Journal of pediatric surgery最新文献

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.

Introduction: Choledochal cyst (CC) excision is indicated to avoid developing complications. There is no consensus on postoperative follow-up investigations, duration, or timing. At our institution, patients are followed for 5 years after CC excision with ultrasound and liver laboratory tests. We aimed to evaluate both the post-operative outcomes after pediatric CC excision, focusing on long-term complications, and the adherence to our postoperative follow-up protocol.

Methods: A retrospective chart review of children who underwent a CC excision at our institution between January 1986 and March 2025 was performed. Complications occurring over 5 years after surgery were defined as late complications. Comparisons were made between management eras (early: 1986-2001 vs. modern: 2002-2025). p<0.05 was considered significant.

Results: While 57 children underwent CC excision, 49 (86%) had postoperative follow-up and were included in outcomes analyses. Median follow-up duration for the entire cohort was 2.4 years (34 days-16.2 years). Out of 50 patients who had undergone surgery over 5 years ago, 22 patients were followed for of at least 5 years (overall adherence to our institutional postoperative follow-up protocol: 44%). Median follow-up for these 22 patients was 12.0 years (5.4-16.2). Eight patients (8/22, 36%) suffered from late complications. Additionally, 8 patients were transitioned to an adult provider.

Conclusion: While most patients have good long-term outcomes after pediatric CC excision, major complications can still occur later than five years after surgery. Studies focusing on late outcomes, including after transition to adult care, are needed to determine the optimal long-term surveillance after childhood CC excision.

Level of evidence: III.

Background: Large language models (LLMs) are promising tools in healthcare, particularly for accessing unstructured, text-based electronic health record (EHR) data. This systematic review evaluates the applications of LLMs in the EHR for pediatric and surgical care, model performance compared to traditional methods, and proposed clinical potential to improve healthcare processes, patient outcomes, and overall quality of care.

Methods: A systematic search of ten databases from inception to November 2024 was conducted according to PRISMA guidelines, focusing on LLM use in EHRs. Two reviewers independently screened studies for inclusion, with a third reviewer resolving conflicts. Risk of bias was assessed using PROBAST.

Results: Among 4326 identified studies, 44 met the inclusion criteria - 30 (68.2 %) in all surgical specialties, 3 (6.8 %) in pediatric surgical subspecialties, and 11 (25 %) in pediatrics. Most studies (59.1 %) were published in 2024. LLM types included Bidirectional Encoder Representations from Transformers (BERT) and their variants (52.3 %), ChatGPT (29.5 %), and other models (18.2 %). Most studies (90.9 %) relied solely on retrospective unstructured data, and 40.9 % focused on classification tasks. LLMs demonstrated performance improvements in 78.1 % of studies with a traditional comparator. Clinical documentation assistance (54.5 %) and diagnostic and clinical decision support (36.4 %) were the most commonly proposed applications for LLMs.

Conclusion: While LLMs offer opportunities for EHR analysis in pediatric and surgical care, most studies remain early-stage, with notable limitations including limited external validation and lack of evaluation in actual clinical workflows. Future research should prioritize rigorous validation and real-world testing to support their safe and effective use in practice.