World Journal of Pediatric Surgery最新文献

Background: The efficacy of performing a restorative proctocolectomy and J-pouch ileoanal anastomosis without diverting ileostomy in children with inflammatory bowel disease has been a longstanding debate. A systematic review and meta-analysis is presented comparing the occurrence of postoperative complications in children who underwent either the pouch-anal anastomosis (IPAA) with ileostomy (diverted) versus the undiverted procedure.

Methods: Records were sourced from CINAHL, CENTRAL, EMBASE and MEDLINE databases. Studies followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and compared postoperative complications in pediatric patients diagnosed with inflammatory diseases aged less than 18 years who underwent J-pouch with ileostomy versus without ileostomy. The primary outcome was the occurrence of postoperative leaks, and the secondary outcomes were presence of postoperative small bowel obstruction (SBO), pouchitis, stricture and fistula complications. A random-effects meta-analysis was used.

Results: Twenty-three observational studies in the systematic review were included with 658 patients (83% diverted, 17% undiverted). Pooled estimates showed no difference in occurrence of leaks in children who underwent J-pouch/IPAA with ileostomy versus without (odds ratio (OR) 0.54, 95% confidence interval (CI) 0.17 to 1.64, I²=16%). There was no difference in the occurrence of SBO, pouchitis or strictures in children who underwent J-pouch/IPAA with ileostomy versus without (SBO: OR 2.27, 95% CI 0.52 to 9.92, I²=0%, pouchitis: OR 1.76, 95% CI 0.95 to 3.24, I²=0%, strictures: OR 2.72, 95% CI 0.44 to 16.69, I²=66%).

Conclusion: The meta-analysis did not find differences in the occurrence of complications in pediatric patients who underwent the IPAA with ileostomy procedure versus without ileostomy.

Background: Necrotizing enterocolitis (NEC) is the leading gastrointestinal cause of death in premature infants and causes long-term disabilities. Previously, enteral heparin-binding epidermal growth factor-like growth factor (HB-EGF) administered after birth demonstrated decreased incidence and severity of NEC in a neonatal animal model of NEC. We investigated the potential prophylactic strategy of preventing NEC using prenatally administered HB-EGF.

Methods: An HB-EGF (800 µg/kg/dose) dose was injected into pregnant rats via tail vein or intraperitoneal route 2 hours prior to delivery. After cesarean section (C-section) at 21 days' gestation, the rat pups were subjected to the NEC protocol by inducing stressors: hypoxia, hypothermia, hypertonic feeds, and orogastric gavage of lipopolysaccharide (2 mg/kg). Postnatally, pups were monitored for 96 hours and assessed for the development of clinical and postmortem histological NEC.

Results: The experimental NEC incidence in untreated, stressed rat pups was 66%. Compared with untreated pups, the maternal administration of HB-EGF correlated with a significant NEC incidence and severity decrease in rat pups. The strongest decrease was seen when HB-EGF was administered via the intraperitoneal route 2 hours prior to C-section (66% vs 31%, *p<0.05). Prenatal HB-EGF administration significantly increased pups' survival after NEC protocol exposure, with the greatest benefit observed in the group that received HB-EGF intraperitoneally 2 hours before delivery.

Conclusions: Prenatal administration of HB-EGF decreases the incidence and severity of NEC, preserves gut barrier function and increases survival. This may represent a novel prophylactic clinical strategy for NEC offered to mothers at risk of delivering a premature infant.

Objective: Previous studies have shown that ex utero intrapartum therapy (EXIT) is safe and feasible for newborns with congenital diaphragmatic hernia (CDH). This study reports our experience with EXIT in fetuses with CDH in an attempt to explore the efficacy of EXIT on the survival rate of this population.

Methods: A retrospective analysis of the clinical data of 116 children with CDH was conducted. The children were assigned to EXIT and non-EXIT groups. Propensity score matching (PSM) toward clinical data was performed, and the clinical characteristics and outcomes were compared. Taking survival at discharge as the main outcome, logistic regression analysis was carried out to explore the efficacy of EXIT on survival.

Results: During the study period, 30 of 116 children received EXIT. After PSM, the survival rates of the EXIT group and the non-EXIT group were 82.76% (24/29) and 48.28% (14/29), respectively (p=0.006). EXIT (OR=0.083, 95% CI=0.013to 0.525, p=0.008), liver herniation (OR=16.955, 95% CI=2.342 to 122.767, p=0.005), and gestational age at diagnosis (OR=0.662, 95% CI=0.497 to 0.881, p=0.005) were independent mortality-related risk factors of all children with CDH. Ninety-nine of 116 children underwent surgery. After PSM, the postoperative survival rates of the EXIT group and non-EXIT group were 84.6% (22/26) and 76.9% (20/26), respectively (p=0.754). Liver herniation (OR=10.451, 95% CI=1.641 to 66.544, p=0.013) and gestational age at diagnosis (OR=0.736, 95% CI=0.577 to 0.938, p=0.013) were independent mortality-related risk factors of children after surgery.

Conclusion: EXIT can be performed safely for selected prenatally diagnosed CDH neonates with potentially better survival and does not cause more maternal complications compared with traditional cesarean section.

Objective: To compare surgical outcomes of percutaneous extraperitoneal simple purse string method of laparoscopic hernia (LH) repair with a traditional open inguinal hernia (OH) repair in children with indirect inguinal hernia in a single center.

Methods: This study is a historical-controlled intervention study of two groups of patients: patients in the controlled group had OH repair performed from January 2016 to December 2017, and patients in the study group had LH repair from January 2018 to December 2019 at a single institution. Outcomes of the OH and LH groups, in terms of operative time, recurrence, complications, incidence of metachronous contralateral inguinal hernia (MCIH) and contralateral patent processus vaginalis (CPPV) were analyzed.

Results: Three hundred and five patients were enrolled in the study. Among them, 95 cases underwent laparoscopic percutaneous extraperitoneal closure herniotomy (LH group), and 210 cases underwent conventional open herniotomy (OH group). In terms of operative time, only unilateral herniotomy in females of the OH group was significantly less than that of the LH group (15.7±7.1 vs 20.5±7.4 min, p=0.004). No significant difference in overall complication was observed between the two groups of patients. The incidence of CPPV in the LH group was 15.7% (15/95), and MCIH in OH group was 10.9% (23/210).

Conclusions: Laparoscopic herniotomy may prevent the need for a second operation of metachronous contralateral hernia. Both open and laparoscopic techniques are equivalent in pro and cons.

Objective: Patients with congenital malformations (CMs) of the gastrointestinal tract (GIT) have a very high mortality. However, the literature on the factors associated with mortality in these patients is scarce in sub-Saharan Africa. The aim of this study is to identify independent risk factors for mortality in patients with CMs of the GIT at our pediatric surgical department.

Methods: We conducted a retrospective analysis of cases with CMs of the GIT managed at a tertiary center from 2018 to 2021. Patients were subdivided into two groups based on the outcomes, and variables with a significant difference were analyzed by logistic regression.

Results: Our review included 226 patients, 63 of whom died (27.88%). Patient age ranged from 0 to 15 years. Taking into account statistical significance, mortality was more frequent in neonates than in older patients (57.30% vs 6.15%), in patients coming out of the Dakar area than in those from the Dakar area (43.75% vs 19.18%), in patients with abnormal prenatal ultrasound than in those with normal ultrasound (100% vs 26.67%), in premature children than in those born at term (78.57% vs 21.87%), in patients with an additional malformation than in those with an isolated malformation (69.23% vs 25.35%), and in those with intestinal, esophageal, duodenal and colonic atresia than in those with other diagnoses (100%, 89%, 56.25% and 50%, respectively). Referred patients died more than those who changed hospitals or came from home (55.29% vs 25% and 9.09%, respectively). On multivariable logistic regression, two independent factors of mortality were identified: presence of associated malformation [odds ratio (OR)=13.299; 95% Confidence interval (CI) 1.370 to 129.137] and diagnosis of esophageal atresia (OR=46.529; 95% CI 5.828 to 371.425).

Conclusion: The presence of an associated malformation or diagnosis of esophageal atresia increases mortality in patients with CMs of the GIT in our environment.

Background: Congenital anomalies are major causes of morbidity and mortality in children under 5 years of age and make a significant contribution to the surgical burden of diseases. Most anomalies have multifactorial causes and commonly affect the central nervous, cardiovascular, gastrointestinal and musculoskeletal systems. Countries with improved pediatric surgical care have shown dramatic reductions in morbidity and mortality rates. The aim of this study was to analyze the pattern of congenital anomalies presenting in our surgical departments in patients under 5 years of age.

Methods: A retrospective descriptive study was done. Data were obtained from clinical records of patients under 5 years of age, who underwent surgical correction of their congenital anomalies between 2017 and 2021. Analysis was done to identify the proportion of congenital anomalies managed in our setting.

Results: Congenital anomalies contributed 4.6% of overall surgical burden. Totally, 822 patients with congenital anomalies were included for analysis. The most commonly diagnosed congenital anomaly was inguinal hernia, followed by hydrocephalus, neural tube defects and cleft lips. The most commonly affected system was the central nervous system, anterior abdominal wall, orofacial and digestive system in decreasing order of frequency. Most of our patients presented outside the neonatal period (84.4%), and few (16.1%) had more than one system affected. Male children comprised 64%.

Conclusions: Delayed presentation of children with congenital anomalies is still a significant problem in our area. Prevention through nutritional supplementation and antenatal screening is crucial. The true epidemiology of congenital anomalies in northern Tanzania is still obscure.

Objective: To investigate the expression of Smad3 (mothers against decapentaplegic homolog 3) protein in postnecrotizing enterocolitis stricture and its possible mechanism of action.

Methods: We used immunohistochemistry to detect the expression characteristics of Smad3 and nuclear factor kappa B (NF-κB) proteins in human postnecrotizing enterocolitis stricture. We cultured IEC-6 (crypt epithelial cells of rat small intestine) in vitro and inhibited the expression of Smad3 using siRNA technique. Quantitative PCR, western blotting, and ELISA were used to detect the changes in transforming growth factor-β1 (TGF-β1), NF-κB, tumor necrosis factor-α (TNF-α), vascular endothelial growth factor (VEGF), and zonula occludens-1 (ZO-1) messenger RNA (mRNA) and protein expressions in IEC-6 cells. CCK8 kit and Transwell cellular migration were used to detect cell proliferation and migration. Changes in epithelial-mesenchymal transition (EMT) markers (E-cadherin and vimentin) in IEC-6 cells were detected by immunofluorescence technique.

Results: The results showed that Smad3 protein and NF-κB protein were overexpressed in narrow intestinal tissues and that Smad3 protein expression was positively correlated with NF-κB protein expression. After inhibiting the expression of Smad3 in IEC-6 cells, the mRNA expressions of NF-κB, TGF-β1, ZO-1, and VEGF decreased, whereas the mRNA expression of TNF-α did not significantly change. TGF-β1, NF-κB, and TNF-α protein expressions in IEC-6 cells decreased, whereas ZO-1 and intracellular VEGF protein expressions increased. IEC-6 cell proliferation and migration capacity decreased. There was no significant change in protein expression levels of EMT markers E-cadherin and vimentin and also extracellular VEGF protein expression.

Conclusions: We suspect that the high expression of Smad3 protein in postnecrotizing enterocolitis stricture may promote the occurrence and development of secondary intestinal stenosis. The mechanism may be related to the regulation of TGF-β1, NF-κB, TNF-α, ZO-1, and VEGF mRNA and protein expression. This may also be related to the ability of Smad3 to promote epithelial cell proliferation and migration.

Background: Pediatric surgical practice lags behind medicine in presence and use of evidence, primarily due to time constraints of using existing tools that are not specific to pediatric surgery, lack of sufficient patient data and unstructured pediatric surgery training methods.

Method: We developed, disseminated and tested the effectiveness of an evidence-based resource for pediatric surgeons and researchers that provides brief, informative summaries of quality-assessed systematic reviews and meta-analyses on conflicting pediatric surgery topics.

Results: Responses of 91 actively practicing surgeons who used the resource were analysed. The majority of participants found the resource useful (75%), improved their patient care (66.6%), and more than half (54.2%) found it useful in identifying research gaps. Almost all participants reported that the resource could be used as a teaching tool (93%).

Conclusion: Lack of awareness of the resource is the primary barrier to its routine use, leading to potential calls for more active dissemination worldwide. Users of the Canadian Association of Paediatric Surgeons Evidence-Based Resource find that the summaries are useful, identify research gaps, help mitigate multiple barriers to evidence-based medicine, and may improve patient care.