832-826-5779 texaschildrens.org/surgery texaschildrens.org/refer 6621 Fannin Street | Houston, Texas 77030

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Texas Children’s Hospital and Baylor College of Medicine. . . . . . . . . . . . . . . . . . . . 3 Department of Surgery. . . . . . . . . . . . . . . . . . . . . . 5 Texas Children’s Hospital West Campus .

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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 .

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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.

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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. 

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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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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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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 12

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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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

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Pediatric General Surgery Urology

110

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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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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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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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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.

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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.

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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% 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

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 (±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 (±3.2) PMF 14.7 years (±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

11.1±3.5 36.7% 57.6% 20.6±4.9

11.0±3.8 42.9% 59.3% 21.6±6.1

Postp-value implementation (n = 189)

11.2±3.5 38.4% 61.7% 20.4±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

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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

8.4±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

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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 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.

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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.

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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

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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/ Toyota® 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.

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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.

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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.

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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%

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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. Piña, 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.

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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, 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.

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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., 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.,  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

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M E D I C A L S TA F F D I R E C T O RY

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