING
During surgery, our pediatric cardiovascular anesthesiologists work closely with surgeons and
perfusionists to provide a consistent approach for cardiopulmonary bypass and anesthetic
management. In an effort to continue to improve our cardiac outcomes, our research teams are
investigating a method to optimize cerebral oxygenation and brain blood flow through a new
method of monitoring called cerebral autoregulation.
Cerebral autoregulation monitoring can show anesthesiologists if blood pressure in the brain is
at adequate levels. Previously, autoregulation monitoring was a tool for neurosurgeons only: an
invasive and slow process that cannot be performed on the brain during cardiopulmonary bypass.
The new process is both noninvasive and rapid enough to guide decisions about blood pressure
in the brain during bypass. Texas Children’s pediatric anesthesiologists Blaine Easley, M.D. and Ken
Brady, M.D. are leading a team of researchers investigating whether neurological outcomes can be
improved with these novel techniques.
The goal of this new monitoring is to help the brain regulate its own blood flow during bypass,
perfusion and other procedures, by showing the range of blood pressure that allows for this
to occur. By “helping the brain to help itself,” this method may prevent strokes in our most
vulnerable patients. Monitoring of this kind has been successful in neurosurgery patients and
appears promising for the cardiac arena. Our patented technology is currently being tested
with the ultimate goal of incorporation into pediatric operating rooms.
D EPARTMENT OF ANESTHESIA CASES
2009
2010
2011
37,134
35,210
32 ,463
by year
30,757
14
2012
Anesthesia case volumes include anesthesia administered by Texas Children’s Hospital physicians
at Texas Children’s Hospital locations.
D E PA R T M E N T O F A N E S T H E S I O L O G Y
2012
*
D EPARTMENT OF ANESTHESIA CASES
by location
Anesthesia procedures in Texas Children’s Hospital operating rooms
WEST TOWE R
1,
64
9
0
88
WEST C AM PU S
10
1, 4 8
CONGE N I TAL H E ART S U R G E RY
269
8
CLINIC AL C AR E C E N T E R
,8
60
7, 9 6 7
3
1
9, 7
44
84
37
3,
Sedation and anesthesia procedures in other Texas Children’s Hospital areas
RADIOLOGY
C AN C E R C E N T E R PATI E N T S U N D E R G O I N G P RO C E D U R E S ( PAC U )
C A R D I AC C AT H E T E R I Z AT I O N L A BS
G A S T RO I N T E S T I N A L P RO C E D U R E S U I T E
M O BI L E S E DAT I O N S
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D E PA R T M E N T O F A N E S T H E S I O L O G Y
DEAN B. ANDROPOULOS, M.D., M.H.C .M., is chief of Anesthesiology at Texas Children’s
Hospital and professor of Anesthesiology and Pediatrics at Baylor College of Medicine. He
received his medical degree at the University of California at San Diego. His residencies in
pediatric medicine and anesthesiology were both at the University of California at San Francisco.
In addition, Dr. Andropoulos earned a Masters of Science in Healthcare Management from the
Harvard School of Public Health. His research focus is neurological monitoring, protection and
outcomes in neonates undergoing complex open heart surgery,
for which he has ongoing National Institutes of Health (NIH)
funding. He is the editor of two major textbooks, Anesthesia
for Congenital Heart Disease, 2nd edition; and Gregory’s Pediatric
Anesthesia, 5th edition. He is also co-principal investigator at
Texas Children’s Heart Center for the NIH-funded Pediatric
Heart Network Core Clinical Center.
To view more Department of Anesthesiology biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
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C O N G E N I TA L H E A R T S U R G E RY
Congenital Heart Surgery
The Congenital Heart Surgery Division provides customized
and comprehensive surgical care for all aspects of pediatric and
congenital heart disease. Texas Children’s Heart Center performs nearly 800 surgical
procedures annually with outcomes among the best in the nation. Additionally, the Heart Center
is consistently ranked among the top pediatric cardiology and heart surgery programs in the
nation by U.S.News & World Report.
We treat children of all ages, including preterm and low-birth-weight newborns, and we
personalize treatments and procedures to best suit the situation of each child and family. This
tailored approach includes cardiopulmonary bypass and neuroprotection strategies focused on
the patient’s condition and needs, which helps to achieve optimal outcomes.
Texas Children’s Heart, Lung and Heart-Lung Transplant Programs, among the nation’s largest and
most successful, are also part of the Congenital Heart Surgery Division.
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C O N G E N I TA L H E A R T S U R G E RY
AUDRINA’S ECTOPIA CORDIS: A CASE STUDY
During a routine ultrasound 16 weeks into Ashley Cardenas’ pregnancy, her sonogram image
indicated that part of Audrina’s heart was forming outside of her chest, also known as ectopia
cordis. Only eight per one million babies are born with this rare congenital malformation, where
the heart is abnormally located either partially or totally outside the chest. Of those eight, 90
percent are either stillborn or die within the first three days of life. On October 16, 2012, a
multidisciplinary team of surgeons at Texas Children’s Hospital saved Audrina’s life during a
miraculous six hour open-heart surgery where the team reconstructed her chest cavity to make
space for the one third of her heart that was outside her body.
Texas Children’s Fetal Center received the referral for Ashley, who was first evaluated just weeks
before she would be scheduled for delivery. Ashley’s initial evaluation included an ultrasound, fetal
echocardiogram and fetal MRI (magnetic resonance imaging), which allowed the maternal fetal
medicine (MFM) and Heart Center teams at Texas Children’s to develop a unique care plan for
her delivery. Texas Children’s Pavilion for Women delivered Audrina by caesarean, and she was
immediately attended to by a large team of neonatal specialists who took over her care.
Once the cardiac surgeons were finished operating on Audrina, the plastic surgery team played a
pivotal role in completing this surgery, as they were responsible for covering her heart beneath
her skin and muscle. Audrina recovered in the cardiovascular intensive care unit at Texas Children’s
Hospital. She will continue to be carefully followed by a multidisciplinary team and will require
specialized care by a pediatric cardiologist for the rest of her life.
C O N G E N I TA L H E A R T S U R G E RY
OUTCOMES OF PATIENTS WITH ANOMALOUS AORTIC ORIGIN OF A CORONARY
ARTERY (AAOCA)
Date range
1995 - 2012
Total patients
50
Patients managed medically
34 patients (68%)
Patients managed surgically
16 patients (32%)
Surgical interventions
Coronary unroofing in 12 patients (75%)
Coronary reimplantation in 3 patients (19%)
Osteoplasty in 1 patient (6%)
Early reintervention after
coronary reimplantation
1 patient
Morbidities
0%
Complete follow-up
80%
Since the creation of the Coronary Anomalies Program at Texas Children’s Hospital in
December 2012:
Total patients
25
Surgery recommended
12 patients (48%)
Surgery completed
7 patients
Surgical interventions
Coronary unroofing in 6 patients
(86%) and coronary translocation
in 1 patient (14%)
Complications
0%
Texas Children’s looks forward to hosting a symposium on congenital
coronary anomalies, the first of its kind, in December 2013.
19
20
C O N G E N I TA L H E A R T S U R G E RY
SURGICAL PULMONARY VALVE/CONDUIT REPLACEMENT OUTCOMES
With the increasing application of percutaneous pulmonary valves, Texas Children’s Heart Center
decided to evaluate our surgical results of pulmonary valve/conduit replacement in order to
provide a reference point for examining outcomes of both modalities in the future. We reviewed
our outcomes from 1995-2010. We have performed pulmonary valve (PV) replacements in 247
patients but to specifically examine the outcomes of patients who would be candidates for a
percutaneous valve, we narrowed our study to include patients who were 5 years old or older
and who weighed 30 kg or more.
Total PV replacements
148
All patients had undergone at least 1 previous
intervention on their PV
Most common
fundamental diagnosis
Tetralogy of Fallot (53%)
Surgical indications
for PV replacement
60% PV insufficiency
26% PV stenosis
13% both PV insufficiency and stenosis
Valves used
73% bioprosthetic valves
27% homografts
Median time to extubation
following surgery
< 1 day
Median ICU length of stay
2 days
Median hospital length of stay
5 days
Hospital survival
100%
Freedom from
reintervention
on the PV
1 year = 99%
3 years = 99%
5 years = 94%
Survival at last
follow-up3
99%
Average length of follow-up five years +/- four years.
3
C O N G E N I TA L H E A R T S U R G E RY
21
CONGENITAL HEART SURGERY OPERATING ROOM CASES AND CLINIC VISITS
2009
2010
O P E R AT I N G RO O M C A S E S
2011
1,457
767
837
1,309
1,422
834
912
1,456
by year
2012
CLINIC VISITS
Total operating room volumes include heart and lung transplantations.
Operating room case volumes and clinic visits include procedures and outpatient visits completed
by Texas Children’s Hospital physicians at Texas Children’s Hospital surgical locations.
22
C O N G E N I TA L H E A R T S U R G E RY
MORTALITY RATES BY RACHS-1 CLASSIFICATION
in 2012
Primary procedure
Number of
procedures
Number of
discharge
mortalities
%
mortality
STS
national
benchmark
Total for Risk Category 1
63
0
0.0%
0.5%
Total for Risk Category 2
218
1
0.5%
1.1%
Total for Risk Category 3
170
4
2.4%
3.5%
Total for Risk Category 4
36
1
2.8%
6.7%
Total for Risk Category 5-6
24
4
16.7%
15.8%
Grand total
511
10
2.0%
3.1%
The Risk Adjustment in Congenital Heart Surgery (RACHS-1)4 categorization is a widely used risk
stratification model to analyze outcomes in congenital heart surgery. The most common surgeries
for congenital heart defects are stratified into six risk categories. Surgeries with higher risk are
placed in higher categories with category six representing congenital heart surgeries associated
with the greatest risk.
2.0%
Overall risk-adjusted hospital mortality rate for our
program in 2012 was 2.0%5. Data collected by the
Society of Thoracic Surgeons (STS) shows the
national hospital discharge mortality rate at 3.1%6.
Jenkins, KJ, Gauvreau K, Newburger JW, et al., Consensus-based method for risk adjustment for surgery for
congenital heart disease. J Thorac Cardiovasc Surg, 2002;123:110-8.
0 07-RACHS-1 Index Surg CHD Volume.
6
Society of Thoracic Surgeons Data Harvest Report, published May 2012.
4
5
C O N G E N I TA L H E A R T S U R G E RY
CHARLES D. FRASER, JR., M.D., is surgeon-in-chief, co-director of Texas Children’s Heart
Center and chief of the Division of Congenital Heart Surgery at Texas Children’s Hospital. His
academic appointments include professor of Surgery in the Michael E. DeBakey Department of
Surgery (tenured) at Baylor College of Medicine, professor of Pediatrics at Baylor College of
Medicine and adjunct professor of Bioengineering at Rice University. Dr. Fraser holds the Susan
V. Clayton Chair in Surgery at Baylor College of Medicine and the Donovan Chair in Congenital
Heart Surgery at Texas Children’s Hospital. Dr. Fraser has a clinical appointment at the Texas
Heart Institute where he serves as director of the Adult Congenital Heart Surgery Program.
Dr. Fraser’s extensive education began as an undergraduate at the University of Texas at Austin,
where he graduated with honors in mathematics. He received his medical degree with honors
from the University of Texas Medical Branch at Galveston. His residency and fellowship training
took place at The John Hopkins Hospital in Maryland. He completed additional fellowship training
in Congenital Heart Surgery at the Royal Children’s Hospital
in Melbourne, Australia. After joining the faculty at Cleveland
Clinic, Dr. Fraser was recruited to Texas Children’s Hospital in
July of 1995 to establish a dedicated pediatric congenital heart
surgery program. Since that time, he and his team have performed
corrective operations in more than 10,000 children and adults
with congenital heart disease.
To view more Congenital Heart Surgery Division biographies, visit
texaschildrens.org/Locate/Find-a-Doctor.
23
24
C O N G E N I TA L H E A R T S U R G E RY
Dental
The Dental Division at Texas Children’s Hospital performs
more than 2,000 procedures each year to ensure patients with
special needs or complex medical diagnoses receive the dental
care they need. In collaboration with nephrology, neurology, Texas Children’s Heart
Center and Texas Children’s Cancer Center, we treat dental patients as outpatients, inpatients or
in the operating room. With expertise in a full range of procedures, our team coordinates each
patient’s care with his or her pediatric subspecialists.
Sometimes dental treatment, such as removal of teeth or replacement of fillings, is needed before
surgery or anesthesia can take place or other health care needs can be addressed. Orthodontia
is provided for children with congenital craniofacial anomalies and/or cleft palates. In addition, we
ensure that the annual dental needs, such as prophylaxis or fillings, of children with special needs
are met.
D E N TA L
The Dental Division participates in the multidisciplinary Craniofacial Clinic to address genetic
abnormalities of the face and head. This collaborative effort brings together experts from
dermatology, genetics, neurosurgery, otolaryngology, plastic surgery, radiology and speech therapy.
Dental surgeon Esther Yang, D.D.S., joined the Dental Division in 2012.
Dr. Yang provides care to patients with special needs such as autism and
those who are medically compromised. As a member of the cleft and
craniofacial team, Dr. Yang helps treat patients born with a variety of facial
abnormalities including cleft lip and palate, hemifacial microsomia, Crouzon
syndrome, Pierre Robin and a variety of other conditions.
DENTAL OPERATING ROOM CASES AND CLINIC VISITS
2009
2010
O P E R AT I N G RO O M C A S E S
2011
785
2 ,245
2 ,472
847
778
810
2 , 559
2 , 596
by year
2012
CLINIC VISITS
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
25
26
D E N TA L
DENTAL OPERATING ROOM PATIENTS
by age
1%
9%
2012
19%
22%
49%
<5 YEARS
5-10 YEARS
11-15 YEARS
16-20 YEARS
>20 YEARS
A. BRUCE CARTER, D.D.S., is chief of the Dental Division and Dental Clinic at Texas Children’s
Hospital. He received his doctorate of Dental Surgery at the University of Texas Health Science
Center at Houston, where he also received his Pedodontic Certificate. After a solo practice and
teaching at his alma mater, he joined Texas Children’s Hospital as the Dental Clinic chief in 1984.
He is member of the American Board of Pediatric Dentistry
Diplomates, the Greater Houston Dental Society, the Texas Dental
Association, the American Dental Association and the American
Academy of Pediatric Dentistry. In conjunction with a grant from
the National Institutes of Health, Dr. Carter studied and published
several articles on the oral manifestations and health of pediatric
HIV patients.
To view more Dental Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
D E N TA L
27
Neurosurgery
The Neurosurgery Division at Texas Children’s Hospital is one
of the most active and experienced pediatric neurosurgery
programs in the nation. Consistently ranked by U.S.News & World Report as a leading
neurology and neurosurgery center, we complete more than 900 procedures each year to address
a broad range of neurological disorders in infants, children and young adults.
Our board-certified pediatric neurosurgeon-scientists provide surgical treatment of neurological
diseases and conditions including but not limited to tumors in or malformations of the brain,
spine and peripheral nervous system, epilepsy and hydrocephalus. We are committed to
discovering groundbreaking diagnosis and treatment approaches and to training the next
generation of expert neurosurgeons.
28
N E U R O S U R G E RY
Texas Children’s Hospital has developed extensive screening and diagnostic algorithms for
pregnancies with myelomeningocele (spina bifida). Spina bifida occurs in three of every 10,000
live births in the United States, and the standard of care is neurosurgical closure of the defect in
the first days of life. The Neurosurgery Division works closely with Texas Children’s Fetal Center,
pediatric general surgery, anesthesiology, neonatology, radiology, cardiology and more to perform
in utero surgery for treatment of spina bifida. To date, four of these highly complex in utero
procedures have taken place at Texas Children’s.
In collaboration with Rice University, the division is investigating neuroregeneration, accomplished
by growing neurons on nanomaterials, as a treatment modality for chronic residual effects of
spinal cord injuries. Funding sources include the U.S. Army, the Neurosurgery Research and
Education Fund and Texas Children’s Hospital.
The Neurosurgery Division continues to use real-time MRI-guided thermal imaging and
laser technology to destroy lesions in the brain that cause epilepsy. This procedure is
a safer and less invasive approach than craniotomy for some patients, and it has a high
rate of success in reducing or eliminating seizures in patients ages 5 to 15. To date, the
Neurosurgery Division has completed 29 stereotactic laser ablation procedures.
MRI-GUIDED STEREOTACTIC LASER ABLATION OF EPILEPTOGENIC FOCI IN CHILDREN
For about 30% of epilepsy patients, pharmaceutical therapy fails to control their seizures. MRI-guided
laser interstitial thermal therapy (MRgLITT) allows for real-time thermal monitoring of the
ablation process and feedback control over the laser energy delivery. The Neurosurgery Division
recently reported7 on minimally invasive surgical techniques of MRgLITT and short-term follow-up
results from the first pediatric cases in which this system was used to ablate focal epileptic lesions.
Total patients
5
Methods
Studied the patients with MRI of the brain, localized the seizure
with video-EEG and used the Visualase Thermal Therapy 25
System for laser ablation of their seizure foci
Incidence of seizure
postprocedure
0
Complications as of
2-13-month follow-up
0
CONCLUSION
MRI-guided laser interstitial thermal therapy has a significant potential to be a minimally
invasive alternative to more conventional techniques to surgically treat medically refractory
epilepsy in children.
Curry DJ, Gowda A, McNichols RJ, Wilfong AA. MR-guided stereotactic laser ablation of epileptogenic foci in children.
Epilepsy Behav. 2012 Aug;24(4):408-14. Epub 2012 Jun 9.
7
N E U R O S U R G E RY
CEREBROSPINAL FLUID (CSF) DIVERSION IN PRETERM INFANTS WITH
INTRAVENTRICULAR HEMORRHAGE
There is little consensus regarding the indications for surgical CSF diversion (either with
implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm
infants with posthemorrhagic hydrocephalus. The authors of this study8 determined clinical and
neuroimaging factors associated with the use of surgical CSF diversion among neonates with
intraventricular hemorrhage (IVH), and describe variations in practice patterns across four large
pediatric centers.
Total patients
110 neonates were surgically treated for
IVH related to prematurity.
Location
Patients were treated at four clinical centers
of the Hydrocephalus Clinical Research
Network (HCRN).
Underwent temporization procedures 73 (66%)
• 50 ventricular reservoir
• 23 subgaleal shunt placements
Use of an implanted
temporizing device
Center (p < 0.001), increasing ventricular
size (p = 0.04), and bradycardia (p = 0.07)
were associated.
Apnea, occipitofrontal circumference (OFC),
and fontanel assessments were not.
Implanted temporizing devices
converted to permanent shunts
65 (89%)
• A full fontanel (p < 0.001) and increased
ventricular size (p = 0.002) were associated
with conversion.
• Center, OFCs and clot characteristics
were not.
CONCLUSION
Considerable center variability exists in neurosurgical approaches to temporization of IVH
in prematurity within the HCRN; however, variation between centers is not seen with
permanent shunting. Increasing ventricular size – rather than classic clinical findings such as
increasing OFCs – represents the threshold for either temporization or shunting of CSF.
8
iva-Cambrin J, Shannon CN, Holubkov R, Whitehead WE, Kulkarni AV, Drake J, Simon TD, Browd SR, Kestle JR,
R
Wellons JC 3rd. Center effect and other factors influencing temporization and shunting of cerebrospinal fluid in
preterm infants with intraventricular hemorrhage. J Neurosurg Pediatr. 2012 May; 9(5):473-81.
29
N E U R O S U R G E RY
2012 Goal
2012 Actual
Neurosurgical shunt infection rate
<5%
2%
Craniotomy9 complications10
<5%
0.9%
Postoperative cerebral-spinal fluid leak
<5%
1.1%
NEUROSURGERY OUTCOMES
NEUROSURGERY OPERATING ROOM CASES AND CLINIC VISITS
2010
O P E R AT I N G RO O M C A S E S
2011
962
4,975
915
4,678
966
4,135
2009
5,689
by year
930
30
2012
CLINIC VISITS
Operating room cases and clinic visits include procedures and outpatient visits completed by
Texas Children’s Hospital physicians at Texas Children’s Hospital surgical locations.
9
Craniotomy for tumor, vascular, trauma, intracranial hemorrhage and craniofacial reconstruction.
Arterial injury, change in neuromonitoring that persists through procedure, unplanned transfusion of blood products,
intraoperative CPR or death.
10
N E U R O S U R G E RY
THOMAS G. LUERSSEN, M.D., F.A.C .S., F.A.A.P., is chief of Neurosurgery and chief quality
officer for Surgery at Texas Children’s Hospital. He is also professor of Neurological Surgery and
director of the Pediatric Neurosurgery Program in the Department of Neurosurgery at Baylor
College of Medicine. Dr. Luerssen attended medical school at Indiana University and completed
his residency in Neurosurgery at Indiana University Medical Center. He completed fellowship
training at Children’s Hospital of Philadelphia and then joined the faculty at the University of
California San Diego. His clinical and research focus was traumatic brain injury in childhood.
Later, Dr. Luerssen returned to Indiana University and spent 18 years as director of the Pediatric
Neurosurgery Service at the James Whitcomb Riley Hospital for Children. In 2006, he was
recruited to Texas Children’s Hospital to be chief of Neurosurgery and was named chief quality
officer for Surgery in 2009. Dr. Luerssen is the past chairman
of the Joint Section on Pediatric Neurological Surgery of the
American Association of Neurological Surgeons and Congress of
Neurological Surgeons and past president of the American Society
of Pediatric Neurosurgeons. He is currently vice chairman of the
American Board of Pediatric Neurological Surgery.
To view more Neurosurgery Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
31
32
N E U R O S U R G E RY
N E U R O S U R G E RY
Ophthalmology
The Ophthalmology Division at Texas Children’s Hospital
Main Campus and West Campus provides the highest-quality
surgical care for anomalies, disorders and injuries of the eyes.
Since its inception, the Ophthalmology Division has grown into one of the premier pediatric
ophthalmology surgery programs in the nation with exceptional expertise, depth and quality of
services, and patient volumes. The Ophthalmology Division is one of the few programs in the
nation with expertise in vitreoretinal surgery for children.
The most common problem corrected with surgery by our ophthalmologists is strabismus,
which is an eye muscle imbalance commonly known as crossed eyes, lazy eyes or wandering
eyes. Both children and adults are surgically treated for strabismus by the physicians at Texas
Children’s Hospital.
OPHTHALMOLOGY
Texas Children’s Hospital Main Campus now staffs an ophthalmology hospitalist, and patients at
Texas Children’s Health Centers are able to receive ophthalmology services for primary eye care
from staff optometrists. In addition, several new physicians joined the team in 2012:
• Amit Bhatt, M.D., contributes to inpatient and outpatient care at the Clinical Care Center at
Main Campus.
• Doug Marx, M.D., an oculoplastics specialist at Baylor College of Medicine, joined us in a more
formal way for complex oculoplastics cases such as treatment of orbital tumors, vascular
abnormalities and craniofacial abnormalities.
• Mary Kelinske, O.D., assists with the outpatient care load as well as the standardization of
optometric services and care across health center practices and physicians at Texas Children’s.
The division recently developed an electrophysiology vision lab that now has the ability
to perform electroretinograms to determine the function of the retina and visual-evoked
potential testing. Additionally, in conjunction with the endocrinology department, we now
perform photographic screening for diabetic eye diseases as part of routine annual diabetes and
pre-diabetes care at Texas Children’s Hospital, the Pavilion for Women and the Health Centers.
PEDIATRIC BLINDING DISORDERS
The Ophthalmology Division recently reviewed and reported11 the available data on pediatric
blinding diseases worldwide in order to present current information on childhood blindness in
the United States and elsewhere. A systematic search of world literature published since 1999
was conducted. Data was also solicited from each state school for the blind in the United States.
Childhood blindness and visual
impairment in developing countries
17% - 31% is avoidable
10% - 58% is treatable
3% - 28% is preventable
Leading cause of blindness in Africa
Corneal opacification
The rate has decreased from
56% in 1999 to 27% in 2012
Leading causes of blindness in
the United States
Cortical visual impairment
Optic nerve hypoplasia
Retinopathy of prematurity
CONCLUSIONS
There are marked regional differences in the causes of blindness in children, apparently
based on socioeconomic factors that limit prevention and treatment schemes. A national
registry of the blind would allow accumulation of more complete and reliable data for
accurate determination of the prevalence of each of the leading causes of blindness in the
United States.
ong L, Fry M, Al-Samarraie M, Gilbert C, Steinkuller PG. An updated on progress and the changing epidemiology of
K
causes of childhood blindness worldwide. J AAPOS. 2012 Dec;16(6):501-7.
11
33
34
OPHTHALMOLOGY
LONG-TERM EFFICACY AND SAFETY OF PHOTOREFRACTIVE KERATECTOMY IN
THE PEDIATRIC POPULATION
The Ophthalmology Division completed a prospective noncomparative interventional case series12
measuring the use of photorefractive keratectomy (PRK) for the treatment of myopia and
hyperopia and to observe long term efficacy and safety in pediatric patients. The main outcome
measures were refractive stability, visual acuity, and corneal clarity. Developmental quotient was
also measured over a battery of developmental areas in the bilateral group preoperatively and at
six and 12 months postoperatively.
Total patients
57
• 44 eyes of 22 patients neurobehavioral
disorders with severe bilateral high
refractive errors
• 35 eyes of 35 patients with severe
anisometropia who failed traditional
therapy were treated with PRK
Time of examinations
Preoperatively and postoperatively at 1
month, 6 months, 1 year and then annually
Average preoperative
refractive error
-9.45 В± 4.16 diopters (D) for myopic patients
+6.32 В± 1.26D for hyperopic patients
Mean spherical equivalent
at year one
-0.92 В± 1.64D for myopic patients
1.48 В± 0.51D for hyperopic patients
Mean corneal haze score and
percentage of eyes with
corneal haze
Decreased from 0.9 to 0.5 and 64% to 25% in
the myopic patients over 3 years of follow up
Uncorrected visual acuity
(UCVA) pre-operatively
Improved from logMar 1.32 В± 0.57 to
logMar 0.58 В± 0.31
Refraction
Stable for up to 5 years of follow up
Developmental quotient
Improved signficantly in 4 subcategories
of development including receptive and
expressive communication, coping and
interpretive socialization
aysse EA, Coats DK, Hussein MAW, Hamill MB, Koch DD. Long-term outcomes of photorefractive keratectomy for
P
anisometropic amblyopia in children, Ophthalmology 2006;113:169-76. (2005 Dec 14 [Epub]).
12
OPHTHALMOLOGY
MEAN SPHERICAL EQUIVALENT (SE) REFRACTIVE ERROR (BILATERAL GROUP)
10
9
8
7
6
5
4
3
2
1
0
MYOPIC
HYPEROPIC
PRE OP SE
ASTIGMATIC
POST OP SE
MEAN UNCORRECTED VISUAL ACUITY(BILATERAL GROUP)
20/800
20/400
20/200
20/100
20/80
20/60
20/50
20/40
20/30
20/20
HYPEROPIC
MYOPIC
PRE OP
6 MONTHS POST OP
35
36
OPHTHALMOLOGY
SUBDOMAINS THAT SIGNIFICANTLY IMPROVED
Test
Vineland II
Domain
Subdomain
Pre op
DQ
Post op
DQ
Communication
Receptive
23.8
31.7
8.9+/-11.9
0.04
Expressive
25.7
31.0
5.3В±10.3
0.02
Interpretive
24.0
28.2
4.2В±4.9
0.04
Coping
20.3
28.1
7.8В±10.1
0.02
Socialization
Mean
P-value13
change+/SD
CONCLUSION
Pediatric refractive surgery results in improvements in visual acuity, refractive error,
stereopsis, communication and socialization with minimal complications.
As one of only two programs in the United States to offer refractive surgery (PRK
laser) for children, we collaborate with Baylor College of Medicine to achieve positive
results with nearsightedness, farsightedness and astigmatism. Approximately 90
percent of our patients who have this procedure improve best vision by at least two
lines on the standard eye chart.
13
Wilcoxon Signed-Rank Test, one tail.
OPHTHALMOLOGY
OPHTHALMOLOGY OPERATING ROOM CASES
1, 317
73
2011
2012
TEXAS CHILDREN’S HOSPITAL
1,244
1,224
2010
1,177
47
2009
1,205
1,105
by year
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
10,570
2,346
2,877
2,748
14, 550
10,499
2,230
97
1,705
11,415
13,742
by year
16,195
OPHTHALMOLOGY CLINIC VISITS
2010
2011
2012
TEXAS CHILDREN’S HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
37
38
OPHTHALMOLOGY
DAVID K. COATS, M.D., is chief of Ophthalmology at Texas Children’s Hospital and professor of
Ophthalmology and Pediatrics at Baylor College of Medicine. He received his medical degree from
Texas Tech University School of Medicine in 1987, followed by an internship in South Carolina and
residency at the Storm Eye Institute at the Medical University
of South Carolina. He completed a fellowship in Pediatric
Ophthalmology and Adult Strabismus at Indiana University
in Indianapolis, Indiana in 1994 and joined the staff at Baylor
College of Medicine in 1996. Dr. Coats is president of the
Texas Ophthalmologic Association.
To view more Ophthalmology Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
39
OPHTHALMOLOGY
Orthopaedics
The Orthopaedics Division at Texas Children’s Hospital
Main Campus and West Campus has extensive expertise
in treatment of all types of bone, neuromuscular and spine
disorders and injuries. Consistently ranked by U.S.News & World Report as a leading
orthopaedic center for children, we treat a variety of orthopaedic injuries and conditions,
from minor fractures to complex problems. More than fifty percent of the surgical procedures
completed in Texas Children’s Level 1 Trauma Center in 2012 were orthopaedic-related.
40
O R T H O PA E D I C S
Our surgeons work closely with experienced advanced practice providers in order to give the
highest level of patient care in the clinic and operating rooms. These advanced practice providers
receive six months of pediatric-orthopaedic-specific training at Texas Children’s and are closely
supervised by Orthopaedic Division faculty. Additionally, a high-tech digital imaging system allows
instant consultation with a physician when needed. Our comprehensive support team also includes
physical and occupational therapists, orthopaedic technicians, social workers and child life specialists.
Nationally renowned leader in the field of pediatric orthopaedics Howard R. Epps, M.D. joined
Texas Children’s Hospital in 2012 as the medical director of pediatric orthopaedic surgery. His
clinical interests include limb deformity and reconstruction, fractures, clubfoot, musculoskeletal
infection and cerebral palsy, which have led him to author more than 35 book chapters and
publications in various academic and medical journals. He currently serves as the chairman of the
research and education committee for Texas Orthopaedic Association, and recently served as
president of Houston Orthopaedic Society.
In August 2013, Texas Children’s Hospital West Campus opened its comprehensive
sports medicine center dedicated to treating children for all types of sports-related
injuries and disorders. The new program, started in 2012, provides comprehensive
and convenient sports medicine care and uses an interdisciplinary approach for the
diagnosis, evaluation and treatment of children and adolescents from the physically
active individual to the pediatric and adolescent athlete.
O R T H O PA E D I C S
MRI FINDINGS IN ADOLESCENT PATIENTS WITH ACUTE
TRAUMATIC KNEE HEMARTHROSIS
Physical examination may be inconclusive in adolescents presenting with an acute traumatic knee
effusion because of pain and guarding. The Orthopaedics Division recently participated in a study14
to describe the magnetic resonance imaging (MRI) findings in adolescents with traumatic knee
effusions and to compare injuries based on age, sex and physeal maturity.
Total patients
131 with acute knee effusion
Date range
2 year period
Age
Younger group: 10 – 14 years (59 patients)
Older group: 15 – 18 years (72 patients)
Pathology
Confirmed using clinical history, MRI and available
surgical reports
Most common injuries15
Injury
Younger group
Patellar dislocations
36%
Anterior cruciate
22%
ligament (ACL) tears
Isolated meniscus tears 15%
Most common injuries
by gender
Injury
Patients who underwent surgery
41
ACL tears
Patellar dislocations
Males
28%
28%
Older group
28%
40%
13%
Females
38%
37%
CONCLUSIONS
Patellar dislocation is a common injury in children who present with a traumatic knee effusion,
especially in young adolescents and females. Adolescents presenting with a traumatic knee
effusion should undergo MRI because of the high rate of positive findings missed by physical
examination and plain radiographs that may warrant surgical repair or reconstruction.
bbasi D, May MM, Wall EJ, Chan G, Parikh SN. MRI findings in adolescent patients with acute traumatic knee
A
hemarthrosis. J Pediatr Orthop. 2012 Dec; 32(8):760-4.
There was a trend toward adolescents with active growth plates sustaining more patellar dislocations and adolescents
with closed growth plates sustaining more ACL injuries.
14
15
41
42
O R T H O PA E D I C S
EPIDEMIOLOGY AND PATHOGENESIS OF DEVELOPMENTAL
DYSPLASIA OF THE HIP
Developmental dysplasia of the hip (DDH) describes a spectrum of conditions related to the
development of the hip in infants and young children. It encompasses abnormal development
of the acetabulum and proximal femur and mechanical instability of the hip joint. Typical DDH,
which generally occurs in otherwise healthy infants, was the focus of a prospective study16 by
the Orthopaedics Division.
Total patients
9,030 (18,060 hips)
Date of initial screening
1 – 3 days of life.
Abnormalities
Detected in 995 hips.
Date of second screening
2 – 6 weeks of life with no interval treatment.
Abnormalities
Detected in 90 hips.
Improvement over time
90%
Affected hip
Both hips are involved in 20% of patients. Among the
unilateral cases, the left hip is affected more often
than the right.
Incidence of DDH by sex
2 – 3 times more common in females.
Breech presentation
The absolute risk of DDH is estimated to be 12% in
breech girls and 2.6% in breech boys.
Family history
The absolute risk of DDH in infants with a positive
family history is estimated to be 4.4% in girls and
0.9% in boys.
The risk of recurrence in subsequent children was 6%
when there was one affected child, 12% when there
was one affected parent and 36% when there was
an affected parent and an affected child.
Incidence of DDH by race
Increased in Lapp and Native American populations.
Decreased in African and Asian populations.
Rosenfeld SR. Epidemiology and pathogenesis of developmental dysplasia of the hip. UpToDate. Waltham, MA. 2012.
16
O R T H O PA E D I C S
CONCLUSIONS
The incidence of DDH depends upon the definition, the method of detection, and the age of
the child at the time of examination.
The incidence of true dislocation is estimated to be one to two per 1,000 newborn infants.
Large studies with ultrasonographic screening suggest that up to 40 percent of newborns have
laxity or immaturity, but 90 percent of these improve spontaneously.
Risk factors for DDH include female sex, breech presentation and other conditions associated
with limited fetal mobility, and family history. However, most patients who are diagnosed with
DDH are without risk factors.
DDH has a multifactorial pathogenesis. Ligamentous laxity predisposes the developing hip to
mechanical forces that cause eccentric contact between the femoral head and the acetabulum.
Abnormal contact results in abnormal development.
ORTHOPAEDICS OPERATING ROOM CASES
TEXAS CHILDREN’S HOSPITAL
2 ,222
382
1,840
2 ,093
2010
1,998
1,844
2009
95
1,918
by year
2011
2012
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
43
O R T H O PA E D I C S
11,101
4,260
4,774
131
3,649
7,160
12,429
11,508
16,352
19,417
by year
23,035
ORTHOPAEDICS CLINIC VISITS
3,792
44
2010
2011
2012
TEXAS CHILDREN’S HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
WILLIAM A. PHILLIPS, M.D., is chief of Orthopaedics at Texas Children’s Hospital and
professor of Orthopaedic Surgery and Pediatrics at Baylor College of Medicine. He graduated
from Notre Dame and received his medical degree from the University of Chicago Pritzker
School of Medicine. Dr. Phillips is a member of the American
Academy of Orthopaedic Surgeons (Fellow), American Academy
of Pediatrics (Fellow), American Orthopaedic Association,
Scoliosis Research Society (Fellow), Pediatric Orthopaedic Society
of North America and the American College of Surgeons. Dr.
Phillips travels around the country lecturing on back problems in
children and other orthopaedic issues to primary care physicians.
To view more Orthopaedic Division biographies, visit
texaschildrens.org/Locate/Find-a-Doctor.
45
OTO L A RY N G O L O G Y
Otolaryngology
The Otolaryngology Division at Texas Children’s Hospital
provides advanced surgical and medical care for the entire
spectrum of ear, nose, throat, and head and neck diseases
and disorders at Main Campus, West Campus and our
Health Centers. In addition to complex procedures, the fellowship-trained
physicians in the division complete a high number of more common surgeries such
as tonsillectomies and insertion of ear tubes. Over half of surgeries done each year
are to address these routine problems. State-of-the-art audiology and speech
diagnostic and therapeutic services are also offered.
46
OTO L A RY N G O L O G Y
Our multidisciplinary clinics bring together top specialists from across the hospital. In particular,
the Aerodigestive Disease Clinic brings together physicians from gastroenterology and pulmonary
medicine to treat patients with complex breathing, swallowing and eating issues. The Voice and
Swallowing Clinic uses a collaborative approach to evaluate, diagnose and treat patients with
disorders involving swallowing and vocalization. Other team members include specialists from
audiology, speech, language and learning.
Several of our physicians won prestigious awards in 2012:
• Julina Ongkasuwan, M.D., received a Thrasher Research Early Career award for her work on the
assessment of vocal fold function in the pediatric cardiovascular intensive care unit. Her goal
was to determine the feasibility and compare the accuracy of ultrasound to flexible scope in
identifying problems with vocal fold mobility, as well as to identify what happens to children’s
pulse, blood pressure and oxygenation during exams.
•M
ary Frances Musso, D.O., received a seed grant from Texas Children’s Hospital to further her
study pediatric obstructive sleep apnea (OSA). Using magnetic resonance imaging (MRI), the
goal of the study is to characterize structural brain changes in children with OSA in comparison
to control children. Preliminary results show that intermittent hypoxemia can alter brain
morphology in patients with severe OSA. Currently no impairment of overall cognitive function
has been noted.
• Deidre Larrier, M.D., won a Fulbright and Jaworski award for excellence in teaching as the
medical student coordinator, director of residency training, and simulation instructor at Baylor
College of Medicine. She ran simulation workshops jointly with the department of Anesthesia
to teach critical airway management to residents and fellows using mannequins prior to the real
life experience. In addition, she worked with a Rice University undergraduate team to develop
a simulation model for the study of peritonsillar abscesses, the drainage of which is a commonly
performed procedure on awake pediatric patients.
OTO L A RY N G O L O G Y
JUVENILE RECURRENT RESPIRATORY PAPILLOMA
The Otolaryngology Division recently completed a retrospective case review17 analyzing the
patterns of surgical frequency in pediatric patients undergoing surgery with CO(2) laser ablation
for juvenile onset recurrent respiratory papillomatosis (JORRP). The hypothesis is that over time,
there is a high variability in surgical frequency independent of the use of an adjuvant therapy.
Total patients
20
Date range
11 years
Rate of procedures findings
5 patients (25%) had a constant rate of procedures
3 patients (15%) had a continual decrease in the
surgical rate
1 patient (5%) had a continual increase in the
surgical rate
11 patients (55%) had a fluctuation in the pattern
of their recurrences
Common determinants on
when to repeat intervention
Standard set interval
Previous operative findings
Previous interval
CONCLUSION
The natural fluctuation in intersurgical intervals without the use of any adjuvant therapy
confounds the use of intersurgical interval as an outcome measure for the success of adjuvant
therapy. Accelerations and decelerations were noted but cannot be explained.
THE ROLE OF DIRECT LARYNGOSCOPY AND BRONCHOSCOPY
IN HOSPITALIZED CROUP
The purpose of this retrospective chart analysis study18 was to review our experience at
Texas Children’s Hospital with direct laryngoscopy and bronchoscopy (DL&B) in patients with
hospitalized croup. We investigated the frequency of viral versus bacterial hospitalized croup, the
epidemiological characteristics of hospitalized croup and the efficacy of applying operative direct
laryngoscopy and bronchoscopy in the detection of other significant respiratory pathology in
certain groups of hospitalized patients.
One of the risks of DL&B is the potential of worsening the respiratory status. Not only is there
the exposure to general anesthesia, but also instrumentation of an already swollen subglottis can
cause further edema. The benefits of diagnosing bacterial tracheitis (and thus changing medical
management) are generally thought to outweigh the risks of worsening the respiratory status if
the patient has viral croup.
Ongkasuwan J, Friedman EM. Juvenile recurrent respiratory papilloma: variable intersurgical intervals. Laryngoscope.
2012 Dec; 122(12):2844-9. Epub 2012 Jul 30.
18
Hede S, Ongkasuwan J. The role of direct laryngoscopy and bronchoscopy in hospitalized croup. Poster presentation at
the Academy of Otolaryngology Head and Neck Surgery Annual Meeting Washington D.C. 2012 Sept.
17
47
48
OTO L A RY N G O L O G Y
Total patients
338
Viral croup
Male – 222 (69.2%)
Female – 99 (30.8%)
Bacterial croup
Male – 11 (64.7%)
Female – 6 (35.3%)
Age
Viral croup
16.8 mo (1.5 mo – 9 yr)
Bacterial croup
31.5 mo (7 mo – 10 yr)
Date range
September 2003 – December 2011
Exclusions
Patients with tracheostomy, epiglottitis and
non-respiratory complications (UTI etc.)
Days of symptoms
before admission
Viral croup
2.21 days (0 – 14 days)
Oxygen saturation (SO2)
> 96% on room air
Fever
Defined as > 100.4 degrees F
Respiratory (RR) and
heart rate (HR)
Based on normative values for age19
Length of stay
Viral croup
2.35 days (0 – 21 days)
Associated diagnoses
Level of care on admission
Bacterial croup
4.65 days (1 – 14 days)
Bacterial croup
5.41 days (1 – 14 days)
Viral croup
URI
Pneumonia
Otitis media
Down syndrome
GERD
42 (12%)
14 (4%)
22 (6.3%)
8 (2.3%)
22 (6.3%)
Floor
PICU/PCU/ICU
214 (66.7%)
107 (33.3%)
Viral croup
Bacterial croup
2 (10.5%)
2 (10.5%)
0 (0%)
0 (0%)
1 (5.3%)
Bacterial croup
8 (47.1%)
9 (52.9%)
hun, Robert, Preciado, Diego, Zalzal, George and Shah, Rahul. Utility of bronchoscopy for recurrent croup. Annals of
C
Otology, Rhinology & Laryngology, 118 (7): 495-499, 2009.
19
OTO L A RY N G O L O G Y
LABORATORY FINDINGS
Medical management alone
DL&B
Bacterial culture
Yes
No
10 (3.2%, + in 90%)
303 (96.8%)
10 (40%, + in 80%)
15 (60%)
Viral culture
Yes
Parainfluenza 1, 2
Flu A/B
RSV
Negative
Pending
EBV / CMV / Other
No
31 (9.9%)
12 (3.8%)
6 (1.9%)
16 (5.1%)
11 (3.5%)
5 (1.6%)
232 (74.2%)
2 (8%)
2 (8%)
2 (8%)
6 (24%)
0 (0%)
1 (4%)
12 (48%)
Blood culture
Yes
No
27 (8.6%, + in 11.1%)
283 (90.4%)
3 (12%, + in 33%)
22 (88%)
CONCLUSIONS
Mild airway anomalies are common in children who are hospitalized for croup and are
undergoing DL&B. Nevertheless, significant findings on DL&B do occur and when detected,
often prevent life-threatening complications.
Of the 25 patients who underwent DL&B, eight patients had bacterial findings and five
patients had other significant airway findings. Seventeen patients in total were diagnosed
with bacterial croup.
Tachypnea, older age and onset of symptoms on admission were found to be statistically
significant signs in distinguishing bacterial croup from viral croup.
Thus, together with a thorough clinical history, DL&B can be used effectively to detect and
manage severe manifestations and complications of these patients.
49
OTO L A RY N G O L O G Y
2009
7,660
8,397
2011
2010
TEXAS CHILDREN’S HOSPITAL
1,743
890
7,507
8,329
7, 521
by year
9,403
OTOLARYNGOLOGY OPERATING ROOM CASES
2012
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
15,239
2010
2011
3,339
4,185
9,829
2,787 2,623
564
11,214
14, 562
by year
11,135
OTOLARYNGOLOGY CLINIC VISITS
18,659
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
2,784
50
2012
TEXAS CHILDREN’S HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
OTO L A RY N G O L O G Y
ELLEN FRIEDMAN, M.D. Since 1991, Dr. Friedman has served as chief of Otolaryngology at
Texas Children’s Hospital and since 2009, she has held the Bobby Alford Department Chair
in Pediatric Otolaryngology at Baylor College of Medicine. Prior to that, she had hospital
appointments at Boston Children’s Hospital and Harvard Medical School. Dr. Friedman is on the
editorial boards of a number of professional journals and has been president of the American
Broncho-Esophagological Association and the American Society of Pediatric Otolaryngology. She is
currently serving as director of the American Board of Otolaryngology - Head and Neck Surgery,
is a representative for Otolaryngology for the Residency Review Committee, is on the advisory
council for the American College of Surgeons and is president of the medical staff at Texas
Children’s Hospital.
Among many professional honors, she was named the 2010 recipient of the Arnold P. Gold
Foundation Award for Humanism in Medicine, which honors compassion and empathy in the
delivery of patient care. Just recently, Dr. Friedman was recognized by the Baylor College of
Medicine Academy of Distinguished Educators with the Fulbright
and Jaworski Faculty Excellence Award in Teaching and Evaluation.
Dr. Friedman stepped down from her position as chief of
otolaryngology in the fall of 2013. David E. Wesson, M.D. is
currently interim chief. For more information on Dr. Wesson,
please see page 94.
To view more Otolaryngology Division biographies, visit
texaschildrens.org/Locate/Find-a-Doctor.
51
52
OTO L A RY N G O L O G Y
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
Pediatric and Adolescent Gynecology
One of the few established programs for surgical treatment of
pediatric and adolescent gynecologic disorders in the United
States and the only such program in Texas, the Pediatric and Adolescent
Gynecology Division at Texas Children’s Hospital is committed to providing the highest level
of clinical care, research and education. Part of the Obstetrics and Gynecology Department at
Baylor College of Medicine and Texas Children’s Hospital, we offer personalized treatment for
common and rare gynecological problems in patients ranging from newborns to 21 years old.
Specialties include vaginal trauma, congenital anomalies and adnexal cysts or masses. Additionally,
we operate one of the few fellowship programs in the United States and Canada for pediatric
and adolescent gynecology.
As an international referral center, the Pediatric and Adolescent Gynecology Division treats a
large population of young women with congenital anomalies of the MГјllerian ducts, which result
in malformation of the uterus and/or vagina. Depending on the disorder, surgical and nonsurgical
treatments as well as counseling are offered to help patients and their families cope with the
diagnosis and possible future fertility issues.
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
VAGINAL PULL THROUGH PROCEDURES FOR DISTAL VAGINAL ATRESIA
Distal vaginal atresia (VA) is a rare MГјllerian anomaly that presents at puberty with
hematometrocolpos (HMC). A vaginal pull through (VPT) can relieve obstruction via anastomosis
of the vaginal mucosa to the perineum. Recently the Pediatric and Adolescent Gynecology
Division completed a retrospective chart review20 on the postoperative course and complications
after VPT.
Total surgical cases
16
Patients with HMC
100%
Date range
July 2007 – January 2012
Mean age
12.9 years (В±1.5)
Average distance to level
of obstruction
1.84 cm (В±1.2)
2 patients had obstructions at > 3 cm with soft inflatable
stents placed postoperatively. Both patients experienced
stricture formation requiring adilation procedure.
When the > 3 cm group was compared to the < 3 cm
group, there was no statistical difference in age,
preoperative HMC, postoperative course or
postoperative vaginal diameter.
Average postoperative
duration of follow up
63 weeks (В±48)
Minor complications
Vaginitis – 4 patients (25%)
Urinary tract infection – 1 patient (6.25%)
CONCLUSIONS
Distal vaginal atresia is managed with a vaginal pull through.
Patients with HMC that extend > 3 cm from the perineum are at increased risk for vaginal
stricture formation and should be followed. Strictures can be easily managed with vaginal
dilation. Other complications are infrequent and minor.
20
ansouri, R, Dietrich, JE. Postoperative course and complications after vaginal pull through procedures for distal vaginal
M
atresia. Journal of Pediatric and Adolescent Gynecology, Vol. 26, Issue 2. April 2013, pp. e48.
53
54
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
LABIAL ADHESIONS AND OUTCOMES OF OFFICE MANAGEMENT
Labial adhesions (LA) are a relatively common complaint seen in the pediatric population. The
hypoestrogenic state seen in prepubertal patients is believed to play a main role; therefore
topical estrogen is the initial treatment of choice. Jennifer Dietrich, M.D., chief of Pediatric and
Adolescent Gynecology at Texas Children’s Hospital, recently participated in a study21 to evaluate
the clinical outcomes of patients with LA in a single institution. The study also examined the
possible association between severity of LA (single versus multiple treatment) and conditions
exacerbated by allergies, including lichen sclerosis (LS), asthma or eczema (ECZ).
Total patients
50
Date range
July 2006 – June 2011
Race
48% Caucasian
Symptomatic at presentation
62%
Topical treatment
100% of patients received estrogen cream
• Single treatment – 26%
• Multiple treatments, including topical steroids – 74%
Severe agglutination
Patients in the multiple treatment group were more
likely to be severely agglutinated (31% vs. 65% P = 0.05)
and were slightly more likely to need a manual
separation after failed topical treatment with
progressive agglutination
Prevalence of asthma,
LS and ECZ
9.8%, 7.8% and 3.9% respectively
No association between the presence and requirement
for one versus multiple treatments
Both asthma (N=4; 14.3%) and LS (N=2; 7.1%) were
more common among the severe than the less agglutinated
group (N=1; 4.5% and N=0; 0% respectively)
No difference in the frequency of ECZ was seen in
either group
CONCLUSIONS
Severe agglutination tends to be associated with a higher likelihood of requiring multiple
treatments and manual separation.
Patients requiring multiple treatments were no more likely than patients responding to single
treatments to have a concurrent diagnosis of asthma, LS or ECZ.
Both asthma and LS appeared to increase with severity of agglutination. However, future larger
studies are needed to confirm these associations.
21
Granada C, Sokkary N, Sangi-Haghpeykar H, Dietrich JE. Labial adhesions and outcomes of office management. Journal
of Pediatric and Adolescent Gynecology, Vol. 26, Issue 2. April 2013, pp e62-e63.
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
LAPAROSCOPIC OUTCOMES FOR PELVIC PATHOLOGY IN CHILDREN
AND ADOLESCENTS
The use of minimally invasive techniques to treat pelvic pathology in female children and
adolescents has increasingly become the standard of care due to faster recovery times, decreased
postoperative pain, and superior cosmetic results. The objectives of this study22 were to evaluate
the surgical indications, outcomes and most common pathologies of premenarchal (PMF) and
menarchal females (MF) undergoing laparoscopic surgery.
Total cases
158
Date range of surgical procedure
July 2007 – January 2012
Mean age
8.6 years (В±3.2) PMF
14.7 years (В±2.3) MF
Surgical indications
Abdominal pain
Congenital anomaly
Solid mass
Ovarian cyst
Paratubal cyst
Ovarian and
paratubal cyst
Procedure
Premenarchal
(N=33)
6 (18.2%)
4 (12.1%)
0 (0%)
13 (39.4%)
8 (24.2%)
2 (6.1%)
Menarchal
(N=125)
15 (12%)
14 (11.2%)
1 (0.8%)
38 (30.4%)
55 (44%)
2 (1.6%)
Diagnostic laparoscopy followed by operative
laparoscopy (75.8% PMF, 59.2% MF)
EBL was recorded as < 20 mL among 91% of PMFs
compared to 81% among MFs
The Hasson trocar was used for entry in the
vast majority of cases (87.8% PMF, 87.2% MF)
and the harmonic scalpel was used commonly
for dissection (75.8% PMF, 89.6% MF)
Anesthesia times were not statistically different
between groups (mean=134 minutes PMF,
mean=123, minutes MF, p=0.09)
22
Complications
0 PMF, 2 MF
Two complications were handled intraoperatively with
no observable effect on hospital course or follow-up
Adnexal torsion
66.7% PMF, 42.8% MF
Same day postoperative
discharge
39.4% PMF, 62.4% MF
Mean length of stay
1.0 days PMF, 1.4 days MF
Outcomes
Follow-up (6 weeks) Premenarchal Menarchal
ieger M, Santos XM, Sangi-Haghpeyker H, Bercaw JL, Dietrich JE. Laparoscopic outcomes for pelvic pathology in
R
children and adolescents. Journal of Pediatric and Adolescent Gynecology, Vol. 26, Issue 2. April 2013, pp e65-e66.
55
56
P E D I AT R I C A N D A D O L E S C E N T
Anesthesia times were not statistically different
between groups (mean=134 minutes PMF,
G Y N E C O L O Gmean=123,
Y
minutes MF, p=0.09)
Complications
0 PMF, 2 MF
Two complications were handled intraoperatively with
LAPAROSCOPIC OUTCOMES FOR PELVIC
PATHOLOGY
CHILDREN
no observable
effect onIN
hospital
course or follow-up
AND ADOLESCENTS continued
Adnexal torsion
66.7% PMF, 42.8% MF
Same day postoperative
discharge
39.4% PMF, 62.4% MF
Mean length of stay
1.0 days PMF, 1.4 days MF
Outcomes
Follow-up (6 weeks) Premenarchal Menarchal
(N=33)
(N=125)
Wound-related
complications
Nausea and vomiting
or constipation
Urinary tract infection
No concerns
Other
3 (9.1%)
5 (4%)
1 (3%)
1 (3%))
24 (72.7%)
4 (12.1%)
8 (6.4%)
1 (.8%)
98 (78.4%)
12 (9.6%)
CONCLUSIONS
Minimally invasive surgical techniques represent a safe and well-tolerated method for treating
pelvic pathology in children and adolescent females.
For physicians evaluating premenarchal females with acute-onset abdominal pain, ovarian
torsion should be prominent among the differential diagnoses.
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
PEDIATRIC AND ADOLESCENT GYNECOLOGY OPERATING ROOM CASES
187
2009
188
177
226
by year
2010
2011
2012
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
PEDIATRIC AND ADOLESCENT GYNECOLOGY CLINIC VISITS
4,230
4,339
145
2010
2011
647 667
4,036
158
3,368
5, 544
by year
2012
TEXAS CHILDREN’S HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
57
58
P E D I AT R I C A N D A D O L E S C E N T G Y N E C O L O G Y
JENNIFER E. DIETRICH, M.D., M.SC ., is chief of Pediatric and Adolescent Gynecology at
Texas Children’s Hospital and an associate professor in the Department of Obstetrics and
Gynecology and the Department of Pediatrics at Baylor College of Medicine. She is also the
division director of Pediatric and Adolescent Gynecology, the fellowship director for Pediatric
and Adolescent Gynecology and the CME director for the Department of Obstetrics and
Gynecology at Baylor College of Medicine. She obtained her medical degree from the Medical
College of Wisconsin in Milwaukee and completed her residency in obstetrics and gynecology
at Baylor College of Medicine. She went on to complete fellowship training in pediatric and
adolescent gynecology at the University of Louisville in Kentucky.
During her fellowship, she also obtained a masters degree in
public health and clinical investigation. Dr. Dietrich is currently
on the editorial board of the Journal of Pediatric and Adolescent
Gynecology and was recently elected to the Board of the
North American Society for Pediatric and Adolescent
Gynecology (NASPAG).
To view more Pediatric and Adolescent Gynocology biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
59
Pediatric General Surgery
The Pediatric General Surgery Division at Texas Children’s
Hospital has the depth of expertise and specialization to
provide optimal care across the surgical spectrum – from the most
routine cases to those that are rare and complex. Each child receives personalized care from the
physician most suited to the case, ensuring the best possible outcomes.
The range of surgical procedures performed by the division include but are not limited to fetal
surgery, abdominal and thoracic surgery, minimally invasive surgery, including laparoscopic and
thorascoscopic diagnosis and treatment, endocrine and biliary surgery and adolescent
metabolic surgery.
Our research programs are supported by the National Institutes of Health (NIH), Cancer
Prevention Research Institute of Texas (CPRIT), private foundations, Texas Children’s Hospital
and Baylor College of Medicine.
60
P E D I AT R I C G E N E R A L S U R G E RY
SURGICAL ONCOLOGY PROGRAM
Partnering with Texas Children’s Cancer Center, one of the largest pediatric cancer centers
in the country, the Surgical Oncology Program within the Pediatric General Surgery Division
performs over 500 operations for the care of children with solid tumors each year. Led by Jed
Nuchtern, M.D., the team includes Eugene Kim, M.D., and Sanjeev Vasudevan, M.D., all three of
whom have extensive experience in pediatric surgical oncology. Because of the volume of patients
and dedication of these surgeons to this particular population, we are able to achieve outcomes
among the best in the nation.
Pediatric Surgical Oncology has an active research program; all three physicians on the team are
studying neuroblastoma in their own basic science labs. They are also engaged in clinical research
on neuroblastoma, Wilms tumors and hepatoblastoma, as well as leading a multidisciplinary study
with oncology, radiology and pathology to determine how the number of cycles of chemotherapy
prior to surgery affect patient outcomes.
Pediatric General Surgery recently participated in a study with the Trauma
Services Division to analyze the importance of surgeon involvement in the
evaluation of non-accidental trauma patients. For more information and the
results of this study, please see page 90.
FETAL ENDOSCOPIC TRACHEAL OCCLUSION
A multidisciplinary team from Texas Children’s Fetal Center completed two successful in utero
fetal interventions to treat Congenital Diaphragmatic Hernia (CDH) in 2012. These are the only
documented cases in the southwestern United States where endoscopic tracheal occlusion has
been used to care for fetuses with severe CDH in utero. The minimally invasive and reversible
fetoscopic tracheal occlusion procedure involves placing a small balloon into the fetus to plug the
trachea. The intervention improves fetal lung growth as a result of successful �plugging/unplugging’
of the trachea, and can considerably alter the outcome of patients diagnosed with CDH. The
balloon is left in place to inflate the lungs over the next several weeks and later removed by a
similar procedure weeks before the anticipated delivery.
While still in the experimental stages, this in utero tracheal occlusion procedure is reserved for
babies with severe diaphragmatic hernia, and some of these devices require special permission
from the FDA. Texas Children’s Hospital is one of the few centers in the United States that has
been given such permission. It is an exciting advancement and provides new hope for future
CDH patients.
P E D I AT R I C G E N E R A L S U R G E RY
LENGTH OF STAY FOR PEDIATRIC ACUTE APPENDICITIS
The Texas Children’s Hospital evidence-based guideline for the treatment of simple, uncomplicated
appendicitis features no antibiotics after surgery and attention to pain control. We recently
evaluated our institutional outcomes for children with simple appendicitis and noted that the
mean postoperative length of stay (LOS) was 1.6 days. We then developed and implemented a
quality improvement initiative consisting of a postoperative order set and patient educational
material in order to decrease the postoperative LOS. The purpose of this study23 was to assess
the efficacy of our intervention in decreasing postoperative length of stay and to identify barriers
to its intended utilization.
Date range
Pre-implementation: January 2012 – September 2012
Transition: October 2012 – December 2012
Post-implementation: January 2013 – March 2013
Intervention
Nursing-driven postoperative order set
Early mobilization
Oral pain medication
Early transition to regular diet
Rapid assessment for discharge
Family education pamphlet
Clinical characteristics
PreTransition
implementation
(n = 470)
(n = 91)
Age
Gender-Female
Race-Hispanic
BMI
11.1В±3.5
36.7%
57.6%
20.6В±4.9
11.0В±3.8
42.9%
59.3%
21.6В±6.1
Postp-value
implementation
(n = 189)
11.2В±3.5
38.4%
61.7%
20.4В±5.3
ER visit and
readmission rates
0% increase after protocol implementation
Mean postoperative LOS
12.7% decreased (28.4 to 24.8 hours)
0.93
0.53
0.63
0.39
Barriers to early discharge
IV antibiotic therapy (3.2%)
in post-intervention patients Inability to tolerate PO (2.1%)
with LOS > 36 hours
Persistent fever (2.1%)
CONCLUSIONS
A fast-track, nursing-driven order set and family educational pamphlet effectively reduce
postoperative LOS and its variation in children with simple appendicitis.
This effect seemed to plateau toward the end of the post-intervention period.
Other process improvement initiatives featuring streamlined patient flow to a dedicated
hospital unit may decrease postoperative LOS in this patient population.
Fallon SC, Zhang W, Kim ME, Hallmark CA, Carberry KE, Nuchtern JG, Rodriguez JR, Wesson DE, Brandt ML, Lopez ME.
Decreasing hospital length of stay in pediatric acute appendicitis: a prospective interrupted time series study. Poster
presentation at AAP. October 2013.
23
61
62
P E D I AT R I C G E N E R A L S U R G E RY
RESOURCE UTILIZATION AFTER GASTROSTOMY TUBE PLACEMENT
Gastrostomy tube (GT) placement is a frequent procedure at a tertiary care children’s hospital.
Due to underlying patient illness and the nature of the device, patients often require multiple
visits to the emergency room for GT-related concerns. The purpose of this study24 was to
characterize the incidence and indication for GT-related emergency room visits and readmission
rates in order to develop family educational material that may allow for these nonurgent concerns
to be addressed on an outpatient basis.
Total patients
247
Date range
January 2011 - September 2012
Median age
15.3 months (range 0.03 months – 22 years)
Purpose of ER visits
Categorized as either mechanical (dislodgement, leaking)
or wound-related (infection, granulation tissue)
Primary outcome of
ER visits
< 30 days after discharge and 30 – 365 days after discharge
Additional outcomes
assessed
Readmission rates, reoperation rates, and the use of
gastrostomy contrast studies
Discharge
219 patients (89%) were discharged
< 30 days post operation
• Of these, 20% (42/219) returned to the emergency room
44 total times within 30 days of discharge for concerns
related to their tube
• Avoidable visits related to leaking, mild clogs, and
granulation tissue were seen in 39% (17/44)
An additional 40 patients (16%, 40/247) presented to the ER
a total of 71 times 31 – 365 days post-discharge; the majority
of these visits were potentially avoidable (83%, 59/71)
Readmission rates related
to the gastrostomy tube
4%
CONCLUSIONS
Few studies have attempted to quantify the amount of postoperative resources utilized
postgastrostomy tube placement in children, and our findings indicated this is not an
insignificant quantity.
In response to these findings, we have developed a series of educational materials and
identified a dedicated nurse to perform inpatient gastrostomy education to these patients.
Correa JA, Fallon SC, Murphy KP, Victorian VA, Bisset GS, Vasudevan SA, Lopez ME, Brandt ML, Cass DL, Rodriguez JR,
Wesson DE, Lee TC. Resource utilization after gastrostomy tube placement: defining areas of improvement for future
quality improvement projects. Study is currently being drafted for submission.
24
P E D I AT R I C G E N E R A L S U R G E RY
PEDIATRIC SNAKEBITE MANAGEMENT
The optimal management of children with snakebite injuries is not well defined. There are
significant variations in practice as the benefits of interventions are unclear. The Pediatric General
Surgery Division recently reviewed25 practice patterns and outcomes at Texas Children’s Hospital,
a tertiary care hospital with a level I trauma center. Our goal was to determine the utility of
antivenom, labs and antibiotics, then use the findings to develop a clinical algorithm.
Total patients
151
Date range
2006 - 2012
Mean age
8.4В±4.3 years
• Males: 66% (n=99)
• Females: 34% (n=52)
Median length of stay
2 days (range 1 – 7 days)
Pediatric wound scale
9% class 1 – patients with minor injuries such as puncture
marks only, or skin abrasion
33% class 2 – moderate injury, puncture marks and cellulitis
or ecchymosis localized to the puncture marks
48% class 3 – class 2 findings with spreading erythema,
induration or purulent material without necrosis
10% class 4 – class 3 findings, tissue necrosis and significant
systemic symptoms irrespective of local findings
25
Injuries
60% (n=91) lower extremity
38% (n=58) upper extremity
Median number of
antivenom vials
6 (range 1-16)
orrea JA, Fallon SC, Cruz AT, Grawe GH, Vu PV, Rubalcava DM, Kaziny B, Naik-Mathuria BJ, Brandt ML. Pediatric snake
C
bite management: are we doing too much. Presented at the South Texas chapter of the American College of Surgeons
meeting. February 2013.
63
64
P E D I AT R I C G E N E R A L S U R G E RY
PEDIATRIC SNAKEBITE MANAGEMENT continued
RESOURCE UTILIZATION by wound score
Interventions
1
(n=14)
2
(n=51)
3
(n=72)
4
(n=14)
Complete blood count
64%
83%
89%
85%
Platelets <100,000
0%
0%
0%
0%
Prothrombin time (PT)/partial thromboplastin time
(PTT)/ international normalized ratio (INR)
71%
86%
93%
100%
INR > 1.5, PT > 15, PTT > 40
0%
0%
17%
43%
Intravenous antibiotics (IV ABX)
14%
39%
54%
71%
Antivenom
36%
37%
32%
36%
Labs + IV ABX + Antivenom
7%
10%
22%
21%
CONCLUSIONS
Envenomation occurs in > 75% of children bitten by a snake.
Despite this high rate of envenomation, there is little morbidity associated with snake bites
in children.
Antivenom is given to approximately one third of all children bitten by a snake, regardless of
degree of envenomation.
We have designed and are starting a prospective study to validate the Texas Children’s Hospital
Snake Bite Classification system. The next step will be to use this validated scoring system to
design a management algorithm based on wound appearance and time of injury.
P E D I AT R I C G E N E R A L S U R G E RY
PEDIATRIC GENERAL SURGERY OPERATING ROOM CASES
5, 564
2011
4,751
5,255
2010
14
432
799
4,823
5,330
5,637
by year
2009
2012
TEXAS CHILDREN’S PAVILION FOR WOMEN
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
7,839
10,613
7,819
1,798
1,886 1,567
996
2,072
379
8,231
10,682
by year
11,292
PEDIATRIC GENERAL SURGERY CLINIC VISITS
2010
2011
2012
TEXAS CHILDREN’S HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
65
66
P E D I AT R I C G E N E R A L S U R G E RY
JED G. NUCHTERN, M.D., is chief of Pediatric General Surgery at Texas Children’s Hospital
and professor of Surgery and Pediatrics at Baylor College of Medicine. He is also director of the
Pediatric Surgery Residency Program at Baylor College of Medicine. A graduate of Princeton
University, Dr. Nuchtern received his medical degree from Harvard Medical School. He completed
his general surgery training at the University of Washington and a research fellowship at the
National Institutes of Health. He received advanced training in pediatric surgery at Baylor College
of Medicine. In addition to a clinical focus on surgical oncology and general pediatric surgery,
Dr. Nuchtern conducts a basic research program that focuses
on molecular target discovery in neuroblastoma, a pediatric
cancer. Dr. Nuchtern is a fellow of the American Academy of
Pediatrics and the American College of Surgeons. He is a member
of the ACS Commission on Cancer and the Children’s Oncology
Group, national consortia of pediatric oncology clinicians and
research professionals.
To view more Pediatric General Surgery Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
67
Plastic Surgery
The Plastic Surgery Division at Texas Children’s Hospital
specializes in surgical treatment of injuries or disorders that
prevent children from functioning fully or looking and feeling
their best. We provide comprehensive care to pediatric patients with complex surgical
needs at Texas Children’s Hospital Main Campus as well as Texas Children’s Hospital West
Campus. The team includes orthodontists with whom we collaborate on surgical treatment and
on orthodontia for children with congenital craniofacial anomalies and/or cleft palate.
Our innovative surgical techniques and therapy in the treatment of cleft lip and cleft palate draw
patients from across the nation with deformities ranging from mildly disfiguring to extremely
complex. In 2012, we performed 242 cleft lip and cleft palate procedures.
68
P L A S T I C S U R G E RY
As leaders in the use of specialized surgeries, appliances and materials such as resorbing plates
and bone-mimicking adhesives, we are able to effectively treat congenital craniofacial disorders or
problems caused by injury, including facial nerve paralysis. Our use of distraction osteogenesis to
correct jaw injuries or facial development issues decreases swelling and blood loss while avoiding
wires, bone harvesting or blood transfusion.
CHANGES IN FRONTAL MORPHOLOGY AFTER SINGLE-STAGE OPEN POSTERIORMIDDLE VAULT EXPANSION FOR SAGITTAL CRANIOSYNOSTOSIS
There is controversy regarding whether the frontal bossing associated with sagittal synostosis
requires direct surgical correction or spontaneously remodels after isolated posterior cranial
expansion. Texas Children’s plastic surgeons participated in a retrospective study26 measuring
changes in frontal bone morphology in patients with isolated sagittal synostosis two years after
open posterior and midvault cranial expansion and compared these changes with those occurring
in age-comparable healthy control groups.
Total patients
43
Age range
≤ 1 year (mean, 6 months)
Frontal bossing
The majority of patients at time of operation had
frontal bossing measures greater than two standard
deviations outside the age-comparable control mean.
Almost all patients were within two standard
deviations of the norm two years later.
Lateral forehead bossing and
anterior cranial growth
Greater the older the patient was at the time
of operation.
Suggesting the more time that passed before the
operation, the more compensatory anterior fossa
growth occurred.
Central forehead position relative Greater the younger the patient was at the time
to the anterior cranial base
of operation.
Suggesting a central forehead bulge was an early
compensatory response to premature sagittal fusion.
CONCLUSIONS
As a group, patients with sagittal synostosis start to normalize their forehead morphology
within two years if an isolated posterior operation is performed at one year of age or younger,
and this occurs by a combination of restriction of growth and reduction relative to patients
without synostosis.
This protocol decreases the risks of intraoperative positioning, forehead contour deformities
and two-stage operations.
26
hechoyan D, Schook C, Birgfeld CB, Khosla RK, Saltzman B, Teng CC, Ettinger R, Gruss JS, Ellenbogen R, Hopper RA.
K
Changes in frontal morphology after single-stage open posterior-middle vault expansion for sagittal craniosynostosis.
Plast Reconstr Surg. 2012 Feb;129(2):504-16.
P L A S T I C S U R G E RY
PARADIGM SHIFT IN CORRECTING MEDIAL ORBITAL
FRACTURE-RELATED ENOPHTHALMOS
Posttraumatic enophthalmos resulting from medial orbital wall fractures presents a complex
challenge. Access to this area through traditional incisions is limited, making visualization of
the fracture site difficult. This can be ameliorated by the transcaruncular approach, but with
the potential for complications both with access and with reconstructive materials. The Plastic
Surgery Division recently completed a retrospective chart review27 on a new technique where
enophthalmos correction would be based on augmenting soft tissue volume rather than reducing
the volume of the bony orbital cone. This was successfully accomplished using porous high-density
polyethylene wedges.
Three patients with postmedial orbital wall fracture enophthalmos were treated using a lateral
approach to place porous high-density polyethylene wedges; this technique adequately corrected
enophthalmos in these patients.
The authors concluded that porous high-density polyethylene wedges can be placed into the orbit
through a small lateral incision to reverse enophthalmos secondary to loss of volume after medial
orbital wall fractures. Current techniques for orbital reconstruction typically focus on reduction
of bony volume; this technique focuses on augmentation of soft tissue volume.
PLASTIC SURGERY OPERATING ROOM CASES
2010
TEXAS CHILDREN’S HOSPITAL
1,058
1,046
12
2009
11
780
791
954
848
by year
2011
2012
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
McNichols CH, Hatef DA, Thornton JF, Cole PD, de Mitchell CA, Hollier LH Jr. A paradigm shift in correcting medial
orbital fracture-related enophthalmos: volumetric augmentation through a lateral approach. J Craniofac Surg. 2012
May;23(3):762-6.
27
69
P L A S T I C S U R G E RY
PLASTIC SURGERY CLINIC VISITS
44
2 ,963
3,539
3, 583
by year
3,635
70
2010
2011
TEXAS CHILDREN’S HOSPITAL
2012
TEXAS CHILDREN’S HOSPITAL WEST C AMPUS
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor
College of Medicine faculty only.
LARRY H. HOLLIER, JR., M.D., F.A.C .S., is chief of Plastic Surgery at Texas Children’s
Hospital. He is also professor and residency program director of the Department of Plastic and
Reconstructive Surgery at Baylor College of Medicine. He earned his medical degree from Tulane
University and completed his plastic surgery residency at the University of Texas Southwestern
Medical Center, where he remained for fellowships in hand and microvascular surgery. He also
completed a fellowship in craniofacial surgery at New York University Medical Center. Dr. Hollier
specializes in pediatric craniofacial surgery, hand surgery, facial
fractures, cranial vault remodeling, and midfacial and mandibular
distraction. He has authored 200 articles in scholarly and
professional publications as well as 37 book chapters, and made
dozens of presentations to professional audiences worldwide on a
full range of topics related to plastic and reconstructive surgery.
To view more Plastic Surgery Division biographies, visit
texaschildrens.org/Locate/Find-a-Doctor.
71
Transplant Services
One of the most active and comprehensive pediatric
transplantation programs in the nation, Texas Children’s
Hospital Transplant Services provides complex, multifaceted
medical and surgical care for newborns to young adults in
need of heart, kidney, liver and lung transplants.
Our staff provides comprehensive, customized attention through all aspects of the transplant
process, from initial referral to hospitalization and long-term outpatient management. Our
pediatric transplant coordinators work closely with patients, families and referring physicians
to ensure the evaluation process is convenient and efficient.
72
T R A N S P L A N T S E RV I C E S
As part of one of the nation’s top pediatric hospitals, Transplant Services offers remarkable
multidisciplinary care from experts in more than 40 pediatric subspecialties. We have a dedicated
team of specialists beginning with Flor Munoz-Rivas, M.D., transplant infectious disease doctor,
Sarah Nicholas, M.D., transplant immunologist, Carlos Javier Campos Lopez, M.D., UNOS transplant
anesthesiology medical director and Laura Loftis, M.D., transplant intensive care specialist.
In addition, the transplant program has promoted several team members in the past year, including
Ross Shepherd, M.D., liver transplant medical director; Richard Link, M.D., Ph.D., living donor
transplant surgeon and George Mallory, M.D., medical director of lung transplantation. We are
also one of the few pediatric transplant programs to have dedicated teams for rheumatology,
pathology, pharmacy, intensive care and operating room nursing
Last year, Transplant Services earned a national certification from the
Centers for Medicare & Medicaid Services (CMS) for heart, liver and lung
transplants. Additionally, the hospital has been recertified by the agency
for kidney transplants.
According to the Organ Procurement and Transplant Network (OPTN), our Liver and Lung
Transplant Programs were the most active pediatric liver and lung transplant centers in the nation
in 2012. With such size and certification comes volume; transplant surgeons at Texas Children’s
Hospital completed 84 solid organ transplants last year.
Texas Children’s Hospital Transplant Services is focused on providing the highest quality of care
and is constantly discovering ways to improve patient outcomes. In 2012, the transplant program
achieved several quality improvement outcomes. One hundred percent of heart transplant
patients were discharged with appropriate steroid taper doses, 90% of kidney post-transplant
patients were vaccinated with Pneumovax, the Liver Transplant Program reduced the wait time
from evaluation to medical review board from 21 days to 11 days and the Lung Transplant
Program vaccinated 98% of its post transplant patients and 100% of its pre-transplant patients.
T R A N S P L A N T S E RV I C E S
Registries and clinical trials
Transplant Services actively participates in the Scientific Registry of Transplant Recipients
(SRTR), which supports the ongoing evaluation of the status of solid organ transplantation
in the United States:
Heart Transplant
The Heart Transplant Program participates in the Pediatric Heart Transplant Study (PHTS), whose
purposes are to establish and maintain an international, prospective, event-driven database for
heart transplantation and to use the database to encourage and stimulate basic and clinical
research in the field of pediatric heart transplantation; and PediMacs, the pediatric portion of
INTERMACS, the Interagency Registry for Mechanically Assisted Circulatory Support established
in 2005 in North America for patients who are receiving mechanical circulatory support device
therapy to treat advanced heart failure. In addition, Aamir Jeewa, M.D., is conducting a prospective
study comparing non-invasively acquired echocardiogram data to cardiac catheterization as a
predictor of rejection and/or coronary artery disease.
Kidney Transplant
The Kidney Transplant Program continues its ongoing studies of vitamin D deficiency and role
of FGF23 and Klotho in all prevalent renal transplant patients at Texas Children’s Hospital. These
studies are being led by Poyyapakkam Srivaths, M.D. and Eileen Brewer, M.D.
Liver Transplant
The Liver Transplant Program is currently studying lab-conjugated bilirubin level of 2.0 mg/dl
or greater in infants 6 months of age and younger as well as conducting a longitudinal study of
the genetic causes of cholestatic liver diseases including Alagille syndrome, progressive familial
intrahepatic cholestasis (PFIC), benign recurrent intrahepatic cholestasis (BRIC) and alpha-1
antitrypsin deficiency in children of any age. The program is also studying biliary atresia in infants
6 months of age and older. The Liver Program participates in SPLIT, the Study of Pediatric Liver
Transplant, a multi-center patient registry for children who have had a liver transplant in place,
used to collect and study outcomes data. Other studies included iWITH, the Immunosuppression
Withdrawal for Stable Pediatric Liver Transplant Recipients, which is a multi-center study
whose focus is to find out whether it is safe to slowly reduce and then completely stop the
immunosuppression drug taken by liver transplant recipients.
Lung Transplant
The Lung Transplant Program continues to be involved with a multicenter, NIH-sponsored
observational clinical study entitled, “Impact of post-transplant respiratory viral infection (RVI)
on immunity and lung transplant outcome in pediatric patients” with an accompanying mechanistic
study entitled, “Mechanisms of immune-mediated graft injury in pediatric lung transplant recipients.”
Transplant physicians and associated colleagues are also examining perceived barriers to patient
adherence after pediatric solid organ transplantation and are continuing work in assessing quality
of life before and after transplantation. Other clinical research includes a retrospective study of
complications after lung-liver transplantation in children, a retrospective and prospective study of
the complex interplay of pharmacokinetics in the first week after lung transplantation highlighting
concomitant use of voriconazole and tacrolimus and a retrospective study on the incidence and
impact of immediate post-transplant bacteremia in lung transplant recipients.
73
TRANSPLANTATIONS
11
83
HEART
15
14
2009
13
11
20
23
23
31
27
32
39
13
71
16
12
80
by organ by year
84
T R A N S P L A N T S E RV I C E S
18
74
2010
2011
2012
KIDNEY
LIVER
LUNG
Operating room case volumes include procedures performed by Texas Children’s Hospital and
Baylor College of Medicine physicians at Texas Children’s Hospital surgical locations. Of the 20
kidney transplatations completed in 2012, 11 were living donors and nine were deceased donors.
TRANSPLANTATIONS
by patient age
4%
19%
2012
28%
11%
22%
< 2 YEARS
2 TO < 8 YEARS
8 TO < 15 YEARS
15 TO 18 YEARS
> 18 YEARS
T R A N S P L A N T S E RV I C E S
ONE-YEAR PEDIATRIC TRANSPLANT PATIENT SURVIVAL RATES 28
84%
88%
94%
95%
29
99%
99%
10 0%
91%
95%
97%
Transplant occurred between 01/01/2009 and 6/30/2011. Pediatric age < 18.
29
HEART (N=32)
KIDNEY (N=12)
TEXAS CHILDREN’S HOSPITAL
LIVER (N=71)
SRTR EXPECTED
LUNG (N=29)
NATIONAL
THREE-YEAR PEDIATRIC TRANSPLANT PATIENT SURVIVAL RATES 28
64%
65%
90%
90%
29
91%
98%
10 0%
83%
86%
82%
Transplant occurred between 7/1/06 and 12/31/08. Pediatric age < 18.
29
HEART (N=34)
KIDNEY (N=22)
TEXAS CHILDREN’S HOSPITAL
LIVER (N=44)
SRTR EXPECTED
LUNG (N=22)
NATIONAL
Scientific Registry of Transplant Recipients (SRTR). Program Specific Reports. Table 11 - www.srtr.org
er the Scientific Registry of Transplant Recipients (SRTR), there are too few events to calculate statistically powerful
P
expected patient survival values for pediatric kidney and lung recipients..
28
29
75
76
T R A N S P L A N T S E RV I C E S
JOHN A. GOSS, M.D., is the medical director of Transplant Services at Texas Children’s Hospital
and surgical director of Liver Transplantation at Texas Children’s Hospital, St. Luke’s Episcopal
Hospital and the Michael E. DeBakey Veterans Affairs Medical Center. He is also professor of
Surgery and chief of the Division of Abdominal Transplantation at Baylor College of Medicine.
He received his medical degree from Creighton University in Omaha, Nebraska and completed
his residency in General Surgery at the Barnes Hospital at the Washington University School of
*
Medicine Surgical Program. Subsequently, Dr. Goss completed a two-year multi-organ transplant
fellowship in the Division of Liver and Pancreas Transplantation at the University of California
School of Medicine in Los Angeles, California, where he was
appointed assistant professor. He has been awarded the American
Surgical Career Development Award, an American Liver Foundation
Award and a Juvenile Diabetes Foundation Award for his efforts
and leadership in transplantation. Throughout his career, Dr. Goss
has performed more than 1,000 transplantation procedures.
To view more Transplant Services biographies, visit
texaschildrens.org/Locate/Find-a-Doctor.
*
77
Urology
As one of the largest groups of fellowship-trained pediatric
urologists in the United States, our physicians provide
comprehensive evaluation, diagnosis, treatment and follow-up
care to infants, children, adolescents, and young adults with
congenital and acquired disorders of the genitourinary tract.
We provide the highest quality of surgical services for all genitourinary conditions and have
specialized focus on minimally invasive, laparoscopic surgical techniques including extremely
delicate procedures in newborns and infants; anorectal malformations; urological conditions
caused by neurological problems such as spina bifida; and management of stone disease.
78
UROLOGY
In addition, we provide care for complex disorders requiring extensive surgical reconstruction
including disorders of sex development (intersex), bladder exstrophy, genital reconstruction and
complete urinary reconstruction. As part of the Minimally Invasive Surgery Program, we have
state-of-the-art treatment modalities for endoscopy, laparoscopic surgery and robotic surgery.
The Urology Division participates in a number of multidisciplinary clinics. In particular, we partner
with experts in nephrology and food and nutrition to address surgical, medical and dietary aspects
of urinary stones (calculi). The division also started the Voiding Dysfunction Clinic in 2013. This
voiding clinic provides specialized care to a large number of children with difficulties controlling
their bladder. As of April 2013, the program has already cared for 542 patients.
The Department of Urology welcomed several new clinicians in 2013 including the new chief
David Roth, M.D. Other appointments are Bruce Schlomer, M.D., Abhishek Seth, M.D., Chester
Koh, M.D., Jessica Schuh, PA and Joanna Marroquin, FNP.
The Urology Division at Texas Children’s Hospital is consistently
ranked among the top urology programs in the nation by
U.S.News & World Report.
EARLY COMPARISON OF NEPHRECTOMY OPTIONS IN CHILDREN
For pediatric patients with nonfunctioning or poorly functioning kidneys, laparoscopic
nephrectomy has been shown to be a safe, viable option to traditional open surgery, with
potential advantages of shorter hospital stays, decreased postoperative pain medication
usage and improved cosmesis. Technological advances have expanded the surgical options
for nephrectomy beyond traditional laparoscopy to robot-assisted laparoscopy and, more
recently, to laparoendoscopic single-site (LESS) surgery, which is also known as single
incision laparoscopic surgery (SILS) or “belly-button” surgery.
The Urology Division recently participated in a study30 comparing the perioperative parameters
of three minimally invasive modalities for pediatric nephrectomy: traditional laparoscopic
nephrectomy (LAP), robotic-assisted laparoscopic nephrectomy (RALN) and LESS nephrectomy,
where these parameters are compared to those of a comparable series of patients undergoing
traditional open nephrectomy (OPEN) during the same time period.
30
im PH, Patil MB, Kim SS, Dorey F, De Filippo RE, Chang AY, Hardy BE, Gill IS, Desai MM, Koh CJ. Early comparison of
K
nephrectomy options in children (open, transperitoneal laparoscopic, laparo-endoscopic single site (LESS), and robotic
surgery). BJU Int 109(6): 910-5, 2012.
UROLOGY
Total patients
69 at a single institution who underwent nephrectomies
for nonfunctioning kidneys in 72 renal units.
• 39 OPEN
• 11 LAP
• 11 RALN
• 11 LESS
Length of stay
and postoperative
pain medication
Minimally invasive modalities in children, including LESS
nephrectomy, were associated with shorter lengths of hospital
stay (P < 0.001) and decreased postoperative pain medication
usage (P < 0.001).
Surgical times
Similar surgical times were noted with LESS and the other
minimally invasive modalities (LAP and RALN) (P=0.056).
However, the minimally invasive modalities (LESS, LAP and
RALN) were associated with slightly longer surgical times
when compared with open surgery (P < 0.001).
CONCLUSIONS
The minimally invasive modalities for nephrectomy in children, including LESS nephrectomy, are
associated with shorter lengths of hospital stay and decreased postoperative pain medication
use when compared with open surgery.
LESS nephrectomy in children is associated with similar surgical times, lengths of hospital
stay and postoperative pain medication use as the other minimally invasive modalities (LAP
and RALN).
Slightly longer surgical times are noted with the minimally invasive modalities, including LESS
nephrectomy, when compared with open surgery, which may, in part, be secondary to learning
curve factors.
79
80
UROLOGY
AUGMENTATION CYSTOPLASTIES
This study31 evaluated national estimates of pediatric patients undergoing augmentation
cystoplasty (AC) in the United States for trends over the 2000s and analyzed patient and hospital
factors associated with outcomes. Patients who underwent AC in the 2000-2009 Kids’ Inpatient
Database were included and estimates of total number of ACs performed and patient and hospital
characteristics were evaluated for trends.
Total ACs performed
792 in 2000
595 in 2009
Length of stay (LOS)
10.5 days in 2000
9.2 days in 2009
AC observations included in
hierarchical models
1,622
Patients with complication
30%
Factors associated with increased
LOS and increased odds
of complication
Bladder exstrophy-epispadias complex
diagnosis (BEEC)
Total hospital charges
Children’s hospitals had 31% higher total charges
Increasing age
CONCLUSIONS
The estimated number of ACs performed on children in the U.S. decreased by 25% in the 2000s
and mean LOS decreased one day. The cause of this decrease in number is multifactorial but
could represent changing practice patterns in the U.S. Thirty percent of patients had a potential
complication during their hospital stay after AC.
Increasing age and a BEEC diagnosis were associated with an increased LOS and increased
odds of having any complication.
31
S chlomer BJ, Saperston K, Baskin L. National trends in augmentation cystoplasties in the 2000s and factors associated
with patient outcomes. J Urol. 2013 Apr 30. [Epub ahead of print]
UROLOGY
2 ,049
1,688
358
3
303
1,792
2 ,044
1,907
by year
2 ,095
UROLOGY OPERATING ROOM CASES
2009
TEXAS CHILDREN’S
PAVILION FOR WOMEN
2011
2010
TEXAS CHILDREN’S HOSPITAL
WEST C AMPUS
2012
TEXAS CHILDREN’S HOSPITAL
Operating room case volumes include procedures performed by Texas Children’s Hospital, Baylor
College of Medicine and private practice physicians at Texas Children’s Hospital surgical locations.
UROLOGY CLINIC VISITS
11,098
5,813
10,809
5,223
2,111
3,158
3,029 2,256
265
5,540
6,907
12 ,395
by year
2010
2011
2012
TEXAS CHILDREN’S
HEALTH CENTERS
TEXAS CHILDREN’S HOSPITAL
WEST C AMPUS
TEXAS CHILDREN’S HOSPITAL
Clinic visits include outpatient visits by Texas Children’s Hospital and Baylor College of Medicine
faculty only.
81
82
UROLOGY
DAVID ROTH, M.D., is chief of Urology at Texas Children’s Hospital and chief of Pediatric
Urology at Baylor College of Medicine (BCM), where he is also professor of Urology and
Pediatrics and serves as The Edmond T. Gonzales Jr., M.D., Endowed Chair in Pediatric Urology.
Board-certified by the American Board of Urology, Dr. Roth earned his medical degree from the
University of Southern California in Los Angeles. After completing his surgical residency program
at BCM in Houston, he went on to pursue specialized training in urology. He then completed a
fellowship in pediatric urology surgery at Children’s Hospital of Michigan in Detroit.
As a prominent leader in the field of pediatric urology for nearly 30 years, Dr. Roth has
distinguished himself in a variety of research, clinical and academic roles. His clinical interests
include urinary tract infection and reflux, congenital abnormalities
of the genitalia, and urinary tract obstruction of the newborn. His
primary research is directed toward improving surgical outcomes
in children with urologic disease. He has authored more than 75
book chapters and publications in various academic and medical
journals and is the recipient of numerous honors and awards,
including his recognition and inclusion on the list of Best Doctors
in America each year since 1996.
To view more Urology Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
83
Inpatient Services
Inpatient Services at Texas Children’s Hospital is a place of hope
for children with any medical need. A child may come to one of our units after
an accident, a special diagnostic procedure or a surgical procedure. All children in our units have
one thing in common – the need for specialized, pediatric-focused patient care.
84
I N PAT I E N T S E R V I C E S
ACUTE CARE SURGICAL FLOOR
The acute care surgical floor, located on the 11th floor of Texas Children’s Hospital West Tower,
is a 36-bed surgical care unit that admits patients of all ages from infancy to adolescents. The
unit receives a wide variety of postoperative surgical patients from orthopaedics, otolaryngology,
pediatric general surgery, plastic surgery and urology. We have four beds dedicated to trauma
patients, and a team of nurses that focuses solely on our trauma patient population. These beds
and trained staff have been key in nearly eliminating transfer denials for trauma patients.
CARDIOVASCULAR INTENSIVE CARE UNIT
The 21-bed Cardiovascular Intensive Care Unit (CVICU) admits newborns, infants, children
and young adults with heart disease. The CVICU cares for children undergoing surgery for
congenital heart disease, children and adolescents with end-stage heart failure before and after
heart transplantation and children whose hearts can no longer adequately support them. Our
multidisciplinary team includes cardiovascular intensivists trained in pediatric cardiology, pediatric
cardiovascular anesthesiology and pediatric critical care. They work alongside our cardiac
surgeons, highly specialized nurses, respiratory therapists, nurse practitioners and physician
assistants to provide the best care for our patients.
PEDIATRIC INTENSIVE CARE UNIT
The Pediatric Intensive Care Unit (PICU) at Texas Children’s Hospital is one of the largest
pediatric intensive care units in the nation. We care for infants and children from around the
globe and strive to give each child and family the best individualized care available. The 31-bed unit
is staffed with critical care physicians, advanced level practitioners and postgraduate fellows all
specialized exclusively in pediatric critical care. Our medical team works seamlessly with a highly
skilled multidisciplinary team of PICU nurses, respiratory therapists, pharmacists, social workers
and child life specialists to care for each patient.
PROGRESSIVE CARE UNIT
The Progressive Care Unit (PCU) is a 36-bed unit located on the 7th floor of Texas Children’s
Hospital West Tower that routinely admits patients ranging in age from infancy to adulthood. These
patients require special care nursing or monitoring requirements. Our multidisciplinary team of
advanced practice providers, physician assistants, nurses, respiratory and physical therapists care
for both acute and chronic conditions. Registered nurses coordinate all nursing care provided,
which includes therapies that may be directed by other disciplines with special emphasis given to
respiratory, neurological and surgical disorders. Many patients depend on technological support,
notably those with tracheostomies. The PCU’s family-centered approach encourages parents to
stay with their child and learn to care for their child upon their return home.
The Cardiovascular Intensive Care and Pediatric Intensive Care Units at Texas Children’s Hospital
are part of the Virtual Pediatric Intensive Care Unit (PICU) System known as VPS. This is a national
pediatric critical care data registry to which all of Texas Children’s critical care units submit data.
The registry applies a predicted mortality score – PIM 2 – for every critical care admission based
upon the child’s diagnosis and other indicators of illness on admission.
I N PAT I E N T S E R V I C E S
CVICU CASES WITH PIM 2 DATA
Total cases
Total
cases
Mortalities
2012
812
812
15
Mortalities
Mortality rate (medical and surgical patients)
15
1.85%
Mortality
(medical
Predicted rate
mortality
rateand surgical patients)
1.85%
3.51%
32
Predicted
mortality
rate
Mortality ratio
(actual/predicted)
3.51%
0.53
Mortality ratio (actual/predicted) 32
0.53
PICU CASES WITH PIM 2 DATA
Total cases
2,400
Total
cases
Mortalities
2,400
91
Mortalities
Mortality rate (medical and surgical patients)
91
3.79%
Mortality
(medical
Predicted rate
mortality
rateand surgical patients)
3.79%
3.66%
32
Predicted
mortality
rate
Mortality ratio
(actual/predicted)
3.66%
1.04
Mortality ratio (actual/predicted) 32
1.04
Compares predicted mortality using PIM 2 risk of mortality with actual mortality. A value of 1.0 indicates that actual
mortality equals predicted mortality.
32
85
86
O P E R AT I N G R O O M A N D P E R I O P E R AT I V E S E R V I C E S
Operating Room and
Perioperative Services
Designed especially for children, Operating Room (OR) and
Perioperative Services at Texas Children’s Hospital provide
comprehensive and specialized capabilities for surgeries ranging
from routine to extremely complex.
More than 25,000 procedures were completed in 30 operating rooms at five sites within Texas
Children’s Hospital, Texas Children’s Hospital West Campus and Texas Children’s Pavilion for
Women in 2012. From admission to recovery, our support team of more than 300 is driven to
ensure an optimum experience for patients and physicians.
O P E R AT I N G R O O M A N D P E R I O P E R AT I V E S E R V I C E S
Many of the surgical suites are fully equipped and integrated with endoscopic equipment including
advanced fetoscopes. Same-floor instrument processing optimizes efficiency, patient care and
safety. For specialized procedures such as fetal and heart surgery, we offer customized equipment
and specially trained support staff.
When children are too sick to be moved to an operating or procedure room, our mobile team,
which includes a fellowship-trained pediatric anesthesiologist, travels throughout the hospital to
perform bedside procedures.
Our commitment to children goes beyond equipment and expertise. Our strong child- and
family-centered focus is one reason we consistently receive patient satisfaction rates of 92% or
higher. To help ease the anxiety many children and their families feel before surgery, we offer a
“virtual OR” simulator to help explain the process. In addition, details including color-coded
pajamas and application of scents, such as bubble gum, to anesthesia masks help children relax
and feel more at ease.
To teach our surgical teams how to work together in stressful situations, build teamwork and
optimize patient safety, our Simulation Center – the only one of its kind in Houston and one of
the few in the nation – uses the latest technology to reproduce a realistic clinical setting.
Texas Children’s Pavilion for Women has opened new avenues in
surgical care. The Fetal Center relocated to the Pavilion in order
to enhance the surgical experience for women while still offering
cutting-edge surgery in utero. Fetal surgeons, neurosurgeons and
other specialists collaborate to perform surgical procedures and
correct defects in unborn babies, allowing the fetus to continue
to develop in the mother’s womb post-surgery.
87
88
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
Trauma Services and the Center for
Childhood Injury Prevention
As a crucial component of Texas Children’s Level I pediatric
trauma center, Trauma Services provides around-the-clock
coverage to evaluate and treat more than 1,200 injured patients
each year.
Teamwork is vital to the rapid and decisive actions needed to treat traumatic injuries. Our
group of pediatric general surgeons and surgical subspecialists; emergency medicine physicians;
anesthesiologists; child life specialists; social workers; physical, occupational and respiratory
therapists; and other support staff work together effectively and efficiently when seconds matter.
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
Dedicated space for trauma cases is available in the emergency center, main operating room
suite and inpatient units. Approximately 70 percent of all trauma cases come from within our
catchment area, which consists of nine counties covering more than 9,500 square miles. In
addition, 50 percent of trauma patients seen at Texas Children’s Hospital are transferred from
other hospitals. The average time to accept a transfer is 15 minutes, which is well below the 30
minute threshold that is allowed by federal regulation.
To enhance the team’s multidisciplinary performance as well as build proficiency in trauma
assessment and patient care, we partner with Texas Children’s Simulation Center to conduct
monthly trauma simulations. One hundred percent of Texas Children’s transport team is
trained in high-quality trauma care and outreach trauma and emergency nursing education is
offered to hundreds of nurses each year, creating a pool of instructors in underserved areas
throughout Texas.
Bindi Naik-Mathuria, M.D., has recently joined Trauma Services as the first
board-certified surgeon in the hospital to have completed her residency in
critical care and fellowship in pediatric rehabilitation.
Run by our nurse practitioners and supervised by Bindi Naik-Mathuria, M.D., the Trauma
Follow-Up Clinic checks on patients who didn’t need surgery during their hospital stay. These
patients, who weren’t sent to a specific clinic, receive care by staff physicians who make sure they
are healing from the conditions that initially sent them to Trauma Services.
In 2012, Texas Children’s Physical Medicine and Rehabilitation Service opened the Inpatient
Rehabilitation Service, which has been a huge success and enhancement to the care provided to
injured children. Children can now receive intensive inpatient rehabilitation in their community,
and it has proven to be a big advantage for outcomes as well as overall patient experience.
CENTER FOR CHILDHOOD INJURY PREVENTION
The Center for Childhood Injury Prevention educates thousands of parents and children each
year on child passenger safety, safe sleep, home safety and bicycle safety. Nearly $500,000 dollars
a year is provided through Texas Department of Transportation, Kohl’s®, Cincinnati Children’s/
ToyotaВ® USA and the Houston Galveston Area Council in grant funds to support our programs.
Texas Children’s Hospital and our 30+ community partners check more than 4,000 car seats a
year and distribute more than 1,000 car seats to needy families. Texas Children’s maintains the
largest network of inspection stations in the United States. Additionally, we distribute bicycle
helmets and safety education to more than 5,000 children and nearly 1,000 pack-n-play cribs per
year to qualifying families so they can provide a safe sleep environment for their infant.
89
90
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
THE IMPORTANCE OF SURGEON INVOLVEMENT IN THE EVALUATION OF
NON-ACCIDENTAL TRAUMA PATIENTS
Non-Accidental Trauma (NAT) is a significant cause of childhood morbidity and mortality. Until
recently, most of these patients were admitted to pediatrics for social reasons or to pediatric
critical care, with surgical consultation only as needed. Texas Children’s recently participated in a
retrospective review33 to evaluate the necessity of primary surgical evaluation and admission to
the trauma service for children presenting with NAT.
Total patients
267
Date range
2007 – 2011
Age range
0.4 – 122 months, median 7 months
Mortalities
17
Admission to critical care
34%
Injuries
Abdominal or thoracic trauma – 80%
Closed head injuries – 72%
Extremity fractures – 51%
Rib fractures – 82%
Overall injuries in NAT patients were more severe than in
accidental trauma (AT) patients; the injury severity score,
ICU admission rate and mortality were all significantly
(P < 0.001) higher in the NAT group. Upon examination
of the injuries identified, isolated injury proved to be the
exception rather than the rule.
Acute rib fractures were associated with abdominal
injuries in 20% of patients.
Polytrauma patients who
received surgical consults
56%
CONCLUSIONS
NAT comprises the largest group of patients with life-threatening injuries at a children’s hospital.
Given the high incidence of polytrauma, a surgeon should promptly evaluate patients with this
mechanism of injury to determine if there are additional acute or recent injuries in evolution.
Admission to the trauma service (at least for 24 hours) and a thorough tertiary survey should
be considered for all NAT patients.
33
L arimer EL, Fallon SC, Wesson DE, Westfall J, Frost M, Naik-Mathuria BJ. Non-Accidental Trauma: The Importance of
Surgical Involvement in Polytrauma Patients. American Association of Pediatrics (AAP), New Orleans, LA, October 2012.
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
TRAUMA ADMISSIONS
1,254
1,247
2009
1,242
1,041
by year
2010
2011
2012
Trauma admissions include Texas Children’s Hospital Main Campus only.
TRAUMA ADMISSIONS
by surgical division
7%
2012
19%
51%
23%
ORTHOPAEDICS
PEDIATRIC GENERAL SURGERY
NEUROSURGERY
OTHER
Other includes congenital heart surgery, ophthalmology, otolaryngology, pediatric and adolescent
gynecology, plastic surgery and urology.
91
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
TRAUMA ADMISSIONS
by injury location
2%
4%
5%
4%
2012
26%
13%
EXTERNAL
34
HEAD
ARM
LEG
22%
FACE
CHEST
24%
ABDOMEN
SPINE 35
46
SPORTS
50
68
FALLS
2012
50
TOP FIVE MECHANISMS OF INJURY
588
92
STRUCK
BY VEHICLE
WHILE ON
BIKE
CHILD
ABUSE
STRUCK
BY AN OBJECT/
PERSON
34
External encompasses skin injuries including cuts, bruises and abrasions.
35
All levels of spine injuries including cervical, thoracic and lumbar are combined.
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
TRAUMA ADMISSIONS by severity
Injury Severity Scores (ISS)
3%
7%
2012
9%
81%
MINOR INJURY, ISS 1-9
MODERATE INJURY, ISS 10-15
MAJOR INJURY, ISS 16-24
SEVERE INJURY, ISS ≥25
MORTALITY FOR MAJOR AND SEVERE TRAUMA 36 by percentage
0%
1.4%
14%
17.9%
Injury Severity Scores (ISS)
TEXAS CHILDREN’S HOSPITAL PEDIATRIC HOSPITALS
M A J O R I N J U RY, I S S 1 6 - 2 4
S E V E R E I N J U RY, I S S > 2 4 ( S E V E R E )
Both Texas Children’s Hospital and the comparative pediatric hospitals had 12% of their cases
categorized as major or severe injuries.
36
National trauma databank benchmark report 2012 (2011 data). Data is not risk-adjusted.
93
T R A U M A S E RV I C E S A N D T H E C E N T E R F O R C H I L D H O O D I N J U RY P R E V E N T I O N
0.94%
CRUDE MORTALITY RATE 37
0.48%
94
TEXAS CHILDREN’S HOSPITAL
PEDIATRIC HOSPITALS
DAVID E. WESSON, M.D., is associate surgeon-in-chief, chief of the Department of Surgery and
Medical Director of Trauma Services at Texas Children’s Hospital. He obtained his medical degree
and completed his general surgery training at the University of Toronto and pursued his training
in Pediatric Surgery at the Hospital for Sick Children in Toronto. Dr. Wesson joined the Baylor
faculty as professor and chief of the Pediatric General Surgery Division and chief of Pediatric
General Surgery at Texas Children’s Hospital in 1997. In 2007, Dr. Wesson was honored with
appointment as the William J. Pokorny, M.D. Professor of Pediatric Surgery at Baylor College of
Medicine. As a member of the American College of Surgeons
(ACS) Committee on Trauma, Dr. Wesson has been an ACS
Trauma Center Site Visitor since 1991. In this capacity, he is a
member of the national ACS site survey team for Trauma Center
designation. He also is a founding member of the International
Society of Child and Adolescent Injury Prevention and serves on
the editorial board of the Journal of Trauma.
To view more Trauma Services Division biographies,
visit texaschildrens.org/Locate/Find-a-Doctor.
37
National trauma databank benchmark report 2012 (2011 data). Data is not risk-adjusted.
M E D I C A L S TA F F D I R E C T O RY
Department of Surgery at Texas Children’s Hospital
D E PA RTM E NT O F S U RG E RY L E A D E R S H I P
R. Blaine Easley, M.D.
Charles D. Fraser, Jr., M.D., Surgeon-in-Chief
Jessica H. Emerald, R.N., M.S., P.N.P.
David E. Wesson, M.D., Associate Surgeon-in-Chief,
Co-Surgical Director, Texas Children’s Hospital
West Campus
Sarah Endique, R.N., M.S., C.R.N.A.
Christopher R. Estrada, M.D.
Edmond T. Gonzales, M.D., Co-Surgical Director,
Texas Children’s Hospital West Campus
Priscilla J. Garcia, M.D.
Mary A. Felberg, M.D.
Nancy L. Glass, M.D.
Thomas G. Luerssen, M.D., F.A.C.S., F.A.A.P.,
Chief Quality Officer
Chris D. Glover, M.D.
H. Mallory Caldwell, Senior Vice President
Cheryl A. Gore, M.D.
John R. Nickens, Vice President,
Hospital-Based Services
Kalyani Govindan, M.D.
Matthew T. Girotto, Assistant Vice President,
Department of Surgery
Ryann Hattori, R.N., M.S., C.R.N.A.
Trent D. Johnson, Director, Surgical Clinics and
Physician Services Organization
Judy Swanson, R.N., M.B.A., Director,
Perioperative Services
Ryan K. Krasnosky, Assistant Director, Surgical
Advanced Practice Providers
D E PA RTM E NT O F A N E S TH E S I O LO GY
Dean B. Andropoulos, M.D., M.H.C.M., Chief
Stephen A. Stayer, M.D., Associate Chief
Cheryl R. Faust, M.P.H., Practice Administrator
Melanie J. Alo, M.D.
Rahul G. Baijal, M.D.
Beth M. Barraza, R.N., M.S., P.N.P.
Sandra L. Benavides, R.N., M.S., P.N.P.
Monique Bernsten, R.N., M.S., P.N.P.
Erin A. Gottlieb, M.D.
Stuart R. Hall, M.D.
Katherine Hengstenberg, R.N.
Lisa D. Heyden, M.D.
Helena Karlberg Hippard, M.D.
Julie Hoang, R.N., M.S., C.R.N.A.
Paul W. Hopkins, M.D.
Matthew D. James, M.D.
Aimee Kakascik, D.O.
Kathleen Kibler, B.S.
Joanna L. Klaas, R.N., M.S., C.R.N.A.
Constance W. LaGrone, R.N., M.S., P.N.P.
Kate O. Lee, R.N., M.S., C.R.N.A.
Yang Liu, M.D.
David G. Mann, M.D.
Virginia F. McWilliams, R.N., M.S., P.N.P.
Marcie R. Meador, R.N., M.S.
Sudha A. Bidani, M.D.
Angela M. Medellin, R.N., M.S., P.N.P.
Glorianne Bond, R.N., M.S., P.N.P.
Douglas J. Miller, M.D.
Kenneth M. Brady, M.D.
Wanda C. Miller-Hance, M.D.
Casey A. Brimmage, R.N., M.S., C.R.N.A.
Princy Mohan, R.N., M.S., P.N.P.
Maria M. Bruno, R.N., M.S., C.R.N.A.
Emad B. Mossad, M.D.
Michelle R. Caballero, M.D.
Pablo Motta, M.D.
Katrin A. Campbell, M.D.
Jessica L. Mouton, R.N., M.S., C.R.N.A.
Carlos J. Campos, M.D.
Kim P. Nguyen, M.D.
Samantha Capehart, R.N.
Olutoyin A. Olutoye, M.D.
Lisa A. Caplan, M.D.
Elyse C. Parchmont, R.N., M.S., C.R.N.A.
Nicholas P. Carling, M.D.
Nihar V. Patel, M.D.
Julia H. Chen, M.D.
Mary E. PiГ±a, R.N., M.S., C.R.N.A.
Hilary Cloyd, R.N.
Robert W. Power, M.D.
Camille M. Colomb, M.D.
Jason Reynolds, M.D.
Christopher Deegear, R.N.
Carlos L. Rodriguez, M.D.
Erin R. Depew, R.N., M.S., C.R.N.A.
Amber P. Rogers, M.D.
Kristy D. DiMascio, R.N., M.S., C.R.N.A.
95
96
M E D I C A L S TA F F D I R E C T O RY
Catherine Seipel, M.D.
Andrew H. Jea, M.D., F.A.C.S., F.A.A.P.
Nicole M. Sevier, R.N., M.S., P.N.P.
William E. Whitehead, M.D., M.P.H.
Thomas L. Shaw, M.D.
Kristen D. Sheehy, R.N., M.S., C.R.N.A.
Shakeel A. Siddiqui, M.D.
Kristen Sowers, R.N., M.S., P.N.P.
Adam Stone, M.D.
Imelda M. Tjia, M.D.
Laura Torres, M.D.
David F. Vener, M.D.
Mehernoor F. Watcha, M.D.
Tracy R. Watkins, R.N., M.S., P.N.P.
Lauren Weaver, R.N., M.S., C.R.N.A.
Erin Williams, M.D.
Saeed Yacouby, R.N., M.S., C.R.N.A., D.N.P.
Jennifer G. Yborra, R.N., M.S., P.N.P.
David A. Young, M.D.
O PHTH A L M O LO GY
David K. Coats, M.D., Chief
Patricia Baker, Practice Administrator
Amit Bhatt, M.D.
Jane C. Edmond, M.D.
Dan S. Gombos, M.D.
Mohamed A. Hussein, M.D.
Mary Kelinske, O.D.
Doug Marx, M.D.
Evelyn A. Paysse, M.D.
Paul G. Steinkuller, M.D.
Kimberly G. Yen, M.D.
O RTH O PA E D I C S
William A. Phillips, M.D., Chief
Michael Zelisko, M.D.
Binta O. Baudy, M.P.H., Practice Administrator
C O N G E N ITA L H E A RT S U RG E RY
Shannon B. Antekeier, M.D.
Charles D. Fraser, Jr., M.D., Chief
Tanisha George Daugherty, PA-C
Shaun E. Custard, M.H.A., M.B.A., F.A.C.H.E.,
Practice Administrator
Howard R. Epps, M.D.
Iki Adachi, M.D.
Jeffrey S. Heinle, M.D.
Amy G. Hemingway,В R.N., M.S.N., C.N.S,
C.P.N.P.-P.C.
Vermicker L. Ible, R.N., C.P.N.P.-P.C.
E. Dean McKenzie, M.D.
Carlos M. Mery, M.D.
Yuji Naito, M.D. (Instructor)
Yishay Orr, M.D. (Instructor)
Mary Tran, PA-C
David P. Antekeier, M.D.
Frank T. Gerow, M.D.
Darrell Hanson, M.D.
Kevin S. Horowitz, M.D.
Meghan M. May, M.D.
Scott D. McKay, M.D.
Scott B. Rosenfeld, M.D.
Janai A. Sells, PA-C
Vinitha R. Shenava, M.D.
Lisa D. Stringer, PA-C
Lindsey E. White, PA-C
Opal J. Willmon, PA-C
D E NTA L
Lisa D. Wilsford, PA-C
A. Bruce Carter, D.D.S., Chief
Vincy D. Zachariah, PA-C
Mary D. Kana, M.B.A., Practice Administrator
Esther Yang, D.D.S.
N E U RO S U RG E RY
Thomas G. Luerssen, M.D., F.A.C.S., F.A.A.P.,
Chief
Lorraine M. Cogan, M.S.W., Practice Administrator
Brandy Berger, R.N., N.P.
Tina R. Bradshaw, R.N., F.N.P.
Daniel J. Curry, M.D.
Robert C. Dauser, M.D.
OTO L A RY N G O LO GY
David E. Wesson, M.D., Interim Chief
Peggy Blum, Manager, Audiology
James P. Carter, M.A., C.C.C.-S.L.P., Manager,
Speech Language and Learning
Amy Bartholomew, P.A.-C., M.M.Sc.
Linda C. Brock, P.N.P.
Binoy M. Chandy, M.D.
Ellen M. Friedman, M.D.
M E D I C A L S TA F F D I R E C T O RY
Carla M. Giannoni, M.D.
Laura Monson, M.D.
John K. Jones, M.D.
John Wirthlin, D.D.S.
Deidre R. Larrier, M.D.
Mary Frances Musso, D.O.
Julina Ongkasuwan, M.D.
TR A N S PL A NT S E RV I C E S
John A. Goss, M.D., Medical Director
Kathy Shelly, PA-C
Ryan W. Himes, M.D., Medical Director of
Quality and Outcomes Management
Marcelle Sulek, M.D.
Jennifer J. Hiser, M.H.A., Director
PE D I ATR I C A N D A D O L E S C E NT
Heart Transplant Program
GY N E C O LO GY
Jeffrey S. Heinle, M.D., Surgical Director
Jennifer E. Dietrich, M.D., M.Sc., Chief
Sandra Tillis, J.D., Practice Administrator
Jennifer L. Bercaw-Pratt, M.D.
Jessica Francis, M.D.
Jennifer Parker Kurkowski, WHNP
Xiomara M. Santos, M.D.
William J. Dreyer, M.D., Medical Director
Antonio G. Cabrera, M.D.
Susan W. Denfield, M.D.
Aamir Jeewa, M.D.
Jack F. Price, M.D.
Kidney Transplant Program
PE D I ATR I C G E N E R A L S U RG E RY
Christine A. O’Mahony, M.D., Surgical Director
Jed G. Nuchtern, M.D., Chief
Eileen D. Brewer, M.D., Medical Director
Paul K. Minifee, M.D., Clinic Chief
Michael C. Braun, M.D., Chief, Nephrology
Cynthia F. Miley, Practice Administrator
Annabelle N. Chua, M.D.
Leah H. Bayliss, PA-C
Ewa P. Elenberg, M.D.
Mary L. Brandt, M.D.
Arundhati S. Kale, M.D.
Darrell L. Cass, M.D.
Mini Michael, M.D.
Bradley P. Herold, PA-C
Poyyapakkam R. Srivaths, M.D.
Clair M. Johny, PA-C
Sarah J. Swartz, M.D.
Eugene S. Kim, M.D.
Scott E. Wenderfer, M.D.
Timothy C. Lee, M.D.
Monica E. Lopez, M.D.
Mark V. Mazziotti, M.D.
Allen L. Milewicz, M.D.
Bindi Naik-Mathuria, M.D.
Oluyinka Olutoye, M.D., Ph.D.
Jamie Ouseph, PA-C
Ashwin P. Pimpalwar, M.D.
J. Ruben Rodriguez, M.D.
Sanjeev A. Vasudevan, M.D.
Veronica A. Victorian, PA-C
David E. Wesson, M.D.
PL A S TI C S U RG E RY
Larry H. Hollier, Jr., M.D., F.A.C.S., Chief
Mary D. Kana, M.B.A., Practice Administrator
Edward P. Buchanan, M.D.
David Khechoyan, M.D.
Liver Transplant Program
John A. Goss, M.D., Surgical Director
Ross W. Shepherd, M.D., Medical Director
Christine A. O’Mahony, M.D.
Beth A. Carter, M.D.
Douglas S. Fishman, M.D.
Donna Garner, P.N.P.
Paula M. Hertel, M.D.
Ryan W. Himes, M.D.
Daniel H. Leung, M.D.
Lung Transplant Program
Jeffrey S. Heinle, M.D., Surgical Director
George B. Mallory, Jr., M.D., Medical Director
Carolina Gazzaneo, M.D.
Ernestina Melicoff-Portillo, M.D.
97
98
M E D I C A L S TA F F D I R E C T O RY
U RO LO GY
TR AU M A S E RV I C E S
David R. Roth, M.D., Chief
David E. Wesson, M.D., Medical Director
Barkha Chandwani, Practice Administrator
Bindi J. Naik-Mathuria, M.D.,
Assistant Medical Director
Edmond T. Gonzales, M.D.
Nicolette Janzen, M.D.
Chester Koh, M.D.
Joanna Marroquin, P.N.P.
Bruce Schlomer, M.D.
Jessice Schuh, PA
Abhishek Seth, M.D.
Mary Frost, R.N., B.S.N., Assistant Director
Mona Jaimee Westfall, R.N., M.S.N., C.P.N.P.
A.C./P.C.
Kelly Ratcliff, M.S.N., R.N., C.P.N.P.
A.C./P.C.
C E NTE R FO R C H I L D H O O D I N J U RY
PR E V E NTI O N
I N PATI E NT S E RV I C E S
Mary Frost, R.N., B.S.N.,В Assistant Director
Lara S. Shekerdemian, M.D., F.R.A.C.P., F.A.A.P.,
M.H.A., Chief
Kristen Beckworth, M.P.H., C.H.E.S.,
C.P.S.T.I., В Manager
Pediatric Intensive Care Unit
Q UA LIT Y
Jeanine M. Graf, M.D., Medical Director
Deborah D’Ambrosio, R.N., M.S.N., N.E.-B.C.,
Assistant Director
Gail Parazynski, R.N., M.S.N., Director, Nursing
Progressive Care Unit
Fernando Stein, M.D., Medical Director
Jacqueline P. Williams, R.N., M.S.N.,
Assistant Director
Gail Parazynski, R.N., M.S.N., Director, Nursing
Cardiovascular Intensive Care Unit
Paul A. Checchia, M.D., F.C.C.M., F.A.C.C.,
Medical Director
Gay N. Matthews, R.N., M.S.N., Assistant Director
Gail Parazynski, R.N., M.S.N., Director, Nursing
Acute Care Surgical Floor
Roxanne M. Vara, R.N., B.S.N., M.B.A.,
Interim Director, Nursing
O PE R ATI N G RO O M A N D
PE R I O PE R ATI V E S E RV I C E S
Judy Swanson, R.N., M.B.A., Director,
Perioperative Services
Ramon Enad, R.N., M.B.A., Assistant Director,
Perioperative Services Texas Children’s Hospital
West Campus
Lynn A. Huffman, R.N., M.B.A., Assistant Director,
Operating Rooms
Ronald Loosle, R.N., M.B.A., Assistant Director,
PACU/Anesthesia
Sheila Winchester, R.N., M.B.A.,
Assistant Director, Perioperative Services,
Texas Children’s Pavilion for Women
Eric A. Williams, M.D., M.S., M.M.M., F.A.A.P.,
Medical Director
Kathleen E. Carberry, R.N., M.P.H.,
Director, Texas Children’s Hospital Outcomes and
Impact Service
99
M E D I C A L S TA F F D I R E C T O RY
6621 Fannin Street | Houston, Texas 77030
6621 Fannin Street | Houston, Texas 77030
832-826-5779
832-826-5779
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©2013 Texas Children’s Hospital. All rights reserved. PedSur088 111113
©2013 Texas Children’s Hospital. All rights reserved. PedSur088 101513
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