Journal of pediatric surgery最新文献

Aim: To evaluate factors associated with excellent correction in pectus excavatum patients undergoing vacuum bell therapy (VBT).

Methods: A single-institution retrospective chart review was performed November 2012-April 2023 to assess corrections of patients who underwent VBT. Patient demographics, presentation, and results were collected. Excellent correction was defined as complete correction or >100 % improved from an average standard chest depth of 0.51 cm. Data are reported using odds ratio & confidence intervals; and paired t-test comparison. A p-value of <0.05 was regarded as significant.

Results: VBT was utilized in 431 patients with 278 patients included and 153 excluded due to loss of follow-up or incomplete data. Of those included, 89 % were male. There were 31 patients with excellent corrections (11 %) and 247 non-excellent corrections. Initial chest depth < 1.5 cm and chest wall flexibility remain important predictors of positive outcome (p=0.008 and < 0.001, respectively). Excellent correction was statistically more likely in patients aged 8 to 12.9 (OR = 2.2, p = 0.039). Surgical correction following VBT was performed in only 15.5 % (42 of 278) of our patients, none of which were in the group with an excellent correction.

Conclusion: Excellent correction for pectus excavatum via VBT was achieved in a small proportion of patients, with improved outcomes in those initiating therapy at a younger age, with a mild defect, and with increased chest wall flexibility. These data may be used to help determine those more likely to achieve complete correction from a nonsurgical approach and guide decisions towards treatment methods.

Aim: Evaluation of ultra-low dose chest CT imaging for the assessment of pectus excavatum severity as determined by pediatric radiologists and pediatric surgeons using Haller (HI) and Correction indices (CI).

Methods: A single institution, prospective evaluation of patients being evaluated for pectus excavatum were scanned with a standard low-dose chest CT protocol (CARE) followed by a consecutive ultra-low dose CT scan (ULTRA). 3 surgeons and 4 radiologists were instructed to determine HI and CI in each series. The Intraclass Correlation Coefficient (ICC) was used to calculate the agreement level between CARE and ULTRA. Bland-Altman (BA) and scatter plots were also performed to determine bias of each approach.

Results: 32 patients had CARE and ULTRA consecutively. The ICC for HI demonstrated good reliability with a value of 0.89 and excellent reliability for CI with a value of 0.91. The reliability for HI was greater in the surgeon group (0.89) compared to the radiologist group (0.88). The reliability for CI was greater in the radiologist group (0.92) compared to the surgeon group (0.90). The Bland Altman plots for the HI and CI demonstrate no consistent bias for CARE or ULTRA approach when evaluating HI and CI.

Conclusion: Ultra-low dose CT scan imaging compared to standard low-dose CT appears to be a reliable alternative for evaluating PE severity as assessed by HI and CI. This work supports the evaluation and potential development of a standardized CT imaging protocol capable of reducing radiation exposure without sacrificing imaging for PE patients.

Level of evidence: 2:

Aim: Adequate post-operative pain relief is associated with shorter recovery time and higher patient satisfaction. Universally, opioids have been the mainstay but are associated with many adverse effects. We aimed to assess the safety and effectiveness of Continuous Incisional Infusion of Local Anaesthetic (CIILA) for postoperative pain relief in the paediatric population.

Methods: After Trust approval for the use of CIILA was obtained, data were collected prospectively from 2019 to 2022. Patients who had previously undergone laparotomy were used as historical controls. Morphine usage, pain scores and complications were documented. Median (IQR) were quoted throughout and comparison between groups performed using a Mann-Whitney U test. p < 0.05 was accepted as significant.

Results: 76 cases with CIILA were included (laparotomies n = 43, renal transplants n = 33), 58 children who underwent laparotomy served as control group. Age at surgery was 9.0 years (IQR: 2.3-13.1) and 6.1 years (IQR: 2.9-10.6), respectively; p = 0.23). Total morphine usage and number of bolus doses (<48 h) were significantly less in the CIILA group [23 (IQR: 2.6-261.6) vs. 460 (IQR: 265.0-566.0) mcg/kg total, and 0.4 (IQR: 0.4-10.0) vs. 10 (IQR: 10.0-10.0) mcg/kg bolus dose respectively, both p < 0001)]. Reported pain scores were similar in both groups [1.0 (IQR: 1.0-7.0) vs 0.0 (IQR: 0.0-0.5); p = 0.13)]. Length of stay was significantly shorter in the CIILA group [(4.5 days (IQR: 3.5-6.0) vs 6.0 days (IQR: 4.0-8.0); p = 0.02)]. There were no toxicity issues nor any local infection complications reported in the CIILA group.

Conclusion: The use of CIILA is safe, and was associated with lower morphine consumption postoperatively. We suggest that CIILA should be more widely used in the paediatric population.

Aim of the study: This study aimed to evaluate contemporary management strategies of pediatric renal trauma, focusing on the failure of conservative management and identifying its predictors.

Methods: The National Trauma Database (2018-2021) was queried for pediatric patients (≤18 years) with renal injury, identified via AIS codes aligned with the AAST kidney injury grading system. Urological surgical procedures were identified via ICD-10 Procedure Codes. Patients were categorized into immediate surgical management (within 4 h), conservative management (no surgery), and failed conservative management (surgery after 4 h). Demographics, injury characteristics, and clinical data were analyzed using descriptive and univariate statistical analyses (Wilcoxon Rank Sum, Chi-square, Odds Ratios).

Results: Of 7266 pediatric renal trauma patients, most were white (63.4 %) males (69.1 %), aged 12-18 (76.6 %), suffering from unintentional blunt trauma (86.9 %). Most (n = 6610, 95 %) received conservative management; however, 4.5 % (n = 298) failed. Common surgical interventions included ureteral stent placement (n = 200, 59 %), renal IR procedures (n = 44, 13 %), and nephrectomy (n = 33, 9.7 %). Nephrectomy rates at low AAST kidney injury grades (I-II) were higher with upfront surgical management (n = 7, 3.5 %) than with failed conservative management (n = 0). Predictors of failed conservative management included higher Injury Severity Score (ISS) and higher AAST kidney injury grades (III-V) (p < 0.05).

Conclusion: Conservative management failed in 4.5 % of paediatric renal trauma cases, associated with higher AAST kidney injury grade and ISS. Upfront surgical management correlated with a higher nephrectomy rate at lower injury grades compared to failed conservative management. Refinement of pediatric trauma protocols is needed for optimal care.

Level of evidence: III.

Introduction: Chronic kidney disease is an irreversible fate of many CAKUT (Congenital Abnormalities of the Kidneys and Urinary Tract) patients. Biomarkers involved in the disease progression are raised early in the disease process and aid in identifying the individuals at risk of progressive renal function decline.

Aims: To determine and compare the initial levels of urinary biomarkers in patients of CAKUT with asymptomatic controls and to correlate the same with progression of renal disease.

Results: This study includes 66 children with CAKUT and 22 healthy controls. Initial levels of three urinary Biomarkers: Trefoil family factor 3 (TFF3), Alpha soluble Klotho and Albumin-to-creatinine ratio (ACR) was recorded. Kidney function was assessed initially and at the end of 1 y follow up. Progressive deterioration of renal disease was noted in 26 (fall in GFR by >10 ml/min/m²). Median levels of urinary TFF3, alpha soluble Klotho and ACR was higher in patients with CAKUT (263, 18, 56 mcg/gCr) as compared to controls (15, 5, 6 mcg/gCr) and was further higher in patients having a progressive kidney disease (586, 40, 182 mcg/gCr). The cut-off value of the TEF3 to diagnose progressive renal disease was 178 mcg/g Cr with sensitivity and specificity of 95 % and 96 %, respectively. Using a cut-off of 29 mg/g Cr for ACR, sensitivity and specificity were 97 and 96 %, respectively. Urinary soluble Klotho was a relatively poor urinary biomarker with sensitivity and specificity of only 70 and 78 %, respectively, at a cut-off value of 18 mcg/g Cr.

Conclusion: TFF3 and ACR are useful biomarkers which can be included in the biomarker panel to identify patients having a progressive renal disease and are at a risk of developing CKD.

Aims: Transition of paediatric patients is challenging. This study aimed to assess the transition pathway for patients who underwent an ACE procedure as a child and to understand ongoing support requirements.

Methods: A retrospective review was conducted of all patients on the Pelvic Floor Clinical Specialist Nurse's (PFCNS) database from a tertiary adult hospital. Patients receiving their ACE as an adult or patients who did not attend any outpatient appointments (OPAs) were excluded. Data was gathered on complications, additional procedures and outcomes.

Results: Sixty-three patients met the inclusion criteria. The median age at referral to an appropriate team was 18 years but the median age of referral to the PFCNS was 23 years. Only 7(11 %) were referred to the PFCNS by Paediatric Services. Patients experienced a variety of problems including change in equipment (n = 38, 60 %), change in washout regime (n = 28, 44 %), ACE leakage (n = 15, 24 %), stenosis (n = 15, 24 %) and ineffective washouts (n = 11, 17 %). Of those where data was available, there was a median of 7 PFCNS and 2.5 Colorectal Consultant (CC) OPAs per patient. Surgical intervention was common including procedures to the ACE (n = 8, 13 %), excision of ACE (n = 5, 7.9 %) manual evacuation (n = 5, 7.9 %) and formation of a stoma (n = 1%). 35 (56 %) were still using their ACE with a median time since transition of 11 years.

Conclusion: Patients with an ACE need considerable ongoing support yet few are appropriately transitioned. There needs to be a clear transition pathway for these patients to the PFCNS and if appropriate a CC.

Background: Anterior anus is considered part of the spectrum of anorectal malformations in girls and has been associated with childhood constipation. However, limited literature exists on outcomes and associated malformations.

Methods: All girls <6 months referred to our centre with suspected anterior anus between January 2015 and December 2022 were identified. Data collected included patient demographics, presence of anomalies, operative management, laxative use and continence. Results are described using descriptive statistics and percentages.

Results: 147 girls were referred with suspected anterior anus of which 95 were confirmed to have an anterior anus. Median age of first assessment was 3 (0-13) months. Median follow up was 24 (1-94) months. 21 (22.1 %) had clinical concern of partial absence of normal circumferential anal corrugation. 10 (10.5%) girls underwent examination under anaesthesia; 4 patients underwent anoplasty with covering colostomy. Laxatives were prescribed in 31 (32.6%) girls. Of the 53 patients followed up to age 4 years and older, 51 (96.2%) achieved continence. On renal ultrasonography significant hydroureteronephrosis was detected in one patient. No significant spinal anomalies were detected on imaging. Two patients had ventricular-septal defects were identified. All significant anomalies were in patients with an ectopic anus/ perineal fistula.

Conclusion: This represents the largest reported series of girls with anterior anus. The incidence of identified associated malformations was low. Furthermore, laxative use and continence outcomes are similar to the general infant/childhood population. Screening and routine follow-up should be reserved for individual cases where there is clinical concern.