Journal of pediatric surgery最新文献

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.

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 within the pediatric population.

Methods: The National Readmissions Database was queried from 2016 to 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: 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 anatomical 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, surgeons 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.

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: 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.

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.