Journal of pediatric surgery最新文献

Background: Global outcomes after esophageal atresia (EA) repair vary widely, yet contemporary data from resource-constrained Middle Eastern settings are scarce. Characterizing risks and care gaps can guide quality improvement. This retrospective study addresses this gap and quantifies mortality, complication severity, feeding status, and determinants of hospital length of stay (LOS) after open thoracotomy EA repair.

Design: Multicenter retrospective cohort of infants undergoing EA repair across five West Bank and East Jerusalem hospitals, 1 Jan 2015 to 31 Mar 2025; n=139 repaired cases.

Main findings: Short-term complications occurred in 29.2% (38/130); long-term complications in 67.0% (73/109). Among 98 with any complication: 8.2% were mild, 50.0% moderate, and 41.8% severe. Median LOS was 23.5 days (IQR 15-41). Prematurity prolonged LOS (51.6±45.6 vs 24.2±18.1 days; p=0.001). Mortality was 20.5% (27/131 with outcome). Short-term complications increased mortality (34.3% vs 11.1%; RR 3.09, 95% CI 1.47-6.48). In regression, higher gestational age (GA) reduced mortality (OR 0.58/week, 95% CI 0.38-0.87; p=0.008); delayed repair increased mortality (OR 1.35/day, 95% CI 1.08-1.71; p=0.010).

Conclusion: Complications, especially anastomotic strictures and respiratory morbidity, are frequent. Mortality and morbidity concentrate among clinically vulnerable infants. Earlier repair may mitigate risk.

Purpose: Neonatal intestinal perforation often necessitates urgent surgery, yet whether enterostomy is necessary or primary repair is preferable remains debated. We estimated the short-term effect of choosing enterostomy versus primary repair after adjustment for preoperative severity.

Methods: We screened data from the National Clinical Database-Pediatric registry and enrolled neonates who underwent surgery for gastrointestinal perforation between 2017 and 2022. Patients were categorized into two initial operative strategies: enterostomy and non-enterostomy, defined as primary closure or resection with anastomosis without a stoma. Propensity score matching was performed to adjust for baseline characteristics. The primary outcomes were 30- and 90-day mortality and any unexpected complication within 30 days after the initial operation. Secondary outcomes included anastomotic leakage and unplanned reoperation within 30 days.

Results: Of the 1,297 identified cases, 914 met the inclusion criteria (enterostomy: 773 versus non-enterostomy: 141). The 30-day mortality rate was significantly higher in the enterostomy group (6.7%, p=0.047), without differences in the 90-day mortality or overall complication rates. In the propensity score matched cohort (all ASMDs < 0.15), mortality and overall complications did not differ between groups, whereas 30-day anastomotic leakage was lower in the enterostomy group (odds ratio, 0.13; 95% CI, 0.03-0.6; p=0.009).

Conclusion: After severity adjustment, short-term outcomes after the initial operation were broadly comparable between enterostomy and primary repair. These findings suggest enterostomy is not universally required and primary repair may be reasonable in carefully selected infants. Longitudinal data are needed to assess cumulative morbidity, including stoma closure, beyond this registry snapshot.

Background: At Geneva University Hospitals, the standard treatment for children with complicated appendicitis (CA) includes an appendectomy followed by intravenous antibiotics. Since 2013, the recommended first-line treatment is Ceftriaxone/Metronidazole (CM). If fever above 38.5°C persists for 72 hours postoperatively, a switch to Piperacillin/Tazobactam (PT) is advised. Currently, fever is the sole criterion for switching antibiotics.

Aims: To identify predictive factors for switching from CM to PT and to evaluate the relevance of PT as a first-line treatment in this patient population, since upfront PT treatment may reduce hospital stay by up to three days.

Methods: This retrospective study includes children aged 0-16 years treated for CA at our institution between 2013 and 2023 according to protocol. Two groups were compared: (1) patients who had required an antibiotic switch and (2) those who did not. Variables included demographics, medical history, biomarkers, imaging and surgical findings.

Results: Among 256 patients (median age: 10 years, IQR: 7-13), 39 (15%) required a switch. Multivariate logistic regression analysis showed a significant association between the switch and both high preoperative CRP levels (p = 0.021) and the presence of an intra-abdominal abscess (p < 0.001).

Conclusion: One in seven children with CA required an antibiotic switch. Elevated preoperative CRP levels and intra-abdominal abscess were significantly associated with the need for CM to PT switch. These patients may benefit from first-line PT treatment.

Background/aims: Intra-diaphragmatic extralobar pulmonary sequestration (IDEPS) is an extremely rare congenital lung malformation characterized by non-functional lung tissue within the diaphragm. Although surgical resection is frequently performed, management strategies vary significantly between centers and remain controversial due to difficulties in accurately locating the lesion intraoperatively and the absence of large case series. This retrospective multicenter study analyzes the experience in the treatment of IDEPS and compares the findings with those reported in the existing literature.

Materials and methods: All pediatric patients treated for IDEPS between 2010 and 2024 were included in the study. Data were collected from hospital records. Demographic characteristics, surgical approach, operative time, complications, and postoperative recovery were analyzed. A literature review was also conducted to identify relevant studies on IDEPS in pediatric patients.

Results: Twenty-three patients (24 IDEPS) were identified, with a male-to-female ratio of 1.8:1. The median age at surgery was 8.2 months. Prenatal diagnosis was confirmed in all cases. Surgical approaches included thoracoscopy (n = 11), laparoscopy (n = 8), and open surgery (n = 5). The conversion rate was 1/11 for thoracoscopy and 0/8 for laparoscopy. A double-cavity approach was required in 3 cases. The median operative time was 157 minutes, and the median hospital stay was 4.5 days. Postoperative complications occurred in 4.3% of patients. Histological examination revealed hybrid lesions in 39% of cases.

Conclusions: IDEPS is a rare condition that presents diagnostic and surgical challenges. Surgical resection remains the treatment of choice, with minimally invasive techniques proving effective when the lesion is well localized. Accurate preoperative imaging and timely intervention are essential for achieving successful outcomes, particularly given the frequent occurrence of hybrid lesions. Further studies are warranted to establish standardized management guidelines.

Introduction: Standardized care pathways for appendicitis are safe and effective ways to minimize practice variation and optimize resource allocation. This project aims to improve appendectomy outcomes through the implementation of an enterprise-wide pathway for appendicitis across a multi-hospital children's healthcare system (Nemours Children's Hospital- Delaware (NCH-DE) and Nemours Children's Hospital-Florida (NCH-FL).

Methods: A multidisciplinary team was convened to create a standard approach to care for patients with appendicitis across the Nemours enterprise. The pathway included standardized antibiotic selection of ceftriaxone and metronidazole, discharge criteria, and a multimodal opioid-sparing analgesic regimen. We evaluated post-operative length of stay (LOS), narcotic prescription at or after discharge, return to emergency department (ED) visits and readmissions 1 year pre- and post-pathway implementation. Special cause variation (SCV) was defined as having eight points above or below center line according to standard criteria.

Results: A total of 560 patients pre-implementation and 781 post-implementation were analyzed. LOS at NCH-FL decreased for both uncomplicated (mean 0.19 to 0.12 days) and complicated appendicitis (mean 3.87 days to 3.28 days), both meeting criteria for SCV. NCH-DE LOS remained stable for both uncomplicated and complicated appendicitis. Narcotic prescriptions at NCH-FL decreased from 35.0% to 0% after pathway implementation. NCH-DE baseline narcotic prescription rate was 0.2% and it remained stable at 0% post-implementation. There were no increases in returns to system.

Conclusion: An appendicitis pathway can successfully be scaled and implemented across a children's hospital system, decreasing LOS and narcotic prescriptions at discharge without increasing returns to the system.

Purpose: End-of-life decision-making in neonates with surgical necrotizing enterocolitis (NEC) is complex and varies between clinicians depending on their interpretation of clinical variables. This study aimed to create transparency in this variability and assess its impact on the use of Behavioral Artificial Intelligence Technology (BAIT) as a tool to inform clinical decision making.

Methods: Attendees of multidisciplinary team meetings where the decision between surgery and comfort care was made for a neonate with surgical NEC were asked to interpret clinical variables required for BAIT. Variability in interpretation was analyzed using standard deviations, and assessed for correlation with variability in BAIT predictions using Spearman's rank correlation. Linear mixed effects models were used to assess the influence of demographics on these predictions and Spearman's rank correlation evaluated association with personal treatment preference, aiming to identify factors contributing to inter-rater differences.

Results: The largest variations were observed in the interpretation of growth since birth (SD=0.29), congenital comorbidities (SD=0.26), and hemodynamics (SD=0.23). Variability in variable interpretation correlated to variability in BAIT predictions (ρ=0.782, p<.001). Clinicians' specialty was the primary factor contributing to these variations, and there was a significant association between treatment preference and model prediction (ρ=0.552, p<.001).

Implications: The decision-making process is highly complex and influenced by personal factors. BAIT can offer transparency into these variations and serve as a reflective tool for clinicians, enabling more informed and consistent decision-making for surgical NEC.

Aims: Simulation training enhances efficacy and safety of preformed silo deployment in gastroschisis. Limitations of existing simulation models include use of biological material, low fidelity, poor durability, and high cost. We developed a novel gastroschisis simulation model and report its validation and performance in a multicentre interventional study.

Method: Paediatric surgeons collaborated with a medical-model specialist to develop a novel GAstroschisis BaBY (GABBY)-T model. This was validated against two existing simulation models by 15 paediatric surgeons using a Likert scale (1-10) to compare each model (A,B,C) to real-life application, including tactile feedback, realism, and usefulness. Data are presented as median (range). Sixteen GABBY-T models were used to teach preformed silo use as part of a Gastroschisis Interventional Study in 37 hospitals across sub-Saharan Africa. Durability of the models was recorded.

Results: GABBY-T model features non-biological silicone bowel, improved fidelity, and ability to simulate all aspects of preformed silo use for gastroschisis care, at $390/model. Usefulness, realism, tactile feedback (p < 0.01) and overall experience (p < 0.05) were all rated significantly higher in the new model compared to the other models (A = 9, 8, 8, 9), (B = 6, 5, 6.5, 5), (C = 6, 5.5, 5, 6), respectively. 33 % of surgeon participants would recommend older models while 100 % recommended the new model for training. During the Gastroschisis Interventional Study, each model was used >100 times. 5/16 models sustained minor bowel tears without affecting performance. Four models suffered damage requiring replacement components.

Conclusions: The GABBY-T model for preformed silo application simulation outperforms previous models. GABBY-T model has high fidelity and durability at moderate cost, facilitating training of large numbers of healthcare providers.

Introduction: Previous studies demonstrated that smoking is a risk factor for gastroschisis. Since smoking rates among young adults have declined, we hypothesized that this would be associated with a concurrent decrease in gastroschisis rates among live births in the United States.

Methods: The Department of Health and Human Services (HHS) dataset encompasses all live births in the US. Data from 2017 to 2023 was compiled and the daily number of cigarettes smoked by the mother prior to conception was included as an independent variable. The primary outcome was a diagnosis of gastroschisis in the newborn.

Results: A total 25,836,224 live births with complete information were identified between 2017 and 2023. 5121 newborns (∼2:10,000 births) were diagnosed with gastroschisis, with 858 (16.75 %) born to mothers with a history of smoking prior to pregnancy. Maternal smoking rates decreased significantly from 9.4 % in January, 2017 to 3.5 % in December, 2023 (p < 0.01). Incidence of gastroschisis decreased from 3.1 cases per 10,000 births in January, 2017 to 1.6 cases per 10,000 births in December, 2023 (p < 0.01). Mothers with any history of smoking three months prior to conception were significantly more likely to deliver a newborn with gastroschisis (OR = 2.82, 95 % CI 2.62-3.04, p < 0.001).

Discussion: There is an association between maternal smoking and gastroschisis diagnosis. Additionally there has been a decline maternal smoking, which paralleled a similar decline in annual gastroschisis rates in the United States.