Journal of pediatric surgery最新文献

Background: Many children with congenital surgical anomalies (CSA) face complex, lifelong healthcare challenges. We aimed to evaluate long-term healthcare utilization patterns to guide effective transition-of-care strategies.

Methods: Our retrospective population study compared CSA patients (n=768) to matched controls (n=7,635). Cox and Poisson regression models assessed time-to-event and frequency of ambulatory visits and hospitalizations, adjusting for sex, socioeconomic status (SEFI), family size and rural/urban residency.

Results: CSA survivors had earlier (HR=1.22, 95%CI: 1.12-1.32, p<0.001) and more frequent ambulatory visits (IRR=1.62, 95%CI: 1.61-1.64, p<0.001). CSA cases attended the most annual outpatient visits per child during the first five years post-discharge with esophageal atresia (EA), anorectal malformations (ARM) and Hirschsprung disease having the highest number of contacts. Ambulatory utilization was greater in urban areas and among smaller families, but lower for males. After excluding perinatal hospitalizations, cases were more likely to require hospitalization compared to controls (HR=3.75, 95%CI: 3.42-4.13, p<0.001) and were hospitalized more frequently (IRR=5.63, 95%CI: 5.37-5.89, p<0.001) at all ages. Lower socioeconomic status, rural setting, female sex and larger households increased the frequency of admission. Cox proportional hazard plots showed that patients with ARM, EA/TEF or Hirschsprung disease required particular early re-admission after postnatal discharge compared to other CSAs.

Conclusion: Patients with CSA exhibit persistently high healthcare use, with EA, ARM and Hirschsprung disease requiring particularly intensive follow-up beyond adolescence. Healthcare utilization among CSA patients is influenced by biological sex, family structure and sociodemographic factors. These findings underscore the need for personalized follow-up models beyond childhood.

Objectives: Pediatric short bowel syndrome (SBS) may cause excessive bowel dilatation leading to worsened outcomes and autologous intestinal reconstruction (AIR) surgery. We addressed efficacy of AIR surgery by measuring duodenal, small bowel and colon dilatation in SBS children with and without AIR surgery in relation to parenteral nutrition (PN) dependency and healthy control patients.

Methods: SBS children having undergone AIR surgery (AIR+, n = 22) and those without AIR surgery (AIR-, n = 56) were included. Intestinal contrast series performed between 2002 and 2020 were analyzed to measure diameter of duodenum, small bowel, and colon, and their postoperative changes. Results were expressed as diameter ratio (DR) standardized to L5 vertebrae height. Previously established cutoff values for abnormal bowel dilatation in unoperated SBS patients and healthy controls were used for comparison.

Results: AIR+ patients had shorter remaining bowel and less frequently ileocecal valve (ICV) preserved. Preoperatively, only small bowel DR (SBDR) was weakly associated with the need for AIR surgery. SBDR decreased significantly (p < 0.05) by 30% after AIR surgery, while no significant decrease of DR was observed in duodenum or colon. Over half of AIR+ patients whose SBDR decreased after surgery (69%), weaned off PN during median follow-up of 7.2 years (3.6-16). Patients with postoperative reduction of SBDR to the degree of unoperated SBS patients were more likely to wean off PN.

Conclusions: Our findings suggest that bowel dilatation is unreliable sole indication for AIR surgery, while effective postoperative reduction of dilatation was associated with weaning off PN.

Background: Continuous antibiotic prophylaxis (CAP) is widely used in children with vesicoureteral reflux (VUR) to prevent recurrent urinary tract infections, but its long-term metabolic effects are uncertain. We evaluated whether oral antibiotic exposure is associated with overweight and obesity in young children with VUR.

Methods: Using the TriNetX Research Network, we conducted a retrospective cohort study of children aged <5 years diagnosed with VUR between 2005 and 2025. Patients were classified as antibiotic-exposed or unexposed based on prescription patterns, and propensity score matching balanced baseline covariates. Overweight and obesity were defined using body mass index (BMI) percentiles and diagnosis codes. We performed U.S.-only sensitivity and age-stratified analyses (<1 year; 1-4 years) and calculated the number needed to harm (NNH).

Results: After matching, 2,665 patients were included per group. In the primary cohort aged <5 years, BMI percentile-defined overweight and obesity occurred in 60 (2.3%) of antibiotic-exposed patients and 21 (0.8%) of unexposed patients (hazard ratio [HR], 3.25; 95% confidence interval [CI], 1.97-5.34; log-rank p < 0.001). Results were similar using diagnosis code-based definitions (1.3% vs. 0.6%; HR, 2.30; 95% CI, 1.27-4.17; log-rank p = 0.005). Associations persisted in U.S.-only analyses and were stronger in children aged <1 year. The NNH for BMI-defined overweight/obesity was 69.

Conclusions: Early oral antibiotic exposure in children with VUR was significantly associated with increased risk of overweight and obesity. However, given the low absolute number of events, these findings should be interpreted cautiously and weighed against the potential benefits of CAP.

Introduction: Low- and Middle-Income Countries (LMICs) have significantly younger populations than High-Income Countries, with a high burden of morbidity and mortality due to operable conditions. However, access to pediatric surgical care and trained specialists remains limited. Mapping existing pediatric surgery training programs in LMICs may guide trainees seeking education and inform global surgery efforts to build capacity.

Methods: A review was conducted using an extensive grey literature search to identify pediatric surgery programs in LMICs. Searches included web browsers, medical school websites, national surgical colleges, and other relevant sources. Data were categorized by World Bank income group and World Health Organization (WHO) region.

Results: Of 132 LMICs, 66 (50.0%) had at least one formal pediatric surgery program. By income group: 56.3% (n=31/55) of Upper-Middle-Income Countries (UMICs), 51.0% (n=26/51) of Low Middle-Income Countries (MICs), and 34.6% (n=9/26) of Low-Income Countries (LICs) had programs. Regionally, the European (n=14/18, 77.8%) Eastern Mediterranean (n=12/16, 75.0%), South-East Asia (n=7/10, 70.0%) regions had the highest proportion of LMICs with pediatric surgery programs. The Western Pacific Region and African Region had the lowest proportion of LMICs programs, with only 6/17 (35.3%) and 15/47 (31.2%) of LMICs having programs, respectively.

Conclusion: Access to pediatric surgery programs in LMICs remains limited and decreases proportionally with country income level. There is an urgent need for sustainable, standardized training-supported by formalized accreditation initiatives-to strengthen pediatric surgical capacity globally.

Background: Prior research has identified disparities in surgical outcomes for children across socioeconomic variables. These studies utilized various social determinants of health (SDOH) indices to assess the association between SDOH and surgical outcomes. However, the association between individual SDOH screening tool responses and pediatric surgical outcomes has not been studied. We sought to determine the relationship between SDOH screening tool responses and post-operative outcomes for children.

Methods: A retrospective analysis of pediatric surgical patients ages 0-21 years was performed at our quaternary pediatric hospital from 11/9/2021-7/9/2024. Bayesian logistic regression was used to assess the relationship between responses from our four-domain SDOH screening tool and 30-day postoperative mortality and serious adverse events (SAE).

Results: Among 28,130 patients included, the incidence of 30-day mortality and SAE were 0.1% and 10%, respectively. On univariable regression, patients with a positive SDOH screen experienced 1.44 times increased odds of 30-day postoperative mortality (95% CI 0.65,3.11) and 1.34 times increased odds of SAE (95% CI 1.20,1.49). Increased risk of SAE were found with housing instability (OR1.38, CI 1.05,1.83) and financial strain (OR1.32, CI 1.14,1.52). After adjusting for ASA, case duration, and patient age on multivariable regression, these domains continued to have a strong association with SAE (PrD > 90%); however, the odds ratios were decreased.

Conclusion: Pediatric surgical patients with a positive SDOH screening tool response experienced higher rates of SAE compared to those patients with a negative SDOH screen. Examining the association between SDOH needs and perioperative outcomes may help improve optimal surgical care delivery for all children.

Level of evidence: Level III.

Background: Artificial Intelligence (AI) techniques can transform and enhance diagnosis and treatment response predictions in pediatric surgical pathology. AI offers the potential to reduce the workload of pathologists by automating routine and labor-intensive tasks. In this systematic review, we investigate current applications of computational pathology in pediatric surgical conditions.

Methods: Nine databases were searched from inception until January 2025 to retrieve articles looking at the use of machine learning, AI, or virtual reality in the pathological diagnosis of pediatric surgical conditions, without language restrictions. PRISMA standards were followed, and abstract screening was performed by two reviewers, with conflicts resolved by the senior author. Original studies and reviews exploring computational pathology for diagnosing, grading, or predicting outcomes in pediatric surgical diseases were included.

Results: The authors screened 3363 articles, with 34 meeting the inclusion criteria. AI applications primarily involved convolutional neural networks (24, 70.6%), trained on whole-slide images. The most frequently studied diseases were childhood cancers (18, 52.9%) and Hirschsprung's disease (8, 23.5%), with diagnostic support being the most common objective (23, 67.6%). Nearly half (15, 44.1%) included model explainability tools, while performance metrics were heterogeneous, most often reporting accuracy (24, 70.6%) and AUROC (21, 61.8%). Twenty-two studies (64.7%) had a high risk of bias, mainly due to small cohorts, poorly defined predictors, and outcome-informed assessments.

Conclusion: Our results highlight promising avenues of AI application in pediatric surgical pathology and identify the current gaps in model validation, performance, and clinical implementation.

Background: Telemedicine has transitioned from emergency pandemic response to routine postoperative pediatric surgical care, yet evidence regarding parental satisfaction with sustained implementation remains limited, particularly using validated instruments across different modalities.

Objective: To evaluate parental satisfaction with telemedicine follow-up after pediatric surgery and identify key factors associated with satisfaction during the post-COVID-19 adoption period.

Methods: Cross-sectional survey of 327 parents whose children received telemedicine follow-up (video or phone) between January 2021 and December 2024. Satisfaction was measured using an adapted Telehealth Usability Questionnaire (TUQ). Multivariable logistic regression identified independent predictors of high satisfaction.

Results: Mean satisfaction score was 4.28/5 (SD 0.51), with 82.0% reporting high satisfaction (TUQ ≥4.0). Video consultations (adjusted OR 1.78, 95% CI 1.10-2.89, p=0.018) and absence of technical problems (adjusted OR 3.14, 95% CI 1.63-6.05, p=0.001) independently predicted satisfaction. Safety outcomes were reassuring: 7.0% required unscheduled in-person visits and 4.6% presented to emergency departments within 14 days, with no significant differences between modalities. Nearly 72% of parents preferred telemedicine for future follow-up appointments.

Conclusions: Telemedicine demonstrates high parental satisfaction with acceptable safety outcomes in routine postoperative pediatric surgical care. Video capability and technical reliability are critical satisfaction drivers. These findings support integration of telemedicine into standard care pathways with attention to infrastructure quality and family-centered flexibility.

Purpose: The optimal management of infants born with asymptomatic congenital pulmonary airway malformations (CPAMs) remains controversial. However, emerging evidence increasingly supports a conservative non-operative approach for these patients. We aimed to evaluate this evidence with the hope of clarifying optimal management for these patients.

Methods: A comprehensive search strategy was developed. Electronic databases MEDLINE and Embase Classic + Embase were searched from inception to December 7th, 2023. EBM Reviews and APA PsycInfo were searched from inception to November 30th, 2023. The primary outcome was complications during expectant management. Secondary outcomes included failure of conservative management resulting in surgical intervention, age at time of surgery if required, presence of malignancy, and length of follow-up.

Results: Ten studies met inclusion criteria, involving 298 patients managed conservatively for asymptomatic CPAM. Among these, 49 individuals (16%) experienced complications, most commonly pneumonia and chronic cough. A total of 58 patients (20%) eventually underwent surgical resection due to complications, lesion progression, or parental preference. No cases of malignancy were identified in resected specimens, and no deaths were reported. The majority of lesions were diagnosed antenatally (87%), by X-ray and CT scan. The duration of follow-up among included studies varied substantially, ranging from 12 to 96 months. These findings support the safety of conservative management and indicate a low risk of serious adverse outcomes with medium-term follow-up.

Conclusion: In asymptomatic patients with mainly antenatally diagnosed lesions, conservative management of CPAM lesions was associated with a complication rate and no reported cases of mortality or malignancy. We hope this information can aid informed and safe shared decision-making with patients and their families.

Level of evidence: V.

Background: Neonatal laparoscopic surgery offers numerous advantages but remains challenging due to limited anatomical workspace and scarce training opportunities. Existing simulators often lack neonatal-specific anatomical realism. We developed and evaluated the Space Child Neonatal Trainer (SCNT), a low-cost (€10), fully 3D-printed neonatal laparoscopic simulator derived directly from patient-specific imaging data, designed to improve anatomical accuracy and training realism.

Methods: The SCNT was developed using anonymized CT scans of a one-month-old neonate. Anatomical segmentation was performed using 3D Slicer, with refinements in Blender and Fusion 360®, integrating realistic trocar entry points. Models were 3D-printed using thermoplastic polyurethane (TPU 87A) with infill density optimized by mechanical testing. Evaluation involved two phases: (1) a laparoscopic skills workshop with 21 pediatric surgery residents and three expert surgeons assessing realism and usability; (2) a comparative evaluation against the validated Pediatric Laparoscopic Simulator (PLS) with 22 first-year medical students, measuring task time, errors, and Objective Structured Assessment of Technical Skills (OSATS) scores.

Results: Participants rated the SCNT highly for anatomical fidelity and usability (trocar placement: 4.0 ± 0.6; workspace adequacy: 4.2 ± 0.7). A comparative assessment revealed similar performance between SCNT and PLS across most metrics. Only tissue handling scores differed significantly, favoring PLS (p=0.014). Mechanical analysis identified 15% infill density as optimal for balancing flexibility and structural integrity, confirmed by expert surgeons for superior haptic realism.

Conclusions: The SCNT provides a realistic, cost-effective, anatomically precise neonatal laparoscopic trainer. Initial evaluations support its value in pediatric surgical education, though further validation in broader educational contexts is necessary.

Background: Necrotizing enterocolitis (NEC) lacks predictive biomarkers and objective early diagnostic markers. Broadband optical spectroscopy (BOS), a transcutaneous noninvasive tool, has previously demonstrated diagnostic specificity and early predictive power for NEC in a mouse model. Here, in continuation of the translational development, we report a first-in-human observational study in premature infants.

Methods: An apparatus for BOS in infants was assembled comprising a handheld probe with broad-spectrum light source coupled to a laboratory-grade spectrometer (ASD LabSpec 4, Malvern Panalytical), with detection range of 350-2500 nm. Inclusion criteria were premature neonates fewer than 36 weeks of gestation without congenital cardiac conditions or abdominal wall defects. Readings were graphed for descriptive comparison and analyzed via support vector machine supervised computer learning.

Results: 96 infants were enrolled over a 3-year period in two large neonatal intensive care units. Four-quadrant abdominal measurements were obtained in under 2 minutes at the time of routine nursing care. Neither patient harm nor any impediments to clinical treatment were noted. Reliable infrared reflectance signals of intra-abdominal intestine were acquired from infants of all Fitzpatrick skin tones. Ten infants developed Bell Stage 2 (moderate) or 3 (severe) NEC during the study and another four had a spontaneous intestinal perforation or other identified intraabdominal process. BOS measurements taken during active NEC episodes were visibly different than same-infant readings and could be retrospectively identified with over 90% sensitivity and specificity in a machine learning model.

Conclusions: BOS is a safe, feasible, noninvasive technology for point-of-care assessment of NEC. The presence of detectable signal changes in premature infants with Bell Stage 2 or 3 NEC suggests that BOS shows promise as a modality of screening or early detection in this vulnerable population.