Jessica Gonzalez-Hernandez M.D.

McLaughlin, C. M., J. Gonzalez-Hernandez, M. Bennett and H. G. Piper (2018). “Pediatric breast masses: an argument for observation.” J Surg Res 228: 247-252.

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BACKGROUND: Pediatric breast masses can be a diagnostic challenge. Nearly all are benign, but there is no consensus on which should be removed. We hypothesized that children with asymptomatic breast lesions can be safely managed nonoperatively. METHODS: We performed a single-institution retrospective review of children (less-than-or-equal-to 18 y) who underwent breast mass excision from 2008 to 2016. Male patients with gynecomastia and those who had needle biopsy without formal excision were excluded. Pearson correlation was used to compare ultrasound and pathologic size. Kruskal-Wallis test was used to compare size and final diagnosis. RESULTS: One hundred ninety-six patients were included (96% female). Mean age was 15 +/- 3 y. Most patients (71%) presented with a painless mass. Preoperative ultrasound was obtained in 70%. Pathology included fibroadenoma (81.5%), tubular adenoma (5%), benign phyllodes tumor (3%), benign fibroepithelial neoplasm (0.5%), and other benign lesions (10%). There were no malignant lesions. Ultrasound size had a Pearson correlation of 0.84 with pathologic size (P < 0.0001). There was no association between the size and final diagnosis. CONCLUSIONS: Over 9 y, all pediatric breast masses removed at a single center were benign, most commonly fibroadenoma. Ultrasound was an accurate predictor of size, but large lesions did not necessarily confer a high malignancy risk. Observation is appropriate for asymptomatic breast masses in children. Decision for surgery should be individualized and not based on size alone.

Gonzalez-Hernandez, J., P. Prajapati, G. Ogola, R. D. Burkart and L. D. Le (2018). “Surgical training in robotic surgery: surgical experience of robotic-assisted transabdominal preperitoneal inguinal herniorrhaphy with and without resident participation.” J Robot Surg. Jan 6. [Epub ahead of print].

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Robotic-assisted surgery is becoming more popular in general surgery. Implementation of a robotic curriculum is necessary and will influence surgical training. The aim of this study is to compare surgical experience and outcomes with and without resident participation in robotic inguinal herniorrhaphy. A retrospective review of patients who underwent either unilateral or bilateral robotic-assisted transabdominal preperitoneal (TAPP) inguinal herniorrhaphy, with and without resident participation as console surgeons from January through December 2015, was performed. Patient demographics, procedure-related data, postoperative variables, and follow-up data were analyzed. A total of 104 patients were included. Patients were significantly older in the Resident group (57.5 +/- 14.1 vs 50.6 +/- 13.5 years, p = 0.01). Gender, BMI, and ASA classification were similar between groups. There were similar mean operative times for unilateral (89.9 +/- 19.5 vs 84.8 +/- 22.2 min, p = 0.42) and bilateral (128.4 +/- 21.9 vs 129.8 +/- 50.9 min, p = 0.90) inguinal herniorrhaphy as well as mean robot console times for unilateral (73.2 +/- 18.4 vs 67.3 +/- 29.9 min, p = 0.44) and bilateral (115.5 +/- 24.6 vs 109.3 +/- 55.4 min, p = 0.67) inguinal herniorrhaphy with and without resident participation, respectively. Postoperative complications included urinary retention (11.1 vs 2.0%, p = 0.11), conversion to open repair (0 vs 2%, p = 0.48), and delayed reoperation (0 vs 4%, p = 0.22) with and without resident participation, respectively. Patients’ symptoms/signs at follow-up were similar among groups. Robotic-assisted TAPP inguinal herniorrhaphy with resident participation as console surgeons did not affect the hospital operative experience or patient outcomes. This procedure can be implemented as part of the resident robotic curriculum with rates of morbidity equivalent to those of published studies.Level of evidence 2b.

Gonzalez-Hernandez, J., P. Prajapati, G. Ogola, V. Nguyen, N. Channabasappa and H. G. Piper (2017). “A comparison of lipid minimization strategies in children with intestinal failure.” J Pediatr Surg: 2017 Oct [Epub ahead of print].

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PURPOSE: The purpose of this study was to compare outcomes of lipid minimization with either Intralipid (IL) or Omegaven(R) in children with intestinal failure (IF) who developed intestinal failure-associated liver disease (IFALD) while receiving parenteral nutrition (PN). METHODS: A retrospective review of children with IF requiring PN who developed IFALD (direct bilirubin >2 mg/dL) while receiving IL (2009-2016) was performed. Clinical characteristics, nutritional, and laboratory values were compared between children treated with reduced IL or Omegaven(R). RESULTS: 16 children were reviewed (8 treated with IL and 8 treated with Omegaven(R) at a median dose of 1g/kg/d). Both groups had similar demographics, small bowel length, and parenteral nutritional intake during the study (82.9+/-27.1 kcal/kg/d vs. 75.9+/-16.5 kcal/kg/d, p=0.54). The mean direct bilirubin (DBili) prior to initiating treatment was 7.8+/-4.3 mg/dL and 7.5+/-3.5 mg/dL (p=0.87) in the IL and Omegaven(R) groups, respectively. The IL group took a median of 113 days to achieve a DBili <0.5 mg/dL compared to 124 days in the Omegaven(R) group (p=0.49). There were no differences in markers of liver function or growth trajectories among groups. CONCLUSIONS: Lipid minimization with either IL or Omegaven(R) has similar success in achieving a normal DBili in children with IF and IFALD without major differences in nutritional status or growth.

Gonzalez-Hernandez, J., Y. Daoud, J. Styers, J. M. Journeycake, N. Channabasappa and H. G. Piper (2016). “Central venous thrombosis in children with intestinal failure on long-term parenteral nutrition.” J Pediatr Surg 51(5): 790-793.

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PURPOSE: Central venous thrombosis (CVT) is a serious complication of long-term central venous access for parenteral nutrition (PN) in children with intestinal failure (IF). We reviewed thse incidence of CVT and possible risk factors. METHODS: Children with IF on home PN (2010-2014) with central venous imaging were reviewed. Patient demographics, catheter characteristics and related complications, and markers of liver function were compared between children with and without CVT. Serum thrombophilia markers were reviewed for patients with CVT. RESULTS: Thirty children with central venous imaging were included. Seventeen patients had thrombosis of >/=1 central vein, and twelve had >/=2 thrombosed central veins. Patients with and without CVT had similar demographics and catheter characteristics. Patients with CVT had a significantly lower albumin level (2.76+/-0.38g/dL vs. 3.12+/-0.41g/dL, p=0.0223). The most common markers of thrombophilia in children with CVT were antithrombin, protein C and S deficiencies, and elevated factor VIII. There was a statistically significant correlation between a combined protein C and S deficiency and having >1 CVT. CONCLUSIONS: Children with IF on long-term PN are at high risk for CVT potentially owing to low levels of natural anticoagulant proteins and elevated factor FVIII activity, likely a reflection of liver insufficiency and chronic inflammation.

Gonzalez-Hernandez, J., Y. Daoud, A. C. Fischer, B. Barth and H. G. Piper (2016). “Endoscopic button gastrostomy: Comparing a sutured endoscopic approach to the current techniques.” J Pediatr Surg 51(1): 72-75.

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PURPOSE: Button gastrostomy is the preferred feeding device in children and can be placed open or laparoscopically (LBG). Alternatively, a percutaneous endoscopic gastrostomy (PEG) can be placed initially and exchanged for a button. Endoscopic-assisted button gastrostomy (EBG) combines both techniques, using only one incision and suturing the stomach to the abdominal wall. The long-term outcomes and potential costs for EBG were compared to other techniques. METHODS: Children undergoing EBG, LBG, and PEG (2010-2013) were compared. Patient demographics, procedure duration/complications, and clinic and emergency room (ER) visits for an eight-week follow-up period were compared. RESULTS: Patient demographics were similar (32 patients/group). Mean procedure time (min) for EBG was 38+/-9, compared to 58+/-20 for LBG and 31+/-10 for PEG (p<0.0001). The most common complications were granulation tissue and infection with a trend toward fewer infections in EBG group. Average number of ER visits was similar, but PEG group had fewer clinic visits. 97% of PEG patients had subsequent visits for exchange to button gastrostomy. CONCLUSIONS: EBG is safe and comparable to LBG and PEG in terms of complications. It has a shorter procedure time than LBG and does not require laparoscopy, device exchange, or subsequent fluoroscopic confirmation, potentially reducing costs.