Mark Wulkan

Childhood obesity remains a significant public health issue. Approximately 8% of adolescent girls and 7% of adolescent boys have severe (≥class 2) obesity. Adolescent severe obesity is associated with numerous comorbidities, and persists into adulthood. Bariatric surgery is the most effective treatment available, resulting in major weight loss and resolution of important comorbid conditions. Clinical practice guidelines for pediatric obesity treatment recommend consideration of surgery after failure of behavioral approaches...

Objective  Outcomes for gastroschisis (GS) remain highly variable and avoiding infectious complications (ICs) may represent a significant improvement opportunity. Our objective was to provide estimates of the impact of IC on length of stay (LOS) and costs. Study Design  Using a national database, 1,378 patients with GS were identified. Patient and hospital characteristics were compared and LOS and costs evaluated for patients with and without IC. Results  Two-thirds of all GS patients had IC, and IC were common for simple and complex GS (65, 73%, respectively)...

BACKGROUND: Postoperative length of stay (pLOS) is an easily tracked outcome that reflects health care efficiency and resource utilization. The purpose of this study was to determine the contribution of practice variation on pLOS for children with perforated appendicitis. METHODS: Children ages 2-18years with appendectomy for complicated appendicitis were selected from the National Surgical Quality Improvement Program-Pediatric. Extended pLOS (EpLOS) was defined as ≥7days (75th percentile)...

BACKGROUND: Hospitals are increasingly focused on demonstration of high-value care for common surgical procedures. Although sociodemographic status (SDS) factors have been tied to various surgical outcomes, the impact of SDS factors on hospital value rankings has not been well explored. Our objective was to examine effects of SDS factors on high-value surgical care at the patient level, and to illustrate the importance of SDS adjustment when evaluating hospital-level performance. METHODS: Perforated appendicitis hospitalizations were identified from the 2012 Kids' Inpatient Database...

BACKGROUND: Variation in care may indicate an opportunity for quality improvement and to decrease waste. Variation in appendicitis practice, resource use, and costs have not been well studied at non-children's hospitals (NCHs) where most children undergo care. The purpose of this study was to quantify variation in care for perforated pediatric appendicitis within and between children's hospitals (CHs) and NCH. METHODS: Using the 2012 Kids' Inpatient Database, 11,216 children with perforated appendicitis were identified...

Pediatric surgical training in the United States remained basically unchanged from the model developed by Ladd and Gross in the 1930s until recently. Standardized curriculum and novel evaluation methods are now being implemented. Pediatric Surgical education is currently undergoing a transition to competency-based evaluation and promotion. Unfortunately, there is little data on the efficacy of these changes. This presents an opportunity for further study of how we conduct training, and how we evaluate and promote our trainees...

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Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results...

PURPOSE: Penetrating pancreatic injuries in children are uncommon and are not well described in the literature. We report a multi-institutional experience with penetrating pancreatic injuries in children. METHODS: A retrospective review of children sustaining penetrating pancreatic injuries was performed at eight pediatric trauma centers. RESULTS: Sixteen patients were identified. Eleven patients were male; (mean ± SE) age was 11.7 ± 1.2 years...

PURPOSE: Controversy remains regarding the management of the asymptomatic heterotaxy syndrome (HS) patient with suspected intestinal rotational abnormalities. We evaluated the outcomes for our HS population to identify frequency of malrotation and identify characteristics of children who might benefit from expectant management. METHODS: After IRB approval, a retrospective review of all patients treated for HS at a large tertiary care children's hospital between January 2008 and June 2012 was performed...

The multi-disciplinary team is essential for the success of an adolescent bariatric surgical program. This article will describe the components of the team and their roles. Essential members include a pediatrician or pediatric subspecialist with an interest and expertise in adolescent obesity, a pediatric surgeon with bariatric expertise, or an adult bariatric surgeon with adolescent experience, adolescent/child psychologist, pediatric nutritionist, exercise physiologist or physical therapist, nursing support, and a patient coordinator...

BACKGROUND: The management of traumatic pancreatic transection remains controversial. STUDY DESIGN: A multi-institutional review from 1995 to 2012 was conducted comparing operative with nonoperative management for grades II and III blunt pancreatic injuries in patients younger than 18 years. RESULTS: Fourteen pediatric trauma centers participated, yielding 167 patients; 57 underwent distal pancreatectomy and 95 were managed nonoperatively...

BACKGROUND: The treatment algorithm for children with suspected choledocholithiasis is not well established because the breadth of minimally invasive surgery and endoscopic techniques continues to evolve. We reviewed our experience with common bile duct explorations (CBDEs) in order to detail the techniques used and describe the rate of complications of laparoscopic CBDE in children. SUBJECTS AND METHODS: As part of an Institutional Review Board-approved study, medical records were reviewed for all patients, 1 month to 21 years of age, undergoing a cholecystectomy at a large tertiary-care children's hospital over an 11-year period...

Neonatal obstructive jaundice is frequently explained by biliary atresia (BA) or the presence of a choledochal cyst (CC). Cystic biliary atresia (CBA) has been a proposed as a subtype of BA with projected improved outcomes. We aimed to characterize these lesions further. We conducted an Institutional Review Board-approved review of all patients treated for obstructive jaundice at our tertiary children's hospital over 10 years. Over the decade we evaluated 91 children with obstructive jaundice: 13 CBA, 52 BA, and 26 CC...

OBJECTIVES: The aim of this study was to determine the benefit of routine postoperative chest radiography after removal of esophageal foreign bodies in children. METHODS: Medical records were reviewed of all patients evaluated with an esophageal foreign body at a single children's hospital over 10 years. Operative records and imaging reports were reviewed for evidence of esophageal injury. RESULTS: Of 803 records identified, 690 were included...

BACKGROUND: Intussusception is a common cause of bowel obstruction in children, which sometimes necessitates operative reduction and or resection. We report our series of patients with intussusception who were treated laparoscopically (LAP group) compared with exploratory laparotomy (OPEN group). SUBJECTS AND METHODS: After institutional review board approval, a retrospective review was performed evaluating outcomes for patients requiring surgical reduction of intussusception over a 10-year period...

INTRODUCTION: Current surgical techniques for gastroesophageal reflux in infants involve gastric fundoplication and crural repair. These operations are complicated by a high recurrence rate in the infant population. The primary cause of failure is generally related to recurrent hiatal hernia. Minimal dissection of the gastroesophageal junction has been linked to reduced hiatal hernia formation. We propose an alternative plication technique for modifying the gastroesophageal junction called cardiaplication...

PURPOSE: Children with a history of a congenital abdominal wall defect (AWD) occasionally require additional abdominal surgery later in life, after their defect is closed. In an effort to evaluate surgical history and assess the feasibility of laparoscopic surgery in this select patient population, a retrospective review was conducted looking at all patients treated with congenital AWD at a tertiary-care facility. PATIENTS AND METHODS: Patients admitted between January 1, 2000 and January 1, 2011 with AWD were included in the study...

PURPOSE: Traumatic pancreatic transection is uncommon. The role of laparoscopy in the setting of this injury has not been well described. PATIENTS AND METHODS: Six large-volume pediatric trauma centers contributed patients <18 years of age who underwent a distal pancreatectomy for traumatic pancreatic transection from 2000 to 2010. RESULTS: Twenty-one patients without another indication for emergency laparotomy underwent a distal pancreatectomy for Grade III pancreatic injuries, of which 7 underwent laparoscopic distal pancreatectomy...

OBJECTIVE: Interstage mortality has been reported in 10% to 25% of hospital survivors after single-ventricle palliation. The purpose of this study was to examine the impact of feeding modality at discharge after single-ventricle palliation on interstage mortality. METHODS: We conducted a retrospective review of all neonates undergoing single-ventricle palliation from January 2003 to January 2010. A total of 334 patients (90%) survived to hospital discharge, comprising the study group...