Journal of pediatric surgery最新文献

Objective: To develop and validate a deep learning-based multi-instance learning model that integrates CT imaging and clinical data to improve the accuracy of discriminating between strangulated small bowel obstruction (StSBO) from simple small bowel obstruction (SiSBO) in pediatric patients.

Materials and methods: This multicenter retrospective study, conducted between January 2018 and June 2024, enrolled hospitalized pediatric patients aged 1 to 14 years with a diagnosis of small bowel obstruction. We developed the clinical, multi-instance learning (MIL), and combined models based on CT and clinical features. Model performance was evaluated using receiver operating characteristic (ROC) analysis, while SHapley Additive exPlanations (SHAP) interpreted feature contributions. We further assessed whether MIL-assisted diagnosis could enhance physician accuracy in diagnosing StSBO.

Results: The study sample comprised 168 patients (mean age, 6.36 ± 3.97, 118 men). Ascites and closed-loop sign were identified as independent predictors of StSBO on multivariate analysis (both p < 0.05). The MIL model achieved the area under the curve (AUC) of 0.86 (95%CI 0.70-1.00), p = 0.01 in the external test cohort. The combined model showed the highest diagnostic performance (AUC 0.87, 95%CI 0.72-1.00, p = 0.01) in the external test cohort, with MIL-derived features showing predominant importance in SHAP analysis. Both junior and experienced radiologists and surgeon demonstrated improved diagnostic performance with MIL assistance, showing AUC increases of 16%, 2%, and 20%, respectively.

Conclusions: The MIL model performed well in diagnosing StSBO, and clinical data integration improved its performance. As a decision support tool, the model may aid risk stratification and facilitate timely escalation of care in pediatric StSBO management.

Children living in remote and Indigenous communities in Canada often face significant barriers to timely surgical care due to geographic isolation, limited local resources, and financial pressures within a publicly funded healthcare system. These challenges frequently create ethical dilemmas for clinicians and families, who must choose between delaying care for transfer to a tertiary center or proceeding locally with limited expertise. This paper explores three illustrative cases including emergent neonatal volvulus with no possibility of transfer, pyloric stenosis with family-declined transfer, and elective hernia repair with family-requested transfer. The purpose is to examine the ethical tensions that arise when access to specialized pediatric surgery is constrained. Applying the principles of beneficence, non-maleficence, justice, and respect for autonomy, each scenario highlights the complex interplay between individual patient needs, professional responsibility, systemic equity, and fiscal stewardship. Through these cases, we argue that ethical decision-making under constraint demands not only clinical judgment but also an understanding of the healthcare system and a nuanced approach. Solutions such as enhanced rural surgical training, telemedicine support, culturally informed care, and robust infrastructure investment are essential to ensure that no child is left behind due to geography or resource scarcity.

Background: Recurrent tracheoesophageal fistula (rTEF) is a rare but serious complication after esophageal atresia (EA) repair. Although various surgical and endoscopic techniques are available, the optimal management remains controversial due to limited data and heterogeneous outcomes.

Purpose: To systematically review and compare the outcomes of surgical and endoscopic interventions for rTEF in pediatric patients.

Methods: A systematic literature search was conducted in PubMed, MEDLINE, and EMBASE for studies published between January 2015 and January 2025. Twenty-seven eligible studies involving 789 children with rTEF were analyzed. Treatment modalities were classified as open surgical management (OSM), thoracoscopic surgical management (TSM), or endoscopic management (EM). Data on demographics, treatment type, and outcomes were descriptively summarized.

Results: The overall incidence of rTEF was 7.17 %. The success rates were 92.9 % for OSM, 86.4 % for TSM, and 67.2 % for EM. Major risk factors were esophageal stricture and anastomotic leakage. Re-recurrence rates ranged from 8.9 % to 21.7 % in surgically treated patients. EM frequently required repeated sessions, and a substantial proportion of patients ultimately underwent surgical repair due to persistent fistula or recurrent symptoms.

Conclusions: Open and thoracoscopic repair remain the most effective treatments for rTEF, while endoscopic methods serve as minimally invasive adjuncts. Standardized definitions and multicenter prospective studies are required to establish an evidence-based treatment algorithm and to improve either short- or long-term outcomes in children with rTEF.

Background: Esophageal button battery impactions are pediatric emergencies with clear guidelines for pre-extraction management, but post-extraction care remains highly variable. Common practices include ICU admission, prolonged NPO, antibiotics, and extensive imaging, though the supporting evidence is unclear.

Methods: We performed a scoping review, searching PubMed, Embase, and Scopus for pediatric esophageal button battery injuries reporting post-extraction management. Variables included imaging strategy and impact, ICU admission, feeding practices, and complications. Case reports, case series, and retrospective cohorts were included. Variables included imaging strategy and impact, ICU admission, feeding practices, and complications. Case reports, case series, and retrospective cohorts were included.

Results: Of 37 studies with 713 patients, complications included 47 esophageal perforations, 37 tracheoesophageal fistulas, 28 esophageal strictures, 26 mediastinitis, 23 esophageal stenoses, 11 vocal cord injuries, 4 aortoesophageal fistulas, and 3 deaths. Post-extraction imaging was reported in 83.8 % of studies with 610 patients; esophagram was most common. In studies that reported imaging details, imaging influenced postoperative management in 12/23 studies using esophagram, 5/12 studies using CXR, 4/6 studies using CT, and 2/3 studies using MRI/MRA. (These were study-level proportions as patient-level counts could not be consistently extracted and modalities overlapped).Time to feeding ranged from 1 h to 233 days via multiple routes. Among 24 studies with known timing, 12/18 resuming <7 days and 2/6 resuming ≥7 days reported morbidity or mortality. Antibiotics were explicitly given in 24 studies.

Conclusion: Routine ICU admission, prolonged NPO, universal antibiotics, and multi-modality imaging are not standard after esophageal button battery removal. We propose a risk-stratified framework for imaging, ICU use, and feeding that reserves advanced imaging, ICU level care, and delayed feedings for patients at highest risk for complications based on their presentation and injury severity.

Background: Congenital lung malformation (CLMs) is a series of developmental lung abnormalities that may persist into adulthood. Some centres would advocate an observation approach rather than opting for surgical excision. However, the potential impact of environmental factors, particularly cigarette smoke exposure, on CLM-affected lung tissue remains poorly understood.

Aim: This study aimed to evaluate the effects of cigarette smoke extract (CSE) on paired normal and diseased airway organoids (AOs) derived from pediatric lung tissue diagnosed as intralobar sequestration, using N-[N-(3,5-Difluorophenacetyl)-L-alanyl]-S-phenylglycine t-butyl ester (DAPT), a γ-secretase inhibitor, to modulate airway epithelial differentiation.

Method: AOs were established from paired normal and diseased regions of pediatric lung tissue. Organoids were cultured under two conditions: without DAPT or with DAPT pretreatment, followed by 4 % CSE exposure. Mucus viscosity, MUC5AC protein expression, PAS staining, and RT-qPCR analysis of airway epithelial cell markers, tight junction proteins (E-cadherin, ZO-1), and proinflammatory cytokines were measured.

Results: Disease-derived AOs exhibited higher mucus secretion compared to normal tissue-derived AOs. CSE exposure enhanced mucus viscosity and MUC5AC expression in both groups, with more pronounced effects in diseased organoids. CSE-induced upregulation of mucins and pro-inflammatory cytokines was particularly evident in disease-derived organoids without DAPT treatment. DAPT pretreatment attenuated these CSE-induced changes, while tight junction protein expression remained stable across conditions.

Conclusion: Our findings demonstrate that diseased airway organoids show enhanced susceptibility to cigarette-smoke -induced mucus hypersecretion and inflammatory responses, suggesting that patients with congenital airway malformations may be particularly vulnerable to the effects of cigarette smoke exposure.

Background: Indocyanine green (ICG) fluorescence imaging is increasingly used intraoperatively to assess tissue perfusion and guide surgical decision-making. While its qualitative use has been associated with improved outcomes, including reduced anastomotic leak rates, interpretation remains subjective and lacks standardization. Quantitative fluorescence analysis may improve reproducibility, precision, and broader clinical applicability.

Methods: Handheld intraoperative ICG fluorescence video from a representative bowel perfusion assessment was analyzed using three quantitative approaches: (1) a static region-of-interest (ROI) "steady lasso," (2) a manually adjusted "moving lasso," and (3) a semi-automated computational method. ROIs were applied to well- and poorly-perfused bowel segments, and mean pixel intensity over time was measured.

Results: The steady lasso method demonstrated substantial signal misalignment due to tissue and camera motion, limiting reliability. The moving lasso improved spatial accuracy and demonstrated earlier signal rise and higher peak intensity in well-perfused bowel compared with poorly perfused tissue. The semi-automated method enabled high-throughput analysis and detailed characterization of fluorescence signal dynamics. Large ROIs demonstrated lower signal variability compared with small ROIs, particularly in poorly perfused tissue. Across methods, visually well-perfused tissue demonstrated faster time-to-peak and higher peak fluorescence.

Discussion: Quantitative analysis of ICG fluorescence in handheld surgical video is feasible and reveals measurable differences in fluorescence signal behavior. While manual techniques improve accuracy over static approaches, semi-automated methods offer a higher degree of scalability. These findings highlight the need for automated ROI tracking and standardized acquisition protocols to support reproducible, real-time quantitative perfusion assessment in surgery.