Journal of pediatric surgery最新文献

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).

Background: Ultrasound guidance for percutaneous central venous access (CVA) insertion has become standard of care. Due to the design of ultrasound devices, the screen is usually positioned in an unergonomic location. In this study, we evaluated the use of a head-up display (HUD) to project the ultrasound image above the eye of the surgeon, overcoming the above limitations.

Methods: Children 0-18 years of age who required CVA were randomized to ultrasound-guided percutaneous cannulation with (+HUD) or without a HUD (-HUD) projecting the live ultrasound image. Patient demographics, time and number of attempts, and complications were recorded.

Results: A total of 40 patients were randomized in the study, 20 in each group. Patient age, weight, height and gender were equally distributed. There was no statistically significant difference in time to first successful intravenous access (+HUD: 43.13sec.

, -hud: 30.02sec., p = 0.38) and number of attempts for cannulation (+HUD: 1/2/3/4 attempts: 80 %/15 %/0/5 %, -HUD: 1/2/3/4 attempts: 85 %/10 %/5 %/0 %, p = 0.53). There were minor complications in the +HUD group in 25 %, and 10 % in the -HUD group (p = 0.21).

Conclusion: This study showed that using a HUD for ultrasound-guided CVA is an ergonomic alternative with comparable results to the standard approach. It is easily implementable in most settings. More future studies on the ergonomic impact of using a HUD for this and other pediatric surgical applications are warranted.

Background: Prenatal imaging plays a central role in risk stratification for congenital diaphragmatic hernia (CDH). We sought to identify the most accurate predictor of mortality and ECMO utilization at early and late gestation timepoints amongst the various lung volume measurements: lung-to-head ratio (LHR), observed-to-expected (O/E) LHR, O/E total fetal lung volume (TFLV) and percent predicted lung volume (PPLV).

Methods: Retrospective cohort study of patients with isolated left and right-sided CDH at our fetal care center from 2012 to 2023. Early gestation imaging was performed at initial evaluation (median 24.6 weeks) and late gestation imaging between 32 and 34 weeks gestation. Receiver-operating characteristic (ROC) curve analysis was performed to establish optimal lung measurement cutoff values (Youden's index) associated with ECMO utilization and mortality.

Results: For left CDH, late PPLV ≤17.6 % was the strongest predictor of ECMO utilization (AUC 0.93), while late PPLV ≤18.0 % was the strongest predictor of mortality (AUC 0.86). Early and late O/E TFLV were also strong predictors of both ECMO utilization (AUC 0.86) and mortality (AUC 0.80-0.82). For right CDH, late PPLV ≤16.4 % was the strongest predictor of ECMO utilization (AUC 0.96), whereas late O/E LHR ≤40.5 % was the strongest predictor of mortality (AUC 0.70). Other early lung metrics demonstrated moderate to poor predictive ability.

Conclusion: O/E TFLV is the best overall predictor of ECMO utilization and mortality in both early and late prenatal imaging. Late gestation PPLV is the best single predictor of ECMO utilization in left and right CDH and mortality in left CDH.

Vascular access in infants and small children can be challenging, particularly when standard techniques are unavailable or unsuitable. In this manuscript, we describe alternative approaches for establishing vascular access in pediatric patients, especially those with conditions that contraindicate conventional access methods. These techniques were used routinely before the widespread adoption of peripherally inserted central catheters (PICC) lines. While a surgeon certainly is capable of placing a PICC line, these procedures are generally performed by non-physicians as part of a vascular access team. As PICC lines have become more ubiquitous, the current generation of pediatric surgeons has less experience with traditional techniques, which are now typically reserved for situations in which it is not possible to place a PICC. Additionally, vascular access techniques for patients with fragile skin conditions, such as epidermolysis bullosa and for hemodialysis access in the neonatal population will also be addressed. By reviewing these techniques and their indications, we aim to provide a resource for pediatric surgeons facing complex vascular access challenges.

Background: Pediatric surgical societies in high-income countries (HICs) have historically offered travel fellowships to surgeons from low- and middle-income countries (LMICs) to attend annual meetings. The value and return on investment of these programs have recently been questioned. We surveyed the experiences and outcomes of these fellows.

Methods: We conducted a sequential, explanatory, mixed-methods study of travel fellows who attended APSA, BAPS, CAPS, or PAPS annual meetings. Participants completed an anonymous online survey exploring their experience, outcomes, and feedback. Amenable participants completed virtual semi-structured interviews, that were transcribed for thematic analysis.

Results: Of 65 fellows contacted, 35 (54 %) provided complete survey responses, including 24 men (69 %) and 11 women (31 %), from 26 LMICs. Fellows' self-reported outcomes were highly favorable with respect to the fellowship's impact on their knowledge, skill acquisition, professional development, networking, and local practice environment. All but one fellow found the fellowship worthwhile, and all would recommend it to a colleague. Currently, most alumni (71 %) hold an academic position at the rank of associate professor or higher. Thematic analysis of the 20 interviews revealed both strengths (international community-building, exposure to a different practice environment) and weaknesses (lack of direct patient care, short fellowship duration, and visa difficulties).

Conclusion: Travel fellowships awarded by HIC pediatric surgical societies to LMIC pediatric surgeons are highly valued by recipients, and foster important collaborations, practice enhancement, and career advancement, albeit not without logistical hurdles. Feedback from recipients can further improve host associations' return on investment.

Level of evidence: Not Applicable.

Purpose: Provide a quantitative summary of parent- and child-reported quality of life (QoL) outcomes in children with congenital diaphragmatic hernia (CDH).

Methods: A systematic search was conducted in MEDLINE, Cochrane, and Embase databases from inception to October 25, 2024. Studies that examined child and parent-reported quality of life outcomes in pediatric patients with CDH were included. Screening and data extraction was conducted by two reviewers. The primary outcome was the reported overall QoL, and the secondary outcomes included QoL of physical, emotional, social, psychosocial, and school functioning domains. A random effects meta-analysis were performed.

Results: A total of 313 articles were screened, and thirteen studies were included. Pooled parent-reported QoL mean estimates were higher in the domains of social and physical functioning, with lower scores observed in emotional, school, and psychosocial functioning. A similar pattern was observed in child-reported QoL scores. The total QoL score reported by parents was 85.10 [82.12; 88.09], compared to 79.19 [76.78; 81.60] as reported by children. The meta-analysis showed that QoL scores were significantly lower for patients with CDH compared to controls in the physical health domain and total score, with mean differences of -6.81 [-10.37; -3.25] and -5.07 [-9.96; -0.18], respectively.

Conclusion: Children with CDH have higher QoL scores in social and physical functioning, with lower scores in emotional, school, and psychosocial functioning. However, they demonstrate overall lower QoL compared to healthy controls. These aspects should be emphasized when counseling the parents of these patients.

Level of evidence: V.

Objectives: To conduct a scoping review of the medical literature on the evaluation, management, and consequences of superabsorbent polymer (SAP) bead ingestion in children.

Methods: We performed a comprehensive search of the following: Ovid MEDLINE, Embase, PubMed, CINAHL, Web of Science. Using prespecified inclusion and exclusion criteria, three independent researchers screened 138 articles. 39 studies met criteria for further evaluation; 24 studies were included. Data were extracted and reported in adherence with the PRISMA-ScR guidelines.

Results: We identified 329 studies based on search criteria. Data extraction and analysis was performed on 24 studies based on our inclusion/exclusion criteria. Two case series described a total of 131 patients who were either asymptomatic or mildly symptomatic and required no reported intervention. 22 symptomatic patients were reported in 18 case reports. Median age at ingestion was 14 months (range: 6 months-19 years) with a 1:1 male-to-female ratio. Signs and symptoms included bilious vomiting, abdominal pain, distension, dehydration, and jaundice. At least one diagnostic imaging modality was utilized with abdominal plain films being the most frequent. Of symptomatic patients, 82% required surgery for definitive management with a complication rate of 14% and 1 mortality.

Conclusion: While many patients who ingested SAP remained asymptomatic and did not require medical intervention, 82% of symptomatic patients required surgery. The data reported in this study help highlight the dangers of SAP bead ingestion, and future studies are needed to establish standardized protocols and help guide management.