Journal of pediatric surgery最新文献

Purpose of the study: In 2019, the APSA guidelines for the management of solid organ injuries in children recommended limiting embolization to patients with evidence of ongoing hemorrhage. We sought to identify patients who presented to our institution with contrast extravasation (CE) on initial imaging, determine the proportion who required embolization, and describe their associated outcomes.

Methods: A retrospective chart review of all patients with blunt liver and/or spleen injuries (BLSI) treated at our institution between 2014 and 2023 was performed.

Results: We identified 219 patients and included 177 patients in our analysis. The majority sustained spleen injuries (64.5%), while the remainder suffered from liver (28.2%) or combined liver-spleen injuries (7.3%). A total of 144 patients had a computed tomography (CT) scan (82.4%) while the remainder only underwent a formal ultrasound. Twelve patients had positive CE (8.3%), 4 had equivocal CE (2.8%) due to BLSI, and 2 had CE from kidney injuries (1.4%). No surgical intervention was performed for bleeding. Only 4 patients required an embolization (2.3% of all study patients, and 25% of those with positive/equivocal CE); all had positive or equivocal CE and required transfusions. Notably, two patients underwent an angiogram for CE on CT, but no bleeding was identified during the procedure. No patients required an embolization after hospital discharge. Five patients were readmitted for complications (2.8%), although none were related to bleeding.

Conclusion: Our experience supports limiting embolization to patients showing signs of hemodynamic instability after adequate resuscitation instead of systemically taking all pediatric patients with CE after BLSI for embolization.

Level of evidence: Level II - retrospective cohort.

Background: While the current American Pediatric Surgical Association (APSA) recommendation is to discontinue prophylactic antibiotics 24 hours after abdominal wall closure in otherwise healthy gastroschisis patients managed with a silo, the evidence supporting this recommendation is limited. We aimed to determine if at our center the odds of infection in cases who received prophylactic antibiotics only up to 24 hours after closure was greater than cases who received longer courses of antibiotics.

Methods: We conducted a retrospective review of neonates with gastroschisis managed with a silo at a tertiary care center from 1991 to 2022. Infants were included if they survived to closure. Excluded infants had ischemia, perforation, no documented prophylactic antibiotics, or delayed closure (>30 days). Patients were classified as receiving either a short-course (≤24 hours post-closure) or prolonged-course (>24 hours) of prophylactic antibiotics. The primary outcome was infection within 30 days of closure (e.g. sepsis, wound infection, central line-associated blood stream infection). Logistic regression adjusted for gestational age, birth weight, delivery type, and time to closure was calculated.

Results: Fifty-three neonates were included: 28 received short-course and 25 received prolonged-course antibiotics. Infection occurred in 16/28 (57%) short-course patients and 11/25 (44%) prolonged-course patients. The adjusted odds ratio of infection for prolonged versus short-course antibiotics was 0.82 (95%CI=0.25,2.65, p=0.74).

Conclusion: Discontinuation of prophylactic antibiotics up to 24 hours after closure was not associated with an increased likelihood of infection in our cohort. This finding supports the current APSA recommendation to discontinue prophylactic antibiotics 24 hours after abdominal wall closure in uncomplicated gastroschisis.

Aims: Posterior tracheopexy has been proposed recently for the treatment of pediatric tracheobroncomalacia (TBM) Robotic approach is rarely reported. The aim of this study is to define feasibility and safety of robotic posterior tracheopexy (RAPT) and to analyze its results.

Methods: We retrospectively reviewed clinical data of pediatric (<18 y.o.) patients who underwent RAPT between 2020-2024. We evaluated the following data: length of surgery and hospital stay, intra- and post-operative complications, endoscopic pattern and symptoms. Endoscopic pattern and symptoms were classified according to tracheomalacia endoscopic and clinical score (TMES - TMCS) and according to ERS statements. Scores were evaluated before and after RAPT. Comparisons were realized with χ²test, Fisher's exact or Mann-Whitney test. All p-values were two-tailed, with significance at p < 0.05.

Main results: Sixteen (56% females) patients were included 4 (25%) patients with moderate TBM at endoscopic score, while 12 (75%) with severe TBM. Age at surgery was 8 years (IQR4-13), with a median weight of 30kg(IQR18-55). Pre-operative TMCS 3(IQR3-5) and TMES 3(IQR3-3) with a total TMS of 6 (IQR5-8). Median operative time was 175minutes (IQR 120-235). Median number of RAPT fixating sutures of 8 (IQR 6-9) and bronchopexy was associated in 7 (43.7%) patients. No conversion to open/thoracoscopic technique occurred. One (6.2%) intraoperative complication was the breach and suture of the thoracic duct. Early post-operative complications occurred in 3 (18.7%) patients, one grade II Clavien Dindo and 2 grade I. Median follow-up was 17months (IQR 6-31), the median post-operative TMS was 1 (IQR 0-2, p<0.0001), with a median post-operative TMCS was 0 (IQR 0-1, p<0.0001) and TMES 0 (IQR 0-1, p<0.0001). Resolution rate was 93.7% (15 patients out of 16 had a final TMS 2).

Conclusions: RAPT is a valid and safe alternative to traditional surgery in case of severe TBM. This approach shows good results also in patient who previously underwent several surgeries such as post esophageal atresia repair.

Background: Early peritoneal dialysis (PD) is widely used after congenital heart disease surgery in neonates and infants, but the impact of PD timing on outcomes remains uncertain.

Methods: We conducted a retrospective single-center cohort study of neonates and infants who underwent cardiopulmonary bypass surgery between 2015 and 2025 and subsequently required PD. Early PD was defined as initiation within 6 hours postoperatively. The primary outcome was in-hospital mortality. Secondary outcomes included duration of mechanical ventilation, ICU stay, postoperative lactate, creatinine and urea levels, PD-related complications, and time to enteral feeding. Logistic regression evaluated the association between PD timing and mortality, and model performance was summarized using the c-statistic.

Results: Seventy-nine patients were included, of whom 36 (46%) died. Mortality was higher in the late-PD group than in the early-PD group (22/36 [61%] vs 14/43 [33%]). Late PD was associated with increased odds of death in unadjusted analysis (odds ratio 3.26; 95% confidence interval 1.29-8.21; p=0.012) and remained significant after adjustment for surgical complexity and major perioperative covariates (odds ratio 4.96; 95% confidence interval 1.45-16.97; p=0.011). Model discrimination improved with adjustment (c-statistic 0.756). Early PD was associated with faster lactate clearance, whereas ventilation duration, ICU stay, and time to enteral feeding did not differ between groups. PD-related complications occurred in 19%.

Conclusions: Early PD was safe, accelerated metabolic recovery, and was independently associated with lower in-hospital mortality compared with later initiation.

Purpose: Eosinophilic esophagitis (EOE) is a known complication in children with esophageal atresia (EA) and tracheo-esophageal fistula (TEF) following repair. Knowledge of EOE prevalence and characteristics among children following EA/TEF repair is limited. This study evaluates the prevalence, time to diagnosis, and clinical characteristics associated with EOE after EA/TEF repair.

Methods: We identified a retrospective cohort of primary EA/TEF patients who underwent repair from Jan 1, 2017, to Nov 1, 2023 at a single institution. Long-term follow-up was obtained through our Esophageal and Airway Clinic (EAC) and chart review. EOE diagnosis was defined as >15 eosinophils per high-power field on endoscopic-directed biopsy.

Results: Sixty-six primary EA/TEF patients who underwent repair and who also had a 1-year EGD with biopsy were included. A diagnosis of EOE was confirmed in 13 patients (19.7%) with a mean time to diagnosis of 22 months. Postoperative outcomes after repair were largely similar across the EOE and non-EOE cohorts. 73% (48/66) of patients underwent at least one stricture dilation postoperatively. EOE patients received significantly more dilations than non-EOE patients (median 7 vs. 2, p=0.005). Kaplan-Meier analysis demonstrated a trend toward significantly earlier dilation among patients with EOE compared with non-EOE patients (log-rank χ²(1) = 3.82, p = 0.05).

Conclusion: In this large cohort of postoperative primary EA/TEF patients we found a high rate of EOE. EOE patients required earlier and more frequent stricture dilations. Our results exemplify the still-undefined physiologic interplay between the underlying pathophysiology of the esophagus after EA/TEF repair and development of EOE.

Level of evidence: III (retrospective cohort study).

Introduction: The impact of hernia sac (HS+) on outcomes in congenital diaphragmatic hernia (CDH) when accounting for defect size is unknown. In a multicenter analysis, considering defect size, we aim to delineate the association of HS+ and morbidity and mortality.

Methods: A retrospective analysis of CDH Study Group (2007-2024) data was performed. Demographics, defect characteristics, morbidity, and mortality were abstracted. Multilevel regression and parallel Bayesian analysis were performed on 80% of the data, tested on 20% hold-out data, and reported in area under the curve (AUC).

Results: 7,828 operative CDH patients were included. HS+ in 20%; most common in A and B defects (24%, 25%), decreasing in C and D defects (17%, 7%); present in a greater proportion of right-sided defects (30% vs 18%, p<.001). On multilevel logistic regression, with random effects for center, controlling for birth weight, major cardiac abnormalities, chromosomal anomaly, utilization of ECLS, side of the defect, CDHSG A-D, HS+ was not associated with survival (OR 1.19, 95% CI 0.92-1.53). On Bayesian analysis the OR of HS+ on survival was 1.07 (95% credible interval 0.87-1.36). HS+ was not associated with pulmonary hypertension (OR 0.97, 95% CI 0.82-1.14) or cardiac dysfunction at birth. HS+ was associated with a reduction in ECLS utilization (OR 0.60, 95% CI 0.48-0.74), oxygen status at 30 days (OR 0.56, 95% CI 0.44-0.70), length of mechanical ventilation (IRR 0.84, 95% CI 0.79-0.89), and length of hospital stay (IRR 0.92, 95% CI 0.88-0.96).

Conclusion: HS+ is not associated with increased survival, with a neutral Bayesian probability of benefit. However, morbidity outcomes were improved in HS+ patients.

Aim of the study: Maternal risk factors associated with gastroschisis occurrence have been identified, but predisposing factors to the complex variant are unknown. This study aimed to identify factors associated with complex gastroschisis by comparing the maternal risk factor profiles of simple and complex gastroschisis pregnancies.

Methods: All cases of gastroschisis managed in one tertiary care hospital between 1991-2022 were identified from a retrospective clinical database. Cases were classified as 'complex' if severe matting, necrosis, atresia or perforation were present; 'simple' gastroschisis was defined as absence of these features. Data on maternal peri-conception and gestational health and lifestyle habits were extracted from the clinical database and a population-based administrative data repository. Logistic regression odds ratios (OR) and Poisson regression rate ratios (RaR) for each variable, or combination of variables, were calculated for 'complex' versus 'simple' mothers.

Results: A total of 194 cases of gastroschisis were included, 155(80%) simple and 39(20%) complex. Univariable analysis showed no effect of smoking, narcotics, cannabis, alcohol, rural residency and low-income. When adjusted for exposure to smoking, narcotics and alcohol use, cannabis use was more likely to have occurred in mothers of children with complex gastroschisis (adjusted OR=2.64). While single urinary tract infection was not associated with complex gastroschisis (OR=2.20), mothers of children with complex gastroschisis had more recurrent urinary tract infections (RaR=3.78). Pelvic inflammatory disease was not associated with complex gastroschisis.

Conclusion: Our results suggest that peri-conceptional and gestational cannabis exposure and recurrent urinary tract infections are associated with complex gastroschisis. These exposures may be modifiable targets to reduce the risk of gastroschisis-related bowel complications and warrant further investigation in larger populations.

Purpose: Linguistic bias limits insight from non-English regions and potentially skews conclusions toward Western contexts. We evaluated the extent and impact of language-based exclusions in systematic reviews (SRs) within pediatric surgery, assessing how such limitations threaten the comprehensiveness and generalizability of evidence syntheses.

Methods: With health librarian oversight, Medline, Embase, and Global Health (via Ovid) were searched from 2020 to 2024 for SRs related to pediatric surgery. A representative sample of 392 articles was analyzed for their country and publisher of origin, practice of language limitation and the transparency of the exclusion process.

Results: Of 82 included SRs, 48 (58.5%) restricted inclusion to English-language studies, and 34 (41.5%) incorporated non-English studies in their search strategies. Transparent reporting of language exclusions was found in 25 SRs (31.7%), primarily in PRISMA flowcharts. Among transparently reporting SRs, the proportion of studies excluded due to language ranged from 0.17% to 98.4% (mean 9.5%). international journals (n = 20) had a mean language-based exclusion rate of 6.0% (median 0.6%, range 0.11 - 98.41%), compared to 1.3% (median 0.23%, range 0.02 - 5.53%) among North American journals. After removing one extreme outlier, the mean exclusion rates were 1.13% and 1.31%, respectively (p = 0.87, Cohen's d = -0.09), indicating no significant regional difference CONCLUSION: Our study demonstrates that nearly 60% of pediatric surgery SRs exclude non-English language studies, often without transparent reporting. This language bias risks underrepresenting global research and potentially skews evidence towards Western contexts. Multilingual inclusion, greater transparency, and utilization of modern translation tools may improve the equity and validity of future pediatric surgical research.

Level of evidence: Level 2 evidence.