Pediatric Surgery International最新文献

Introduction: Urethrocutaneous fistula (UCF) is the most common complication after hypospadias repair, with an variable incidence of 2-35%, depending on defect type. The interposition of tissue between the neourethra and the skin or glans is considered an important factor to reduce the risk of UCF. Literature has focused on the comparison of different types of second layers, but there is still no consensus regarding the best tissue to adopt. By contrast, literature regarding not-covered urethroplasty is lacking. Our aim is to investigate the value of hypospadias repair without a second-layer and to compare the results with hypospadias repaired with the use of an alternative, easily available second layer of periurethral tissue.

Methods: All distal and mid-penile hypospadias treated with single-stage urethroplasty at our centre between 2016 and 2020 were reviewed. Cases were divided according to the surgical technique: Group-A (urethroplasty with a second layer of periurethral tissue) and Group-B (single-layer urethroplasty). Anagraphic data and complications such as UCF and meatal stenosis were analysed.

Results: 425 single-stage urethroplasties were collected. 30 cases of UCF were observed (7%), 11/164 for Group A (6,7%) and 19/261 for Group B (7,3%) at a mean follow-up of 3 years. The difference was not statistically significant (p = 0.8). In 11/30 patients (37%) the UCF was associated with meatal stenosis.

Conclusions: A well-performed urethral suture, more than a second layer, is fundamental to prevent UCFs. Periurethral tissue is a valid second layer, providing good coverage with minimal tissue manipulation. Larger, prospective and randomised studies could be encouraged to confirm our data.

Purpose: This study aims to evaluate the effectiveness of alternative autologous vessel grafts in creating a Meso-Rex bypass (MRB) compared to the distal splenorenal shunt (DSRS) in resolving symptoms of portal hypertension in children.

Methods: All children with EHPVO evaluated for surgery at Siriraj Hospital from January 2011 to December 2023 were reviewed. Alternative autologous vessel grafts were used in all cases where MRB was feasible. DSRS was performed in patients for whom MRB was not possible. Baseline characteristics and outcomes were compared between the two groups.

Results: Eight children underwent successful MRB with alternative autologous vessel grafts, while six required DSRS. Children in the modified MRB group were significantly younger, with upper gastrointestinal bleeding the most common presenting symptom. In contrast, children in the DSRS group had significantly lower preoperative ammonia levels and platelet counts, with hypersplenism being the most common presenting symptom. All patients experienced complete relief of variceal bleeding and hypersplenism post-surgery. Complicated shunt thrombosis occurred after MRB using the gastric coronary vein graft. A significant decrease in ammonia levels was observed after MRB, whereas levels increased after DSRS.

Conclusion: Alternative autologous vessel grafts are effective for constructing the MRB to resolve portal hypertension compared to DSRS.

Aim of the study: Patients with congenital lung malformation (CLM) may present pulmonary inflammatory changes. However, little is known about the factors influencing local inflammation. The aim of this study was to evaluate the factors that may affect inflammatory changes in CLM.

Methods: Patients with CLM operated upon between 2005 and 2021 were included. The grade of inflammation was defined with a purpose-made inflammatory score (IS) ranging from 0 to 5. The association of type of CLM and age at surgery with IS was analyzed. Results are means (standard deviation).

Main results: Data from 105 patients with CLM were collected, 56 had congenital pulmonary airways malformation (CPAM), 24 bronchopulmonary sequestration (BPS), and 25 congenital lobar emphysema (CLE). 91 patients (87%) had inflammatory changes. IS was 2.1 (1.5), 1.2 (1.0), and 1.3 (1.5) in CPAM, BPS, and CLE respectively (One-way ANOVA p = 0.0101). CPAM showed a significantly higher IS as compared with BPS (p = 0.0242) and CLE (p = 0.0495). Age at operation significantly correlated to IS (r² = 0.14; p < 0.0001). Patients aged below 6 months at operation had lower IS [1.4 (1.2)] as compared to those over 6 months [2.0 (1.6)] (p = 0.018). Age at operation significantly correlated with the IS in CPAM (r² = 0.17; p = 0.0016) and CLE (r² = 0.47; p < 0.0001) patients.

Conclusions: Patients with CLMs often present inflammatory changes in their lungs. Grade of inflammation significantly correlates with age at surgery and type of anomaly, with CPAMs having the highest grade. These findings support early resection in patients with CLM, especially in case of CPAM.

Background: The efficacy of transanal endorectal pull-through (TERPT) in treating classic Hirschsprung's disease may be enhanced by incorporating laparoscopic-assisted endorectal pull-through (LERPT). This study was done to compare the long-term outcomes of TERPT and LERPT in the treatment of classic segment Hirschsprung's disease.

Methods: Longitudinal study.

Results: Between 2015 and 2019, a total of 154 patients underwent pull-through procedures. Of these, 113 were treated with TERPT and 41 with LERPT. The median operative time was significantly shorter for TERPT (109.5 min) compared to LERPT (144.6 min; p < 0.001). In terms of long-term outcomes, no significant differences were observed between the two procedures regarding complication rates and stooling patterns.

Conclusions: Both TERPT and LERPT are effective surgical approaches for children with classic segment Hirschsprung's disease. The study found no significant differences in long-term outcomes between the two techniques.

Background: The optimal technique for gastrostomy tube (GT) placement in pediatric patients remains controversial. Percutaneous endoscopic gastrostomy (PEG) was the preferred approach over open gastrostomy. With the advent of laparoscopy, many advocate for laparoscopic (LAP) placement to avoid potential visceral injury. Additionally, PEG patients may undergo an additional procedure for conversion to a low-profile button. We sought to compare outcomes including complications, need for subsequent procedures, and anesthesia exposure in LAP vs. PEG patients.

Methods: Patients (ages 0-18) who underwent GT placement at our pediatric healthcare system between 2018 and 2021 were retrospectively reviewed. Patients were excluded if they underwent fundoplication, gastro-jejunostomy tube placement, open placement, tube placement in concurrence with other intestinal procedures, or failed primary attempt at gastrostomy placement. Data related to demographics and GT placement were recorded. Our primary outcomes were complications, need for subsequent procedures, discrete anesthesia exposures, and cumulative anesthesia exposure. The Wilcoxon rank sum test, Pearson's Chi-squared test, and Fisher's exact test were used to compare characteristics and clinical measurements between PEG and LAP patients.

Results: Six hundred and eighty-eight (688) patients underwent GT placement during the study period, 234 (34.0%) LAP and 454 (66.0%) PEG. LAP patients were younger and weighed less than PEG patients (p = 0.005 and p = 0.002, respectively). Gender distribution, primary insurance status, and ASA (American Society of Anesthesiologists) classification were similar. Within the group excluded, 5 failed PEG placements, while 0 failed LAP GT attempts (p = 0.173). Major complication rates were comparable (1.3% vs. 2.4%, p = 0.401); however, PEG patients were more likely to have skin erythema/local infection (p = 0.006). PEG patients tended toward undergoing subsequent procedures (10.9% vs. 6.5% for LAP, p = 0.061) such as GT revision or conversion to gastro-jejunostomy tube. Additionally, 60.5% of PEG patients required > 2 anesthesia events, most often due to exchange of PEG to a low-profile button, while 93.6% of LAP patients required only one (p < 0.001). Finally, the median total general anesthesia exposure for the PEG group was 75 min (IQR 53-97) and 79 (IQR 67-98) in the LAP group (p = 0.002).

Conclusion: PEG technique is associated with more discrete anesthesia exposures and may also require more subsequent operations related to its placement. However, at our institution, overall major complications are similar in both techniques, while PEG tubes are prone to skin erythema/local infection.

Level of evidence: Retrospective Comparative Study, Level III.

Purpose: The aim was to determine gastrointestinal (GI)-related QoL in children born with gastroschisis (GS).

Methods: Totally, 58/83 families of children (aged 2-18 years) operated for GS at a tertiary pediatric surgical center accepted participation. Children aged 5-18 and one parent (child aged 2-18) completed the Swedish version of the PedsQL™ gastrointestinal symptoms module, evaluating GI-related QoL with 14 different GI-specific scales, norm values for Hirschsprung's disease (HD), esophageal atresia (EA), and functional constipation (FC) that were used for comparison.

Results: Children with GS had significantly lower parent-reported scores on "Gas and bloating" compared with children with EA (77.0 vs 85.5, p = 0.039). In the child report and in the parent report, scores on several GI scales were like those of children with EA. Parents of children with GS had higher scores for 8/14 scales compared to HD and higher scores for 12/14 scales compared to FC. Clinical GS-specific factors for worse GI-QoL were identified, including "Days in ventilator" and "Days with Silo and Patch".

Conclusions: GS has an impact on GI-related QoL, comparable to that in EA, but not to HD or FC. The GS-specific factors of worse QoL show the importance regarding a GS follow-up program including considering clinical factors.

Purpose: The aim of this study is to analyze the effect of increasing enema pressure on enema outcomes.

Methods: We conducted a retrospective study to compare the effect of increasing enema pressure on enema outcomes. The primary outcome was the success rate of reduction, while secondary outcomes included intestinal perforation and recurrence rate.

Results: From May 2017 to April 2021, a total of 531 intussusceptions in 499 patients (Group A 247 patients, Group B 252 patients) were collected. The overall success reduction rate was 97.00%. The success reduction rate in Group A was 99.20% (245/247) and 94.8% (239/252) in Group B (P = 0.004). The overall recurrence rate within 48 h after the initial enema reduction was 8.02%, and beyond 48 h was 6.41%. The recurrence rates within 48 h and beyond 48 h were 9.39% and 6.53% in group A and 7.11% and 6.69% in group B, respectively (P = 0.526). No complications were associated with the enema reduction procedure.

Conclusion: Our study has shown that using a hydrostatic pressure of 130 mmHg for enema reduction is both effective and safe, with a higher success rate and no increased risk of complications.

Level of evidence: Therapeutic study, III.

Purpose: To explore health literacy (HL) among parents of children with Hirschsprung disease (HD).

Methods: Norwegian-speaking parents of children under 16 who underwent HD surgery at a tertiary center were surveyed using the Health Literacy Questionnaire-Parent, electronic Health Literacy Scale, General Self-efficacy Scale, and a study-specific questionnaire. Demographics were collected and ethical approval was obtained.

Results: Among 132 parents (77 mothers) of 91 children (median age 8 years), high HL scores appeared in the domains "understanding health information" and "active engagement", with lower scores in "provider support", "health information appraisal", and "social support". Higher HL correlated with parents aged over 40 and higher education. Lower scores were seen with non-exclusive Norwegian use at home and not living with the child's other parent. High electronic HL scores were common (mean 3.6, maximum score 5). 69% had high self-efficacy scores (score > 2, maximum score 4). Self-efficacy correlated strongly with higher HL scores.

Conclusion: Parents of children with HD feel healthcare providers lack understanding of their child's challenges, experience limited social support and struggle with interpreting health information. We suggest targeted HL interventions for young, lower-educated, non-cohabitating parents and those not primarily speaking the official language at home.

Purpose: To describe the outcomes of infants with gastroschisis treated with a preformed silo (PFS) and determine whether routinely measured early physiological parameters, sepsis (blood culture positive), gastroschisis complexity or location of birth influenced the length of stay (LOS) and duration of parenteral nutrition (PN).

Methods: Infants cared for in a tertiary surgical neonatal intensive care unit during a 10-year period were identified.

Results: Seventy-seven infants were assessed [median gestational age 36 + 6 (IQR 35 + 3 to 38 + 0)] weeks. All survived; 82% were inborn. The median LOS was 37 (IQR 28-76.5) days and duration of PN was 28 (IQR 21-53) days. In the first 72 h, the worst median lactate, base excess and 'toe-core' gap were 4.2 (IQR 3.0-5.8) mmol/l, -7.0 (IQR - 5.55 to - 9.35), 3.4 (IQR 3.0-4.2) °C respectively. There were no significant correlations between early physiological parameters or place of birth and LOS or PN days, but sepsis (n = 18 infants) and complex gastroschisis (n = 13 infants) were associated with an increased LOS and PN duration (both p < 0.001).

Conclusions: Survival was 100% in infants with gastroschisis who were managed with PFS, sepsis and gastroschisis complexity were associated with a longer hospital stay and duration of parenteral nutrition. Level of Evidence (I-V): IV.