Journal of pediatric surgery最新文献_第6页

Pre-hospital Tourniquet Use in Adolescent and Pediatric Traumatic Hemorrhage: A National Study 青少年和儿童创伤性出血的院前止血带使用情况：一项全国性研究。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-10 DOI: 10.1016/j.jpedsurg.2024.161955

Alice M. Martino , Andreina Giron , John Schomberg , Makenzie Ferguson , Jeffry Nahmias , Sigrid Burruss , Yigit Guner , Laura F. Goodman

Background

Tourniquet placement (TP) is a crucial intervention to control hemorrhage, but limited literature exists for use in children. This study aimed to evaluate the effectiveness of tourniquet application by different providers (Emergency Medical Services (EMS), first responder (FR), and bystanders), hypothesizing equivalent impact on outcomes for pediatric trauma patients for all providers.

Methods

Data from the National EMS Information Systems (NEMSIS) 2017–2020 was used to examine patients 0–19 years old and assess the outcomes of tourniquet application. We considered demographics, procedure success, timing of TP relative to EMS arrival, revised trauma score (RTS), and improvement in acuity. Multivariable logistic regression models were employed to predict initial acuity and likelihood of acuity improvement after TP, while accounting for patient and provider-related variables.

Results

301 patients were included with a median age of 17 and 86.7 % male. TP by any provider before EMS transport arrival was associated with reduced odds of critical acuity upon EMS arrival (OR = 0.84, CI = 0.76–0.94, p = 0.003). After EMS arrival, bystander- and FR-placed tourniquets were associated with increased odds of improved acuity compared to EMS-placed tourniquets (OR = 1.90, CI = 1.06–3.41, p = 0.03). There was only one TP failure (0.43 %) in the EMS group. TP failure was associated with decreased odds of acuity improvement (OR = 0.62, CI = 0.44–0.86, p = 0.005).

Conclusion

Early TP for pediatric traumatic hemorrhage is crucial. Failures were rare. Placement by bystanders and FR were associated with improved acuity when controlling for other factors including RTS and EMS arrival time. These findings emphasize the importance of training on TP for all providers in prehospital settings.

Level of Evidence

IV.

背景：止血带止血（TP）是控制出血的重要干预措施，但用于儿童的文献有限。本研究旨在评估不同医疗服务提供者（紧急医疗服务（EMS）、急救人员（FR）和旁观者）使用止血带的效果，假设所有医疗服务提供者对儿科创伤患者的治疗效果具有同等影响：我们使用国家急救医疗信息系统（NEMSIS）2017-2020 年的数据对 0-19 岁的患者进行了检查，并评估了止血带应用的效果。我们考虑了人口统计学、手术成功率、止血带使用时间与 EMS 到达时间的关系、修订创伤评分（RTS）以及急性期的改善情况。我们采用了多变量逻辑回归模型来预测止血带应用后的初始敏锐度和敏锐度改善的可能性，同时考虑了与患者和提供者相关的变量：共纳入 301 名患者，中位年龄为 17 岁，86.7% 为男性。在急救车到达之前，由任何医疗服务提供者进行 TP 都会降低急救车到达后出现危急情况的几率（OR = 0.84，CI = 0.76-0.94，P = 0.003）。急救人员到达后，与急救人员放置止血带相比，由旁观者和前线人员放置止血带与改善急性损伤几率相关（OR = 1.90，CI = 1.06-3.41，p = 0.03）。急救小组中只有一次止血失败（0.43%）。TP 失败与急性期改善的几率降低有关（OR = 0.62，CI = 0.44-0.86，P = 0.005）：结论：小儿创伤性出血的早期 TP 至关重要。结论：早期 TP 对小儿创伤性出血至关重要。在控制其他因素（包括 RTS 和急救到达时间）的情况下，由旁观者实施 TP 和 FR 与急性期的改善相关。这些发现强调了在院前环境中对所有医护人员进行TP培训的重要性：证据等级：IV。

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引用次数: 0

Congenital Diaphragmatic Eventration: Should we Maintain Surgical Treatment? A Retrospective Multicentric Cohort Study 先天性膈膨出：是否应继续手术治疗？一项回顾性多中心队列研究。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-10 DOI: 10.1016/j.jpedsurg.2024.161991

Lymeymey Heng , Khalid Alzahrani , Louise Montalva , Guillaume Podevin , Françoise Schmitt

Background

The aims of this study were to describe the characteristics of children with congenital diaphragmatic eventration (CDE) and compare the outcomes of surgical and conservative treatment of pediatric CDE in France.

Methods

Retrospective study on cohort data conducted in 22 paediatric surgery departments, including patients less than 16 years of age diagnosed with CDE between 2010 and 2021. Patients with surgical or conservative treatment were compared.

Results

139 patients were included, with a median age of 8 [1–16] months. CDE occurred in boys in 68.3% and was right-sided in 66.7% of the cases. Indication for treatment depended essentially on respiratory symptoms and level of the diaphragmatic dome. The initial treatment was a surgical, with a diaphragmatic plication, in 87 cases (62%) and conservative, consisting of clinical follow-up in 52 children (38%). Of the latter, 25 children underwent surgery secondarily. Intra- and early post-operative complications occurred in 32 children (29%) and eventration recurrence in 8 children (7%). With a median follow-up of 28 months, the median level of diaphragmatic dome improved from the 6th to the 9th back rib, and the rate of respiratory symptoms decreased from 64% to 14% in the overall cohort of patients.

Conclusions

Diaphragmatic plication is effective in symptomatic patients with a dome level above the 6th posterior rib, but is associated with a 29% complication rate and 7% of recurrence.

ClinicalTrials

NCT04862494, April 28, 2021.

Level of evidence

level III treatment study.

研究背景本研究旨在描述先天性膈肌连枷锁（CDE）患儿的特征，并比较法国小儿CDE手术治疗和保守治疗的结果：方法：对22个儿科外科部门的队列数据进行回顾性研究，包括2010年至2021年期间被诊断为CDE的16岁以下患者。结果：共纳入139名患者，平均年龄为16岁：共纳入 139 名患者，中位年龄为 8 [1-16] 个月。68.3%的 CDE 患者为男孩，66.7%的病例为右侧。治疗指征主要取决于呼吸道症状和膈穹的水平。87名患儿（62%）的初始治疗是通过手术进行膈肌成形术，52名患儿（38%）的初始治疗是保守治疗，包括临床随访。在后者中，有25名患儿接受了二次手术。32名患儿（29%）出现了术中和术后早期并发症，8名患儿（7%）复发。中位随访时间为28个月，膈肌穹隆的中位水平从第6根肋骨改善到了第9根肋骨，在所有患者中，呼吸道症状发生率从64%降至14%：结论：膈肌成形术对穹隆水平高于后第6根肋骨的有症状患者有效，但并发症发生率为29%，复发率为7%：临床试验：NCT04862494，2021年4月28日。证据级别：III级治疗研究。

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引用次数: 0

Prospective Outcomes of Standardized Non-operative Management of Pancreatic Trauma With Ductal Injury in Children: Less is More 儿童胰腺创伤伴导管损伤标准化非手术治疗的前瞻性结果：少即是多

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-10 DOI: 10.1016/j.jpedsurg.2024.161976

Bindi Naik-Mathuria , Peter F. Ehrlich , Mauricio A. Escobar Jr. , Richard Falcone , Ankush Gosain , Adam M. Vogel , Mubeen Jafri , Rajan K. Thakkar , Bethany J. Slater , Robert T. Russell , Brendan Campbell , Marianne Beaudin , Shawn D. St Peter , Katie W. Russell , Nathaniel Kreykes , Barbara Gaines , David M. Notrica , Chad Hamner , Elizabeth Renaud , David Gourlay , Jana DeJesus

Background

Traumatic pancreatic laceration with ductal injury in children can be managed non-operatively (NOM); however, variable management affects outcomes. We hypothesized that a standardized management approach with early feeding and limited resource utilization is safe and improves outcomes.

Method

Prospective, multicenter study of 13 pediatric trauma centers (2018–2022). Children with blunt pancreatic trauma with ductal injury were managed per a standard NOM pathway. Outcomes were compared to a historical NOM cohort with variable management.

Results

Of 22 patients, the median age was 7.5 years (range 1–14 years). Low-fat diet was started at median 4 days [IQR 2–7] and median hospital stay was 8 days [IQR 4–10]. One patient failed NOM and underwent distal pancreatectomy. Of the rest, most (17/21, 81%) had early recovery and discharged in median 6 days [IQR 4–8.25] while 4 (19%) had prolonged recovery (median stay 24 days, IQR 19.8–30.5) and higher peri-pancreatic cyst development (early 23.5% vs prolonged 75%,p = 0.05). Pancreatic ascites at presentation correlated with cyst development (p < 0.0001). Endoscopic stent (optional) was placed in 33% and did not prevent cyst development. Delayed exocrine pancreatic insufficiency was noted in 1 patient. Compared to the historic cohort (32 patients), TPN use was lower (pre-protocol 56% vs post 23%, p = 0.02), days to diet was shorter (pre-protocol 7 vs post 4; p = 0.03), and cyst development was lower (pre-protocol 81% vs post 33%, p < 0.001).

Conclusion

Children with traumatic pancreatic ductal injury can be safely managed per the PTS NOM clinical pathway and most recover rapidly. Pancreatic ascites may predict pseudocyst formation.

Levels of Evidence

IV. Study type: therapeutic, comparative.

背景：儿童外伤性胰腺裂伤伴导管损伤可采用非手术治疗（NOM），但不同的治疗方法会影响治疗效果。我们假设，早期喂养和有限资源利用的标准化管理方法既安全又能改善预后：13 个儿科创伤中心的前瞻性多中心研究（2018-2022 年）。钝性胰腺创伤伴导管损伤的患儿按照标准 NOM 路径进行管理。结果与历史上管理不一的NOM队列进行了比较：22名患者的中位年龄为7.5岁（1-14岁）。开始低脂饮食的时间中位数为 4 天[IQR 2-7]，住院时间中位数为 8 天[IQR 4-10]。一名患者 NOM 失败，接受了远端胰腺切除术。其余患者中，大多数（17/21，81%）恢复较早，中位住院时间为 6 天[IQR 4-8.25]，4 例（19%）恢复时间较长（中位住院时间为 24 天，IQR 19.8-30.5），胰周囊肿发生率较高（早期 23.5% 对长期 75%，P = 0.05）。发病时的胰腹水与囊肿的发展相关（p 结论：胰腺外伤性囊肿患儿的胰腺腹水与囊肿的发展相关：外伤性胰腺导管损伤患儿可根据 PTS NOM 临床路径进行安全处理，大多数患儿可迅速康复。胰腹水可预测假性囊肿的形成：IV.研究类型：治疗、比较。

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引用次数: 0

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161996

Rebecca Chae , Laura Bricklin , Anireddy R. Reddy , Charlotte Z. Woods-Hill , Garrett Keim , Nadir Yehya

Background

Firearm injury is the leading cause of pediatric death in the United States (US), but few investigations have focused on the healthcare cost and burden of hospitalized survivors. We aimed to delineate the landscape of pediatric firearm hospitalizations, with a focus on sociodemographic characteristics and on acquired morbidity among survivors.

Methods

We performed a retrospective cohort study of hospitalized children (<21 years old) with firearm injuries using the 2019 Kids’ Inpatient Database, representing 80% of pediatric hospitalizations nationally.

Results

There were 5998 hospitalizations with 5592 hospital survivors, giving a US population-adjusted hospitalization rate of 9.7 per 100,000 subjects <21 years. Black subjects (37.9 per 100,000) were admitted at higher rates than other races and ethnicities (3.8–6.2 per 100,000). Non-survivors were overrepresented in White subjects who were disproportionately victims of suicide. There were 199 new invasive medical devices placed (3.3% of hospitalized subjects), including 194 in 5592 survivors (3.5% of survivors): 87 tracheostomies, 30 feeding tubes, and 77 both. Suicide attempt was overrepresented as a cause of injury in subjects needing new devices. Charges and length of stay were longer for subjects needing new devices. Total charges for all hospitalized subjects exceeded $1.05 billion for 2019, $136 million (13%) of which represented the 3.3% of admissions needing new devices.

Conclusions

Among pediatric firearm hospitalizations in 2019, Black children were overrepresented among assaults, and White children for suicide attempts. Suicide attempts were overrepresented among non-survivors, those requiring new devices, and contributed disproportionately to total hospital charges.

Level of Evidence

Level 3.

背景：枪伤是美国儿科死亡的主要原因，但很少有调查关注住院幸存者的医疗成本和负担。我们旨在描述儿科枪伤住院情况，重点关注幸存者的社会人口特征和获得性发病率：方法：我们对住院儿童进行了一项回顾性队列研究：结果：共有 5998 例住院病例，5592 例住院幸存者，经美国人口调整后的住院率为每 10 万人中有 9.7 例：在 2019 年住院治疗的儿童枪支案件中，黑人儿童在袭击案件中的比例偏高，而白人儿童在自杀未遂案件中的比例偏高。自杀未遂在非幸存者、需要新装置的儿童中占比过高，对住院总费用的贡献也不成比例：证据等级：3 级。

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引用次数: 0

Contemporary Ethical Considerations for Pediatric Metabolic and Bariatric Surgery. 小儿代谢和减肥手术的当代伦理考虑。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161988

Marla A Sacks, Catherine Hunter, Patrick J Javid, Baddr A Shakhsheer

Background: The prevalence of pediatric obesity continues to increase dramatically. Though metabolic and bariatric surgery (MBS) is efficacious and is supported by high-quality data in this population, it remains underutilized. This paper aims to discuss current ethical concerns, considerations, and controversies of pediatric MBS.

Methods/results: Three case studies are utilized to illustrate ethical issues related to pediatric MBS: 1) a teenager with obesity and an unsupportive parent; 2) a teenager with morbid obesity and developmental delay; and 3) a young child with severe liver damage from hepatic steatosis.

Conclusions: The prevalence of pediatric obesity is rising exponentially with more cases resistant to lifestyle modifications and medical therapies. Metabolic and bariatric surgery (MBS) in children is efficacious and should prompt thoughtful multi-disciplinary discussion to best help the patient regardless of racial, ethnic, or socioeconomic status. Decision making involves consideration of patient assent, parent/guardian consent, and balance of current and future risk. Providers caring for patients should utilize "obesity-friendly" language to lessen stigma.

Level of evidence: Level V.

背景：小儿肥胖症的发病率持续大幅上升。虽然代谢与减肥手术（MBS）在这一人群中具有疗效，并得到了高质量数据的支持，但仍未得到充分利用。本文旨在讨论当前儿科代谢减重手术的伦理问题、考虑因素和争议：方法/结果：本文通过三个案例研究来说明与小儿多器官功能障碍相关的伦理问题：1）一名患有肥胖症且父母不支持的青少年；2）一名患有病态肥胖症且发育迟缓的青少年；3）一名因肝脏脂肪变性而导致严重肝损伤的幼儿：结论：小儿肥胖症的发病率呈指数上升趋势，越来越多的病例对改变生活方式和药物疗法产生了抗药性。儿童代谢和减肥手术（MBS）疗效显著，应引起多学科深思熟虑的讨论，以便为患者提供最佳帮助，而不论其种族、民族或社会经济地位如何。决策制定需要考虑患者的同意、家长/监护人的同意以及当前和未来风险的平衡。为患者提供护理的医疗人员应使用 "肥胖友好型 "语言，以减少耻辱感：证据等级：V 级。

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引用次数: 0

Cloacal Exstrophy Closure Without Osteotomy and Immobilization: A Recipe for Failure 没有截骨和固定的泄殖腔外翻闭合术：失败的秘诀

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161995

David Heap , Ahmad Haffar , Chad B. Crigger , Tanisha Martheswaran , Alexander Hirsch , Victoria Maxon , Paul D. Sponseller , Heather N. Di Carlo , John P. Gearhart

Background

Cloacal exstrophy (CE) remains one of the most severe birth defects compatible with life with a constellation of anomalies involving the bladder, genitalia, hindgut, and spinal cord. Pelvic osteotomy and immobilization have been utilized to facilitate bladder closure, yet their role as adjuncts remains a topic of debate. The authors sought to evaluate the outcomes of CE closure without the use of osteotomy or lower extremity (LE)/pelvic immobilization.

Methods

An institutional database of 173 CE patients was reviewed for patients closed without osteotomy and/or limb immobilization. Patient records were reviewed for continence procedures, reclosure operations, and continence outcomes.

Results

A total of 59 closure surgeries that met inclusion criteria were identified in 56 unique patients. Thirty-seven closure procedures developed eventual failure (63%) with secondary closure events also resulting in failure. Most closures did not use an osteotomy, 93.2%. LE immobilization-only was used in most closures (43/59), of which only 37% were successful. Failures were attributed to dehiscence (14/37), bladder prolapse (19/37), or both dehiscence and prolapse (4/37). The median age at closure was 3 days old (1–18.5 IQR) with the majority of closure events (47) closure events taking place in the newborn period. Median diastasis prior to primary closure was 6 cm (4.8–8 cm IQR). The median number of closure attempts needed to close the bladder was 2 (1–2 IQR). Of the 56 patients, 31 have >3 h of daytime continence, with the entirety of these patients catheterizing a stoma or below.

Conclusion

These results highlight the critical role of osteotomy and lower limb immobilization in successful closure of the bladder and abdominal wall in CE.

Type of Study

Treatment Study.

Level of Evidence

Level III.

背景：膀胱外口萎缩症（Cloacal exstrophy，CE）是最严重的出生缺陷之一，其膀胱、生殖器、后肠和脊髓均存在异常。骨盆截骨术和固定术被用来促进膀胱闭合，但它们作为辅助手段的作用仍是一个争论不休的话题。作者试图评估在不使用截骨术或下肢（LE）/骨盆固定的情况下进行 CE 闭合的结果：方法：对173例CE患者的机构数据库进行了审查，以了解未进行截骨术和/或肢体固定的闭合患者的情况。方法：对173名CE患者的机构数据库进行审查，以了解未进行截骨术和/或肢体固定的闭合患者的情况：结果：在 56 名患者中，共发现 59 例符合纳入标准的闭合手术。37例闭合手术最终失败（63%），二次闭合也导致失败。大多数闭合手术没有使用截骨术，占 93.2%。大多数闭合手术（43/59）只使用了LE固定，其中只有37%成功。失败的原因包括裂开（14/37）、膀胱脱垂（19/37）或裂开和脱垂（4/37）。闭合时的中位年龄为出生 3 天（1-18.5 IQR），大多数闭合事件（47 例）发生在新生儿期。初次闭合前的裂隙中位数为 6 厘米（4.8-8 厘米，IQR）。闭合膀胱所需的闭合尝试次数中位数为 2 次（1-2 次，IQR）。在 56 位患者中，31 位患者的日间尿失禁时间超过 3 小时，这些患者全部使用造口或造口以下的导尿管：这些结果凸显了截骨术和下肢固定在成功关闭 CE 膀胱和腹壁中的关键作用：治疗研究：证据等级：三级。

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引用次数: 0

Management of External Ventricular Drains for Neuromonitoring and Traumatic Brain Injury Treatment in Pediatric Patients Outside of Intensive Care Units: A Single-Institution Retrospective Study. 在重症监护室外对用于神经监测和创伤性脑损伤治疗的儿科患者进行脑室外引流的管理：单机构回顾性研究。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161993

Matthew C Findlay, Katie W Russell, Samuel A Tenhoeve, Monica Owens, Rajiv R Iyer, Robert J Bollo

Background: Most pediatric hospitals manage patients who require external ventricular drains (EVDs) exclusively within pediatric intensive care units (PICUs) because of institutional protocols. Our institution commonly manages patients with EVDs on the neurotrauma floor (NTF). We evaluated whether this practice results in more EVD-associated complications.

Methods: A retrospective cohort study at our Level 1 pediatric trauma center identified all trauma patients ≤18 years old who received an EVD in 2018-2023. Demographics, presenting characteristics, in-hospital management, and EVD management details were recorded. The primary outcome was EVD-related complication events.

Results: Of the 81 patients who had EVDs placed after neurotrauma, 45 had their EVD managed exclusively in the PICU (PICU-EVD) and 36 had their EVD for some time while on the NTF (NTF-EVD). The groups were similar in sex (p = 0.87) and age (p = 0.054). PICU-EVD patients underwent fewer neurosurgeries (55.6% vs. 77.8%, p = 0.04) but spent more time on ventilators (10.6 ± 8.7 days vs. 6.4 ± 4.8, p = 0.02) and in the PICU (11.8 ± 9.0 days vs. 8.4 ± 5.9, p = 0.02). Total hospital stay was similar between groups (p = 0.44). NTF-EVD patients were on the drain longer (9.0 ± 7.4 days vs. 13.1 ± 9.1, p = 0.03), including 5.9 days on the NTF. Four EVD-related complications occurred overall: 2 accidental dislodgements and 2 cerebrospinal fluid leaks. EVD complication rates were similar on the NTF and PICU (2.2% vs. 8.3%, p = 0.21). All complications occurred late in the hospital course and were minor. A Poisson regression model comparing complication rates between PICU-only and NTF management (433 vs. 441 catheter days, respectively) found a complication rate of 6.8 per 1000 catheter days in the NTF group versus 2.3 per 1000 catheter days in the PICU-only group, yielding a rate ratio of 2.95 (95% confidence interval 0.29-30.4, p = 0.35). However, this difference was not statistically significant.

Conclusion: Our center routinely discharges patients from the PICU to the NTF with EVDs in place. This practice may be associated with no increased risk or rate of EVD-related complications compared to PICU-only management.

Level of evidence: IV.

背景：大多数儿科医院根据机构规定，只在儿科重症监护病房（PICU）内管理需要进行脑室外引流（EVD）的患者。我们的医院通常在神经创伤楼层（NTF）管理 EVD 患者。我们评估了这种做法是否会导致更多与 EVD 相关的并发症：我们一级儿科创伤中心的一项回顾性队列研究确定了 2018-2023 年接受 EVD 的所有年龄小于 18 岁的创伤患者。研究记录了人口统计学、发病特征、院内管理和 EVD 管理细节。主要结果为EVD相关并发症事件：在81名神经创伤后置入EVD的患者中，45名患者的EVD完全在PICU（PICU-EVD）进行管理，36名患者的EVD在NTF（NTF-EVD）进行了一段时间的管理。两组患者的性别（p = 0.87）和年龄（p = 0.054）相似。PICU-EVD 患者接受的神经外科手术较少（55.6% vs. 77.8%，p = 0.04），但使用呼吸机的时间（10.6 ± 8.7 天 vs. 6.4 ± 4.8 天，p = 0.02）和在 PICU 的时间（11.8 ± 9.0 天 vs. 8.4 ± 5.9 天，p = 0.02）较长。两组患者的总住院时间相似（p = 0.44）。NTF-EVD患者的引流时间更长（9.0 ± 7.4天 vs. 13.1 ± 9.1天，p = 0.03），其中NTF患者的引流时间为5.9天。总计发生了4例EVD相关并发症：2例意外脱落，2例脑脊液漏。NTF和PICU的EVD并发症发生率相似（2.2% vs. 8.3%，p = 0.21）。所有并发症均发生在住院后期，且均为轻微并发症。泊松回归模型比较了仅在 PICU 和 NTF 管理下的并发症发生率（分别为 433 对 441 个导管日），发现 NTF 组每 1000 个导管日的并发症发生率为 6.8，而仅在 PICU 组每 1000 个导管日的并发症发生率为 2.3，比率比为 2.95（95% 置信区间为 0.29-30.4，p = 0.35）。然而，这一差异并无统计学意义：我们中心的常规做法是将患者从 PICU 转至 NTF，同时安装 EVDs。与仅在 PICU 进行管理相比，这种做法可能不会增加 EVD 相关并发症的风险或发生率：证据级别：IV。

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引用次数: 0

SIPA Poorly Predicts Outcomes in Young Pediatric Trauma Patients SIPA 难以预测小儿创伤患者的预后。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161997

Katherine B. Snyder , Ryan Phillips , Kenneth Stewart , Zoona Sarwar , Catherine J. Hunter , Alessandra Landmann , Roxie Albrecht , Jeremy Johnson

Introduction

The shock index pediatric adjusted score (SIPA) predicts the need for blood transfusion (BT), hemorrhage control interventions (HCI), morbidity/mortality among older pediatric trauma patients but is less predictive in younger patients. We hypothesize that SIPA will be predictive among older pediatric patients for BT, HCI, mortality, and need for trauma intervention (NFTI), however we aim to further delineate the gap in utilizing SIPA in younger patients.

Methods

Using the ACS NTDB for 2017–2021 we evaluated patients 1–14 years old who were transported by EMS from the scene for definitive care. Patients were divided into three age groups: 1–4, 5–9, and 10–14 years. Recursive partitioning was used to identify separate SIPA cut-points predictive of BT, HCI, NFTI, and morbidity/mortality. Cut-points from the partitions were evaluated using Area-under-curve (AUC) statistics and response probabilities were obtained from corresponding Leaf Reports.

Results

Four SIPA cut-points from the recursive partitioning were selected for each age group. SIPA was more predictive of the need for HCI. BT showed similar results consistent with previous literature. SIPA alone showed poor discrimination in relation to NFTI and mortality, and again predictive value was slightly higher in older children.

Conclusion

While SIPA alone showed discrimination of specific outcomes of BT and HCI, it was poorly predictive of both the NFTI and mortality in children. The youngest pediatric patients continue to be elusive. Utilizing SIPA in combination with additional scores may be necessary to triage young children appropriately. This study also indicates the need to develop NFTI criteria specific to children.

Level of Evidence

IV.

简介：儿科休克指数调整评分（SIPA）可预测老年儿科创伤患者的输血（BT）需求、出血控制干预（HCI）、发病率/死亡率，但对年轻患者的预测性较低。我们假设 SIPA 可以预测老年儿科患者的输血需求、出血控制干预、死亡率和创伤干预需求（NFTI），但我们的目标是进一步明确 SIPA 在年轻患者中的应用差距：利用 2017-2021 年 ACS NTDB，我们评估了由急救中心从现场运送到医院接受最终治疗的 1-14 岁患者。患者被分为三个年龄组：1-4 岁、5-9 岁和 10-14 岁。我们使用递归分区来确定预测 BT、HCI、NFTI 和发病率/死亡率的不同 SIPA 切点。使用曲线下面积（AUC）统计对分区的切点进行评估，并从相应的Leaf报告中获得反应概率：结果：从递归分区中为每个年龄组选择了四个 SIPA 切点。SIPA 更能预测对人机交互的需求。BT 显示的结果与之前的文献类似。单独使用 SIPA 对 NFTI 和死亡率的分辨能力较差，对年龄较大儿童的预测价值也略高：结论：虽然单独使用 SIPA 可以区分 BT 和 HCI 的特定结果，但它对儿童 NFTI 和死亡率的预测性较差。最年轻的儿童患者仍然难以捉摸。可能有必要将 SIPA 与其他评分结合使用，以便对幼儿进行适当分流。本研究还表明，有必要制定专门针对儿童的 NFTI 标准：证据等级：IV。

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引用次数: 0

Thoracoscopic Lobectomy for Congenital Lung Malformation in Children: Evolving Management Strategies and Their Impact in Outcomes 胸腔镜肺叶切除术治疗儿童先天性肺畸形：不断演变的管理策略及其对疗效的影响。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-09 DOI: 10.1016/j.jpedsurg.2024.161992

María López-Diaz , Indalecio Cano Novillo , Rocío Morante-Valverde , Araceli García Vázquez , Manuel Romero Layos , Alberto Galindo Izquierdo , Juan L. Antón-Pacheco

Background

The aim of this study was to determine the incidence of complications after thoracoscopic lobectomy in children according to a verified classification. Secondary aim was to evaluate the modifications made in our management protocol in order to decrease the rate of complications.

Methods

Retrospective study of pediatric patients in whom a lobectomy was performed for congenital lung malformation (CLM) in our institution between 2003 and 2021. The following data were collected: demographics, preoperative clinical symptoms, surgical technical details, and postoperative complications following the Clavien-Dindo (CD) classification. Main outcome measure was the presence of complications in the first month after lung lobectomy.

Results

90 lobectomies were performed in 89 patients. There were 46 girls (51.6%) and 43 boys with a median age of 12.4 months. Most patients (86.6%) remained asymptomatic until the surgical procedure. Postsurgical complications were detected in 26 cases (28.8%) and distributed into their respective category according to CD classification. In our experience, closure of the bronchial stump with interrupted suture or placement of an endoloop showed a statistically significant association with complications (p = 0.022 and p = 0.006 respectively). Moreover, patients in which a device combining sealing and section was used showed significantly fewer complications (p = 0.006).

Conclusions

Thoracoscopic lobectomy continues to be a challenging procedure. The CD grading system for postoperative complications has proved to be useful in this setting. Evolving surgical strategies and new miniaturized endosurgical devices have enabled a safer and quicker procedure with a positive impact in the development of complications.

Level of Evidence

III.

背景：本研究的目的是根据经过验证的分类确定儿童胸腔镜肺叶切除术后并发症的发生率。次要目的是评估我们为降低并发症发生率而对管理方案做出的修改：方法：对2003年至2021年间在我院因先天性肺畸形（CLM）而接受肺叶切除术的儿童患者进行回顾性研究。研究收集了以下数据：人口统计学、术前临床症状、手术技术细节以及按照克拉维恩-丁多（CD）分类的术后并发症。主要结果指标是肺叶切除术后第一个月出现并发症的情况：89名患者共进行了90例肺叶切除术。结果：89 名患者接受了 90 例肺叶切除术，其中 46 名女孩（51.6%），43 名男孩，中位年龄为 12.4 个月。大多数患者（86.6%）在手术前没有任何症状。有 26 例（28.8%）患者发现了手术后并发症，并根据 CD 分类法将其归入相应的类别。根据我们的经验，用间断缝合法缝合支气管残端或放置内环与并发症有显著的统计学关联（分别为 p = 0.022 和 p = 0.006）。此外，使用结合密封和切口的装置的患者并发症明显较少（p = 0.006）：结论：胸腔镜肺叶切除术仍然是一项具有挑战性的手术。结论：胸腔镜肺叶切除术仍然是一项具有挑战性的手术，术后并发症 CD 分级系统已被证明在这种情况下非常有用。不断发展的手术策略和新型微型化内外科设备使手术更加安全快捷，并对并发症的发生产生了积极影响：证据等级：III。

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引用次数: 0

Effectiveness of Preoperative Intrahepatic Portal Venous Classification System in Guiding Preoperative Surgical Decisions and Predicting Hypotensive Effects After Meso-rex Bypass for Children With EHPVO. 术前肝内门静脉分类系统在指导 EHPVO 患儿术前手术决策和预测中肾旁路术后低血压效应方面的有效性。

IF 2.4 2区医学 Q1 PEDIATRICS

Journal of pediatric surgery

Pub Date : 2024-10-05 DOI: 10.1016/j.jpedsurg.2024.161990

Xiaopan Chang, Lu Liu, Jieqin Wang, Qifeng Liang, Jiankun Liang, Zhenyin Liu, Zhe Wen

Background: The categorization of intrahepatic portal venous system (IHPS) patterns using wedged hepatic venous portography (WHVP) has proven to be an effective tool in the preoperative evaluation of Rex recessus and in identifying pediatric patients with extrahepatic portal vein obstruction (EHPVO) who are suitable for meso-Rex bypass (MRB). Despite this classification system being proposed a decade ago, its clinical application remains underutilized.

Methods: A single-center retrospective study of 182 children with EHPVO was conducted between October 2014 and July 2023 when MRB was attempted. Data on demographics, etiology, imaging examinations, procedures, and follow-up were collected for 161 patients included. Two interventional radiologists used deVille's method to classify patients into types A to E based on WHVP imaging, with interobserver agreement analyzed. Associations between IHPS patterns and surgical outcomes following MRB were investigated.

Results: Two radiologists had a high level of agreement on identifying IHPS patterns and suitable patients for MRB. Of the 161 cases, 130 were type A, 10 were type B, 5 were type C, 7 were type D, and 9 were type E. One hundred and forty-five patients with types A, B and C underwent successful MRB, showing feasibility for 90% of patients. Children categorized as types A and B experienced more significant benefits than type C, including intraoperatively decreased portal vein pressure, esophageal/gastric varices relief, decreased portal venous collaterals and a lower rate of bypass occlusion after one year. The surgical outcomes of patients with types A and B were not influenced by the diameter of the Rex recessus as suggested by WHVP.

Conclusions: The majority of pediatric patients with EHPVO in mainland China have opportunities to receive successful MRB. There are potential differences in the etiology of Chinese and Western patients. The IHPS classification system aids in guiding preoperative surgical decisions and predicting hypotensive effects after MRB. Type C patients should be carefully chosen for MRB.

背景：使用楔形肝静脉造影术（WHVP）对肝内门静脉系统（IHPS）模式进行分类，已被证明是一种有效的工具，可用于术前评估雷克斯凹陷（Rex recessus），并确定哪些小儿肝外门静脉阻塞（EHPVO）患者适合进行中-雷克斯搭桥术（MRB）。尽管该分类系统早在十年前就已提出，但其临床应用仍然不足：方法：2014 年 10 月至 2023 年 7 月期间，对尝试 MRB 的 182 名 EHPVO 患儿进行了单中心回顾性研究。收集了161名患者的人口统计学、病因学、影像学检查、手术和随访数据。两名介入放射科医生采用德维尔方法，根据 WHVP 成像将患者分为 A 至 E 型，并分析观察者之间的一致性。研究了IHPS模式与MRB术后手术结果之间的关联：结果：两位放射科医生在识别 IHPS 模式和适合 MRB 的患者方面意见高度一致。在161例患者中，130例为A型，10例为B型，5例为C型，7例为D型，9例为E型。A 型和 B 型患儿比 C 型患儿有更明显的获益，包括术中门静脉压力降低、食管/胃静脉曲张缓解、门静脉袢减少以及一年后旁路闭塞率降低。A型和B型患者的手术效果并不受WHVP提出的Rex凹直径的影响：结论：在中国大陆，大多数小儿高血压脑血管畸形患者都有机会成功接受MRB手术。中西方患者的病因可能存在差异。IHPS分类系统有助于指导术前手术决策和预测MRB术后的降压效果。C 型患者应慎重选择 MRB。

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引用次数: 0