European Journal of Pediatric Surgery最新文献

Introduction:  The Dynamic Imaging Grade of Swallowing Toxicity (DIGEST) scale was developed to evaluate the safety, efficiency, and overall pharyngeal swallowing performance in patients with dysphagia (DIGESTs, DIGESTe, and DIGESTt, respectively). Although various types of swallowing dysfunction are encountered in children with esophageal atresia (EA), oropharyngeal dysphagia poses risk for aspiration. Therefore, a retrospective study was performed to evaluate the safety and efficacy of swallowing by using DIGEST score in children with EA.

Patients and methods:  Thirty-nine EA patients were included. The demographic features, respiratory problems, results, and outcomes of surgical treatment were evaluated from medical records. The videofluoroscopic swallowing evaluation investigated for both airway protection and bolus residuals at the level of vallecula, posterior pharyngeal wall, and pyriform sinus at liquid and pudding consistencies. The penetration and aspiration scale (PAS) was used to define penetration and aspiration severity, and DIGEST was used to evaluate DIGESTs, DIGESTe, and DIGESTt.

Results:  The median age of the patients were 13 months (7-39 months), and male-to-female ratio was 25:14. Sixty-seven percent of patients were type-C EA and 61% of them has associated anomalies; 38% of patients had aspiration (PAS = 6-8) in liquids and 10% in pudding consistency. Life-threatening/profound swallowing dysfunction in DIGESTe (DIGEST = 4) was seen in 13% (n = 5) of patients; 40% of EA patients showed severe problems in DIGESTt.

Conclusion:  DIGEST is a valid and reliable tool to define the efficacy and safety of swallowing in children with EA.

Aim of the study: Esophageal atresia (EA) is associated with impaired motor development, cardiopulmonary function and physical activity (PA). Despite missing scientific evidence, this fact is often attributed to associated congenital heart disease (CHD). The aim of this study is to investigate PA in EA patients without CHD compared to CHD patients and healthy controls.

Methods: In this multicenter study, EA patients aged 6 through 17 years were included. Moderate-to-vigorous physical activity (MVPA, minutes per week) was assessed using the standardized and validated questionnaire MoMo-PAQ. EA patients were randomly matched 1:4 for gender and age with patients with CHD (n=1262) and healthy controls (n=6233). Patients born with both EA and CHD were excluded. Means and 95%-confidence intervals (95%-CI) were calculated. To identify associated factors, Spearman correlation was performed.

Main results: Overall, 69 EA patients were matched with 276 CHD patients and 276 controls (57% male, 43% female, mean age 10,3 years, 95%-CI: 9,5-11,1). Mean MVPA was reduced in EA (492 minutes, 95%-CI: 387-598) and CHD patients (463 minutes, 95%-CI: 416-511) compared to controls (613 minutes, 95%-CI: 548-679). In subgroup analysis, MVPA was reduced further in females and older age groups with EA and CHD. For EA patients, there was no statistical association between Gross type, current symptoms, surgical approaches and MVPA.

Conclusions: Isolated EA and CHD were associated with reduced PA, especially in females and teenagers. To avoid additional morbidity associated with sedentary behaviour, PA should be promoted during follow-up.

Introduction:  Anorectal malformations (ARMs) are rare birth defects affecting the anorectum and oftentimes the genitourinary region. The management of ARM patients is complex and requires highly specialized surgical and medical care. The European Reference Network eUROGEN for rare and complex urogenital conditions aimed to develop comprehensive guidelines for the management of ARM applicable on a European level.

Methods:  The Dutch Quality Standard for ARM served as the basis for the development of guidelines. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from seven European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected and recommendations were formed considering the current evidence, expert opinion, and the European context.

Results:  Surgical and medical treatment of ARM, postoperative instructions, toilet training, and management of fecal and urinary incontinence were addressed. Seven new studies were identified. The panel adapted 23 recommendations, adopted 3, and developed 8 de novo. The overall level of newly found evidence was considered low.

Conclusion:  Treatment of ARM patients requires a multidisciplinary team and expertise about anatomical and surgical aspects of the disease, as well as long-term follow-up. This guideline offers recommendations for surgical and medical treatment of ARM and associated complications, according to the best available evidence and applicable on a European level.

Introduction:  Anorectal malformations (ARMs) are complex congenital anomalies of the anorectal region, oftentimes also affecting the genitourinary system. Although successful surgical correction can often be achieved in the neonatal period, many children will experience functional problems in the long term. The European Reference Network for rare and complex urogenital conditions (eUROGEN) assembled a panel of experts to address these challenges and develop comprehensive guidelines for the management of ARM.

Methods:  The Dutch Quality Standard for ARM served as the foundation for the development of guidelines applicable on a European level. Literature was searched in Medline, Embase, and Cochrane. The ADAPTE method was utilized to incorporate the newest available evidence. A panel of 15 experts from 7 European countries assessed currency, acceptability, and applicability of recommendations. Recommendations from the Dutch Quality Standard were adapted, adopted, or rejected and recommendations were formed considering the current evidence and/or expert consensus.

Results:  Lifelong follow-up, integration, and transition of care were assessed. A total of eight new studies were identified. The panel adapted 18 recommendations, adopted 6, and developed 6 de novo. Overall, the level of evidence was considered low.

Conclusion:  Successful lifelong follow-up and transition of care require a dedicated team of pediatric and adult specialist and an individually tailored patient-centered approach. This guideline summarizes the best available evidence on follow-up of ARM patients and provides guidance for the development of structured transition programs.

Introduction Management of testicular torsion varies between specialties resulting in lack of standardization. The aim of this survey was to assess pre-, peri-, and postoperative differences.

Methods An online questionnaire was distributed in 2023 to general and pediatric surgeons, pediatric urologists, and urologists by the Trainees of European Pediatric Surgery.

Main Results Among 88 respondents (92% tertiary referral hospital), 38% always or usually perform sonography in case of suspected torsion respectively. In addition, 15% always attempt manual detorsion and 44% depending on the clinical presentation. Most surgeons (93%) favor a scrotal approach. Interestingly, pediatric surgeons choose a transscrotal while other specialties opt for a midline incision (p = 0.002). The majority (57%) employ a three-point fixation, while 42% opt for a two-point fixation. In case of necrotic testis, 61% puncture the testis with 52% opting for surgical removal, while 33% perform orchiectomy and 6% leave it in situ. Regarding necrotic or borderline-appearing testis, 54% take a biopsy. Furthermore, 82% perform prophylactic orchidopexy of the contralateral side during the same session. Postoperative antibiotics are always administered by 12%, while 52% do so sometimes. Most perform sonographic (58%) or clinical (57%) follow-up 3 months postoperatively. Notably, pediatric surgeons and urologists perform follow-up more frequently themselves, while general surgeons/urologists recommend follow-up by pediatricians (p = 0.002). In addition, 76% of responders affirm adhering to European Association of Urology guidelines. Unawareness of guidelines and institutional practices are reasons most commonly cited for nonadherence.

Conclusion Our study reveals significant disparities in the pre-, peri-, and postoperative management of testicular torsion underscoring the need for establishing standardized practices.

Objective:  This study aims to assess the histopathological characteristics of the fistulous tissue in males with anorectal malformation (ARM) to determine its suitability for use in constructing a neoanus.

Methods:  This prospective observational study included male ARM patients with recto-urethral fistula. All other types were excluded. The tissue specimens comprised 0.5 to 2.0 cm of the most distal part of the rectal pouch and the fistulous tissue. Hematoxylin and eosin-stained sections were prepared. Histological features, viz. internal sphincter, anal grand and crypts, ganglion cells, presence of subepithelial fibrosis, thickened nerve trunks, and metaplasia, were evaluated.

Results:  Of 65 patients of ARM admitted, 24 met the inclusion criteria. Gross and microscopic internal sphincter was not found in any sample. The anal mucosa was visualized in all samples; however, crypts were irregular and distorted architecture was seen in 4 (16.67%) samples. Urothelial metaplasia was identified in 10 (41.67%) samples. Adequate ganglion cells were seen only in 6 (25%) samples. Significant submucosal fibrosis was seen in all samples. Thickened nerve trunks were identified in 4 (16.67%) samples.

Conclusions:  All normal anal histological features could not be found together in the fistula tissue. With the absence of normal features, such as internal anal sphincter muscles, and the presence of abnormal histopathological features, such as subepithelial fibrosis, thickened nerve trunks, and metaplasia, there are high chances of abnormal bowel function like constipation if the fistulous tissue is used for neoanus construction. It may have an impact on the quality of life of patients.

Introduction:  Intra-abdominal testis (IAT) remains a challenging and controversial subset within the management of cryptorchidism. While Fowler-Stephens orchidopexy (FSO) is still being advocated as the gold standard for the treatment of this entity, there is new and conflicting evidence on the comparative outcomes between single- or two-stage laparoscopic FSO (LFSO). The aim of the study is to investigate whether staging has benefits in children receiving LFSO.

Methods:  We searched the PubMed, Medline, Embase, and Cochrane Trials databases for studies comparing single- with two-stage LFSO in children from January 1, 1995 to December 31, 2023. We assessed the identified studies for quality and performed a systematic review and meta-analysis in accordance with the Preferred Reporting of Systematic Reviews and Meta-Analyses. The main outcome measures examined were success rate (in terms of the scrotal position of the testis) and testicular atrophy, which were analyzed using fixed effect models.

Results:  We included 17 eligible studies that involved a total of 499 operated testes. The overall success rates of single- and two-stage LFSO were 79.4 and 90.3%, respectively. The overall testicular atrophy rates of single- and two-stage LFSO were 17.3 and 11%, respectively. Fixed effect model analysis showed that two-stage LFSO is significantly superior to single-stage LFSO in overall success rate (odds ratio [OR: 2.57]; 95% confidence interval [CI]: 1.50-4.39, p = 0.0006) and testicular atrophy rate (OR: 0.48; 95% CI: 0.28-0.79, p = 0.004). There is no heterogeneity in the reports, and the funnel plot showed no publication bias.

Conclusions:  Two-stage LFSO remains the first choice of operation for children with a high IAT, with a significantly higher success rate and a lower testicular atrophy rate.

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.

Introduction:  Despite advances in neonatal intensive care, fetuses with congenital diaphragmatic hernia (CDH) remain to have a poor prognosis. Exclusive postnatal treatment is inadequate in patients with moderate CDH (observed than expected lung-to-head ratio [O/E LHR] 26-45%) and can lead to respiratory failure at birth, requiring extracorporeal membrane oxygenation in 75% of cases. An ex-utero intrapartum treatment (EXIT) procedure may be beneficial in these cases, improving the fetal-neonatal transition.

Material and methods:  We review all pregnancies with fetal isolated left CDH with moderate O/E LHR delivered by EXIT in our center from January 2007 to December 2022. Maternal and neonatal variables were analyzed. As primary outcomes, we included neonatal survival and mortality rates, surgical and infectious complications, uterine scar dehiscence, and blood loss during EXIT. As secondary outcomes, we studied recurrences of the diaphragmatic defect, long-term evolution, subsequent pregnancies, and mode of delivery.

Results:  A total of 14 patients were delivered by the EXIT procedure, with a neonatal survival rate of 85.7%. All these children had optimal physical and neurocognitive development and no pulmonary morbidity. We found no major complications and 7.1% of minor maternal complications. There were no cases of surgical wound infection or endometritis. The median decrease in hemoglobin during the EXIT procedure was 1.9 mg/dL, and only one case required postoperative transfusion. Two out of the 14 women became pregnant again, and both pregnancies were uneventful.

Conclusions:  In our series, the EXIT procedure allows for adequate airway management associated with a high neonatal survival rate in patients with moderate O/E LHR CDH, with a low rate of neonatal and maternal complications.

Background:  Surgical wound dehiscence (SWD) in neonates is a life-threatening complication. The aim was to define risk factors of postoperative incision dehiscence in this population.

Methods:  Data of 144 patients from 2010 to 2020 were analyzed retrospectively. All full-term newborns or preterm newborns up to 42 weeks of amenorrhea (adjusted) who had a laparotomy within 30 days were included. Descriptive patient information and perioperative data were collected. SWD was defined as any separation of cutaneous edges of postoperative wounds.

Results:  Overall, SWD occurred in 16/144 (11%) patients, with a significantly increased incidence in preterm newborns (13/59, 22%) compared with full-term newborns (3/85, 4%; p < 0.001). SWD was significantly associated with exposure to postnatal steroids (60% vs. 4%, p < 0.001) and nonsteroidal anti-inflammatory drugs (25% vs. 4%, p < 0.01), invasive ventilation duration before surgery (median at 10 vs. 0 days, p < 0.001), preoperative low hemoglobin concentration (115 vs. 147 g/L, p < 0.001) and platelet counts (127 vs. 295 G/L, p < 0.001), nonabsorbable suture material (43% vs. 8%, p < 0.001), the presence of ostomies (69% vs. 18%, p < 0.001), positive bacteriological wound cultures (50% vs. 6%, p < 0.001), and relaparotomy (25% vs. 3%, p < 0.01). Thirteen of 16 patients with SWD presented necrotizing enterocolitis/intestinal perforations (81%, p < 0.001).

Conclusion:  This study identified prematurity and a number of other factors linked to the child's general condition as risk factors for SWD. Some of these can help physicians recognize and respond to at-risk patients and provide better counseling for parents.