Journal of pediatric surgery最新文献

Purpose: To examine the association between pyloric stenosis development and seasonal variation or feeding practices.

Methods: Ethical approval was obtained. A retrospective chart review was conducted for patients treated for pyloric stenosis at our centre in central Canada between January 1st, 2012 and December 31st, 2022. Sex and age-matched controls were identified as patients admitted within two months of age with pneumonia, inguinal hernia, or orthopedic conditions. Cases and controls were also matched by season of hospital admission. Descriptive statistics and regression analyses were conducted using Microsoft Excel and R.

Results: A total of 296 pyloric stenosis cases and 296 controls were reviewed. Using Poisson regression, the effect of season on pyloric stenosis rates was evaluated while adjusting for year. A statistically significant association between season and PS incidence (p = 0.007) was found. Compared to the winter, pyloric stenosis rates were 1.33 times higher in the fall (95 % CI: 0.93-1.92), 1.41 times higher in the spring (95 % CI: 0.99-2.02), and 1.80 times higher in the summer (95 % CI: 1.29-2.54). Additionally, when controlling for age, sex, and season, there was a significant association between feeding practices and pyloric stenosis development (p < 0.001). Formula-fed infants were 3.7 times more likely to be diagnosed with pyloric stenosis compared to breast milk fed infants, while those fed both breast milk and formula had 1.7 times the odds of diagnosis.

Conclusion: Pyloric stenosis incidence shows significant seasonal variation and feeding practice associations, suggesting potential modifiable risk factors in its development.

Level of evidence: III.

Type of study: Retrospective Case-Control Study.

Purpose: Pediatric inguinal hernia repair (PIHR) is a common procedure performed using either open or laparoscopic techniques. Both approaches require detailed anatomical knowledge and specialized training. To address these training needs, we developed a low-cost, 3D-printed Pediatric Open and Laparoscopic Integrated Simulator for Inguinal Hernia Repair (POLISHeR). This study aimed to validate POLISHeR as a simulation tool for essential PIHR skills.

Methods: Experienced pediatric surgeons and surgical trainees performed simulated PIHR using POLISHeR. Participants evaluated the simulator's face and content validity using a 5-point Likert scale. Two experienced pediatric surgeons assessed video-recorded simulations using procedure (PCL) and error (ECL) checklists. An Entrustable Professional Activity (EPA) scale measured participants' competence. Construct validity was assessed by comparing expert and trainee performance using the Mann-Whitney U test.

Results: Twenty-six participants completed simulations (open: n=11; laparoscopic: n=15), including 14 expert pediatric surgeons (open: n=5; laparoscopic: n=9). In laparoscopic PIHR, trainees made significantly more errors (p < 0.001), completed fewer key steps (p < 0.001), and received lower EPA scores (p < 0.001) than experts. In open PIHR, trainees made more errors (p = 0.03), had lower EPA scores (p = 0.05), and received lower PCL scores (p = 0.410), though not statistically significant. Experts reported strong anatomical realism and accurate step representation.

Conclusion: POLISHeR demonstrates strong face, content, and construct validity. It effectively differentiates between expert and trainee performance and represents an affordable, practical tool for teaching and evaluating PIHR skills.

Introduction: Firearm injuries are prevalent among children in the United States and induce significant psychological distress. This study aims to identify clinical predictors for developing mental health disorders (MHD) and substance use disorders (SUD) after firearm injury withi1n the pediatric population.

Methods: The National Readmissions Database was queried from 2016-2022 for patients ≤18 years old with hospital admissions for firearm injuries. The primary outcome was the presence of new MHD or SUD during hospital readmissions. Multivariable regression analysis was used to test the independent association of medical and surgical complications with MHD and SUD while controlling for confounders, including the presence of MHD and SUD at index admission.

Results: There were 35,733 hospital admissions, with a mortality rate of 6.4%. Survivors were mostly male (86%), with a median age of 17 years [IQR 15, 18]. Patients were most commonly from the lowest income quartile (57%). Baseline MHDs or SUDs were present in 20% of the population, and these patients suffered worse injuries and more complicated hospital courses. New MHDs or SUDs occurred in 2.2% of the population. Females, those with self-inflicted injuries, those who underwent surgical procedures, and those with medical/surgical complications are at increased risk of developing new MHDs or SUDs. Within the same calendar year, 11% of patients were readmitted, and 33% of patients requiring readmission presented to a different hospital.

Conclusion: MHD and SUD are prevalent after pediatric firearm injuries in the United States. Children with complicated hospital courses after firearm injury may benefit from early mental health screening and intervention.

Level of evidence: IV STUDY TYPE: Retrospective cohort analysis.

Purpose: Congenital H-type tracheoesophageal fistula (H-TEF) is a rare congenital esophageal malformation. Treatment involves minimally invasive surgery; however, accurate fistula localization remains challenging. Real-time imaging via near-infrared (NIR) thoracoscopy facilitates the distinction between different tissue structures. Therefore, we aimed to evaluate the clinical efficacy of the NIR-thoracoscopic simple clip method for treating congenital H-TEFs in neonates.

Methods: Neonates with H-TEFs underwent thoracoscopic NIR localization using indocyanine green (ICG) injection, followed by clipping and division. The inclusion criteria were: (1) H-TEF confirmed by esophagography and/or bronchoscopy, (2) fistula below T2 level, (3) birth weight ≥2.0 kg, and (4) parental consent. The exclusion criteria were: (1) severe cardiopulmonary malformations/coagulopathy, (2) prior TEF repair, and (3) surgical contraindications. After successful general anesthesia, the patient was placed in the supine position, and ICG (0.1 mg/mL) was injected into the fistula lumen under bronchoscopic guidance. The patient was then moved to the right supine position for the thoracoscopic surgery.

Results: Six neonates (male: 4, female: 2; median operative age: 7 days, range: 3-15 days; birth weight: 2.8 kg, range: 2.1-3.5 kg). They presented with dyspnea (6/6), cyanosis during feeding (6/6), and persistent pulmonary infection (4/6). The median operative time was 65 min (range: 53-77 min), and blood loss was <5 mL. Transient hoarseness occurred in one patient (resolved in 7 days). No recurrences or strictures were observed during follow-up (median, 18 months).

Conclusion: Preoperative bronchoscopic ICG injection facilitates NIR thoracoscopic localization and dissection of intrathoracic H-TEFs in newborns.

Background: Manual reduction of incarcerated inguinal hernias is a fundamental skill to decrease morbidity from bowel strangulation. It is essential in low-income countries, where surgical care may not be available at the initial receiving facility. We created a low-cost, reproducible simulator using materials available in Rwanda. The simulator teaches learners to identify and reduce incarcerated bowel, stabilizing the bowel with two hands to guide it into the inguinal canal. We implemented it in the context of a structured training course on initial management of pediatric surgical conditions for Rwandan general practitioners at rural hospitals.

Methods: The design was adapted from a previously described simulator, costing $95USD, replacing components with low-cost materials totaling $0.92USD. We utilized 12-inch balloons as scrotum, water bottle necks as inguinal canal, long balloons as bowel, vinyl as skin, styrofoam as the patient, and lubricating jelly. Pre- and post-training data were analyzed using Rstudio v1.1.4.

Results: Fifty-nine Rwandan general practitioners at rural hospitals tested the simulator. On a 5-point Likert scale, self-rated comfort with manual reduction of inguinal hernias improved from 2.95 ± 1.15 to 3.85 ± 1.2 (p < 0.001). Learners perceived that the simulation was useful, resembled real life, and should be used to train colleagues.

Conclusions: This simulator is effective for training Rwandan general practitioners in operative pediatric hernia repair. It can be readily assembled, allowing practical training at multiple trainee or provider levels. Simulation can be additive to instruction in developing global surgery coursework.

Objective: Access to specialized pediatric surgical care is crucial for optimal child health outcomes; however, geographic barriers may limit timely access. This study examines national variations in distance to pediatric general surgeons across the United States.

Methods: We performed a cross-sectional analysis using 2020 American Pediatric Surgical Association membership data to identify board-certified pediatric surgeons, linked with population demographics from the 2020 U S. Census. Straight-line distances from each ZIP code to the nearest pediatric surgeon were calculated, both allowing and restricting crossing of state lines. Distances were compared across demographic, geographic, and socioeconomic factors. State-level surgeon-to-child ratios were standardized and analyzed.

Results: Among 73,103,902 children and 1527 pediatric surgeons (47,874 children per surgeon), 89.2 % of children lived within 60 miles of a pediatric surgeon, while 10.8 % lived farther away. Median travel distance differed by race, with Native American children traveling the farthest (86.4 miles), followed by White (28.7), Black (16.9), and Asian (11.8) children. Rural and economically distressed areas were disproportionately affected, with 45.4 % and 18.8 %, respectively, living more than 60 miles from care. Restricting travel within state lines increased the proportion of children living more than 60 miles from a surgeon to 13.8 % and to 54.1 % in rural areas. State-level distances varied from 9.1 miles in Rhode Island to 360.7 miles in Alaska. Nineteen states had more pediatric surgeons than expected based on population, while 31 had fewer.

Conclusions: Despite increased availability of pediatric surgeons, significant geographic and demographic disparities persist, highlighting the need for targeted policies to promote equitable pediatric surgical care nationwide.

Background: Children with autism spectrum disorder (ASD) may experience communication differences and sensory sensitivities relevant to perioperative care. Evidence comparing perioperative outcomes and opioid prescribing practices in this population is limited. We evaluated the perioperative course and discharge opioid prescribing patterns in children with ASD versus matched neurotypical peers undergoing ambulatory surgery.

Methods: We conducted a retrospective matched cohort study (June 1, 2015-June 1, 2025) of children <18 years undergoing ambulatory surgery at a tertiary pediatric hospital. ASD patients were matched 1:2 with neurotypical controls by age, sex, American Society of Anesthesiologists (ASA) classification, and procedure type. Communication and behavioral characteristics reflected documented history; controls were selected to exclude neurodevelopmental diagnoses. Outcomes included perioperative agitation, recovery time, unplanned admission, and discharge opioid prescribing. Opioid doses were converted to morphine milligram equivalents (MME). Group comparisons used chi-square/Fisher exact and Wilcoxon rank-sum tests.

Results: Forty-five ASD patients and 90 controls were included. Preoperative agitation (11.1% vs 1.1%) and benzodiazepine use (11.1% vs 1.1%) were more common in the ASD group (p=0.016). Pain scores, recovery duration, and postoperative analgesic use were similar. Unplanned admission occurred only in the ASD group (6.7% vs 0%, p=0.02), exclusively for agitation. ASD patients were less likely to receive an opioid prescription (13.3% vs 31.1%, p=0.03), with comparable MME among those prescribed (p=0.82).

Conclusions: Children with ASD undergoing ambulatory surgery demonstrate similar postoperative pain outcomes and comparable opioid doses when prescribed. Higher perioperative agitation and unplanned admissions support individualized preparation and sensory-aware strategies to promote equitable recovery.

Purpose: Pediatric thoracic and abdominal tumours present unique challenges due to complex anatomic relationships. Patient-specific anatomical models can enhance surgical planning and conduct. Our objective was to evaluate the clinical impact of these models in the perioperative management of patients with thoracic and abdominal tumours.

Methods: At the request of the attending surgeon, patient-specific anatomical models (virtual and/or 3D printed ) were created for patients undergoing surgical treatment for tumours in the thorax or abdomen at a tertiary children's hospital. Following surgery, clinicians completed a survey with Likert-scale and open-ended questions to assess the model's utility. Descriptive statistics were used to analyze patient data, while text responses were summarized narratively.

Results: Models were created for 15 patients between 2021 and 2025. The mean age at surgery was 5.3 years [IQR = 1.8, 7.8]. 33.3% of patients were female. Tumours were evenly split between thoracic and abdominopelvic locations. Pathologies included neuroblastic tumours (n=8, 53.3%), nephroblastoma (n=2, 13.3%), hepatoblastoma (n=1), epithelioid sarcoma (n=1), osteosarcoma (n=1), and Ewing's sarcoma (n=1). One additional case (n = 1) was later reassessed as an empyema. Most surgeons (93.8%) felt the models accurately represented radiologic and surgical findings, while 80% reported an improved ability to anticipate surgical challenges. Surgeons also endorsed a favourable impact on family understanding of the disease (85.7%) and trainee understanding of the operative plan (70%).

Conclusions: Anatomical models enhance perioperative planning and multidisciplinary communication in pediatric thoracic and abdominal tumour cases. Expanding in-house patient-centred anatomic modelling capacity at high-volume pediatric centres may help with the perioperative and intraoperative optimization of surgical planning.

Background: Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease affecting preterm neonates, characterized by intestinal inflammation, epithelial injury, and microbial dysbiosis. Prebiotics such as short-chain fructooligosaccharides (scFOS) have been proposed as nutritional interventions to support intestinal health, but their protective mechanisms in NEC remain incompletely understood.

Methods: Using a neonatal mouse model of NEC, we investigated the protective effects of scFOS supplementation on intestinal injury, regeneration, inflammation, and microbial composition. Histological analysis, immunostaining, cytokine quantification, quantification of Lactobacillus abundance, Western blotting, and phosphoproteomics were employed to assess intestinal damage and underlying signaling pathways.

Results: scFOS-treated NEC mice exhibited significantly improved intestinal architecture, reduced histological injury scores, and enhanced epithelial regeneration, as evidenced by restored Ki67 and β-catenin expression. Inflammatory cytokine expression (TNF-α, IL-6) was significantly attenuated, and the abundance of Lactobacillus was increased, indicating a partial correction of NEC-associated dysbiosis. Mechanistically, phosphoproteomic profiling and Western blot analysis revealed that NEC suppressed AKT phosphorylation and activated GSK-3β, leading to β-catenin degradation and impaired repair. scFOS supplementation restored AKT/GSK-3β signaling, promoting mucosal regeneration.

Conclusion: scFOS protects against NEC-associated intestinal injury through coordinated effects on epithelial regeneration, inflammation, and microbial composition. These benefits are mediated, at least in part, by reactivation of the AKT/GSK-3β/β-catenin signaling axis. These findings support the potential of scFOS as a promising nutritional strategy for NEC prevention in preterm infants.

Purpose: To describe enteral feeding practices and clinical outcomes among infants with gastroschisis at neonatal intensive care units (NICUs) in Canada.

Methods: Infants with gastroschisis were identified using data from the Canadian Neonatal Network and Canadian Pediatric Surgery Network. These included patients with (1) mild or no matting, (2) severe matting, and (3) complex gastroschisis (i.e., presence of intestinal necrosis, perforation, and/or atresia). We explored patterns of enteral feeding and associated clinical outcomes during the NICU admission.

Results: We identified 348 infants with gastroschisis: 297 had mild or no matting, 24 had severe matting, and 27 had complex gastroschisis. During the NICU admission, 64 % received exclusive human milk (i.e., mother's own milk, human donor milk, or both) and 36 % received one or more days of formula. There were no differences between infants with mild or no matting, severe matting, or complex disease in terms of use to formula (36 % vs 33 % vs 44 %, p = 0.63) or donor milk (19 % vs 17 % vs 22 %, p = 0.87). Exclusive human milk use at the time of discharge from NICU was high across all groups (79 % vs 86 % vs 86 %, p = 0.62). The frequency of donor milk use increased from 5 % in 2015 to 31 % in 2023 (p < 0.001).

Conclusion: We conclude that most infants with gastroschisis in Canada receive exclusive human milk during their NICU admission. The remainder receive one or more days of formula, but most patients transition to exclusive human milk by the time of NICU discharge. The use of donor human milk is increasing.

Level of evidence: Level IIb (Individual Cohort Study).