European Journal of Pediatric Surgery最新文献

Aim of the study:  To assess the incidence and types of complications and patient-reported outcomes in pediatric patients with therapy-resistant constipation or fecal incontinence (FI) without constipation who underwent Chait Trapdoor™ cecostomy (CTC). The findings contribute to the discussion on selecting the optimal antegrade continence (ACE) procedure for this population.

Materials and methods:  A retrospective review was conducted on all pediatric patients with therapy-resistant constipation or FI without constipation who underwent a CTC procedure at our tertiary referral center between 2009 and 2023. Postoperative complications were classified using the Clavien-Madadi classification. At their most recent follow-up in 2023, patients reported satisfaction with their CTC.

Results:  The study included 62 children (median age 12 years [IQR 8-14; range 1-17], 42% male), with a median follow-up of 4 years (IQR 2-8, range 0-14). Underlying diagnoses were functional constipation (n = 39, 63%), spina bifida (n = 11, 18%), and anorectal malformations (n = 5, 8%). A total of 49/62 patients (79%) experienced 89 CTC-related complications. Minor complications (Clavien-Madadi I-II) affected 29 patients (47%) and most commonly included granulation. Major complications (Clavien-Madadi III-IV) requiring surgery occurred in 32% of patients. Despite these complications, 40/62 (65%) patients reported satisfaction with their CTC, as determined by partial or complete symptom resolution.

Conclusions:  Although complications were common, 65% of the patients reported satisfaction with their CTC. These findings emphasize the need for thorough patient selection, informed counseling on potential risks, and individualized management strategies to enhance outcomes.

Introduction: To evaluate the diagnostic accuracy of uroflowmetry in detecting pediatric urethral strictures following Tubularized Incised-Plate (TIP) and non-TIP urethroplasty.

Materials and methods: A retrospective cohort study was conducted on children who underwent primary hypospadias repairs from June 2016 to June 2023 at our institution. Patients were categorized into the TIP and the non-TIP groups. Urethral calibration and uroflowmetry were used to evaluate urethral patency following urethroplasty. Data on demographic characteristics, perioperative information, uroflowmetry results, urethral calibration outcomes, and postoperative complications were collected. The relationship between calibration and uroflowmetry and the diagnostic accuracy of uroflowmetry for urethral strictures were analyzed.

Results: A total of 62 cases were included, with 38 in the TIP group and 24 in the non-TIP group. Ten patients were diagnosed with urethral strictures. The maximum urinary flow rate (Qmax) exhibited a higher area under the curve (AUC) than the average urinary flow rate (Qave) in both the TIP and non-TIP groups. The Qmax in the non-TIP group demonstrated a higher AUC than in the TIP group (non-TIP: AUC=0.94, Cut-off=6.65 ml/s, sensitivity=100%, specificity=81.0%; TIP: AUC=0.80, Cut-off=5.75 ml/s, sensitivity=100%, specificity=58.1%). A significant quadratic correlation was found between Qmax and urethral calibration (non-TIP: C2=14.72*Qmax, R2=0.96; TIP: C2=14.76*Qmax, R2=0.88). The Qmax nomogram interval ≤ -3 standard deviation was a significant predictor for non-TIP urethral strictures (Kappa=0.70).

Conclusions: Uroflowmetry, particularly Qmax, shows promise as a non-invasive screening tool for detecting urethral strictures after hypospadias repair, with high diagnostic accuracy in non-TIP cases but limited utility in TIP cases.

Background In patients with Hirschsprung disease (HD), pelvic floor physical therapy (PFPT) is recommended for persistent incontinence or constipation refractory to other treatment, but there are no studies on utilization of PFPT. We aimed to assess clinical and sociodemographic factors associated with successful establishment with PFPT and outcomes following PFPT. Methods We performed a single-institution, retrospective chart review of patients with HD referred to PFPT between 2020 - 2023, involving both exercise and biofeedback. Data were collected on clinical factors, sociodemographics, and symptoms before and after PFPT. Those who "saw PFPT", defined as at least one in-person appointment, were compared to those who did not see PFPT; symptomst were also compared. A p-value of 0.05 was considered significant. Results There were 83 patients, of which 37 (44.6%) saw PFPT. There were no differences in age, transition zone, prior interventions, or symptoms. Half of patients who saw PFPT only completed an initial visit; one fifth completed the series. Most common reason for failure to see PFPT was scheduling issues. Patients who failed to see PFPT had financial stressors (42.5% vs 16.1%, p=0.02) and required formal support systems (28.2% vs 3.3%, p=0.02). In patients seeing PFPT, incontinence significantly improved (81.1% before vs 40.5% after, p=0.001). Conclusion While PFPT is recommended in children with HD, those with financial stressors or scheduling issues may have barriers to access. However, those who see PFPT have improved symptoms. This suggests a need for improved accessibility of pediatric PFPT to children with HD, such as integration of PFPT into colorectal clinics.

Background: Symptomatic diaphragm paralysis in the pediatric patient is an uncommon condition. This study aims to evaluate the outcomes and technique of phrenic nerve reconstruction and its application to pediatric patients with unilateral and bilateral diaphragm paralysis at a single institution. The objective of this study is to demonstrate the application of a well-studied reconstructive technique in a population of patients not previously studied.

Methods: A retrospective review of pediatric patients between 2012 and 2022 with symptomatic diaphragm paralysis treated with phrenic nerve reconstruction. 9 patients with a median age of 10 years old were offered surgical treatment. The etiology of their paralysis include: birth trauma, congenital cervical anomaly, mediastinal neoplastic disease, cervical spinal cord injury, and acute flaccid myelitis. Measures of postoperative improvement include fluoroscopic sniff testing, pulmonary function testing, electromyography/nerve conduction testing, ultrasound evaluation and ventilator requirements.

Results: 100% patients with unilateral paralysis demonstrated improvement, defined as improvements in dyspnea, orthopnea, fatigability, and decreased respiratory infections. This was corroborated by sniff testing, pulmonary function testing, and electrodiagnostic evaluation. In 80% of patients, there was recovery of diaphragm excursion on the chest fluoroscopy, and a 10% or greater improvement on pulmonary spirometry (Forced Expiratory Volume in 1 Second, FEV1, and Forced Vital Capacity, FVC) percent predicted values. In patients with bilateral diaphragm paralysis, 75% demonstrated improvement in sniff testing, ultrasound findings and ventilator requirements. 25% of the patients did not improve. There were no post-operative complications defined as hematoma, wound infection, pleural effusion, pneumonia, sepsis, nerve injury, or hardware malfunction seen during follow-up.

Conclusion: Phrenic nerve reconstruction in pediatric patients demonstrates potential as a safe and effective surgical option for symptomatic diaphragm paralysis. In patients with unilateral paralysis, this intervention consistently improved respiratory function. In patients with bilateral paralysis, the results were variable but showed promise in facilitating ventilator weaning when performed early. These findings underscore the importance of early surgical intervention. Larger, multicenter studies are needed to validate its long-term potential.

Background: The classification of fractures is necessary to ensure a reliable means of communication for clinical interaction, research, and education. Distal humeral coronal plane shear fractures (CSF) are very rare in the growing-age population, despite that multiple classification schemes exist.

Objective: The aim of this study was to assess the inter- and intra-rater reliability of the 4 most commonly used CSF classifications and their role in guiding treatment decisions in everyday clinical practice.

Materials and methods: 51 patients with CSF were retrospectively analyzed in a multicenter study. Of these, X-rays in two planes of 20 randomly selected CSF were given to 8 independent raters for classification according to Dubberley, Bryan & Morgan, Murthy, and AO. Cohens Kappa statistic was used to assess inter-rater agreement and intra-rater consistency. Intra-class correlation coefficient (ICC) estimates and 95% confident intervals (CI) were calculated. Reliability values were classified as excellent (ICC ≥0.8), substantial (ICC 0.61-0.80), moderate (ICC 0.41-0.6), fair (ICC 0.2-0.4), slight (ICC 0.00-0.2), and poor (ICC <0.00).

Results: All patients received x-rays in 2 planes initially. Cross-sectional imaging was added in 76.5% of cases (CT 58,8%, MRI 11,7%, both 5,9%). Inter-rater reliabilities were classified as fair for Dubberley (ICC 0,354; 95% CI 0,198; 0,573) and Bryan & Morgan (ICC 0,357; 95% CI 0,200; 0,576), slight for AO (ICC 0,226; 95% CI 0,100; 0,434), and poor for Murthy (ICC -0,012; 95% CI -0,063; 0,102). The Dubberley subtype showed slight agreement at lower ICC values (ICC 0,024; 95% CI -0,041; 0,161). Intra-rater agreement was moderate to substantial for most of the 8 raters, and did not differ between the four classification systems. The rate of surgical treatment was 49/51 patients.

Conclusion: The most commonly used classification schemes for CSF failed to achieve a substantial agreement among the raters. This is probably because the fracture patterns of CSF in adolescence and high adulthood differ significantly. An adaptation of the classification for pediatric and adolescent patients is necessary, but only for scientific purposes. Classification is not necessary for the clinical management of patients, as virtually all patients require surgical treatment.

Introduction:  Indocyanine green (ICG) fluorescence-guided surgery (FGS) is reported extensively in adult operations, but its safety and applications in pediatric populations remain to be comprehensively understood. The dose, administration protocols, and intraoperative imaging benefits in pediatric hepatobiliary operations are not clear.

Objectives:  This study aimed to identify the feasibility and applications of ICG FGS in hepatobiliary surgeries (for biliary atresia, choledochal cyst, and cholelithiasis) in children.

Methods:  This is a prospective observational study conducted from January 2021 to December 2022. A standard ICG dose of 0.5 mg/kg/dose was administered intravenously to children undergoing operations for biliary atresia (18-24 hours), choledochal cyst (12-18 hours), and cholelithiasis (2-6 hours) before the operation. Intraoperative imaging features and adverse events were recorded.

Results:  ICG FGS was performed in 17 patients. In biliary atresia (n = 9), liver fluorescence varied in each case, the gallbladder did not show fluorescence, and there was increasing fluorescence as we reached the right depth during the excision of fibrous biliary remnants. In choledochal cyst (n = 6) operations and cholecystectomy (n = 2), real-time imaging provided anatomical details of the biliary tree and helped in safe dissection. No ICG-related adverse events occurred.

Conclusion:  ICG FGS appears safe, feasible, and beneficial in pediatric hepatobiliary surgeries. For conditions like biliary atresia, choledochal cysts, and cholecystectomy, ICG facilitates safer surgical navigation and may reduce intraoperative complications. Future studies with standardized protocols and quantitative fluorescence assessment are needed to further refine its use and confirm its impact on surgical outcomes.

Background:  Kasai procedure (KPE) is a palliative intervention in infants with biliary atresia (BA) aiming to restore biliary drainage. While the measure of success in BA is the post-Kasai native liver survival (NLS), BA remains the most frequent indication for liver transplantation in children. While a considerable amount of children fail to clear their jaundice following KPE, resulting in early liver failure and transplantation, some children become jaundice-free after "successful" KPE. However, sequelae of chronic liver disease might affect those children, becoming a later risk for NLS. While liver transplantation is inevitable in the majority of children, various salvage procedures have been recently described to maintain NLS. This article provides a comprehensive overview of procedures performed after KPE to prolong NLS in BA patients from early childhood to late adulthood and discusses their indications and limitations.

Methods:  A literature-based search for surgical and radiological interventions performed in BA patients after KPE to prolong NLS (salvage procedures) was performed using PubMed. Data from case reports, retrospective studies, and registries were included.

Results:  Fifteen studies included 794 patients who underwent post-KPE salvage procedures. The Oxford Centre for Evidence-Based Medicine levels were IIc to IV.Interventions included redo-Kasai's (n = 710) for cessation of bile flow post-KPE, surgical and radiological procedures (n = 14) for bile lakes, and recurrent cholangitis, shunt surgery (n = 49), and transjugular intrahepatic portosystemic shunt (n = 21) for portal hypertension in BA patients. Age at the time of salvage interventions varied considerably, including redo-Kasai's at 27 days of life and percutaneous biliary interventions in a 35-year-old.

Conclusion:  Salvage procedures can maintain NLS after KPE in BA patients with disease sequelae. However, indications remain scarce and liver transplantation is ultimately unavoidable in the majority of patients. While redo-Kasai numbers are globally decreasing with the advances in liver transplantation, procedures for bile lakes and portal hypertension can be viable options for patients with complications but otherwise stable liver function. Discussion on those procedures should be held by multidisciplinary expert teams, involving pediatric hepatologists, pediatric surgeons, and transplant surgeons to elaborate on the potential of maintaining NLS or proceeding with transplantation.

Background/purpose:  Gastroesophageal reflux disease (GERD) after lung transplantation (LuTx) can lead to chronic lung allograft dysfunction. Our aim was to assess the prevalence of GERD in pediatric LuTx recipients and to investigate the impact of medical and surgical GERD treatment on lung function.

Methods:  Ethical approval was obtained. Data of all consecutive patients who underwent LuTx from 2013 to 2023 and aged < 18 years at the time of the study were prospectively collected. A GERD diagnostic algorithm was established, including assessment of symptoms (vomiting, heartburn, regurgitation, cough, recurrent airway infections), bronchoscopy, forced expiratory volume in 1 second, and pH impedance. Further investigations included upper gastrointestinal series and esophagogastroduodenoscopy. Patients with GERD underwent medical treatment or fundoplication. Lung function was monitored.

Results:  Thirty-six patients (2 months-18 years, 50% male) were included. Twenty-nine (80%) underwent spirometry, 16 (45%) pH impedance study, and 14 (39%) esophagogastroduodenoscopy. Twenty-two (61%) had no GERD symptoms and 12 (33%) showed normal pH impedance study or esophagogastroduodenoscopy. Fourteen (39%) patients had GERD symptoms, all 9 tested symptomatic patients (25%) had pathological GERD-specific diagnostics. Three (8%) patients underwent fundoplication after a median of 1.6 years (range 1.1-5.7 years) post-LuTx without surgical complications. After a median follow-up of 2.3 years (range 1.3-2.8 years) post-fundoplication, all (n = 3) had complete remission of GERD symptoms and lung function improvement. Lung function decline was observed in 6 (67%) of the tested symptomatic patients on proton-pump inhibitors (PPIs) treatment.

Conclusion:  Over one-third of our patients presented with GERD symptoms after LuTx. Symptoms and lung function may be reliable GERD indicators. Given the high prevalence of GERD, we suggest a routine posttransplant diagnostic algorithm including pH impedance study. Eighty percent of all symptomatic patients had a lung function decline despite PPI. Fundoplication is safe and may improve long-term outcome in pediatric LuTx recipients.

Introduction:  The objective of this study is to analyze the conversion rate of abstracts presented at the European Paediatric Surgeons' Association (EUPSA) congress into full-text publications and to conduct a thorough analysis of the attributes and quality of the papers published.

Materials and methods:  Abstract books including the years 2017 to 2022 were reviewed. Searches on PubMed and Google Scholar, utilizing keywords from the titles and the author names, were conducted to trace subsequent full-text publications. A categorical analysis detected variations and trends, with a significance threshold of p < 0.05. Quantitative data were presented as means ± standard deviations, whereas categorical data were represented as counts (n) and percentages (%).

Results:  A total of 2,139 abstracts were presented at the EUPSA annual meetings during five consecutive congresses. The average number of presented abstracts was 427.6 ± 20.4 per year from across 63 different countries. European countries contributed the majority (71%). The presentations included both oral (n = 817, 38.2%) and poster presentations (n = 1,322, 61.8%). They predominantly focused on clinical topics (90.6%). Single-center retrospective studies were the most common study design (43.7%). Out of all abstracts presented, 1,033 (48.3%) were published within an average time interval of 1.39 ± 1.19 years after presentation. Most journals had an impact factor (IF) between 1 and 5 (74.5%). There was no significant year-to-year variation in publication rates (p = 1). Basic science studies were published in journals with significantly higher IF compared with clinical studies (p < 0.001).

Conclusions:  The publication rate of abstracts presented at the EUPSA annual congress stands at 48.3%, aligning with the rates observed in other similar studies. This suggests that abstracts submitted to the EUPSA congresses were evaluated and scored rigorously, adhering to international selection criteria. Furthermore, the majority of these abstracts were published in journals with moderate to high IFs, providing quantitative evidence of the scientific quality of research within the field of pediatric surgery.

Aim:  This survey analyzed techniques in laparoscopic inguinal hernia repair (LIHR) across pediatric age groups.

Materials and methods:  Data were collected through an online survey for pediatric surgeons, comprising of 38 questions, conducted by the European Pediatric Surgeons' Association (EUPSA) Trainees of European Pediatric Surgery (TEPS) LIHR Working Group.

Results:  The survey was completed by 183 surgeons from 22 countries. Seventy-seven percent of respondents had performed LIHR at least once. Regarding preferences about the patient's gender, 7% respondents perform LIHR only in selected females, 9% routinely in females, 15% in both genders with age/weight restrictions, 24% routinely in both genders, 31% in selected cases, and 14% never perform LIHR. Percutaneous internal ring suturing (PIRS) was the preferred technique in all age groups, with totally extraperitoneal and transabdominal preperitoneal repairs preferred by 9% in adolescents. The majority (59%) repaired a contralateral patent processus vaginalis if present. Hydro-dissection (21%) and additional intra-abdominal instruments (42%) were preferred more often for male patients. The distal hernia sac was left intact by most respondents (92%). Responses regarding recurrence rates varied: 40% responded that LIHR had recurrence rates comparable to open surgery, whereas 10% reported increased recurrences and hence limited its use, and 10% consider that slightly increased recurrences are outweighed by lower complication rates associated with laparoscopic methods and thus continue LIHR.

Conclusions:  PIRS is the preferred choice for pediatric LIHR. Surgical techniques vary and are influenced by patient gender and age. The survey gives insights into demographics, case selection, and approaches among pediatric surgeons with regard to LIHR.