Journal of pediatric surgery最新文献

Background: In 2019, the PlaNeT-2 trial reported an increased risk of death and/or major bleeding among neonates transfused with platelets at liberal compared to restrictive thresholds. However, especially in the perioperative setting, clinicians often administer platelet transfusions to neonates at higher platelet count thresholds in hopes of reducing the risk of bleeding. In this study, we investigated if platelet transfusion practices changed in neonates with primary surgical diagnoses after the implementation of a restrictive platelet transfusion guideline in January of 2019.

Methods: In this retrospective study, platelet transfusions administered to infants who underwent at least one operation between January 2017 and December 2020 were classified as either indicated or non-indicated using the new guideline. Patient characteristics, diagnoses, platelet counts, and transfusion indications were collected.

Results: 58 surgical patients received 221 platelet transfusions. The number of indicated platelet transfusions did not change between periods, but the number of non-indicated transfusions significantly decreased (73 pre-vs 20 post-guideline, p < 0.0001). The median platelet count prompting transfusion decreased from 31 × 10⁹/L to 26 × 10⁹/L, p = 0.0074. There were no differences in the number of platelet transfusions administered for active bleeding in either period.

Conclusion: Platelet transfusions pose risks in neonates and data from a large, randomized trial supports the use of restrictive guidelines to minimize harm. In this study, we found that implementation of a restrictive platelet transfusion guideline decreased the number of non-indicated platelet transfusions in neonates with primary surgical diagnoses without an increase in transfusions given in the setting of active bleeding.

Background: It is unknown if there is hospital variation in postoperative mortality among infants. The purpose of this study is to describe variation in hospital postoperative mortality among infants and the extent to which gestational age may be a contributing factor.

Methods: The Pediatric Health Information System® database (2012-2020) was used to identify infants (<365 days old at the time of surgery) who underwent one of 38 operations associated with significant postoperative morbidity and mortality. Infants were stratified by gestational age (>36 weeks, 33-36 weeks, 29-32 weeks, 25-28 weeks, <25 weeks). Hospitals were stratified into tertiles of risk and reliability-adjusted postoperative mortality (below average mortality [tertile 1-T1]; above average mortality [tertile 3-T3]). Nonparametric test of trend was used to compare mortality rates across hospital tertiles stratified by gestational age. Multivariable hierarchical regression was used to evaluate the association between mortality, hospital mortality tertile, and gestational age.

Results: Overall, 69,963 infants were identified across 48 academic, pediatric hospitals. Adjusted hospital mortality rates ranged from 3.4 % [2.5-4.3] to 8.8 % [7.7-10.0]. Relative to infants treated at T1 mortality hospitals, the odds of mortality increased by 75% at T3 mortality hospitals (odds ratio [OR] 1.75 [1.57-1.94]). This relationship was consistent across all gestational ages and demonstrated a dose-dependent association with decreasing gestational age for preterm infants (33-36 weeks, OR 1.52 [1.09-2.13]; 29-32 weeks, OR 1.59 [1.18-2.15]; 25-28 weeks, OR 1.77 [1.37-2.27]; <25 weeks, OR 2.06 [1.39-3.05]).

Conclusions: There is over 2-fold variation in infant postoperative mortality with variation more pronounced among infants with extreme prematurity (≤28 weeks). These findings suggest future work is needed to understand the care processes at high performing centers associated with better surgical outcomes.

Level of evidence: Level II, Retrospective cohort study.

Introduction: Esophageal atresia-tracheoesophageal fistula (EA-TEF) is amongst the most common life-threatening developmental anomalies. For the surgical repair of esophageal atresia-tracheoesophageal fistula (EA-TEF), several interventional modifications have been suggested. One such modification is the preservation of the azygos vein, a key draining vein for the esophagus and surrounding structures. However, there is no clear consensus on the subject.

Objective: To evaluate whether preservation of the azygous vein offers clinical benefits compared with its ligation during primary repair of esophageal atresia METHODOLOGY: A comprehensive review of the literature was conducted across PubMed, Cochrane Library (CENTRAL), ScienceDirect, and Google Scholar for eligible studies from inception till July 2025. Eligible studies included were Randomized Controlled Trials (RCTs) and non-Randomized Control Trials (non-RCTs) comparing surgical correction of EA-TEF in neonates with Azygous vein ligation vs preservation. Quality assessment was done using Cochrane RoB-2 and ROBINS-I, while Eggers Begg test was used for Publication bias. Data was pooled using a Random-effects model, and heterogeneity was assessed via I² statistics.

Results: Nine studies, six RCTs, two retrospective studies, and one prospective study, including a total of 955 newborns, met the inclusion criteria. The analysis indicated that preservation of the azygos vein was associated with decreased incidence infections (RR=0.34; 95% CI: 0.22 to 0.52; P<0.001), and mortality (RR= 0.46; 95% CI=0.27 to 0.77; P=0.003). However, no significant difference in operative time, anastomotic leakage, incidence of tracheoesophageal fistula and esophageal stricture were identified between the two groups.

Conclusion: Preservation of the azygos vein during esophageal atresia repair appears to reduce mortality and postoperative infections. However, further high-quality multicenter studies are needed to confirm these benefits.

Background: Urethrocutaneous fistula remains the most common complication after hypospadias repair. We performed an updated systematic review and meta-analysis to identify modifiable and non-modifiable risk factors for fistula formation following primary hypospadias surgery.

Methods: PubMed, Scopus, Embase, Web of Science, and Cochrane databases were systematically searched from January 2000 to November 2025. Studies reporting risk factors for urethrocutaneous fistula after primary pediatric hypospadias repair with extractable odds ratios or raw data were included. Pooled odds ratios (OR) and mean differences were calculated using random-effects models. PRISMA 2020 guidelines were followed.

Results: Fourteen studies comprising 3794 patients were included. Proximal hypospadias (OR 2.03, 95 % CI 1.12-3.70) and one-stage repair (OR 1.67, 95 % CI 1.05-2.67) were significantly associated with higher fistula risk. Shorter postoperative stenting duration (<7 days) was associated with markedly increased odds (OR 3.96, 95 % CI 1.88-8.37) and longer urethral defect length (≥2 cm) with a modestly increased risk (OR 1.57, 95 % CI 1.05-2.33); however, both findings are derived from only two studies each, are imprecise, and should be considered hypothesis-generating rather than practice-changing. Age at surgery, chordee severity, suture material/technique, and urethroplasty method (TIP vs. Others) showed no significant association.

Conclusion: Proximal meatal location and one-stage repair are robust predictors of urethrocutaneous fistula (moderate certainty of evidence). Shorter postoperative stenting duration (<7 days) and longer urethral defect length (≥2 cm) show preliminary associations with higher risk (low certainty). These findings support preferential consideration of staged repair in proximal cases and prolonged stenting (≥7 days) in selected high-risk patients, while acknowledging the need for confirmatory trials. Age, suture characteristics, and choice of TIP versus flap techniques do not meaningfully affect fistula rates in modern series.

Background: Thymic epithelial tumors (TETs), including thymoma and thymic carcinoma, are rare in young patients, with limited data on clinical characteristics and outcomes. We aimed to evaluate demographics, treatment strategies, and outcomes in pediatric/adolescent, and young adult (YA) patients with TETs.

Methods: The National Cancer Database was queried for patients aged 0-39 years with thymoma or thymic carcinoma from 2004-2019. Descriptive statistics were performed, and overall survival was analyzed using Cox regressions. Kaplan-Meier analysis was stratified by age (pediatric/adolescent: 0-21 years; YA: 22-39 years) and tumor type.

Results: 1,069 patients were identified, of which 193 (18%) had thymic carcinoma and 876 (82%) had thymoma. Pediatric/adolescent patients accounted for 98 cases (9%). Most patients underwent surgical resection (77%), primarily via open approach (72%); fewer received radiation (43%) or chemotherapy (45%). Five-year survival was 36% for thymic carcinoma and 87% for thymoma. On multivariable analysis, thymic carcinoma (HR 2.9, p<0.001), advanced Masaoka stage (III: HR 2.0, p=0.001; IV: HR 3.0, p<0.001), positive margins (HR 1.6, p=0.015), and chemotherapy (HR 1.5, p=0.020) were associated with worse survival, while surgery (HR 0.2, p<0.001) and older age (HR 0.97, p=0.002) were associated with improved survival. Thymic carcinoma outcomes were significantly worse for pediatric/adolescent patients compared to YAs (p=0.03) - a difference not observed in thymoma (p=0.17).

Conclusion: Thymic carcinoma and advanced disease predict poor survival, while complete resection is associated with improved outcomes. Notably, younger patients with thymic carcinoma have significantly worse survival, highlighting the need for age- and histology-specific treatment strategies.