The University of Chicago Medicine - Comer Children's Hospital

Department of Pediatrics 2017 Annual Report

Comer Children's Hospital Surgical Partners

Jessica Kandel, MD, with patient

We have the surgical expertise to treat the rarest of anomalies

Although only 18 months old, Bennett Carroll has had nine surgeries, six hospital admissions--including a four-month stay in the Neonatal Intensive Care Unit--and five Emergency Department visits. At least 50 physicians, nurses and therapists claim Bennett as their patient, and he is one of only a handful of babies who has been reported to have a teratoma present as a lymphangioma, a congenital malformation of the lymphatic system.

Pediatric otolaryngologist and head and neck surgeon Fuad Baroody, MD, met Bennett for the first time at his delivery at 31 weeks. Baroody’s first challenge was extremely delicate: to navigate the endotracheal tube around the cysts covering the 4-pound-1-ounce infant’s larynx and guide it to his windpipe to allow him to breathe. As neonatologists kept Bennett nourished with a nasogastric tube—Bennett also had a cleft palate—and managed complications related to his prematurity, Baroody performed three surgeries through Bennett’s mouth to debulk cysts measuring 2 x 1.5 inches and 2 x 1 inch. In separate surgeries, Jessica Kandel, MD, a specialist in vascular anomalies, removed an outer layer of cystic tissue and drained a remaining cyst in Bennett’s neck, and interventional neuroradiologist Seon-Kyu Lee, MD, PhD, injected a sclerosing agent to cause the lesions to regress.

When the cysts’ location caused Bennett to develop bradycardia and severe sleep apnea, Baroody and Kandel operated again to shave off more cystic tissue and drain the cysts that continued to fill with fluid and put pressure on Bennett’s airway. Speech and swallowing therapists worked with Bennett until he could swallow with control, and he went home without a tracheotomy and or a gastrostomy tube.

Bennett’s cysts, however, didn’t respond to the sclerosing agent as expected. When Lee tried again when Bennett was 10 months old, the team found out why. The fluid Lee aspirated from a cyst in Bennett’s neck looked different than before. The pathologist who reviewed the cytology and pathology suspected that Bennett had a teratoma rather than lymphangioma, a suspicion that was confirmed by pathologists at Seattle Children’s Hospital. “The treatment for a teratoma is surgical excision—a big undertaking in Bennett’s case because a portion of his cysts was located at the skull base,” says Baroody.

Besides Baroody, the team for the seven-hour surgery included surgeon Nishant Agrawal, MD, a specialist in the management of tumors of the head and neck; Michael Gluth, MD, an expert in neuro-otology; and pediatric neurosurgeon David Frim, MD, PhD, who was on standby to assist in case removal of the cysts caused any injury to the brain or its lining.

This was a very difficult problem that required multidisciplinary care by many specialists.

~ Fuad Baroody, MD

Baroody and the surgical team opened Bennett’s neck and removed one large and two smaller cysts. This involved penetrating his nasopharynx and dissecting his facial nerve to preserve it. The larger cyst was pulled off his skull base with no injury to the brain. “We were particularly worried about damaging Bennett’s facial nerve, the vagus nerve, and the major vessels because the lesions were very close to these important structures,” says Baroody. “Fortunately, we had to sacrifice only a few sensory nerves, and we don’t think that will lead to significant functional sequlae.” Bennett recovered from the long surgery very well and left the hospital able to swallow despite the significant extent of the operation.  A few weeks later, he took his first steps.

Bennett still needs his cleft palate repaired and possibly the slight deformation of his mandible caused by pressure from the cysts. But the major challenges are now behind him. “This was a very difficult problem that required multidisciplinary care by many specialists,” says Baroody. “Coordination of care is critical for these patients—and it was seamless.”

Trauma interventions should be right-sized for kids

Surgeon Mark Slidell, MD, in one of Comer Children's trauma bays

Children with traumatic injuries often have better outcomes when they are treated at pediatric trauma centers rather than adult trauma centers. Recent research suggests that children involved in motor vehicle collisions have fewer complications and children with severe traumatic brain injuries have lower mortality when pediatric trauma specialists and critical care teams are managing their care. “We want to take care of injured children where we can deliver the best care for their particular injury,” says pediatric trauma surgeon Mark Slidell, MD, MPH, director of pediatric trauma.

In a unique collaboration, Comer Children’s Level I trauma center will partner with the University of Chicago Medicine’s new adult Level I trauma center when it opens in May 2018 to create comprehensive care of pediatric trauma patients. In Illinois, emergency medical services bring children ages 16 and older to an adult trauma center, whereas children younger than 16 can be cared for at a pediatric trauma center. Slidell and Selwyn O. Rogers Jr., MD, MPH, director of the UChicago Medicine adult trauma center, are aligning policies and protocols to build a seamless approach to treating all injured children, regardless of age.

“Collaboration across the two trauma centers will augment and strengthen the state-of-the-art trauma services provided by Comer Children’s and allow us to define a new level of excellence in pediatric trauma care,” says Slidell. “It will also enable us to expand our efforts to prevent traumatic injuries and to enhance our current outreach programs that help kids and families heal from both the physical and psychological effects of trauma.”

Anesthesiology

We’re taking the lead in MALS pain management

Alina Lazar, MD, with patient Christina Mazza

University of Chicago Medicine investigators are hoping to fill the void in literature concerning pain management of median arcuate ligament syndrome (MALS) in pediatric patients. The rare vascular disorder is caused by external compression of the celiac artery and plexus by the median arcuate ligament, a preaortic continuation of the diaphragmatic crura. MALS patients exhibit chronic, difficult-to-control abdominal pain with ischemic and neuropathic elements.

Managing pain in these patients is very challenging, says Alina Lazar, MD, a pediatric anesthesiologist at UChicago Medicine, which is known internationally for its expertise in treating MALS patients. Because few other institutions have a large enough MALS patient database, UChicago Medicine is taking the lead in developing comprehensive protocols for managing pain in pediatric MALS patients.

We are very invested in finding the right solutions for our pediatric patients who face debilitating pain from MALS.

~ Alina Lazar, MD

Recent data from a study conducted by Lazar provides evidence that multimodal analgesia is essential in the management of MALS patients. This research also suggests that intraoperative administration of intravenous ketamine in addition to epidural analgesia provides significantly better pain relief postoperatively compared to epidural analgesia alone, with the most pronounced effect on postoperative day one. Further studies are needed to validate these results and to determine whether the continuation of the ketamine infusion postoperatively offers additional benefit.

In collaboration with Tina Drossos, PhD, from the UChicago Department of Psychiatry and Behavioral Neuroscience, Lazar evaluated the impact of psychological factors on postoperative pain management. The researchers found a high prevalence of anxiety and pain catastrophizing, which correlated with higher opioid consumption in the postoperative period. The strongest correlation between opioid requirement and catastrophizing was found in patients receiving epidural analgesia. This finding suggests that a multimodal, balanced analgesic technique may mitigate the effect of catastrophizing on opioid requirement in patients whose pain is medically treated.

“We are very invested in finding the right solutions for our pediatric patients who face debilitating pain from MALS,” Lazar says. “Expanding our data base over the years with more patients, including adults, will help us develop modalities that will be more effective in controlling that pain.”

Surgical Partners

PEDIATRIC SURGERY

  • Jessica J. Kandel, MD
    Mary Campau Ryerson Professor of Surgery
    Chief, Pediatric Surgery
    Named a Top Doctor in 2018 by Chicago magazine

PEDIATRIC ANESTHESIOLOGY

  • Ellen Choi, MD
    Assistant Professor of Anesthesiology
    Director, Pediatric Anesthesia Fellowship 

PEDIATRIC BURNS/COMPLEX WOUNDS SURGERY

PEDIATRIC CARDIAC SURGERY

  • Gerhard Ziemer, MD, PhD
    Professor of Surgery
    Director, Pediatric Cardiac Surgery
    Director, Adult Congenital Heart Surgery
    Co-Director, Chicago Pediatric Heart Center 
    Named a Top Doctor in 2018 by Chicago magazine

PEDIATRIC COCHLEAR SURGERY

  • Dana L. Suskind, MD
    Professor of Surgery and Pediatrics
    Director, Pediatric Cochlear Implantation Program
    Founder and Director, Thirty Million Words Initiative
    Founder and Director, Project ASPIRE 

PEDIATRIC HEPATOBILIARY SURGERY

  • Talia Baker, MD
    Associate Professor of Surgery
    Director, Living Donor Liver Transplant Program
    Surgical Director and Program Director, Liver Transplant Program 
  • John Fung, MD, PhD
    Professor of Surgery
    Chief, Transplant Surgery
    Director, Transplantation Institute

  • Mark Slidell, MD, MPH 
    Assistant Professor of Surgery
    Director, Pediatric Trauma Program

PEDIATRIC LIVER TRANSPLANTATION

  • Talia Baker, MD 
    Associate Professor of Surgery
    Director, Living Donor Liver Transplant Program
    Surgical Director and Program Director, Liver Transplant Program

  • John Fung, MD, PhD
    Professor of Surgery
    Chief, Transplant Surgery
    Director, Transplantation Institute

  • J. Michael Millis, MD
    Professor of Surgery
    Vice Chair, Global Surgery

PEDIATRIC NEUROSURGERY

PEDIATRIC OPHTHALMOLOGY

PEDIATRIC ORTHOPAEDICS

PEDIATRIC OTOLARYNGOLOGY SURGERY

  • Fuad Baroody, MD
    Professor of Surgery and Pediatrics
    Director, Pediatric Otolaryngology
    Named a Top Doctor in 2018 by Chicago magazine

PEDIATRIC PLASTIC/CRANIOFACIAL SURGERY

PEDIATRIC UROLOGY SURGERY

  • Mohan S. Gundeti, MD
    Professor of Surgery, Pediatrics and Obstetrics and Gynecology
    Director, Pediatric Urology
    Named a Top Doctor in 2018 by Chicago magazine
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Pediatric Surgery Special Programs

ADVANCED CANCER THERAPIES Neuroblastoma Surgery, Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Thomas K. Lee, MD
Professor of Surgery

Grace Mak, MD
Associate Professor of Surgery
Program Director, Pediatric Surgery Fellowship
Medical Director, Comer Children’s Hospital Operating Rooms

ECMO AND SURGICAL CRITICAL CARE

Nikunj K. Chokshi, MD
Assistant Professor of Surgery
Director, Pediatric Surgical Critical Care

FETAL CONSULTATION

Erik Barthel, MD, PhD
Assistant Professor of Surgery

Deborah Loeff, MD
Assistant Professor of Surgery
General Surgery Team

TRAUMA

Mark Slidell, MD
Assistant Professor of Surgery
Director, Pediatric Trauma Program

VASCULAR ANOMALIES

Jessica J. Kandel, MD
Mary Campau Ryerson Professor of Surgery
Chief, Pediatric Surgery

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