TY - JOUR
T1 - The dual-staged pathway for closure in cloacal exstrophy
T2 - Successful evolution in collaborative surgical practice
AU - Jayman, John
AU - Michaud, Jason
AU - Maruf, Mahir
AU - Trock, Bruce J.
AU - Kasprenski, Matthew
AU - Sponseller, Paul
AU - Gearhart, John
N1 - Funding Information:
The authors dedicate this paper to the memory of Dr. Jacob Alex Haller our teacher, role model and dear friend who developed and fostered the science of all pediatric surgery specialities at Johns Hopkins. His contributions to children's surgery have been felt throughout the world and he is sorely missed. The Kwok Family Foundation of Hong Kong supports the exstrophy database and laboratory research.
Publisher Copyright:
© 2019 Elsevier Inc.
PY - 2019/9
Y1 - 2019/9
N2 - Introduction: A successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures. Methods: A prospective database of 1332 Exstrophy–Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected. Results: There are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011). Conclusion: The standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes. Level of evidence: Level III, retrospective comparative study.
AB - Introduction: A successful abdominal wall and bladder closure is critical in the management of cloacal exstrophy (CE). This study examines closure outcomes and practices over the last 4 decades at the authors' institution. Beginning in 1995, the authors' institution standardized CE closure and management with the Dual-Staged Pathway (DSP). The DSP consists of a staged bladder closure, a staged or concurrent osteotomy, and postoperative immobilization with external fixation. The authors hypothesize that the DSP has provided better outcomes in CE closures. Methods: A prospective database of 1332 Exstrophy–Epispadias Complex (EEC) patients was reviewed for CE patients closed between 1975 and 2015. The DSP consists of a staged osteotomy and a staged bladder closure in CE patients with a diastasis greater than 4 cm. To evaluate the DSP, outcomes of closure at the authors' institution were compared between two equal, twenty-year periods before and after its implementation. Data on timing of closure, postoperative management, surgical complications, and outcomes were collected. Results: There are 142 CE patients in the database. In this study, 49 CE patients with 50 closures met inclusion criteria. The overall success rate of closures from 1975 to 1994 was 88% (14 of 16), while the success rate of the DSP was 100% (n = 34), p = 0.098. Twenty-two (65%) primary and 12 (35%) secondary closures were performed using the DSP. Overall complication rates of the DSP remained similar to previous closures, (29% vs 19%, p = 0.508). Since incorporation of the DSP, patients referred for closure have generally had a larger preclosure diastasis (7.2 cm vs 5.1 cm, p = 0.011). Conclusion: The standardized DSP closure has proven successful in 34 primary and reoperative cloacal closures in the past 20 years. With this approach, the authors feel that the DSP offers greater patient safety and better outcomes. Level of evidence: Level III, retrospective comparative study.
KW - Bladder closure
KW - Cloacal exstrophy
KW - Exstrophy–epispadias complex
KW - Osteotomy
KW - Staged
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U2 - 10.1016/j.jpedsurg.2019.01.005
DO - 10.1016/j.jpedsurg.2019.01.005
M3 - Article
C2 - 31003729
AN - SCOPUS:85064322383
SN - 0022-3468
VL - 54
SP - 1761
EP - 1765
JO - Journal of Pediatric Surgery
JF - Journal of Pediatric Surgery
IS - 9
ER -