Pediatric Surgery International最新文献

Background: Enhanced recovery after surgery (ERAS) pathways has become well established for operations as diverse as hip replacement and coronary artery bypass. We designed an ERAS gastrostomy pathway in children based on best practice to facilitate 23-h discharge.

Methods: An ERAS pathway for laparoscopic Seldinger gastrostomy insertion was developed in 2018 with standardisation of all phases from first pre-operative visit to discharge. A series of videos uploaded to YouTube accessed via a QR code were created to educate parents. The post-operative feeding regime, nurse-led training and discharge plan were standardised on a single page so it could be shared and viewed easily on a smart phone.

Results: Data were collected prospectively for isolated elective laparoscopic gastrotomy insertion from 2019 to 2022. A total of 155 patients were eligible for the ERAS gastrostomy pathway (median age: 3.9 years; median co-morbidities: 4). Length of post-operative stay was a median 26 h with 60/155 (39%) of patients leaving by 10 am the next morning. Post-operative complications were noted in 20 patients with 6 readmissions none of which were due to early discharge. Multiple non-clinical reasons were identified for delays to discharge.

Conclusions: Multiple major co-morbidities were not a contraindication to following the ERAS. In total, 39% of the patients were discharged by 10 am the next morning. Key to success was having a single surgical technique, standardisation of pre- and post-operative pathways and nurse-led discharge. Further improvements should be possible by closer adherence to the guidelines.

Background: DiGeorge syndrome (DGS) is a condition typically associated with athymia, parathyroid hypoplasia or aplasia, and congenital heart defects. Athymia in these patients causes severe immunodeficiency, causing high mortality and morbidity, often requiring thymic tissue transplantation. The present systematic review aims to consolidate the present evidence on thymus transplantation in DGS.

Methods: An electronic literature search of five databases (PubMed, Medline, Scopus, EBSCOhost, and CINAHL) was performed from inception till September 2024. Relevant articles were selected, and data was extracted by two independent reviewers.

Results: A total of 16 articles were included from an initial set of 1227 articles. Patients diagnosed with DGS in the included studies were predominantly male, and the age at which thymus transplantation was done typically varied from 0.8 to 26 months. Several patients had chromosome 22q11 hemizygosity. Thymic tissue was taken from tissues of pediatric patients undergoing cardiothoracic surgery. Pre-transplant medication included immunosuppressants with rabbit anti-thymocyte globulin (RATGAM) being frequently used alongside steroids and tacrolimus. This tissue was cultured and transplanted into the quadriceps muscle of the patients under general anesthesia. Thymopoiesis was well described in most patients with graft failures and rejections occurring rarely. Naive T-cell development was noted in almost all patients with clearance of infections in many cases. Common postoperative complications include sepsis, haemorrhage, gastrointestinal disturbances, among others. Mortality was uncommon but often associated with intracerebral hemorrhages and sepsis.

Conclusion: Thymus transplantation is a relatively safe and effective procedure in patients with DGS with athymia. Future research should explore the addition of allogenic parathyroid gland transplantation along with thymic tissue.

Purpose: The study aimed to explore the feasibility and effect of pulmonary rehabilitation (PR) in the recovery of children who underwent thoracoscopic pulmonary resection.

Methods: From January 2015 to December 2021, consecutive patients who underwent thoracoscopic pulmonary resection were divided into group A and group B. All of them were treated with the same perioperative protocols except for group A with perioperative lung rehabilitation management, while group B was not. Demographics, operative data, postoperative complications and clinical outcomes were compared between these two groups.

Results: Sixty eight cases enrolled with 33 in group A and 35 in group B. Demographic data was comparable between the two groups, as well as the dose of tramadol and diclofenac sodium. Few patients in group A had temperature higher than 38℃ in the first 3 days after the surgery. The mean time of the first ambulation after the operation was shorter in group A than that in group B. The drainage time and the postoperative hospital stay were similar. No interventions needed for complications.

Conclusion: The application of perioperative PR in children who underwent thoracoscopic pulmonary resection is safe and feasible.

Objective: To assess the efficacy of local volume reduction of the dorsal glans groove in hypospadias repair with small glans.

Methods: This retrospective comparative study included 107 children treated between January 2017 and December 2020. Patients were divided into two groups: Group 1 (2017-2018) underwent onlay island flap urethroplasty alone, while Group 2 (2019-2020) underwent the procedure with additional local volume reduction of the dorsal glans groove. Hypospadias objective scoring evaluation (HOSE) scores and postoperative complications, including glans dehiscence, meatal stenosis, and urethrocutaneous fistula, were compared.

Results: The mean follow-up was 40 months (Group 1) and 32 months (Group 2). Urethrocutaneous fistula rates were 4% (Group 1) and 2% (Group 2; P = 1). Glans dehiscence occurred in 16% (Group 1) and 4% (Group 2; P = 0.0451). Meatal stenosis rates were 16% (Group 1) and 2% (Group 2; P = 0.0184). Overall success rates were 65% (Group 1) and 92% (Group 2; P = 0.0008). HOSE scores showed no significant difference (P = 0.219).

Conclusions: Local volume reduction of the dorsal glans groove significantly reduces postoperative complications in hypospadias repair with small glans.

Oral mucosa graft urethroplasty (OMGU) is a surgical technique used in complex hypospadias repair. However, long-term outcomes in prepubertal boys, particularly through and after puberty, are not well established. To systematically review the long-term outcomes of OMGU in prepubertal boys with hypospadias, focusing on changes observed after puberty. A systematic literature search was conducted in PubMed, Embase, and Cochrane Library. Studies reporting long-term outcomes of OMGU in prepubertal boys with hypospadias were included. The quality of evidence was assessed using the ROBINS-I tool. Three studies of moderate quality met the inclusion criteria. Outcomes were mixed, with some patients experiencing favorable results and others facing complications such as meatal stenosis, urethral strictures, and fistulas. The scarcity of high-quality, long-term studies highlights a significant knowledge gap in this area. This systematic review reveals insufficient evidence to establish the long-term efficacy and safety of OMGU in prepubertal boys with hypospadias, particularly concerning pubertal development and post-pubertal outcomes. Future research should prioritize prospective, longitudinal studies with larger sample sizes and standardized outcome measures to address these critical gaps in understanding.

Background and aims: Various venous approaches are possible during implanting a totally venous access port. In this study, we compare the result of venous access port implantation using external and internal jugular vein cut-down in young children to determine the safest method, associated with less complications and higher quality of life.

Patients and methods: January 2018 to January 2022 who received a TIVAP were included in the study and written informed consent was obtained from parents of all children at least 24 h prior to the intervention. One hundred and seven patients who needed TIVAP were randomly allocated into external jugular vein cut-down group (EJVCP) (n = 55) and internal jugular vein cut-down group (IJVCP) (n = 52) in this study.

Results: Mean operative time was 32.5 ± 17.1 min in EJVCP group, and 63.6 ± 28.3 min in IJVCP group. The difference of operation time between the two groups was statistically significant (P < 0.05). The overall incidence of late complications found in this study was 14.5% in EJVCP group and 13.4% in IJVCP group, indicating that no statistical difference was observed.

Conclusions: Compared with internal jugular vein, external jugular vein access has obvious advantages: the location of external jugular vein is superficial and easy to find, the utilization of external jugular vein is easy to learn and master, and the external jugular vein is of little importance to the human body. Through our study, we found that the external jugular vein access does not increase complications. External jugular vein access can be used as the first choice.

Introduction: Surgical procedures in children involve significant psychological traumatic stress leading to the development of psychologic distress and dysfunction after surgery. Pediatric medical traumatic stress (PMTS) ensues from negative medical experiences which is a trauma that can have a devastating effect on children and their families. Awareness and early identification are important to provide psychological intervention at the correct time.

Aims and objectives: This study aims to determine the prevalence of PMTS along with the associated surgical and psychosocial factors involved in pediatric surgical patients at our institute.

Methods: We included patients admitted to the pediatric surgery ward, for elective or emergency surgeries, and a three-point assessment was done. It was done pre-surgery, at 1 month for diagnosis of PMTS, and at 3 months for any spontaneous resolution. Along with we recorded data regarding surgical and psychosocial factors in play for each child.

Results: A PMTS prevalence of 16.26% was seen in the age group of 1 to 7 years and 12.64% in 8 to 18 years on evaluation at 1 month after surgery. A significant association was calculated with factors like duration of surgery, duration of hospital stay, staged approach of surgery, malignancy or congenital anomalies, postoperative pain, postoperative complications, multiple admissions, creation of stoma, need for additional interventions on follow-up, parental anxiety, and socioeconomic status. A significant spontaneous resolution at 3 months was also noted.

Conclusion: With this study we can establish a significant prevalence of PMTS in pediatric patients undergoing surgery and the significantly associated determinants have been identified. The healthcare team as a whole can work toward reducing the risk of the development of PMTS, both in parents and children.

Level of evidence: Level II.

Introduction: The advancements in neonatal resuscitation and surgical care have enabled children with congenital abnormalities to receive corrective surgeries and achieve lifespans well into adulthood. These patients may require long-term follow-up as they continue to have risks of developing sequelae from their original diseases or surgical interventions.

Purpose: This study aimed to investigate the current practice and barriers to the transition of care (TOC) from the perspectives of adult surgeons.

Methods: A cross-sectional study was conducted with purposive sampling of adult surgeons from different subspecialties. An online self-administered questionnaire was distributed.

Results: There were 60 respondents. 62% of the respondents had experience managing referrals for continuation of care or complications in patients with congenital abnormalities. 38% of the respondents believed that TOC should be implemented when patients reached ages 17-18 years. 93% of the respondents agreed that a proper TOC model would greatly benefit patient care, and 97% asserted the need to develop TOC pathways in Malaysia. The absence of a proper guideline was the greatest barrier to a smooth TOC.

Conclusion: This study offered insights into the obstacles to TOC based on the perspectives and experiences of adult surgeons who participated. While not exhaustive, our study provided a better understanding of the challenges in developing the appropriate referral pathways for the continued care of these patients.

Purpose: Initial recommendations for ECMO had relative contraindications for low birth weight (BW) or low gestational age (GA) babies. However, more recent literature has demonstrated improved and acceptable outcomes of ECMO in smaller neonates. The purpose of this study was to understand both utilization and survival in patients with lower GA and BW.

Methods: All neonates captured in the Extracorporeal Life Support Organization (ELSO) registry who underwent a single ECMO run from 2009 to 2019 were included. The primary outcome measure was mortality and the secondary outcome measure was major adverse outcomes, defined as a composite outcome variable any severe ECMO complications. Univariate and multivariable statistical tests were performed to estimate the association between GA and BW with both outcome variables.

Results: A total of 14,167 cases met inclusion criteria. Univariate analysis noted that birth weight, gestational age, ECMO mode, pulmonary support type, pH and ventilator settings were highly significant predictors of survival. Multivariable assessment noted significant linear relationship of mortality rates with increasing GA and BW (p < 0.001, OR = 0.82 GA, 0.51 BW). The highest ECMO-related mortality was observed in neonates with GA 30-31 weeks and BW 1.5-2.0 kg, with a 70-75% in-hospital mortality rate.

Conclusions: Decreasing GA and BW were strongly correlated with increasing odds of mortality and/or ECMO-related complications. However, even in low GA or BW neonates, survival may be possible in up to a quarter of patients put on ECMO.