Journal of pediatric surgery最新文献

Background: There is no consensus on the appropriate duration of postoperative antibiotics for complicated appendicitis in children. Commonly used antibiotic endpoints include normalization of white blood cell count (WBC) or completion of a minimum number of prespecified treatment days. We compared clinical outcomes resulting from varying postoperative antibiotic protocols for complicated appendicitis in children.

Methods: National Surgical Quality Improvement Program Pediatric (NSQIP-P) data from nine children's hospitals was used to identify a retrospective cohort of children (<18 years) who underwent laparoscopic appendectomy from 2021 to 2023 with intraoperative findings of complicated appendicitis. Participating hospitals were classified into four groups based on discharge protocol: 1) no discharge antibiotics, 2) oral antibiotics for elevated WBC on the day of discharge, 3) oral antibiotics to complete a minimum number of total antibiotic days, and 4) routine discharge antibiotics regardless of inpatient antibiotic duration. Univariate analysis was completed between groups.

Results: We identified 1342 patients with complicated appendicitis who underwent laparoscopic appendectomy. Patients were similar by age and BMI. Median length of stay (5 days) and rate of post-discharge percutaneous drainage (9.4 %) were highest at the center with a standardized minimum duration of discharge antibiotics. There were no statistical differences among treatment groups for surgical site infection (5.7-9.8 %), emergency department visits (9.0-15.6 %), or readmissions within 30 days (2.9-7.6 %).

Conclusion: The incidence of SSI and readmission following appendectomy did not differ based on the discharge antibiotic protocol, however, the incidence of post-discharge drainage was highest in the center with protocolized discharge antibiotics. These findings highlight an opportunity to minimize unnecessary blood draws and extended postoperative antibiotics.

Level of evidence: III.

Introduction: Perinatal management of gastroschisis remains a subject of substantial research. Current models, including teratogenic, genetic, and surgical approaches, often fail to accurately replicate gastroschisis, exhibiting limitations such as inaccurate phenotyping, low success rates, high mortality, lack of scientific validation, and significant technical challenges. Refined disease models are essential for improving the understanding of GS. This study seeks to develop and validate a minimally invasive transuterine experimental model of GS that overcomes these existing constraints to advance gastroschisis research.

Methods: A gastroschisis model was surgically created in rat fetuses at E17 (n = 51 fetuses from n = 13 dams). Intestines were harvested at term and divided into herniated gastroschisis (GS-H), intra-abdominal gastroschisis (GS-I), and control (Co) groups. Morphometric analysis, histopathological examination, immunohistochemistry for interstitial cells of Cajal (ICC), double immunofluorescence for ICC and mast cells, TUNEL assay for apoptotic cells, and multiplex cytokine assay were performed to assess intestinal architecture, inflammation, ICC network, apoptosis, and cytokine levels across studied groups.

Results: Histology from GS intestines revealed subchronic inflammation, peel formation, and architectural disruption. Herniated intestines exhibited a significantly increased weight/length ratio and thicker outer layers (p < 0.001) compared with control intestines. Herniated intestines had elevated inflammatory cytokine levels (GS-H vs GS-I and Co, p < 0.05 for G-CSF, GM-CSF, IL-12p70, IL-1beta) and increased apoptotic activity.

Conclusions: We developed and validated a new surgical model of GS that offers improved survival and feasibility. The key morphological changes and molecular markers observed in this experimental model resemble human gastroschisis.

Background: Rural facilities that provide pediatric surgical services are a critical resource to local communities. Our aim was to characterize differences in outpatient pediatric cholecystectomy outcomes performed at rural and urban hospitals with the hypothesis that rural hospitals would have similar outcomes.

Methods: The Nationwide Ambulatory Surgery Sample (NASS), which contains ambulatory surgery encounters at hospital-owned facilities, was used to perform a retrospective cohort analysis of pediatric patients age 18-years and younger who had a cholecystectomy (n = 15,449) between 2016 and 2018. Survey-weighted multivariate regression analyses were used to evaluate the association of rural and urban hospital locations with the primary outcome of routine discharge. Models were adjusted for sex, age, comorbidities, insurance, income quartile, indication for operation, and hospital characteristics.

Results: Patients receiving care at rural hospitals were more commonly in the lowest two median income quartiles compared to urban hospitals (91.1 % versus 58.2 %, p < 0.01) and had more complex chronic comorbidities (63.1 % versus 57.2 %, p < 0.01). In both settings, the most common surgical indication was cholecystitis followed by biliary dyskinesia; nearly all procedures were performed laparoscopically (>99 %), and complications were rare with no deaths. Survey weight multivariate regression analysis showed patients cared for at rural hospitals had a higher odds ratio of routine discharge compared to those cared for at urban hospitals (adjusted OR 2.27, 95 %CI 1.04-4.99, p = 0.04).

Conclusions: Pediatric patients at rural hospitals have lower median income and a higher mean morbidity index. Despite these challenges, outpatient cholecystectomy was safe at rural hospitals and associated with increased odds of routine discharge when compared with urban hospitals.

Background: We aimed to analyze the effect of age and weight on 30-day outcomes of single-stage endorectal pull tthrough (ERPT) procedures for Hirschsprung's Disease (HD) using the National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database to identify an optimal time for surgery.

Methods: We queried NSQIP-P for children <2 years with HD who underwent ERPT between 2016-2021 and did not have a preoperative stoma. Patients were stratified by age (<3 months, 3-6 months and >6 months) and weight (<4 kg, 4-8 kg, and >8 kg) at the time of surgery. The primary outcome measure was major adverse outcomes, and the secondary outcomes were 30-day unplanned readmission and reoperation. Multivariable logistic regression was conducted to analyze the association between age and weight and each outcome.

Results: A total of 1002 patients were included with a median age of 31 days (IQR: 10-106 days). Patients were stratified by age (n = 702, 70.1 %; n = 158, 15.8 %; n = 142, 14.2 % respectively from youngest to oldest) and weight (n = 472, 47.1 %; n = 421, 42.0 %; n = 109, 10.9 % respectively from lowest to highest weight) groups. On multivariable analysis, age>6 months and weight>8 kg were independently associated with a higher rate of major complications (aOR = 2.741, 95 % C.I. = 1.234-5.880 and aOR = 4.627, 95 % C.I. = 1.761-11.775 respectively). Conversely, being in the highest age (aOR = 0.359, 95 % C.I. = 0.176-0.699) and weight brackets (aOR = 0.396, 95 % C.I. = 0.171-0.801) independently predicted lower 30-day readmission rates.

Conclusion: Earlier single-stage ERPT for HD was found to be associated with lower complication rates in a select group of patients but may result in increased rates of readmissions and hospital resource utilization.

Level of evidence: Level III evidence.

Type of study: Retrospective cohort study.

Background: The Heineke-Mikulicz anoplasty (HMA) is a technique for addressing skin-level postoperative strictures following posterior sagittal anorectoplasty (PSARP) and posterior sagittal anorectovaginourethroplasty (PSARVUP). We aimed to evaluate the long-term outcomes with HMA as a treatment for postoperative anal strictures.

Methods: A retrospective review was conducted for patients with a history of ARM who underwent HMA for skin-level anal strictures. Data were collected regarding indication for HMA, most recent anorectoplasty preceding HMA (primary or redo), timing of HMA, extent of stricturoplasty, change in caliber of anus, and postoperative outcomes. Descriptive statistical analysis was performed.

Results: From 2015 to 2024, 138 patients with history of ARM underwent HMA. Median age at time of HMA was 4 years [IQR 2-6] with median follow up time of 3.0 years [IQR 1.0-4.0]. HMA was performed after primary PSARP or PSARVUP in 29 % of patients and after redo surgery in 61.6 %. The minimum time between index operation and initial HMA was 2 months and the median was 5 months [IQR 3-24]. 14.5 % of patients required repeat HMA. The median time between index operation and repeat HMA was 24 months (IQR 12-39). There was a significant trend between number of quadrants where HMA was performed and need for repeat HMA.

Conclusion: HMA is a safe and durable procedure that can treat skin-level postoperative anal strictures in most patients following PSARP and PSARVUP. Patients can frequently be managed with a one-time HMA. HMA should be considered as an alternative to dilation for skin-level anal strictures, especially in an older patient after redo surgery.

Objectives: Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children and young adults. Typically, treatment involves a multimodal approach, with radiotherapy (RT) being a standard choice alongside surgical resection for local control, particularly in cases harboring fusions involving FOXO1. However, the long-term consequences of offering RT especially to the extremity in children can be significant including growth delay, contracture, arthritis, and secondary malignancy. Herein, we report the outcome of 10 consecutive patients with extremity RMS from two high-volume institutions who did not receive RT to primary site.

Methods: Demographic, genetic, tumor characteristics, surgical details, post-resection overall survival and event-free survival data were retrospectively collected from the CanSaRCC (Canadian Sarcoma Research and Clinical Collaboration) database.

Results: Despite the absence of adjuvant RT to the primary tumor site, 90 % of this cohort patients experienced no local failure and the single patient with local failure was subsequently salvaged with RT and further chemotherapy.

Conclusion: By presenting this distinctive real-world data, our aim is to illustrate that in a select high-volume pediatric sarcoma center, extremity RMS can potentially be effectively managed through surgery and chemotherapy alone.

Type of study: Clinical research paper.

Level of evidence: Level IV.

Objective: To establish risk models for long-term native liver survival (NLS) in patients with biliary atresia.

Methods: In this retrospective study, we analyzed data from 1792 patients registered in the Japanese Biliary Atresia Registry. Using multivariate logistic regression, we created predictive models for NLS at 1, 5, 10, 15, and 20 years postoperatively. Variables at the first year of age and those at 1 and 5 years postoperatively were used. The variables used in this model were selected using a forward-backward stepwise selection method. The models were further assessed using C-statistics of internal validation with 1000 bootstrapping resamples.

Results: The models using only variables at the first year of age showed insufficient predictive ability. The variables used in the model for NLS at 20 years postoperatively included the age at Kasai procedure, high levels of gamma-glutamyltranspeptidase at 1 year postoperatively, and low levels of cholinesterase at 5 years postoperatively. The models with internally validated C-statistics greater than 0.8 were as follows: NLS at 5 years postoperatively based on the variables at 1 year postoperatively (internally validated C-statistics: 0.88), at 10 years postoperatively based on the variables at 1 year postoperatively (0.86), and at 20 years postoperatively based on the variables at 1 year (0.81) and 5 years (0.83) postoperatively.

Conclusion: Overall, we developed satisfactory risk models for NLS up to 20 years postoperatively using variables up to 5 years postoperatively.

Introduction: There is equipoise among pediatric urologists regarding endoscopic versus surgical intervention for symptomatic Grade 4-5 Vesicoureteric Reflux (VUR), particularly in infancy. Our aim was to assess outcomes of first-line endoscopic treatment in all cases of symptomatic Grade 4-5 VUR and we hypothesised that using endoscopic Dx/HA as first line management for primary VUR would obviate the need for ureteric reimplantation in the majority of cases.

Methods: Retrospective single-surgeon analysis of consecutive patients with primary Grade 4-5 VUR over 15 years. Indication for intervention was breakthrough UTI on prophylaxis. Endoscopic dextranomer/hyaluronic acid co-polymer (Dx/HA; Deflux®) injection was first-line procedure. Primary outcomes were both post-procedure febrile culture positive urinary tract infection (UTI) and VUR recurrence on post-operative VCUG requiring further surgical intervention. We postulated that risk factors influencing outcome are: age under 1 year, female gender, postnatal versus antenatal presentation, duplex anatomy, circumcision status and presence of congenital uptake defects on DMSA. Data analysed using Fisher's Exact Test/Multivariate Analysis.

Results: 77 patients with Grade 4-5 VUR were identified, of whom 49 (11 bilateral) underwent a Dx/HA injection at median 12 (3-84) months. Median follow-up post-injection was 32 (2-145) months. There were no reported complications or ureteral obstruction. Sixteen (33 %) patients suffered a febrile UTI at follow-up; on further investigation, half (8/16) of these were found to have recurrent VUR. Therefore 67 % were symptom free and 84 % did not require further intervention after one injection (41/49), and 98 % after further injections (48/49). Duplex systems had a similar outcome of 80 % not requiring further intervention. On multivariate analysis, males were found to have a significantly better outcome than females (p < 0.015) irrespective of circumcision status. Forty-one percent of the children in our cohort had uptake defects on DMSA prior to intervention, but this did not have any difference on outcome.

Conclusion: Endoscopic Dx/HA injection is a safe first-line, day-case treatment for Grade 4-5 VUR in children of any age, with a low complication rate. Two-thirds of patients are asymptomatic after one injection; 84 % do not require further procedures after one injection, and 98 % after 2 injections.

Disaster events such as weather events and mass casualty events are increasing in frequency and severity. Caring for children during a surge requires a regional approach given limited pediatric inpatient capacity and expertise. During the 2024 American Academy of Pediatrics National Convention and Exhibition, the Section on Surgery and Council on Children and Disasters (COCD) partnered to present a joint symposium emphasizing importance of pediatric readiness and disaster preparedness and role of pediatric trauma surgeons in disaster preparedness and response in all communities.