Landon’s Life-Saving Jejunal Atresia Surgery

Lizette Lough, experiencing a seemingly normal pregnancy, was making final preparations to welcome her first baby, when her water unexpectedly broke at 33 weeks. She was rushed to San Antonio Regional Hospital in Upland, close to home, where her son Landon was born early on May 3, 2016.

After a few days in the hospital, Lizette and her husband Sean noticed the baby had not made a bowel movement. Tests revealed that Landon had an obstruction in his intestine. His physician recommended Landon be transferred immediately to CHOC for an emergency surgery with Dr. Peter Yu, a pediatric general and thoracic surgeon.

“My husband and I lost it,” Lizette says. “Our baby was only three days old and weighed about 4 pounds. The thought of surgery was beyond frightening.”

Upon arrival at CHOC, the Loughs were immediately made to feel at home by the staff, who helped them find a nearby hotel. Dr. Yu explained every scenario of the complex surgery in a compassionate and confident manner, the Loughs recall.

Jejunal atresia
Landon was born at 33 weeks and diagnosed with jejunal atresia, despite prenatal genetic testing and a healthy pregnancy.

“Landon was in stable condition when he arrived at CHOC, and I’m very pleased that our expert transport team was able to get him here quickly and safely. If there had been a delay in transfer, Landon could have become very sick and it’s very possible that more of his intestine could have died. If that would’ve happened, he may not have had enough bowel to adequately digest food, which can be incompatible with life,” Dr. Yu says.

Landon was diagnosed with jejunal atresia, a rare condition – approximately 1 in 5,000 births – in which the small intestine is incompletely developed, leading to one or more gaps, or blockages, in the intestinal tract.

Lizette had gone through the required genetic tests prior to Landon’s birth, and jejunal atresia – often diagnosed prenatally – was not detected.

Additionally, Landon had malrotation of his intestines, which failed to coil in the proper position in the abdomen. This led to twisting of his bowel. If surgery had been delayed for longer, Landon could have died.

Landon’s surgery involved making an incision on his abdomen, examining the entire length of his intestine and untwisting it, removing the dead bowel, stitching together his small intestine, and performing a Ladd’s procedure. A Ladd’s procedure places the intestines back into the abdomen in a safe configuration to prevent future twisting of the bowel.

jejunal atresia
Landon and his dad Sean in the surgical NICU at CHOC after Landon’s jejunal atresia surgery

Sean, who works as a law enforcement officer, recalls how traumatic this was for his family. “I’m used to working in stressful situations, but this was a different kind of stress,” he says. “We were so happy that our baby had a successful surgery and that he was better. However, we were still waiting for him to have his first bowel movement. We were trying to stay positive.”

After his first bowel movement indicated that his intestines were recovering well, and spending about a month in CHOC’s surgical NICU, Landon was finally able to go home with his family.

jejunal atresia
Landon and his mom Lizette during his first feeding, which took place in the surgical NICU at CHOC after his jejunal atresia surgery

“It takes a team to successfully care for sick babies and complex patients,” Dr. Yu explains. “Landon would not have had the excellent outcome that he had without our wonderful neonatologists, experienced and skilled pediatric anesthesiologists, Melissa Powell, our dedicated surgical neonatal nurse practitioner, and the outstanding NICU nurses who have dedicated their lives to taking care of newborn babies such as Landon and countless others. Together, we have the only dedicated surgical NICU in the area, with a special focus on taking care of newborns with surgical problems.”

Thanks to the expert multidisciplinary care provided at CHOC, today Landon is a happy baby, meeting all his milestones. The Loughs are enjoying their brave little boy, and look forward to his first birthday next month.

jejunal atresia
Landon is looking forward to celebrating his first birthday at home with his parents.

“Dr. Yu and the nurses in the NICU were so empathetic and amazing. They saw us through so much throughout our stay and we will forever be thankful,” Lizette says.

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10 Questions to Ask Your Child’s Anesthesiologist

By Dr. Eric Ontiveros,  chair of pediatric anesthesiology at CHOC Children’s

You want to know your child who needs surgery is in the best hands. Kids’ bodies are completely different inside, and pediatric specialists know the difference. Pediatric anesthesiologists at CHOC Children’s, who lead your child’s surgery team, have compiled a list of questions commonly asked before surgery. Any question about your child is a good question. If there is ever anything you do not understand, ask your child’s surgery team.  They are there to help.

Am I allowed to be with my child before surgery? If so, for how long?

Before surgery, you and your child will be taken to the pre-operative unit, or “pre-op.”  A nurse will review the information needed to safely perform the child’s procedure. The surgeon and the anesthesiologist will evaluate your child and answer any questions you have. You will be asked to sign any necessary paperwork and then accompany the child to the operating room doors. After another hug and kiss, the team will assume care of your child.

Am I allowed to be with my child while anesthesia is being given?

You child’s safety is our biggest priority. Having a parent in the operating room can distract the team’s focus away from your child. To ensure the safest environment possible for your child, you will be taken to the waiting room.

Will my child have pain when getting an IV?

Depending on the child’s age and planned procedure, we may start an IV in the pre-op unit. An IV is a small plastic tube inserted into the vein and  used to deliver medication. Depending on the age of your child, a small amount of anti-anxiety medicine may be given orally before placement of the IV. The staff will also use special numbing medicine to reduce the discomfort of IV insertion. A child life specialist will provide age-appropriate distractions such as books, games, or bubbles to aid in the process.

What kind of anesthesia will my child be given?

Anesthesia is broken down into three main categories: General, Regional, and Local.

General anesthesia makes and keeps a person completely unconscious (or “asleep”) during the operation. It can be administered through an IV, or by inhaling an anesthesia gas delivered by mask.

Regional anesthesia is when a drug is injected near the spinal cord, numbing a large area of the body. An example is an epidural. It is often combined with general anesthesia in kids and used for pain control after the surgery.

Local anesthesia numbs a small, specific area of the body- for example, a foot, hand or patch of skin. It can be given as a shot, spray or ointment. Local anesthesia is often used to reduce the pain after surgery.

The anesthesia your child receives is tailored to their needs and depends on factors including:

  • The type of surgery
  • The location of the surgery (hospital, outpatient surgery center or doctor’s office)
  • How long the surgery will take
  • Current and previous medical condition
  • Previous reactions to anesthesia (in your child or family members)
  • Medications your child is currently taking
  • Age, height and weight

No matter which type of anesthesia your child receives, your anesthesiologist will be available before, during and after the operation to monitor the medications your child receives and ensure they are receiving the right amounts.

Will my child be sedated before anesthesia is given?

Your child may receive medication to help them remain calm and feel sleepy before the procedure or surgery. This medication is usually given by mouth and before starting the IV. Many children are curious about the operating room and prefer to experience falling asleep in the OR, so they skip the sedative.

Will my child still have an IV in or be hooked up to any monitors or equipment after surgery is over?

Your child will usually wake up with their IV in place. This is helpful as additional medications are sometimes needed to treat pain or nausea. Your child will also wake up with several monitors that help the anesthesiologists and nurses monitor your child’s recovery from anesthesia. These monitor blood pressure, heart rate and oxygen levels. As your child recovers from anesthesia, the IV and monitors will be removed.

How long will it take my child to fully wake up from general anesthesia?

The anesthesiologist will begin to “wake up” your child after the surgery is completed. This amount of time varies from child to child and is dependent on their medical history and type of surgery performed. This can take up to an hour, and most children wake up in the recovery room (also referred to as the post anesthesia care unit, or PACU) in a shorter amount of time. Full recovery can take up to several hours.

How soon after the surgery can I see my child?

After the surgery is completed, the surgeon will speak with you in the Tidwell Procedure Center lobby. It may take an additional 20 to 30 minutes for the nursing staff and anesthesiologist to recover your child from anesthesia before having you enter the recovery room (PACU).

How soon after the surgery can my child eat, drink, go to school, or drive [if you have a teen]?

If your child is going home after surgery, the nurse will offer your child a snack and drink in the recovery room. No driving for teens the day of surgery. The surgeon will provide a school note if time off is required. If a hospital stay is required, and depending on the procedure, the surgeon will order the appropriate diet.

How soon after the surgery can my child go home?

Children usually spend 30-90 minutes in the recovery room. Patients heading home will be provided a discharge plan. This plan may include instructions on how to take care of the operative site, what medications to take, what your child should eat that day, and what activities the child may participate in. It will also have instructions on what to look out for and when to call the doctor. Download a copy of the discharge questions worksheet.

You will receive a phone call from a CHOC nurse within 72 hours of the patient’s discharge from the hospital. Our nurse will ask about how the child is feeling and will be able to answer any additional questions you may have.

Download these questions and answers.

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A Road Map to Surgery at CHOC Children’s

Having surgery at a hospital can be a scary thought for children and parents, alike.  Knowing what to expect can help alleviate fear and anxiety.  The photos below highlight some key aspects of the patient and family journey through the Tidwell Procedure Center at CHOC Children’s Hospital.

surgery at choc

Welcome to CHOC Children’s Hospital – a hospital for children and teens, only. When a child requires surgery, his needs are different than an adult. CHOC has specialized in pediatric surgery since we welcomed our first patient in 1964. Today, our nationally recognized surgeons perform the latest procedures using equipment customized to pediatric patients, from newborns to adolescents.

surgery at choc

After checking in at our first floor lobby, surgical patients and their families are directed to our Tidwell Procedure Center, which includes seven operating rooms, five procedure rooms and two cardiac catheterization labs. The Center boasts leading-edge technology and safety features, as well as a calm, healing environment. Here’s the Center’s bright, colorful lobby, featuring natural light, bubble columns and interesting artwork. There’s also a family room and playroom.

surgery at choc

We want our patients and their siblings to still have the opportunity to act like kids while facing the adult issues of surgery. In addition to a playroom in the lobby, we have an area for play, stocked with books and toys in pre-op. Dedicated child life specialists help normalize the experience by making the environment less strange. Providing distraction and developmentally appropriate education, child life specialists are important members of the surgical team.

surgery at choc

Child life specialists are at the bedside to provide developmentally appropriate education. Patients are able to see pictures of the operating rooms on iPads, which helps to limit stress and anxiety without the use of medication.

surgery at choc

Before heading into the operating room, patients stop at what is affectionately called the “kissing spot.” Here’s where they can say “see you later” to their loved ones before “taking a nap” for surgery.

surgery at choc

Child life specialists escort patients into the operating rooms and to provide distraction and emotional support while pediatric anesthesiologists and other staff members prepare patients for surgery.

surgery at choc

Following surgery, patients recover in our PACU (post anesthesia care unit). As soon as the patient is stabilized, parents/legal guardians are escorted into the area. During this time, patients need as much rest as possible to help their bodies heal and give pain medication time to take effect. The environment is kept calm and quiet. From here, the patient will either be taken to a hospital room, or discharged home.

Our physicians, nurses and staff are dedicated to getting kids better and back to their normal activities as quickly as possible. Patients and families are our partners in this effort; knowing what to expect before, during and after surgery can make a big difference on the experience and recovery. For more information, visit www.choc.org/surgery.

Take a virtual tour of the Tidwell Procedure Center

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A Day in the Life of Pediatric Surgeon Dr. Peter Yu

By Dr. Peter T. Yu, pediatric general and thoracic surgeon at CHOC Children’s

5:00 a.m.: Alarm rings. I hit snooze once, for an additional 9 minutes of peace. Then it is time to get up and at ’em. In the dark, I attempt to avoid injuring myself on the various toys that are strewn about the house–one of the hazards that comes with raising young children. I start the coffee maker, brush my teeth, shave, get dressed and kiss my slumbering family good-bye. Then it is off to swim practice.

7 a.m.: Swim practice is over. Fatigued but happy, I shower and joke with the teammates on my masters swim team. I am grateful for my health and momentarily enjoy the small personal accomplishment of having completed my workout for the day.

7:30 a.m.: After navigating moderate traffic and enjoying NPR, I arrive at CHOC. I meet with the very kind family of my first patient, a 5-year-old boy who is having inguinal hernia/hydrocele surgery today. In children, an inguinal hernia is a small, congenital opening in the groin that allows communication between the abdomen and the scrotum in boys and the labia in girls. Thus, things like fluid, fat, omentum or intestines can pass through this opening, creating a bulge and sometimes causing pain. A hydrocele is related to an inguinal hernia and is due to fluid that has passed from the abdomen, through the opening, and into the scrotum. Inguinal hernias occur in about 1-5 percent of all children. Hernia and hydrocele surgery are routine operations for all pediatric general and thoracic surgeons and, as expected, the operation goes smoothly.

9:00 a.m.: For my second operation of the day, Dr. Mustafa Kabeer, a fellow pediatric general and thoracic surgeon, and I perform a minimally invasive Nuss procedure on a teen athlete. This patient, who hopes to earn a college scholarship, has pectus excavatum or sunken chest, the most common congenital chest wall abnormality in children. For many, this is far more than a cosmetic problem. Using small incisions that will ultimately be well-hidden in this patient’s armpits, we are able to insert a metal bar between his heart and his chest wall that helps to pop the sternum out into normal position. This bar will stay in place for three years, before it is removed in an outpatient procedure. Our operation today took only 2 small incisions and 45 minutes of operating time. We prefer the minimally invasive Nuss procedure to the older, more invasive Ravitch procedure since it achieves a wonderful outcome with less pain, minimal blood loss and only tiny, hidden scars.

10:00 a.m.: As the anesthesiologist and the operating room staff prepare for my final case of the day, I walk over to the surgical neonatal intensive care unit and medical/surgical unit to make rounds and touch base with my team of excellent, experienced surgical nurse practitioners (NPs). Not a day goes by that I am not thankful for their contributions to the outstanding care of our surgical patients at CHOC. Currently, on the surgical floor, I have patients who have recently had appendectomies, a cholecystectomy (removal of the gallbladder), lysis of adhesions (cutting of intra-abdominal scar tissue) to treat a small bowel obstruction, port placement for chemotherapy, and a Nissen fundoplication for gastroesophageal reflux disease. In the NICU I have one baby with congenital diaphragmatic hernia whom I recently placed on ECMO (extracorporeal membrane oxygenation), state-of-the-art technology that supports the heart and lungs by taking over the heart’s pumping function and the lung’s oxygen exchange. A second patient of mine in the NICU is a baby who recently had esophageal atresia/tracheoesophageal fistula surgery to repair a congenital defect where the trachea, or windpipe, abnormally communicates with the esophagus, or food tube. Fortunately, all patients are doing well, I am able to address the questions of each of my patients and their parents, and the NPs and I come to a consensus on the plan of care for the day for each one.

dr peter yu
Dr. Peter Yu, pediatric general and thoracic surgeon at CHOC Children’s

10:30 a.m.: Once rounds are done, I head back to the operating room for my final case of the day, a thoracoscopic lung lobectomy. This is one of my most favorite operations and is my area of expertise. This 3-month-old patient was diagnosed prenatally when an ultrasound showed a congenital lung lesion, also known as a CPAM (congenital pulmonary airway malformation, formerly known as CCAM). This diagnosis is becoming more and more prevalent, occurring in about 1 in every 5,000 babies. Fortunately, more than 90 percent will be symptom-free during pregnancy and after birth, allowing pediatric general and thoracic surgeon such as myself to hold off on surgery until the infant is a few months old and better able to tolerate the stress of an operation. Even though infants with CPAMs may be asymptomatic, it is still recommended that these lesions be removed because they can often become infected and, in rare instances, may become a cancer later in life. The benefit of operating sometime during the first several months of life is that the CPAM has yet to become infected, making surgery easier and allowing for a minimally invasive removal. Thanks to the patient’s young age, the remaining portion of her healthy lung will grow in size and compensate for the removed lobe.

Thoracoscopic lung lobectomy is extremely technically challenging because the surgeon navigates major blood vessels such as the pulmonary artery and pulmonary vein, and operating time can vary from two to six hours depending on a patient’s particular anatomy. Fortunately, this little baby’s anatomy is favorable and I am able to complete the minimally invasive operation in about 2 hours with minimal blood loss and an excellent outcome. After surgery, I have the privilege of giving her parents good news, which is always the best part of my work day. I anticipate that she will have a two-day hospital stay with minimal pain and no complications, and her tiny scars will ultimately be unnoticeable by others (except for mom! Pediatric surgeons know that moms see everything J).

1:00 p.m.: I have a quick lunch with my NPs and Dr. David Gibbs, another pediatric general and thoracic surgeon at CHOC who is also the medical director of trauma. He has established the excellent trauma program we have here, the only trauma center in Orange County that is exclusively dedicated to children. We take a moment to enjoy each other’s company, get trusted input on current clinical situations, and catch our breaths from this very typical, fast-paced workday.

2:00 p.m.: I participate in a fetal counseling session. Given my special training in fetal surgery, I work closely with community perinatologists (also known as high-risk obstetricians or MFMs–maternal fetal medicine physicians) to counsel expectant mothers and fathers on what to expect when their baby has been diagnosed in utero with a condition that will require surgery.

Today, I meet with parents whose daughter has been prenatally diagnosed with congenital diaphragmatic hernia, or CDH. Simply put, CDH is a hole in the diaphragm, which is the muscle that divides the abdomen from the chest. The diaphragm helps us breathe, and a hole here allows things that are normally in the abdomen, such as the liver or intestines, to pass into the chest. Besides potentially compromising the intestine itself, this can also lead to small lungs (pulmonary hypoplasia) which may not be able to adequately oxygenate the body. Another severe consequence of CDH is pulmonary hypertension, which is abnormally high pressure in the blood vessels of the lungs. This is a problem because a newborn’s heart must work extra hard to pump blood into this abnormal high-pressure system, which can lead to heart failure and death if not appropriately treated.

I go over the diagnosis with mom and dad, and explain to them that, after birth, their baby will require a breathing tube and ventilator to support her small lungs. Special inhaled and intravenous medications will be used to decrease the high blood pressure in the blood vessels in the lungs and to help support her beating heart. If these measures are not enough, we will need to use ECMO. If ECMO is needed, I will perform a surgery to make an incision on her neck to access her carotid artery and jugular vein so that ECMO catheters can be placed.

Ultimately, once their daughter’s heart and lung condition has stabilized—which may take days to weeks after birth—I will repair the congenital diaphragmatic hernia. To do this, I will make an incision on the abdomen, move the intestines and liver from the chest back into the abdomen, and stitch the hole closed.

I am careful to be upfront and honest about the situation: CDH is a serious and frequently life-threatening condition and the national average for survival is approximately 65 percent. Their daughter will likely require a two to three month stay in our NICU and may need to go home with supplemental oxygen and special medications for a period of time. However, I’m able to reassure them as well. Nearly 90 percent of newborns that have this surgery at CHOC survive. At CHOC, we are fully equipped and have the expertise to handle any possible outcome, thanks in part to our surgical NICU, the only one of its kind of the west coast.

Mom and dad are tearful at the gravity of their daughter’s situation but they also express how grateful they are for the opportunity to learn more about CDH, have their questions answered, and leave feeling better prepared for the next steps. They know they can contact us at any time, day or night, and we will be there to address any problem and provide support. They also feel relieved that they will be surrounded by familiar, trusted faces when their daughter is born.

3:00 p.m.: I head back to my office with some precious time to complete some homework—yes, I said homework—and work on research projects. Believe it or not, I have gone back to school to get my Master of Public Health degree from Johns Hopkins University. This is feasible because I am able to complete the majority of my coursework online. I wanted to get this additional degree to gain knowledge and experience in outcomes research, a relatively new branch of public health research that seeks to understand the end results of particular health care practices and interventions. While pursuing this degree, I am simultaneously working on outcomes research projects with my research partner, Dr. Yigit Guner, another pediatric general and thoracic surgeon at CHOC. Together we are utilizing large national databases to create risk calculators that can help better predict CDH outcomes, as well as predict outcomes in other neonatal diseases such as VACTERL (vertebral defects, anal atresia, cardiac defects, trachea-esophageal fistula, renal anomalies, and limb abnormalities).

6:00 p.m.: I head home for the day. En route, I call my mother who lives out-of-state to check in. My father recently passed away after a long struggle with illness and I just want to make sure she’s doing alright. She assures me that she is, and stubbornly resists my suggestions to have her move to Orange County. She is happy and comfortable in her home, which makes me happy as well, but I am concerned that I will be unable to adequately help her in the years to come should her health someday fail.

6:30 p.m.: I’m happy to be home with my family. It’s dinner time and I’m famished. I relish the chance to catch up on the day’s events with my wife and kids. I play with the kids for a bit and then it is time to help my oldest with homework. After that, my wife and I get all the kids ready for bed and tuck them in.

9:00 p.m.: My wife and I finally have a precious moment to ourselves. We watch a favorite TV show together and I barely make it to the end before falling asleep. It feels so good to lie in bed, with the cool night breeze filtering in through my bedroom window. I dream of my family, work and old friends. Tomorrow, I have clinic and then I will spend the remainder of the day and night in the hospital, as I am on call for any pediatric general, thoracic and trauma emergencies that come to CHOC. I feel so blessed to have the family that I have, and to be able to do the meaningful work that I do.

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7 Things You Didn’t Know about Pediatric Anesthesia

By Dr. Eric Ontiveros,  chair of pediatric anesthesiology at CHOC Children’s

Finding out that your child needs surgery can be scary for parents to hear. You want to know that your child is in the best hands possible, and the nationally ranked surgeons and pediatric anesthesiologists at CHOC Children’s specialize in the care of kids. Your child’s pediatric anesthesiologist is not only an important member of your child’s surgery team but also the entire perioperative experience (before, during, and after surgery).

7 things you may not know about pediatric anesthesia:

  1. Before surgery, the preoperative area is the location where you will meet your child’s full surgical team. During this time, questions about your child’s medical and surgical history will be asked and the perioperative plan is adjusted to fit your child’s medical needs.
  2. It is normal for children to feel anxious before surgery. Premedication for anxiety may be administered, either orally or intravenously prior to surgery. This may require the help of a parent. The goal of premedication is to reduce the anxiety and facilitate a smoother transition to general anesthesia. Evidence shows that easing a child’s anxiety prior to heading into surgery may limit the emotional disturbances felt during recovery after surgery. Child life specialists are also available, and may use distraction, video or music therapy to calm an anxious patient.
  3. Anesthesiologists will use a multimodal approach to pain management when appropriate. In addition to pain management during surgery and in the recovery room, a particular child and surgery may qualify for a regional anesthesia procedure or “pain block” that will help control postoperative pain during the days following surgery.
  4. For younger children who meet specified criteria, an inhalational technique may be used to initiate general anesthesia. This technique administers anesthesia through a mask (with a flavor of your child’s choosing) and avoids the placement of an IV until after your child is asleep. For older children, an IV may be placed in the preoperative area after receiving anti-anxiety medicine in oral form.  This allows general anesthesia to be administered in IV form.
  5. You know you’re not supposed to eat or drink anything before surgery. But do you know why? When general anesthesia is administered, your muscles relax, including the muscles in your stomach and esophagus. The body’s reflex to swallow is also briefly suspended during anesthesia. This combination makes the lungs vulnerable to aspiration of food, which can be very dangerous. Abstaining from food for 8 hours prior to surgery is very important for the safety of anesthesia for your children.
  6. Common side effects of general anesthesia include nausea, vomiting, itchiness and something called emergence delirium. Emergence delirium lasts 5-15 minutes and happens during the process of waking up. It usually goes away on its own but can be very concerning for parents because your child may not recognize or respond to you. If your child experiences any of these symptoms after a procedure, their care team will be available to provide appropriate medication to treat those side effects.
  7. Difficulty sleeping may occur for a few nights after a surgical procedure. Night terrors are a common occurrence in children ages 3-6 who have had ear, nose and throat procedures. This difficulty sleeping is often troubling for parents but will typically resolve after a few days and requires no additional treatment. Maintaining a consistent bedtime routine as well as eliminating sources that may interfere with sleep (caffeine, sugar, high energy activities and electronics before bedtime) may help in dealing with these disturbances.

The more information you have, the calmer you and your child will be prior to surgery. Parents are encouraged to ask as many questions as possible when you meet their child’s anesthesiologist, before or after surgery.

In the video below, a pediatric general and thoracic surgeon answers parents’ most common questions about surgery and anesthesia:

Video: Get answers about anesthesia

 

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Skin Lumps: When Parents Should Worry

Noticing a skin lump on a child can be scary for parents, and it’s easy to automatically assume the worst. Fortunately, most skin lumps are benign and not a major cause for concern, according to Dr. Saeed  Awan, a pediatric general and thoracic surgeon at CHOC Children’s.

skim lumps
Dr. Saweed Awan, pediatric general and thoracic surgeon at CHOC Children’s, offers advice on skin lumps

Some children are born with skin lumps, and some lumps appear later. The majority of patients with skin lumps will not have any other symptoms, but they can include pain, bleeding, redness, loss of appetite and night sweats. Surgery is often recommended in order to remove these skin lumps, to avoid the risk of infection.

Lymph nodes are the most common lumps that parent notice and worry about. Most parents find lymph nodes in the neck area but can also notice them around the ears and at the back of the skull.

“A pea-sized, rubbery node beneath the skin is nothing to worry about,” says Dr. Awan. “Healthy lymph nodes fluctuate in size- they grow and they shrink, but bad lymph nodes keep growing and are not subtle.”

A lymph node over one centimeter in diameter needs further investigation by a medical professional, especially when associated with loss of weight or appetite, fever or night sweats.

Dermoid cysts, another common lump, typically appear at the part of the eyebrow closest to the temple, but can occur in the middle (midline) of the neck or in the upper chest area. They are rubbery and the size of a pea. These cysts generally do not pose a hazard to your child’s health, but are typically removed to prevent infection. A midline dermoid cyst on the scalp needs more investigation from a pediatric surgeon.

Another common lump is pilomatrixoma, which usually appears on the face, neck or arms, and originates in the hair follicles. It usually manifests as a solitary, asymptomatic, firm nodule.

Hemangiomas develop in the skin when there is an abnormal buildup of blood vessels. This can occur at birth or shortly after. These lumps may increase in size during the first year and then go away on their own over the next three to four years. Most of these do not require surgery unless they are blocking the airway, vision or nostril. Lymphangiomas are rare, but are characterized by swelling on the side of neck.

Thyroglossal cysts are the most common cause of midline neck masses and are generally located just below the hyoid bone, yet these neck masses can occur anywhere along the path of the thyroid gland.

Branchial cysts and sinuses are swelling on the side of the neck. They are typically removed in order to prevent infection.  There are pre-auricular sinuses or skin tags. All of these need to be removed to prevent infection

If you see a skin lump on your child, consult your primary care doctor. If the lump changes size or color, or there is pain associated with the bump, or your child also experiences weight loss or appetite loss, night sweats or a fever, urgent evaluation and further investigation is needed.

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CHOC Children’s Expands Plastic Surgery Services

A pediatric plastic surgeon specializing in reconstructive plastic surgery has joined CHOC Children’s. Dr. Raj Vyas sees patients with a variety of complex conditions including clefts and craniofacial anomalies.

plastic surgery
Dr. Raj Vyas

“Care at CHOC is delivered in such a multidisciplinary fashion, allowing for complex higher-level discussions and nuanced treatment planning in both standard and exceptional circumstances. There is also an emphasis on safety and process improvement, both critical for a state-of-the-art facility serving a complex and diverse patient population,”Dr. Vyas says.

During his third year of medical school at UCLA David Geffen School of Medicine, the  Southern California native discovered that plastic surgery was his newfound passion.

“I unexpectedly fell in love with plastic surgery, particularly craniofacial surgery,” Dr. Vyas explains.  “My appreciation for the depth and breath of plastic surgery grew from my experiences during this rotation in medical school. I remember seeing a child with hypertelorism undergo a facial bipartition and I was fascinated.”

Following medical school, he completed a plastic surgery residency in Boston at the Harvard Combined Plastic Surgery Residency Program. He then completed a craniofacial surgery fellowship at New York University Medical Center, where he treated children and adults undergoing facial reconstruction for congenital anomalies or after suffering trauma and cancer. He also gained expertise in microvascular surgery and virtual surgical planning.

Dr. Vyas is working with the team at CHOC to build a multidisciplinary program in facial reanimation. By combining craniofacial surgery with microsurgery, he hopes to restore facial form and function in children and teens with facial paralysis.

“We have a great team at CHOC. Dr. Daniel Jaffurs has been an incredible mentor,” Dr. Vyas says. “My goal is to help make the program the best in Southern California and beyond.”

Dr. Vyas enjoys working with virtual scanning and 3D modeling technology available at CHOC, as it helps him plan and ensure optimal safety and precision before a procedure.

“Today, we are able to use cone beam CTs to significantly minimize radiation exposure while still obtaining high quality 3D imaging. This allows for virtual surgical planning that is both precise and extremely effective in reducing uncertainty in the OR,” Dr. Vyas explains. “In neonates with upper airway obstruction, for instance, who are scheduled to undergo mandibular distraction, we are able to customize bony osteotomies in a way that prevents injury to dental structures and nerves, while optimizing distraction vectors that improve the airway and maintain cosmetic considerations. We can also virtually anticipate the extent of facial movements and design custom splints that facilitate orthognathic (upper and lower jaw) surgery. The benefit of these types of pre-planned procedures are expanding as surgeons utilize this technology in a variety of craniofacial reconstructions.”

When this dedicated physician is not busy helping patients at the hospital, he volunteers with Global Smile Foundation, a nonprofit organization that treats children with facial congenital deformities in underserved countries. Most recently he went to Trujillo, Peru, where he helped over 100 patients.

“It’s so rewarding to work with children,” he says. “Their reconstructions have a long-life impact.”

Dr.Vyas is board certified in plastic surgery and a member of the American Society of Plastic Surgeons, American Society of Craniofacial Surgery, American Cleft Palate-Craniofacial Association and International Cleft Lip and Palate Foundation, among other professional organizations.

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Tips for Minimizing Scarring After Surgery

A child’s skin is much different than an adult’s skin, and has the potential to react to scarring much different than the way their parents’ might. In this episode of CHOC Radio, Dr. David Gibbs, a pediatric surgeon and the director of trauma services at CHOC, discusses tips for minimizing scarring after surgery, including:

  • Which children are more predisposed to scarring
  • What pediatric surgeons at CHOC do during surgery to help minimize scarring
  • What parents can do in the year after surgery to help mitigate scarring
  • Other advice for parents whose child is preparing for surgery

CHOC Radio theme music by Pat Jacobs.

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Know the Risks of Pectus Excavatum (Sunken Chest)

Pectus excavatum, or sunken chest, is the most common congenital chest wall abnormality in children. Although some may think of the abnormality as purely a cosmetic problem, the limited chest cavity space can displace the heart as well as limit lung capacity, says Dr. Mustafa Kabeer, a pediatric surgeon at CHOC Children’s. Fifteen percent of patients can experience arrhythmia (an abnormal heart rhythm) or mitral valve regurgitation, wherein the heart valves allow blood to leak back into the heart, as a result of the inward compression from the sternum.

pectus excavatum
Dr. Mustafa Kabeer, pediatric surgeon at CHOC Children’s

Surgery to expand the chest wall can eliminate many symptoms. The pediatric surgeons at CHOC perform the Nuss procedure to repair pectus excavatum.

The Nuss procedure is a newer, minimally invasive procedure that dramatically reduces the appearance of incisions and the time spent in the operating room. A small incision is made on either side of the chest, and a small camera is inserted for observation as the surgeon passes a thin, curved metal bar through the chest cavity below the sternum. When the bar is flipped, the sunken chest is instantaneously repaired. The bar remains in place for two years, and is periodically monitored by a pediatric surgeon.

A historical approach to these surgeries involved a large incision across the chest, and up to six hours in the operating room as the chest wall was taken apart and then reconstructed, known as the Ravitch procedure. There can also be significantly greater blood loss with the Ravitch procedure, and virtually none with the Nuss procedure.

The pectus excavatum team at CHOC is comprised of experts in pediatric pulmonology, cardiology and surgery. The multidisciplinary team performs various tests to examine heart and lung function, before and after surgery. By using the latest techniques in minimally invasive surgery, along with recent improvements in pain management, patients are able to return home and get back to their daily activities sooner than ever before.

Although the cause is unknown, 40 percent of patients report a family history of pectus excavatum, and 40 percent of cases occur in tandem with scoliosis, says Kabeer.

Parents may notice an indentation in their child’s chest wall either when they are first born, or closer to puberty, when changes in the chest wall can become more pronounced.

“When pectus excavatum presents itself closer to puberty, it may be difficult for parents to notice, since teens or pre-teens are more clothed than they were as babies, so their parents might not see the change in their chest wall right away,” says Kabeer.

Warning signs tend to be subtle, but if your child experiences frequent shortness of breath, difficulty breathing during exercise, chest pain or light- headedness, or otherwise is not able to keep up with their peers, consult your child’s primary care physician, who may refer you to a pediatric surgeon or pectus excavatum specialist.

Learn more about CHOC’s surgical services.

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Meet Dr. Maryam Gholizadeh

CHOC Children’s wants its patients and families to get to know its specialists. Today, meet Dr. Maryam Gholizadeh, a pediatric surgeon. Dr. Gholizadeh attended medical school at George Washington University, and completed her residency at Eastern Virginia Medical School. She completed a pediatric surgery fellowship at Children’s National Medical Center in Washington D.C., and a pediatric surgical oncology fellowship at Memorial Sloan Kettering Cancer Center in New York. She is currently the chair of pediatric surgery, and a member of the credentialing, medical executive and medical staff performance committees. She has been on staff at CHOC for 13 years.

Dr. Maryam Gholizadeh

Q: What are your special clinical interests?

A: All aspects of pediatric and neonatal surgery, surgical oncology and minimal invasive surgery.

Q: What are your most common diagnoses?

A: Appendicitis, hernias, lumps and bumps, as well as complex congenital pediatric and neonatal conditions.

Q: What would you most like community/referring providers to know about your division at CHOC?

A: As a general pediatric surgery division, we can take care of a variety of conditions such as hernias, hydroceles, gastrointestinal conditions requiring surgery, thoracic conditions, oncological problems requiring surgery such as neuroblastoma, Wilms’ tumor and teratomas.

Q: What inspires you most about the care being delivered here at CHOC?

A: We have a great group of specialists at CHOC who can deliver a high quality of care to our patients.

Q: Why did you decide to become a pediatric surgeon?

A: I decided to become a pediatric surgeon when I was a third year surgical resident on pediatric surgery rotation. Pediatric general surgery is the only field where you are able to take care of a variety of conditions. I found this field extremely rewarding, at the same time challenging.

Q: If you weren’t a physician, what would you be and why?

A: An athlete. I love the challenge, the discipline, and the fact you are always trying to do your best.

Q: What are your hobbies/interests outside of work?

A: Running, cycling, skiing and playing with my dogs.

Q: What was the funniest thing a patient told you?

A: There was a young child around 8-9 years old and we were going to remove his appendix with laparoscopy. I was standing on his left side because with laparoscopy we make our incision on the left side. Just before he went to sleep he looked up at me and said, “Why are you standing on my left? My appendix is on the right.” I was amazed at how knowledgeable this kid was!

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